Transcript 2015-03-27 DOPL Presentation

The Normal Physician
A partially compensated,
obsessive-compulsive
neurotic
with a tendency to depression
-Roy W. Menninger
“…some level of impairment in
residents is a common and
predictable sequelae to the time
they spend at traditionally
‘catastrophic levels of stress.’..”
Levey RE: Acad Med 76:142, 2001
Physicians in Crisis
• 85% Family life suffers due to emotional
•
•
•
•
demands of job
58% Have high “emotional exhaustion”
30% Would change professions
56% Biggest concern is lack of time
with family and friends
59% Feel guilty that patients’ don’t get
enough attention
Kam, K; Hippocrates, Jan 1998
Things I Wish They Taught in
Medical School II
• How to Say “I Don’t Know”
• How to Say “No”
• Inevitability of Ambiguity &
Uncertainty
• Danger of Self-Medication
Pfifferling JH: Res and Staff Phys, 36:85, 1990
RECOMMENDATIONS FOR
PHYSICIANS I
• Regular Source Of Health Care
• Seek Help For Mood Disorders, Substance
Abuse, And/Or Suicidality
• Learn To Recognize Depression And
Suicidality In Themselves And Educate
Medical Students And Residents To Do
Likewise
• Become Informed About State And Federal
Protections For Confidentiality & Legal
Protections For Physicians And Others With
Disabilities
RECOMMENDATIONS FOR
PHYSICIANS II
• Physician Health Programs In All States
Include Outreach and Education, Guidance
Through Evaluation and Treatment,
Monitoring, and Advocacy
• Routinely Screen All Primary Care Patients
For Depression As Recommended By The US
Preventive Services Task Force
• Screening For Depression In Patients Can
Help Physicians Recognize Depression In
Themselves
• If sued for malpractice, seek as many
resources as you can.
Illness versus Impairment
Short List of Examples
Concern is for effect on Patient Care
▪ Less Common Disorders
▸ Seizures
▸ Diabetic Neuropathy
▸ Pain
▸ Parkinson’s Disease
▸ Alzheimer’s Disease
▸ Stroke
▸ Mental Illness
▸ Hyperthyroidism/Hypothyroidism
▪ Common Disorders
▸ Substance Abuse or Dependency
▸ ?Disruptive Behavior? ?Impulse Control?
How Addicted Physicians
Differ from the Addicted Lay
Patient
Diagnosis, Intervention and Treatment Considerations
•Presumed above average intelligence. (Perhaps knowledge of
addiction.)
•Subscribes to defined ethical principles.
•Holds public trust and are valuable to society.
•Believe they are unique.
•Respected by their peers.
•Feel pressured to perform.
•Enjoy great deal of autonomy.
•Are held to a higher standard in many ways by themselves and the
public they serve.
•Tend to be defined by what they do, know and provide.
•Deal with life and death on a daily basis.
•Are trained to be in charge, to know what to do in all situations.
PHP Relative Risk by Specialty
Signs and Symptoms to Look for
Listed in General Order of Occurrence
▪ Loss of Spiritual Connectedness
▪ Family Relationship Problems *
▪ Disconnection from the Community
▪ Physical Status Changes
▪ Office “Problems”
▪ Hospital “Problems” *
▪ Checkered Professional History and CV *
Loss of Spiritual
Connectedness
▪ Personal spirituality loss is an early sign.
▪ It stems from the high levels of guilt and shame
brought about by the addictive behavior.
▪ Addicts really do have a conscience, but when they
keep violating their own ethics, albeit involuntarily,
they have to enter denial and rationalization,
projection and minimization modes in order for the
Id, let alone the Ego, to survive.
Family Problems
Addiction is a Disease of Relationships
▪ Withdraws from family activities
▪ Spouse becomes caretaker, enabler
▪ Fights become common as spouse attempts to control the abuser’s
behavior
▪ Spouse becomes isolated and angry at home, but still attempts to
look good for the community
▪ There is always child abuse; always emotional and occasionally
physical
▪ Children assume adult roles prematurely
▪ Children may develop antisocial behaviors
▪ Sexual problems emerge (impotence or affairs)
▪ Spouse may start abusing drugs or enter a recovery program
Community Problems
▪ Physician isolates; withdraws from clubs, church, hobbies,
peers
▪ Exhibits embarrassing behaviors at parties
▪ Receives DUI, has legal problems, exhibits rolediscordant behaviors
▪ Behavior is unreliable and unpredictable in social activities
▪ Engages in excessive spending and risk taking behaviors
Physical Status Changes
▪ Weight loss, pale skin, constricted/dilated pupils,
diaphoresis, tremors, chills
▪ Personal hygiene deteriorates, may always wear long
sleeves if abusing intravenously
▪ Clothing and dress habits deteriorate
▪ Multiple physical illnesses and complaints
▪ Writes numerous prescriptions for personal use
▪ Has frequent hospitalizations
▪ Numerous visits to other physicians or dentists
▪ Has multiple accidents or other traumas
▪ Evidence of serious emotional crisis
Office Problems
▪ Schedule becomes disorganized and starts
progressively later
▪ Is hostile (disruptive) and unreasonable with staff
and patients
▪ Spends longer amounts of time behind locked
doors
▪ Orders excessive supplies of drugs
▪ Patients complain to office staff about his behavior
▪ Frequently absent from the office for a variety of
reasons
Hospital Problems
▪
▪
▪
▪
▪
▪
Late rounds, abnormal behaviors, disruptive outbursts
Decreased performance in staff presentations, charting, etc.
Errors in orders increase, overprescribes CS
Hospital staff report their behavior has changed
Malpractice suits increase
ER reports they are unavailable or respond inappropriately
or very late to calls
▪ Does not respond to pages
▪ Reluctant to undergo PE or UA
▪ Drinks heavily at staff functions
▪ Volunteers for undesirable shifts
Professional History
Clues from the CV
▪ Has changed jobs numerous times in last 5 years
▪ Frequent geographic relocations without clear explanations
▪ History of frequent hospitalizations
▪ Complicated and elaborate medical history
▪ Unexplained time lapses between jobs
▪ Submits inappropriate medical references and vague letters
of reference
▪ Has been employed in positions not appropriate to
qualifications
▪ Professional productivity has declined inconsistent with age
NIDA Principles of Drug Addiction Treatment
Addiction is a complex but treatable disease that affects brain function and behavior.
• No single treatment is appropriate for everyone
• Tx needs to be readily available
• Meets multiple needs, not just drug use
• Must be assessed continually and modified as indicated to meet changing needs
• Adequate amount of time in Tx is critical
• Counseling/behavior therapies are important elements of Tx
• Medications are an important element for many
• Co-existing mental disorders must be concurrently treated
• Medical detoxification is only the first stage of treatment and by itself does little to change
long-term drug use
• Treatment does not need to be voluntary to be effective
• Monitoring for possible drug use during treatment is necessary
• Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and
C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction
counseling to help patients modify or change behaviors that place them at risk of contracting or
spreading infectious diseases
JCAHO Medical Staff Standard 2.6
• Requires Hospitals to Handle Physician
Health Separately From Physician Discipline
• Educate Physicians and Staff About Physician
Impairment
• Procedure to Identify Impaired Physicians To Be
Referred for Evaluation and Treatment
• Many Hospitals Are Turning to State PHPs to Help
in This Process
History of Diversion Concept
• Airline Industry
• Railroad Industry
• Medical Profession
• Variety of Models
Association Sponsored
Third Party Providers
Medical Board Sponsored
State Statute Governed
• Common Goals
• Other Professions
• Lay Public Drug Court
The New Republic
Correspondence: What About Physician Health Programs? by Robert
L. Dupont and Gregory E. Skipper
“We are convinced by the still growing
mountain of evidence of the high rates of
success for PHPs that there should be a
greater focus on early referral prior to overt
impairment or overdose, aided by
workplace drug testing of physicians
(something that is only beginning to occur).
And when problems are identified, we think
they should be immediately referred to
PHPs so they can be properly managed to
assure patient safety and good outcomes.”
The Road to Recovery
Utah Recovery Assistance Program
www.dopl.utah.gov
(801) 530-6428..Susan Higgs
(801) 530-6718..Debbie Harry
(801) 530-6106..Charles Walton, M.D.
What is URAP?
▪ A confidential structured monitoring program to
assist and support the professional who has a
problem with substance abuse or dependence or
certain behavioral issues.
▪ It is defined by statute as being non-disciplinary,
therefore, not reportable to data banks.
Criteria for Consideration for
Admission
▪ First time offense, no prior disciplinary actions.
▪ No egregious harm can have occurred to other
individuals.
▪ No financial or personal gain of any type can have
occurred in connection with the problem.
▪ An investigator and a bureau manager must sign
off on the admission. (new since 2013)
Referral Process
▪ Self (Investigator interview required)
▪ Peers or family or friends
▪ Via investigation by DOPL investigator
Referral Source (375 MD from 16 states)
Percenta
ge
4
0
Sel
Colleagu
f
Famil
e
y
Treating
OPM
MD
Hospit
C
unknow
al
Patie
n
Pharma
nt
cy
3
0
2
0
1
0
0
Referral
Source
The Advantages
▪ License will remain in full and good standing. No
database report.
▪ Structured monitoring has been shown to effectively
double the chances of staying in recovery.
▪ Avoidance of potentially more serious consequences if
addiction remains unchecked.
▪ Any investigation will be suspended during the diversion
period and closed and permanently sealed if diversionee
completes the program successfully.
Advocacy
• State Medical Boards
• Regulatory Agencies
• Employers, partners
• Malpractice Insurance
• Hospitals
• Criminal Justice
• Other
The General Requirements
▪ Completion of formal rehabilitation program
▪ Attendance at weekly aftercare
▪ 12-step meeting attendance
▪ Professional support group attendance
▪ Random urinalysis program participation
▪ Individual counseling and possibly psychiatric care
as indicated
Conclusions The risk of relapse
with substance use was increased
in health care Professionals
(292 physicians) who used a major
opioid or had a coexisting psychiatric
illness or a family history of a
substance use disorder. The presence
of more than 1 of these risk factors
and previous relapse further increased
the likelihood of relapse. These
observations should be considered in
monitoring the recovery of health care
professionals.
JAMA. 2005;293:1453-1460
Bottom Line
▪ Addiction kills, rehabilitation works.
▪ Intervening is a profound act of caring.
▪ No one has to “bottom out” before seeking
treatment for these difficulties.
▪ The rehabilitation experience is usually viewed as a
great gift by those who truly grasp the concepts.