Presented by Dan Angres, MD
Transcript of Presentation
Over the last three decades, I’ve worked in the area of physician wellness, helping heal the healers who struggle with addiction. We’ve found that with the proper environment and monitoring, impaired physicians can enjoy excellent outcomes — fully able to return to work, relationships and productive lives.
In our society, a number of threats to physician well-being and a culture of safety exist and must be addressed in physician wellness programs. These include substance use disorders, mood disorders, anxiety disorders, sexual boundary violations, disruptive physicians, personality disorders, mis-prescribing drugs and cognitive impairment.
A culture of safety strikes a “tough love” balance. There’s a critical need to both protect patients from physicians whose practice is impaired and care for the physician, so he or she can resume safe practice. Too much emphasis on one side can overly support the physician without requiring sufficient transparency or accountability. In this scenario, an impaired physician could be sent to a community provider, with no reporting to the organization, and come back with a note indicating he or she can return to work with no ongoing monitoring.
On the other extreme, hospitals may adopt a punitive response and fire a physician out of hand. In those environments, problems go underground. No one wants to report an impaired physician who will lose his or her livelihood. No one wants to seek help.
Because physicians tend to become focused, they generally respond well to structured programs. Still, some challenges exist. Physicians may have a limited capacity for introspection that leads them to dismiss their problem usage. Pressured to see more patients in less time with fewer resources, they often rely on “curbside consults” or misdiagnose themselves. They can be defensive about any intervention that may threaten their licenses, making it important to support reentry to practice when possible.
Other factors increase the risk of addiction for physicians. They have easier access to controlled substances, though less than in the days when pharmaceutical companies flooded hospitals and offices with samples. They can write prescriptions for themselves or others, though that also is more limited thanks to pharmacists on the watch for inappropriate prescribing. Like other users, they can access drugs online and on the street. Young physicians, residents and medical students in particular, are affected by the heroin epidemic sweeping the country. Like their peers, many start using opioid pain killers, find them too expensive and shift to heroin.
Implementation of an independent physician health program may be driven by hospital administration, but it is also a Joint Commission standard. Typically, hospitals create a wellness committee comprised of knowledgeable volunteers kept separate from the organization’s disciplinary department, with the understanding that if the wellness committee fails to successfully intervene, it may be compelled to take the issue to the medical staff disciplinary department. The reverse is also true. Disciplinary teams may refer physicians to a wellness committee when it becomes obvious a physician has diverted drugs or has impaired practice.
Physician health programs today adopt a number of different structures, with some affiliated with state medical boards and others functioning as separate wings of licensing boards. Physician health programs are not treatment programs. They assist in educating healthcare entities in their state about physician impairment and the culture of safety, provide assistance and triage for assessors and undertake long-term monitoring of physicians — ideally for at least five years — who have gone through treatment.
A potentially impaired physician typically will be referred to a multidisciplinary team of experts that conducts a comprehensive evaluation, gathering extensive collateral data from workplace associates and family with permission. The assessment also will include neuro-psychological screening and a comprehensive toxicology assessment to identify substance use disorder or other issues. For example, specialists may assist if someone presents with a possible neurodegenerative disorder as the root cause of behavior. The team will create a detailed report that could stand up in a deposition or court.
Like the assessment, treatment also should be multidisciplinary, with members who have proven expertise treating physicians and their unique needs. Programs should use a medical model, be physician driven and encourage participation in a 12-step program for the best outcome. Physicians need a community of other healthcare professionals, as bonding and connecting with peers significantly increases success. Family involvement is also critical, ideally with family involvement for at least three days each month.
Psychological and medical comorbidities may complicate treatment. Programs should include assessments of addictive interactive disorders, such as eating disorders, sexual addiction or gambling addiction, which are common in individuals with substance use disorder, as well as other conditions such as depression and personality disorders. Integrated programs that teach well-being strategies, such as meditation, and incorporate psychotherapies, medication-assisted recovery, proper nutrition and exercise tend to produce the best outcomes. All programs should require total abstinence.
The vast majority of physicians with substance use disorders return to work right after treatment, though they may need to make significant changes. Some will change jobs to achieve a better balance between their work, recovery program and family or to reduce stress. A few physicians with advanced disease may delay return for three to six months or a year to prioritize recovery. Some in high-risk specialties, such as anesthesia and ER medicine, may need to retrain to avoid continued easy access to addictive substances and relapses. Physicians rarely fail to return to practice entirely, though that can happen in cases of poor compliance or repeated relapses.
A physician in recovery needs support in the workplace. Organizations may need some guidance to ensure legal or human resource policies do not sabotage successful reentry to the workplace or ongoing recovery. They also may require assistance to establish procedures that promote compliance and accountability over the long term, which are in the interest of both the physician and the organization. Multiple studies show that physician participation in such programs for five or more years results in an 80% abstinence rate and reduces malpractice claims by 20%.
Physicians experience very good outcomes if appropriately assessed, treated and monitored, which makes physician-focused programs good for the doctors as well as their families and community. To ensure impaired physicians are identified quickly, receive the treatment they need and safely return to the workplace, we must create a culture of openness, support and accountability within our healthcare organizations.