- 00:21 Introduction
- 02:59 Scope/Definitions
- 08:05 Systems for Physician Impairment
- 13:50 Barriers to Care
- 24:48 Helping an Impaired Physician
- 28:44 Systems Level Change
- Physician Impairment (FSMB definition): “the inability to practice medicine with reasonable skill and safety.”
- Common types of physician impairment
- Substance Use Disorders (SUD)
- Most common reason for identified physician impairment
- 2011 survey of physicians of all specialties with over 7000 respondents found that over 15% had an AUDIT-C score indicating significant alcohol use or dependence
- #1 = alcohol; #2 = opioids
- Mental Health (MH) disorders
- Disruptive behavior
- Cognitive decline/dementia
- Substance Use Disorders (SUD)
- Illness vs Impairment
- How do physicians with potential impairment get care?
- Medical Boards
- Often related to significant patient safety concerns or harms
- Mandatory, probationary contracts with limits to licensure
- Stiff penalties have contributed to suicide among impaired physicians
- Judgements are not beholden to administrative courts of law (i.e., limited legal recourse for disputes on penalties)
- Physician Health Programs
- State based advocacy groups designed to help manage physician treatment for potentially impairing conditions without public discipline
- Offers voluntary monitoring agreements to create accountability and proof of fitness for duty
- Rigorous recommendations for treatment => costly but higher quality of care than non-physicians with the same condition
- May have to report non-compliant members to state medical boards
- Wellbeing committees
- Present in every hospital by JCAHO standards
- Separate from disciplinary bodies, may offer individualized monitoring agreements
- Medical Boards
- What are the potential barriers to accessing care?
- Denial that there is a problem
- Conflicting messages during training, with valorization of work through severe hardship (e.g., performing procedures after overnight call)
- Concerns about confidentiality & stigma
- Negative attitudes towards SUD and MH persist within medicine itself
- Secretive use of mental healthcare may stifle access to community resources (e.g., AA meetings)
- Concerns about professional consequences
- Disclosure of potentially impairing illness on medical license applications can lead to:
- Invasive & costly evaluations
- Probationary medical licenses
- Public disclosure of illness
- Concerns about cost
- Costs of treatment (e.g., extended inpatient treatment centers)
- Costs of monitoring (e.g., urine drug testing)
- Costs of time (e.g., attending therapy, groups)
- Largely not be covered by insurance
- Denial that there is a problem
- How should a colleague intervene?
- Call for help (wellbeing committee, PHP, other colleagues)
- PHPs are accessible in 47 states
- Can inquire about consequences of initiating intervention
- Take some action, you could save their life and career
- Can initiate interventions anonymously through PHP or Wellbeing Committees
- Find workable solutions, often through others who’ve been there
- Look for other sober physicians
- Call for help (wellbeing committee, PHP, other colleagues)
- How do we improve our physician health system?
- Ending invasive health inquiries
- Deter physicians from seeking help
- Betrays guidance from AMA, APA, and FSMB
- May be a violation of the Americans with Disabilities Act
- Restoring & regulating PHPs
- States with no PHPs (CA, NE, WI) => direct disciplinary action from medical boards for impairment, which deters reporting
- PHPs have no appeals system or national oversight
- Ending Stigma for MH and SUD treatment
- Many physicians in the disability community share that experiencing health challenges builds insight & empathy, and can make one better equipped to provide care
- A retrospective review in 2013 showed that those who had gone through a Colorado PHP treatment monitoring cost the insurance company 20% less than a matched cohort of insured physicians
- Sharing personal stories of accessing care as a healthcare professional can enable our peers to seek help
- Ending invasive health inquiries
Resources to Access Help
IDAA – International Doctors in Alcoholic Anonymous (listings for local Caduceus Meetings, confidential phone helpline, and national conferences)
Physician Health Programs (state-by-state contact information)
Physician Suicide Prevention (confidental helplines):
SUD Treatment Centers with Healthcare Professionals Programs
- Bradford Health Services (Warrior, AL)
- Center for Professional Recovery (Malibu, CA)
- Talbott Recovery (Atlanta, GA)
- Tranquil Shores (Madeira Beach, FL)
- Pine Grove (Jackson, MS)
- Marworth (Waverly, PA)
- Caron (Wernersville, PA)
- Sante Center (Argyle, TX)
- Hazelden Betty Ford Foundation (CA, CO, FL, IL, MI, NY, OR, WA)
Skipper: I was a young internist in 1980 and I broke my leg, playing soccer. And I got put on pain meds and liked them too much. You know, it went too far. I started taking samples which were more readily available back then. And, uh, finally got confronted by colleagues. I was scared to death at the time. I went to a treatment program and started my own personal recovery.
Jafar: The story we just heard comes from Dr. Greg Skipper. His journey may have started with own sobriety, but because of his experiences he was called to help other colleagues who also struggled with substance use. His career quickly became one of advocacy, research and direct clinical work with impaired physicians–not just with substance issues, but all kinds of health conditions. Along the road he’s worked with medical boards, insurance companies, hospitals, treatment centers, lawyers, even politicians, and he’s currently the medical director of the Center for Professional Recovery in Malibu, CA. And so he knows first hand all the complexities that go into evaluating the health of those who care for the health of others.
Today we’re going to cover what physician impairment really means. We’ll start off by talking about how illness relates to impairment, and then explore some of the systems in place for physician health and monitoring. We’re also going to talk about the barriers to care caused by these systems, what we can do to improve it, and how to help a colleague who might be in trouble. Welcome back to At The Bedside! I’m Jafar.
Tamar: I’m Tamar
Margot: And I’m Margot
Jafar: I’m gonna come out and say that this is a dense, legally messy, and ethically treacherous topic, and one I’ve been warned more than once how difficult this is to cover. On the one hand we have this immense privilege to care for our patients, and so of course there’s got to be some accountability for our fitness to do the job. But when does that accountability threaten our right to some privacy in our health, and how fair are those systems that evaluate us? These – really legitimate – questions leave too many of us in medicine walking around with this sense of shame, fear, and secrecy, trying to pretend we’re invulnerable to the illnesses we treat every day, and the vague dread that if that facade breaks down, we may lose our right to practice medicine.
So in addition to Dr. Skipper, we spoke to many doctors who have gone through this process, one of whom was gracious enough to be interviewed for this episode.
David: There was an active narrative in my head that this was not going to be good and it was going to take me down. And that was playing in my head at the same time that another part of my head was well aware that I wasn’t going to stop.
Jafar: Dr. David McDonough is an internist from Los Angeles who recounts his own struggles with methamphetamine, and all the psychological and professional tensions that held him back from help sooner. Physician wellness is, rightly, a topic that so many more people are talking about these days. We hope his experience and those of many others we spoke with can illuminate this topic in a way that doesn’t get covered nearly as often.
Tamar: Like Jafar said, this is a complicated and sensitive topic and we really want to recognize that each experience of impairment, recovery, and everything else along the way is different from person to person. So, we wanted to start by taking a step back to discuss the different situations, life events, and illnesses that can lead to impairment. Dr. Skipper spoke to us about the wide spectrum:
Skipper: So there’s substance use disorders, there’s anxiety disorders, OCD, depression, bipolar disorder, And then you’ve got more, just what we call, you know, disruptive behavior or behavioral problems. People with disruptive behavior should get a workup because maybe they’re abusing drugs and it could be because they’re sick. Maybe they’ve got severe hyperthyroidism, maybe they’ve got a brain tumor. And then you’ve got cognitive decline, which is becoming a real hot button issue as like our physician population is aging and you know, what do we do with doctors in their seventies, eighties?
Tamar: Dr. Skipper’s list is of course not a comprehensive one, but the point is that clinician impairment can occur for many reasons. And the prevalence of all these is not necessarily easy to study or report. Since so much of the physician health system around impairment focuses on substance use, we wanted to mention a 2011 survey of physicians of all specialties. There were over 7000 respondents and the authors found that over 15% had an AUDIT-C score indicating significant alcohol use or dependence. But again, the true prevalence is hard to capture, especially through self-reporting. And, more importantly, there’s a significant difference between drinking and having a substance use disorder that is impairing.
Illness vs Impairment
Margot: So let’s talk about that difference. There’s an important distinction we want to dig into: illness versus impairment. Substance use disorder is an illness, and illness just means having a disease
Skipper: So you can have diabetes and be stable and not impaired. But if your diabetes is out of control and you’re having hypoglycemic episodes, you could be impaired and it shouldn’t be operating.
Margot: The worse an illness gets, the more likely it is to lead to impairment – but impairment can be tricky to define.
Skipper: So impairment means unable to practice with skill and safety and it’s a subjective thing. Okay. So at what point does a physician… what point is their function decreased from optimal? At what point do you say, well, they’re unsafe now, you know, somebody could have real bad case of the flu and come into work or just got divorced and come into work. There’s things, any kind of number of things that could decrease your performance, you know, because you’re distracted or you’re not feeling well. And when do you pull the plug and say, this person is impaired. They cannot practice with skill and safety. That’s a hard decision, a lot of times.
Margot: I think of illness and impairment kind of like a venn diagram: they’re two distinct categories but they have an area of overlap. On one side, you can have an illness, but not be impaired – this is where a condition like diabetes would fit. On the other side, you can be impaired without having an illness – and Dr. Skipper’s example of someone going through a divorce would fit here. Impairment is also on a spectrum, where someone might be able to do simpler task like repleting electrolytes, but not harder ones like doing a procedure.
Skipper: Impairment does vary depending on the demands of the job and what the person needs to do, you know, physically and mentally and d things like duration of work. I’ve had a doctor that loved OB and as she got older, she did was not handling sleep loss. And she started falling asleep during deliveries and everybody got concerned.
Margot: The culture of medicine can make it a bit tough to recognize when something is impairing. Doctors are regularly called in the middle of the night about emergencies, or work 27-hour shifts in the ICU. When it’s considered normal to put in a central line after working for 26 hours, you can start to see how clinicians can have trouble recognizing that something is impairing. In general, though, doctors aren’t flagged for intervention for intermittent stressors like fatigue – it generally has to be a serious, ongoing, and impairing health condition to need intervention. While it can be difficult to know when illness has crossed the line into impairment, Dr. Skipper describes why it’s important to act early.
Skipper: We want to intervene before there’s impairment, if possible, because that way we avoid a crisis and harm to patients and to the doctor’s career. So with substance use disorders, it’s pretty clear although there are gray zones in there too. It’s pretty clear that when somebody is manifesting, a substance use disorder it’s progressive. I think it’s very prudent to intervene before they’re impaired at work, if possible.
Margot: In this episode, we’ll mostly be talking about substance use disorders, where the line between illness and impairment is a bit easier to draw. However, this discussion is still relevant for other conditions that can lead to impairment.
How do physicians with impairment get care?
Jafar: So how do clinicians with impairment get help for their problems? The majority of physicians with potentially impairing conditions will receive care privately, oftentimes even secretively, for reasons we’ll get into. But when something reaches the attention of employers or colleagues to the point where they feel the need to intervene on a physician, it generally goes to one of three places: medical boards, physician health programs and wellbeing committees.
Jafar: Let’s start from the obvious: if there’s a patient safety issue or worse a patient harm, and it’s believed to be related to physician impairment then that person is likely to be reported to their state medical board. This might be initiated by their employer or even by the patient themselves. Medical boards issue licenses to practice medicine in a particular state. So, if a patient or their advocate issues a complaint to the medical board, this is often followed up by an investigation, which may then trigger a formal evaluation for impairment.
Skipper: Because the boards are legal entities, they have lawyers and investigators and bureaucrats, and very few doctors are involved with the board.
Jafar: Unfortunately, even if they find that incident was a result of illness, the result is still most often some kind of formal probation. This can come in the form of contracts stipulating random drug testing, work hour restrictions, and assigning worksite monitors. Physicians that don’t follow through can have their license fully revoked, and get orders to stop all clinical work, often with little or no legal recourse.
Physician Health Programs
Jafar: Until the early 1980s, this was the only model for intervening on physician impairment, and the results of these kinds of stiff penalties were, frankly, disastrous. One study of physicians enrolled in the Oregon state monitoring board in 1977 reported a suicide rate of 20% in that year alone, driven explicitly by the stresses of probation.
Skipper: This movement got started of saying, well, we need to do something clinical. Like we need to try to do early intervention and get help for doctors instead of just waiting until there’s a problem and then, you know, come in with investigators and sort of discipline them.
Jafar: The result was what’s generally known as the physician health program, or PHP. A state-based advocacy group that can help manage physician treatment for potentially impairing conditions without public discipline, usually in the form of voluntary monitoring agreements.
Skipper: That’s for physician health. And they do things like inquiries and interventions and, you know, interface with hospitals, do education and all the things they do. So in every state now, except for two or three, there’s an active physician health program.
David: For instance, Tennessee, you joined the Tennessee medical foundation. And if you do, you go under treatment of whatever your impairment is, whether it’s an anxiety disorder, et cetera, and that your treatment is structured to make sure that you can practice safely without harming yourself or others. And in an, if you’re enrolled in that program, being taken care of, the medical board in Tennessee actually cannot injure you. They cannot take your license, they can’t suspend you. They can’t, they can’t, um, take punitive measures against you, which are not going to help you in an impairment.
Jafar: But, the protection provided by PHPs is not without its limits. These entities have to balance confidentiality with an accountability to keep patients safe.
Skipper: We did have an agreement that if there was a doctor in trouble who could be a harm to patients and they were unwilling to stop practicing voluntarily, then I had to report that person to the board and then the board could take legal action to stop the doctor.
Jafar: So that’s that’s balance we need to strike: because PHPs still have a responsibility to medical boards and the public, physicians who come to them still need to prove their fitness for duty. The upside is that physicians often end up with a higher quality of care than non-physicians with the same condition.
Skipper: We have high standards. And so we’ll often say, well, you need to go get a thorough evaluation. And they’re like, you mean I have to stop working for a few days? These are that kind of thing. So, you know, when they call me like that, I always tell them, look, you know, you’re probably gonna think we’re doing more than you need, but trust me, this is going to be the best way to go.
Jafar: The question is really how many physicians are over-treated in the interest of patient safety. While PHPs are confidential and voluntary, some may actually be as rigorous and invasive as what the medical board may mandate – for instance in terms of the frequency of psychiatric care, drug and alcohol screening, or support group attendance. And it varies a lot state to state
Skipper: And that has been where the crux of the problem is nationally as it goes sort of back and forth in different ways in different States, depending on the current mood of the public and the governor and, you know, it gets political.
Jafar: Needless to say, so much variability doesn’t always inspire trust or referral, leading some hospitals to simply work out their concerns with the physician in a more direct way. The Joint Commission’s standards for physician health actually require each hospital to have policies in place to help in the recognition and referral of practitioners who may be impaired, usually in the form of an independent wellbeing committee. Membership and expertise may vary, but their core function is to be a resource separate from other disciplinary bodies, in that the focus is on physician health and access to appropriate care. So an impaired clinician may enter a voluntary contract with their local wellbeing committee.
Skipper: If the person gets access to those entities, they typically will be protected. You know, their , career’s protected. Those, those entities are there to protect careers and help doctors, you know, again, so the patients will be safer. I think ultimately you’re helping somebody to get help early before the catastrophe, because I’ll tell you this. If somebody actually hurts the patient, their career’s pretty much over.
What are the potential barriers to accessing care?
Margot: So medical boards, PHPs, and wellness committees are all ways that impaired physicians can get care. But unfortunately while those resources exist, there are huge barriers to actually accessing that care. I’ll talk about denial and stigma, then I’ll turn it over to Tamar to discuss professional and financial consequences. The first big hurdle is denial: To accept help, you first need to accept that you need help – and that’s a tough step to take.
David: As physicians, we are put in positions where we’re supposed to always have the answers and always have the solutions and always solve all the problems. And I’ll always take care of everyone else. And our own personal, um, health is just not, it’s ignored. And we, and that’s, that’s also our, you know, it’s our fault because we take on that role, we accept that role and we shouldn’t accept that role. We should, you know, realize that we are just like anybody else, and we’re not superhuman. We’re not up to these tasks that, that no one should be asked to do.
Margot: The culture of medicine tends to valorize people who are able to work under all kinds of conditions, which makes it hard to take sick days or admit that you need time off to care for yourself.
Skipper: There’s a tendency for physicians not to want to have any illness, you know, nobody wants to be sick with anything, you know, it’s hard a lot of times for physicians to even go to a cardiologist. They don’t want to be sick, you know, so they tend to be a little more in denial. For some reason they get curbside consults, they don’t get legitimate care. Um, so that’s in the background. Now with mental illness, you’re stepping up a notch because there’s more stigma. Um, and then you step it up even further with substance use disorders, and so doctors are embarrassed and don’t want to get care.They think it’ll, you know, ruin their life that they’ll be labeled and they don’t know really what will happen, but there’s a lot of fear.
Margot: On top of the stigma, it can be hard to recognize when a problem has crossed the line into impairment. Sometimes, work is the last thing to be affected.
Skipper: You know, a lot of doctors start having a problem with substance abuse, either alcohol or drugs, mostly alcohol is the most common substance used by doctors. Um, but they started having a problem and it creeps up on them and they protect their workplace, you know, because they know that’s really important. So it starts showing up more in their family, uh, maybe in their health, maybe a legal problem, like a DUI. Uh, but oftentimes they do, they do well at work and they’re not impaired until it gets even further alone.
David: Now you’re actually two hours late to work and it just keeps evolving, you know? Um, and the next thing, you know, you’re up for, you’re up for 36 hours and you’ve, you’re going back into work, you know, um, not having rested, not having anything, just shower and change your clothes and come right back. Um, and then the next day, when work is over, you go out and do it again. So in a way, there’s no way not to realize that that’s a problem, but, but the denial and the rationalization of it is, is every bit as strong as your realization that there is a problem.
Margot: Once someone has accepted that they have an illness, and recognized its potential for impairment, they still might believe they can get through it without help. To someone who made it through years of medical school and residency, substance use disorder may just feel like another obstacle to overcome.
Skipper: You know, everybody’s always thinking, well, I’ll quit, you know, I’ll, I’ll stop. I’ll, uh, I’ll keep taking my meds or I’ll, you know, if they’re on meds for say bipolar or something, they’ll swear that they’ll do better. Um, or if they have an alcohol problem, they they’re always going to quit tomorrow, you know, so that that’s part of the illness.
Margot: Denial is a challenge for anyone with substance use disorder, but the culture of medicine presents an extra set of hurdles. Some of the very traits that help us in our careers – independence, perseverance, perfectionism – can make it really challenging to accept that there’s a problem, and ask for help.
Concerns about confidentiality/stigma
Margot: The next barrier we want to touch on is the stigma around substance use disorder. I mentioned that stigma plays into denial, but it can also present an obstacle to treatment once a physician recognizes he needs help.
David: This is an illness that is not acknowledged like an illness, this is an illness that’s, uh, stigmatized, it’s criminalized. Uh, it’s, it’s an illness that people end up with felonies over, their lives are destroyed over.
Margot: Attitudes towards substance use disorder vary from one clinician to another, but there isn’t uniform sympathy for patients struggling with addiction. This can make it really challenging for physicians to be open about the fact that they themselves have a problem.
David: I’ve had so many discussions with people with this disease that when they eventually get, get it, look back at their career and their attitudes toward people with substance use disorders before they understood it themselves and their judgmental attitudes about it. Oh, here comes this guy again, you know, I mean, he almost died last time in the hospital with his damn pancreatitis. We really don’t do anything, but patch them up for the pancreatitis and then back out the door and then wonder why it keeps happening. So the medical community stigmatizes it, the medical community doesn’t really understand how to treat it.
Margot: Mental health conditions and substance use disorder face a stigma that people with physical illnesses don’t face. There’s an added pressure for physicians, who are held to a very high standard because we have patients to care for.
David: The medical, board’s not going to find out that you have a lumbar problem and you’re overweight and take your career away from you. Okay. But the medical board finds out that you’ve tasted some methamphetamine. Okay, they’re going to take your career away from you. Um, and they’re going to punish you and they’re not going to treat you.
Margot: The stigma can create a very understandable wish for confidentiality. But too much secrecy can make it harder to find support.
Skipper: There’s a lot of fear about what will happen if I actually asked for help. Um, they might go to a local counselor or psychiatrist because there is that, uh, commitment to confidentiality that’s afforded by HIPAA and CFR 42 part two, the federal laws that give confidentiality around mental illness, they might do that. It could result in improvement in health, but you know, the thing with substance use disorders in particular is that you sort of have to have a community of support, you know, others that have been through it that, that understand that you can have buddies that you call and talk to them about issues. And, and so somebody that’s being secretive and going to a psychiatrist or a therapist in private, and doesn’t want anybody to know about it, boy, that really handicaps their ability to fully recover and do well.
Concerns about losing their job
Tamar: Another huge barrier to seeking help is the fear of professional consequences. And these fears are very valid ones, especially thinking about how Dr. Skipper explained the role of medical licensing boards earlier. License applications frequently ask invasive questions about mental health history that deter physicians from seeking help out of fear. And for those that do get the help they need for mental health or substance use, declaring this on their application may result in costly evaluations, getting a restricted, probationary license, or even public disclosure of their illness. So, again, these concerns are real and understandable. Despite this though, Dr. Mcdonough and others we spoke to emphasized that there are also immense benefits to getting treatment as early as possible, both in a physician being able to take care of himself and, crucially, in protecting patients.
David: There was a ton of fear about that because it was true. You couldn’t just disappear from a private practice for, for months and months and months a month and expected it was still going to be there. And that was all true. But I, but, you know, I used that as the rationale as to why, why I couldn’t do it. Of course the reality was if I had, if I had done that in 2011 and actually, uh, gotten into the program or whatever, I probably would’ve, you know, I would have saved millions of dollars and not lost my house and not lost all everything I lost. If it were easy to go into treatment and save your career, I maybe, maybe, hopefully I would have done it way, way, way, way, way earlier. And, um, I was relieved. I was absolutely relieved for the first time in my life to get, to not have to work in medicine and, and to obsessively work in medicine and to just take care of myself
Tamar: There is also encouraging literature on the success of physician treatment programs, even though these studies do have limitations in their generalizability. For example, in a 2008 BMJ paper, of over 800 physicians admitted to a PHP, the authors reported that 78.7% of these physicians were licensed and working at five-year follow-up. And among the over 500 physicians who successfully finished their contract with the PHPs, the number was even higher — 95% were still licensed after five years.
Concerns about cost
Tamar: Another barrier to seeking help is the considerable financial burdens. There are costs associated with both receiving treatment and the monitoring for substance use after returning to clinical work. Anecdotally, multiple people we spoke to said this can amount to tens of thousands of dollars per year. And many of these costs, even when through PHPs or specialized treatment referral centers, may not be covered by insurance. Beyond these big financial constraints, there is also the cost of time spent attending appointments, counseling, and supervised monitoring, such as regular drug testing — and this time can obviously be extra difficult to find for a full-time clinician or trainee. And while acknowledging these large burdens, Dr. Skipper still pushed that these costs provide a worthwhile value.
Skipper: So there is a trade off, you know, and, but in, in treatment, when I have doctors in treatment, uh, we talk a lot about these things. You know, five years of monitoring is what the standard is and people go five years that is long, and what I tell them is, look, that’s why we have such a great success rate. You know, it holds you accountable. You want to stay sober. This is really not that bad. And I have him interact with doctors that are in monitoring and they say “Yeah, it’s a nuisance, but you know, you get used to it. You check this app every day and you’d go, you know, give us a urine sample when, when prompted.” But, um, it’s no, it’s, it’s a lot better than being addicted and having all this trouble with the addiction and relapse and stuff. So they know it’s accountability and documentation of their sobriety, which can help them in the future.
How should a colleague intervene?
Jafar: Ok, so on the one hand, there are major consequences of unchecked illness on a physician’s life and career. On the other hand, getting involved in physician monitoring programs is not so easy either. And that’s exactly why we made this episode–it’s often very hard to know how to navigate individual situations. So we want to talk about you can help a colleague who seems like they might be impaired–both on an individual level, and with systems-level changes. Let’s start with the first question: how to help one-on-one
Skipper: You know, it depends on your level of comfort. I think you can go to the person and say, look, I’m really concerned about you. Expect that they’re going to come up with some kind of reassurance and sort of, “I’m fine. It’s a misunderstanding, you know, I’ll be okay. I won’t do it anymore.” You know, stuff like that. So if the, if the concern continues, you probably need to take it to a supervisor, head of a department, wellbeing committee. If there’s a state physician health program, you can go right to them. You know, I got calls from people all the time. When I ran a program in Alabama, you know, I’m concerned about a colleague, here’s what I’m seeing. And, you know, we could initiate a supportive intervention even without telling the person who called us.
Jafar: And if you’re worried about what the consequences of initiating an intervention on a colleague might be, you can always simply call and ask! Call and speak to your state’s PHP or local wellbeing committee before breaking their anonymity.
Skipper: So it’s good to make inquiry. But the thing I would say is do something, you know, because it usually doesn’t end well. And so you’re going to be doing something good. It’s basically appealing to the person’s professionalism and saying, look, if you continue on like this, you’re going to ruin your career, let us help you now, you know, and that kind of thing, most people will, they really want help. Anyway, they’re just afraid. And so it’s a matter of, you know, having somebody that knows how to do it, help you do the intervention.
David: Don’t back down, um, stick to your guns. If you see impairment, the person needs help. And, um, you, they may not like it, but you may, you may be the person that saves their life. You may be the person that gets them into help before they lose more than they are going to lose.
Jafar: And this was a message that I really took away from talking with David: that providing real, meaningful help for a sick physician is not a one-off event–it’s a process of integrating recovery with a busy career, and being mindful of all those difficulties will help your colleague accept what you’re offering
David: There was no conceivable solution being offered. People showing up and saying, you’ve got to just quit and go to rehab. What translated, what that meant was you got to lose everything and go to rehab. If there was some way to, to say, okay, we’re going to help you figure this out so that you can work, you know, much less while doing partial treatment, and we’re going to help you keep the practice going, or we’re going to, or we’re going to help you restructure things, or, you know, to help come up with solutions.
Jafar: To that end, sometimes the most valuable thing is to connect that physician to someone else who has gone through the process of getting help for impairment, a resource that can be found through a PHP, a wellbeing committee, or local AA meetings specifically designed for medical professionals, called Caduceus meetings.
How do we improve our physician health system?
Jafar: Finally, we want to discuss the systems-level changes that could make care more accessible–not only for those with active impairment but to the many, many more of us at risk. And there is so much that needs to change, but for the sake of time I want to end this episode by highlighting 3 important steps we can take: 1) reforming the way we ask about physician health on license applications; 2) restoring and regulating how PHPs operate; and 3) working to end the stigma around mental illness and substance use disorders within our profession.
Ending invasive health inquiries
Jafar: As we all know – and you’ve heard over and over again today – early intervention on illness will bring about better outcomes. Too often, though, care for physicians gets delayed because of fears around loss or limits to licensure if a potentially impairing illness is identified. While it may be appropriate to ask about active, functional impairment in practicing medicine, the way medical license applications ask broadly about a physician’s health history may be a violation of the Americans with Disabilities Act, and it betrays guidance from American Psychiatric Associations, the American Medical Association, and even the Federation of State Medical Boards themselves. And it’s gotta stop.
Restoring and regulating PHPs
Jafar: Next is the issue of PHP regulation. Like we discussed earlier, PHPs fill an important gap in the health system by shielding and advocating for physicians with impairment-related health conditions. But as Dr. Skipper was saying, these groups operate very differently in different states, and in some states, including Nebraska, Wisconsin, and California, they don’t exist at all, leaving physicians very vulnerable.
Skipper: So everybody that gets in trouble has to go through the board. And what that does is it drives people underground. So, you know, nobody wants to report somebody and nobody wants to come forward and ask for help because there is no physician health program in California.
Jafar: Unfortunately, even PHPs can sometimes be as bureaucratic and punitive as medical boards are, and while they’re voluntary, for many physicians, compliance is a condition for employment. Not all of them are patient-centric, and there is often no appeals system for disagreements with their treatment recommendations. The bottom line is that this is a high stakes system, and we need national oversight to keep these systems accountable and fair. And the more we treat this as a system that advocates for health rather than one that punishes us for being ill, the easier it will be to reach out for help:
David: So for instance, if you have a patient with a seizure disorder, you want to make sure that their guardrails, so that they’re not going to go into a full blown seizure and fall and hit their head, but you, you come up with things to protect them and hopefully allow them to function and live a normal life. Instead of let’s punish, let’s criminalize, let’s take away, let’s charge them, let’s lock them up, let’s take away their privileges, uh, on all kinds of levels. That just says that it’s not understood that this is a disease, and this is not an intentional choice that is being made.
Jafar: Finally, as we’ve discussed, getting help for mental health and substance use disorders is really hard because of all the rampant misunderstanding and stigma surrounding these issues, not just in society but also within medicine itself:
David: I guess it’s not a criticism of them. They also don’t know what to do because we don’t, we don’t give the people around the person with the disease, any tools of knowing what to do. So that’s, that’s a piece that would, you know, it’s just a shame. I mean, really, it just, because, because we haven’t addressed this disease correctly in our society, nobody knows what to do at that. The people around the person with the disease and the people with the disease just don’t get handled right. And don’t know what to do on any level.
Jafar: The truth is that medical professionals who’ve gone through these problems and received effective care have with them a bank of experiences that may make them more empathetic and aware than those who haven’t. And this is something that Dr. Skipper witnessed on a practical level during his work with medical malpractice insurance companies, where he found physicians who have been through treatment for substance use issues subsequently had fewer malpractice claims made against them than other physicians insured with that company. Now, at first this was an internal analysis conducted with one insurance group he worked with in Alabama, but speaking with his colleagues, this finding was actually reproduced at multiple other medical malpractice carriers across the country! A retrospective review in 2013 actually quantified the medical malpractice risk from physicians insured through the Colorado Physician Insurance Company. The authors specifically looked at those who had gone through a Colorado PHP treatment monitoring agreement, and saw that they actually cost the insurance company 20% less than a matched cohort of insured physicians.
Skipper: And maybe that’s because they’ve gained some humility or they, you know, become more psychologically minded or, get support from their peers.
Jafar: There’s so, so many physicians in the disability community who feel that going through illness has made them a better doctor. But those who have had substance use and mental health issues are afraid to speak out, not only out of fear of being discovered and labelled as impaired, out just from the fear of being judged by others:
David: I think that physicians also in a way can be their own worst enemy. We don’t want to show weakness. We don’t want to appear that we’re lesser than, than our colleagues. It’s embarrassing to us because we’re programmed that we’ve got to have the answers.
Jafar: In our hyper-competitive, overworked, and overstressed lives as medical professionals, we’ve normalized the process of being ill on the job but have not yet normalized the process of getting help. But studies show that our willingness as healthcare professionals to talk about our own experiences getting help can enable our peers to seek help–a culture of vulnerability that can make us all stronger:
Skipper: I think if we promote the idea that substance use disorders and mental health disorders are illnesses, you know, they’re not crimes, it’s not bad people that, you know, good people get these problems and then encourage people that have gotten help to come forward. I love it when a doctor in recovery actually speaks out in his community and says, you know, I’m in recovery, I’ve been through this and I’d like to help other people. So if we create a culture where people acknowledge the, either vulnerable vulnerability, it takes a lot of courage to be vulnerable, but if we can be more vulnerable I think it’ll be good.
Tamar: Thanks for tuning in! We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences with physician impairment. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website: www.coreimpodcast.com
If you enjoyed listening to our show, please give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions.
Finally, special thanks to all our collaborators on this episode: our expert discussants Dr. Skipper and Dr. McDonough, our wonderful audio editors Michael Shen and Daksh Bhatia, illustrations from – yet again! – Michael Shen, moral and executive support from Shreya Triveda, and most importantly thanks to you, our listeners!
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Tags: cost, impairment, mental health, primary care, stigma, substance use disorder, wellness
2 comments on “Physician Impairment”
Thank you so much for this commentary covering important aspects about physician impairment. As I listened, I was reminded of the delicate balance between promoting recovery and protecting the public who we serve as physicians. The questions which arise from then tension between physician’s rights and the rights of patients are important and need to be considered.
I was blessed by my involvement in the California Diversion program and how they directed my recovery, particularly since my great thinking got me addicted to cocaine, psychotic, unable to safely practice or live functionally. I was required to attend residential treatment for 4 months, begin limited part time work at 6 months sober, live in a recovery home until I had a year sober and participate in weekly Diversion groups and regular uTox testing. Those requirements, which cost time and money provided the structure and guard rails which encouraged my staying sober for the first 5 years. I attribute that direction and guidance, while imperfect, to the foundation which has enabled me to stay sober for 33+ years. I still believe that part of my success has been “not doing it my way, ” realizing that I may not know what is best for me and living with humility enables learning. Thanks again.
I am in the CPH program in New York and am grateful for the program. I am in academic medicine and am fortunate that my Institution is supportive of the process. I would very much like to help other physicians who might be starting such programs and have anxiety over the process.