1 Impaired Physicians: Helping Good People With Problems Continue to Do A Good Job McGaw Medical Center & Perspectives Housestaff Assistance Program “HAP”

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Impaired Physicians: Impaired Physicians: Helping Good People With Helping Good People With Problems Continue to Do A Problems Continue to Do A

Good JobGood Job

McGaw Medical Center

&

Perspectives Housestaff Assistance Program “HAP”

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What We Will Cover:What We Will Cover:

Physician ImpairmentHistory of Physician HealthAlcohol and Other Mood Altering

SubstancesIdentification of Addiction in PhysiciansMcGaw Medical Center Housestaff

Assistance Program “HAP”

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Physician Impairment Physician Impairment Defined:Defined:

“A physician who is unable, or potentially unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skills, or excessive use or abuse of drugs including alcohol.”

AMA “The Sick Physician”, 1973

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History of Physician HealthHistory of Physician Health

1910 Flexner Report on medical education– State Medical Societies and

Legislatures began regulating medical practice

– Requiring physicians and surgeons be free of “vice, moral turpitude and the intemperate use of alcohol and drugs”

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1914 The Harrison’s Narcotics Drug Act

– Began process of classifying, regulating and controlling drugs that have the potential for abuse.

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1920 English Parliament Dangerous Drug Control Act– Registration of addicts as an attempt to

control addiction– Nearly 25% of the registered addicts

were doctors, dentists, veterinary surgeons or nurses

Stimson, Oppenheimer and Stimson, “Drug Abuse in the medical profession”, British Journal of Addiction 79: 395-402

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1970 Florida “Sick Doctor Statute”– Defined inability to practice medicine

with reasonable skill and safety– Revised the grounds for professional

discipline under the state’s medical practice act

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1973 AMA Council on Mental Health – “The Sick Physician”– State Medical Societies establish programs

or committees devoted to identifying and helping impaired physicians

– AMA develops model legislation to amend state practice acts so that treatment was available instead of punitive disciplinary measures

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History of Physician HealthHistory of Physician Health2001 JCAHO Standards

– Physician Health- “Medical staff implements a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function.”

Joint Commission on Accreditation of Healthcare Organizations, Web site, November 2000

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History of Physician Health: History of Physician Health: 2001 JCAHO Standards2001 JCAHO Standards

Physician Health– Design a process that: - provides education about physician

health- addresses prevention of physical,

psychiatric, or emotional illness- facilitates confidential diagnosis, treatment

and rehabilitation of physicians who suffer from a potentially impairing condition Joint Commission on Accreditation

of Healthcare Organizations, Web site, November 2000

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History of Physician Health: History of Physician Health: 2001 JCAHO Standards2001 JCAHO Standards

Physician Health– The purpose of the process is:

- assistance and rehabilitation, rather than discipline

- to aid a physician in retaining or regaining optimal professional

functioning, consistent with the protection of patients

Joint Commission on Accreditation of Healthcare Organizations, Web site, November 2000

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Alcohol and Other Mood Alcohol and Other Mood Altering SubstancesAltering Substances

Use, Abuse and Dependence

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NIAAA – Safe Levels of NIAAA – Safe Levels of DrinkingDrinking

Two drinks per day for malesOne drink per day for females

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What Is a Drink?What Is a Drink?

Beer (12 ounces)Wine cooler (12 ounces)Wine (5 ounces)Liquor (1.5 ounces / 80 proof)

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Substance Abuse – DSM-IVSubstance Abuse – DSM-IV

A maladaptive pattern of substance use, as manifested within a 12-month period by one of the following:

• Recurrent substance use leading to failure to fulfill major role obligations

• Use of substances in situations where it is physically hazardous

• Legal problems associated with the use• Continued substance use despite persistent or

recurrent social/interpersonal problems

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Substance Dependence – Substance Dependence – DSM-IVDSM-IV

A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following seven criteria, occurring at any time in the same 12-month period:

• Tolerance• Withdrawal• Use of larger amounts or longer than intended

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Substance Dependence – Substance Dependence – DSM-IV - ContinuedDSM-IV - Continued

• Unsuccessful efforts to cut down or control use• A great deal of time spent obtaining, using or

recovering from effects• Important activities are given up• Use is continued despite having recurrent or

psychological problems

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Chemical Dependence Chemical Dependence DefinedDefined

A chronic, progressive disease characterized by a repetitive, unpredictable, and inconsistent loss of control or drug use that results in problems for user, his/her family, friends, others

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Identification of Addiction in Identification of Addiction in PhysiciansPhysicians

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IrritabilityIrresponsibilityInaccessibilityInabilityIsolationIncidentals

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Irritability

- Mood swings

- Negative attitude

- Argumentative

- Inappropriate anger

- Overreaction to criticism

- Altercations with staff, peers, and patients

- “Personality change”

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Irresponsibility- Shifts Work Load- Manipulates Schedule

- ER, OR, On-Call- “Hurry Up – Catch Up”

- Hasty rounds- Short cuts

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Inaccessibility- Frequent tardiness- Frequent absence- “MIA” – missing in action

- Frequent trips to bathroom, parking lot- Prolonged lunch breaks- Unavailable when on call

- Frequent beeper failure- Frequent illness

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Inability- Decreased performance- Inappropriate orders- Inadequate charting- Frequent malpractice action- Frequent “forgetfulness”- Deviation from standard procedures

- Drug procedures

- Use of excessive amounts

- Unwitnessed wasting- Insufficient patient analgesia- Excessive spillage/breakage

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Isolation

- Odd Hours for rounds

- Volunteers for “Graveyard shift”

- Absent from Dr’s Lounge

- Eats alone

- Avoids

- Departmental Meetings

- CME Events

- Medical Society events

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Incidentals- Disheveled appearance- Tremors- “Green tongue” from mints- Bruises- Needle tracks- Heavy drinking at staff or social functions- Off-duty intoxication

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Incidentals- Runny nose, raspy voice, alcohol on breath- Red, yellow or black and blue eyes- Dilated or constricted pupils- Staff, patient or peer complaints- Slurred speech on phone- Black outs- Subject of hospital gossip (marital problems, DUI, Financial Problems, “party” reputation)

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Other

- Unexplained intervals between jobs

- Frequent job changes

- Frequent relocations

- Indefinite references

- Unusual medical history

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Prevalence rates- Brewster et al 1986

- No difference than general population- Hughes et al 1992

- Physicians were five times more likely than controls to take sedative and minor tranquilizers without medical supervision- Physicians self prescribing

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Risk Factors- Family history of chemical dependence- Family history of psychiatric disorders- Mood disorders- Certain personality characteristics

(overconfidence, sensation-seeking, risk avoidance)

- Stress and poor coping skills- Availability of drugs

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Early Detection Difficult

- Physicians tend to have negative consequences to physical health, family, community, finances, spiritual, and emotional health- Job performance affected last, therefore disease usually progressed

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Colleagues “Enable” By:Colleagues “Enable” By: Believing addiction or mental illness can’t happen to a

professional Making excuses for an impaired colleague’s behavior

or performance Minimizing the obvious effects of alcohol/other drug

use in a friend or colleague Rationalizing changes in a colleague’s performance,

behavior or appearance Covering for a colleague’s errors or omissions Not using the peer assistance network available Diagnosing or treating

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The Good News!The Good News!

The success rate of health professionals in programs dedicated to staying clean and sober is 95%!

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McGaw Medical Center McGaw Medical Center Housestaff Assistance Housestaff Assistance

Program “HAP”Program “HAP”

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PerspectivesPerspectives1 (800) 456-63271 (800) 456-6327

BenefitVoluntaryConfidentialAny Personal ProblemAssessment & ReferralShort-Term Counseling When IndicatedFollow-Up and Monitoring

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The HAP Addresses These The HAP Addresses These Problems:Problems:

Marital/Family Emotional Stress Eldercare/Aging

Parents Addiction

Communication Childcare Grief/Loss Legal Financial

ms

Problems

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How to Access The HAPHow to Access The HAP

Call Perspectives at 1 (800) 456-6327 to schedule an appointment

Call is answered by receptionist and is transferred to Access Center, staffed by licensed clinicians

Demographic information is collected and in-person or telephonic appointment is scheduled, as appropriate

Assessment is completed Recommendations are given

ProblemsCall

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HAP Flow ChartHAP Flow Chart

Self-Referral

Supervisory Referral

Community Resources

Legal Financial Marital/Family Medical Psychological Alcohol/Drug Treatment Self-Help Day Care Elder Care Other

HAPShort-Term Counseling

Follow-Up/Monitoring

HAP Counselor Assessment

Counseling

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Other Services Provided By Other Services Provided By Perspectives Include:Perspectives Include:

Wellness workshops CISD (Critical Incident Stress Debriefing) Management consultation Licensed Counselors available for emergencies

24 hours a day, 7 days a week Perspectives “On Line”

Counseling

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Summary of the HAP BenefitSummary of the HAP Benefit

FreeConfidentialBenefit provided by employerFor housestaff and family membersAssessment, short-term counseling

(when appropriate) and referral services

ProblemsCall

Documents

1 Impaired Physicians: Helping Good People With Problems Continue to Do A Good Job McGaw Medical Center & Perspectives Housestaff Assistance Program “HAP”