Impairment is Not a Moral Defect to be Avoided… Impairment is an Illness to be Treated

Vita McCabe, MD Chair, Committee of Physician Wellness, Resilience and Well-Being, Trinity Health

Member, Physician Well-Being Committee, St Joseph Mercy Health System Michigan Board of Medicine Representative to HPRP

vita.mccabe@stjoeshealth.org

Conflict of Interest Disclosure

Vita McCabe, MD does not have any real or apparent conflict(s) of interests or vested interest(s)

that may have a direct bearing on the subject matter of the continuing education activity.

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Learning Objectives This presentation will enable participants to: • List the function of a Well-Being Committee

and who should be referred. • Recognize rates of substance abuse disorders

in health care providers. • Explain a referral process to Health

Professionals Recovery Process.

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Definitions • Burnout: Physical, mental and emotional exhaustion

due to chronic stress and inadequate coping mechanisms

• Wellness: State of a healthy balance of the mind, body and spirit that results in an overall feeling of wellness

• Well-Being: The Joint Commission's term for addressing a state of impairment where an individual is weakened or damaged mentally, emotionally or physically and requires intervention. This includes physicians struggling with disruptive behavior, alcohol or drug abuse/addiction, aging, etc

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What is Resilience? • Traditionally, resilience has come to mean an individual's

ability to overcome adversity and continue his or her normal development.

• More recently and cross-culturally (Ungar, 2008): " In the context of exposure to significant adversity, whether psychological, environmental, or both, resilience is both the capacity of individuals to navigate their way to health-sustaining resources, including opportunities to experience feelings of wellness, and a condition of the individual’s family, community and culture to provide these health resources and experiences in culturally meaningful ways."

8 ©2015

Multidimensional Model of Resilience

Self-Aware

Self-Care

Relationships Mindfulness

Purpose

CASE PRESENTATION #1: Physician

• 24 y/o surgical resident falls from horse – Shatters left elbow with ulnar nerve damage – Transferred to specialty hospital for complex

repair – ORIF, mesh, cadaver graft, ulnar nerve transposition, compartment syndrome release

CASE PRESENTATION

• Post-op course – Massive DVT

• dx of Factor V Leiden

– Intra-arterial axillary local block • cardiac arrest

– Required re-operation at 6 mos x2 for 90 degree contracture

– Able to resume duties for 3 mos prior to re-op with some limitations in OR

CASE PRESENTATION 2009

• December 2009 - C5/6 ACDF – Back to work in 4 weeks

• March 2014 – Motor problem dominant hand – Broke down above and below – C4-7 redo ACDF – 8 weeks in cervical collar

CASE PRESENTATION

• March 2014 – Called CMO and CEO – Able to obtain permission to hire another

surgeon (had been budgeted for next fiscal year) as recovery of hand movement unclear

• August 2014 – Spontaneous rupture T12 resulted in ED visit

• ED physician notes hypercalcemia dating back at least 8 years

CASE PRESENTATION

• Primary Hyperparathyroidism – Adenoma excision via neck exploration

• Back to work with proctoring and limited duties

• T12 symptoms progress despite 3 epidural injection – T12 lami

• Back to work part-time

CASE PRESENTATION

• Difficulty managing small cases due to hyperflexion

• Practice changes in management

• Continued limited clinical practice despite upper extremity neuropathy

• THEN – partners left town and physician to be on call alone…..

CASE PRESENTATION

• Physician became honest with risk imposed upon patients

• Concluded with treating physicians that it was time to stop – patient safety at risk

CASE PRESENTATION IMPAIRMENT

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Is Impairment new?

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The Emotional Impact of Medical Training

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The Resulting Internal Characteristics

Culture of Blame

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Why Care???

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Some of the ways we pay now ...

• Clinical outcomes • HCAAPS scores • Physician misalignment • Disruptive physicians • Passive-aggressive behavior • Toxic impact on culture • High cost of replacing • physicians • Staff morale and turnover

“Don’t Ask-Don’t Tell”

The Joint Commission:

“a medical staff must implement a process to identify and manage matters of individual physician health that is separate from the

medical staff disciplinary function”

Birth of Physician Well-Being Committees (PWBC’s)

Designed to promote:

• Public Safety

• Physician Wellness

• Quality Medical Care

• Oh yes, and TJC mandate!

• TJC mandate, 2 separate committees: • Peer Review = Clinical Competence • Physician Well Being Committee = Provider Health

PWBC vs Peer Review Moving Toward Provider Well-Being • Many institutions adopting health of all

providers on medical staff who are subject to medical staff bylaws: – Some include: Nurse Practitioners, Physician

Assistants, CRNAs

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Recommendations for PWBCs:

Seven components to a fully functioning PWBC: 1. Education of medical and organizational staff about illness

and impairment issues specific to physicians/providers 2. Referral source for physicians/providers and organizational

staff 3. Evaluation of the credibility of a complaint, allegation or

concern 4. Maintenance of the confidentiality of the physician/provider

seeking referral or referred for assistance

Recommendations for PWBC Components to a fully functioning PWBC (cont’d): 5. Referral of physician/provider to appropriate

internal/external resources for diagnosis and treatment of the condition/concern

6. Monitoring of the affected physician/provider and safety of patients until recover/rehabilitation or disciplinary process is complete

7. Reporting to medical staff leadership any instances in which a physician/provider is providing unsafe treatment

CMA ON-CALL Document #5177

Who belongs on a PWBC?

• Ideally 6-8 committee members: • At least one psychiatrist • At least one physician with expertise in addiction

medicine • Physician/provider in recovery from addiction • Physician/provider who has dealt with mental

health issues • Neurologist or psychologist • Multidisciplinary

PACE, University of California, San Diego

WHO GETS REFERRED? The 4 L’s

• LIVER

• LOVER

• LEGAL

• LIVELIHOOD

The 4 L’s 1. Liver – medical problems arising from ongoing destructive

substance use/abuse

2. Lover – Family member – spouse, children etc., report concern re physician’s ability to cope with responsibilities

3. Legal – DUI, DIP, Rx fraud (for self use etc.)

4. Livelihood – Reports from work environment of concerning behavior

BEHAVIORS THAT PROMPT A REFERRAL • Evidence of recent substance use (smelling of alcohol at

work slurring words, stumbling gait) • Erratic work performance • Mood swings • Anger outbursts • Multiple missed pages/phone calls • Unexplained absences while on duty • Problems with law enforcement • Ongoing domestic problems

PWBC IN ACTION (Referral Process)

1. Call received from referral source to Committee Chair – ask for specific concerns

2. Committee members (always in TWO’S) meet with referred physician

3. Information gathering from collateral sources

4. Urine toxicology at time of first meeting

5. Committee discusses physician/provider and develops action plan

6. Committee follows recommendations of outside assessment/evaluation

7. Appropriate recusal of members as needed

ILLNESS ≠ IMPAIRMENT

ILLNESS = Presence of a Disease

• AMA definition:

“The inability to practice medicine with reasonable skill and safety to patients

by reason of physical or mental illness, including deterioration through the aging process,

the loss of motor skills, or the excessive use or abuse of drugs,

including alcohol.”

Physician Impairment

AMA Code of Medical Ethics

Illness that may impact physician/provider ability • Diabetes • Stroke • Cardiac Disease • Arthritis • Dementia • Cancer • Spine disease

40% of physicians claim disability at some point in their career.

Substance Use Disorders (in order of prevalence)

1. Alcohol 2. Opiates 3. Benzodiazepines 4. Marijuana

• Dr. William Halstead, father of modern surgery – Addicted to cocaine, then morphine

• Dr. Sigmund Freud, father of psychoanalysis – Addicted to cocaine and tobacco

Early 20th century, prevalence of impaired MDs reported as 10-40% - this problem is not new!

Famous Impaired Doctors Modern Times

• Regard addiction as a moral problem • 1% of medical school curriculum • Fail to adequately screen • Believe interventions are ineffective

JAMA, 2003:290, 1299

Changing Trends: • ~5-15% of physicians who have impairment

issues have opiates as their primary problem when entering treatment

• Opiate dependence is compounded by the emerging trend of adding benzodiazepines

• 10-15% of health care professionals will misuse substances at one point in their career

• Alcohol – most commonly abused • Opioids and stimulants – next most common • Recreational drugs (marijuana, cocaine) use is less than

general population

Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 (Suppl.)

• Family and marital problems occur first • Financial issues, legal issues (DUI) • Work performance is typically not impaired

until the more advanced stages • 43% of opioid-using doctors had been using

opioids for > 2 years before detection

Wilson et al. Psychiatrically impaired medical practitioners. Australasian Psychiatry. Vol 17, No 1 . February 2009

Identifying Providers in Danger • 95% of doctors agreed that they have an

ethical obligation to intervene, but only 67% will report appropriately

What would you do?

First Things First…

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I must examine my own beliefs, attitudes, and behaviors: • If I currently use alcohol, tobacco, other drugs • If I’m an ex-user • My family and friends

• Addiction is a brain disease, not a moral or ethical failure

• Low threshold for intervention, not “beyond reasonable doubt”

Points to Ponder

Who? • The most frequent disabling condition among physicians • Rates of SUD much higher than general population

(benzodiazepines, opioids) • ED/psychiatrists/anesthesiologists/solo practitioners

at higher risk

Mansky PA: Physician health programs and the potentially impaired physician with a substance use disorder. Psychiatr Serv 1996; 47:465–467

Talbott G, Wright C: Chemical dependency in healthcare professionals. Occup Med 1987; 2:581–591

Colleagues Enable • Believing it can’t happen to one of us • Making excuses for behaviors and performance • Rationalizing changes in behavior • Covering up for errors/omissions • Writing Rx without medical assessment

Professional Groups Enable

• Fostering unrealistic expectations and ideals

• Remaining uneducated about the disease

• Disciplining colleagues instead of assisting them

• Acting only when cases are obvious or advanced

Institutions Enable

• Keeping secrets to avoid upset, avoid litigation or to save face

• Denying the existence of the problem • Failure to develop written policies or peer

assistance programs

16 US Physician Health Programs, 1995-2001 – 904 doctors, 5 year follow-up – 647 (80.7%) completed treatment • 79% were licensed and back to work • 11% had their licenses revoked • 3.5% retired, 3.5% died • 3.2% unknown status • During 5 years of monitoring, 81% had negative

drug/alcohol test results

Prognosis

McLellan et al. 5-Year Outcomes in a cohort study of physicians treated for SUDs in the US. BMJ 2008; 337.

Dupont et al. Setting the standard for recovery: Physician’s Health Programs. JSAT 2009(36): 159-171.

Outcomes

57 Dupont et al. Setting the standard for recovery: Physician’s Health Programs. JSAT 2009(36): 159-171.

Outcomes (cont’d)

58 Dupont et al. Setting the standard for recovery: Physician’s Health Programs. JSAT 2009(36): 159-171.

Michigan HPRP • Formed in 1994 • Monitoring program for health care professionals

(Article 15 Public Health Code) dealing with SUD and/or mental disorders that may impair their ability to safely practice their profession

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Michigan HPRP • Overseen by LARA/HPRC • HPRC = representation from each professional

regulatory board and 3 public members • Members responsible for: – Developing policies and procedures for contractor – Reviewing and analyzing stats – Reviewing participant appeals

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Michigan HPRP • Participants required to maintain sobriety/stability

1-3 years • HPRP makes referrals and arranges for monitoring • After successful completion, records kept for 5

years then destroyed • Noncompliance = reporting to Bureau of

Professional Licensing (by law)

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MI HPRP: FY2015 N=838 Licenses Monitored

NursingPAMedicinePharmacy

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DISRUPTIVE BEHAVIOR

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• Primary prevention: the roles of medical schools and residency programs

• Secondary prevention: – Hospital/medical group orientation programs for new physicians – Development and retention of strong medical staff leadership – 360 Evaluations, Staff surveys

• Tertiary prevention:

– Dealing with the individual or team directly

How to Deal with Disruptive Behavior: Prevention is the Best Intervention

• For first instances of disruptive behavior that are mild to moderate in nature, perhaps an informal “cup of coffee” conversation is sufficient

• For second instances or more severe episodes, the appropriate clinical leader (e.g., Chief, Chair, etc.) may intervene

• For repetitive and/or severe instances a formal process is required, likely involving Department and Medical Center leadership and possibly other resources (e.g., Provider Well Being Committee, etc.)

A Multi Tiered Approach Mental Illness

• Depression

• Bipolar Disorder

• Psychotic Disorders

Mental illness in Physicians • Major depression lifetime prevalence in U.S. male

physicians: 12.8% (general population 12%) • Major depression prevalence in women

physicians 19.5% (= general population women) • Ethnic differences: Asian female docs lower • Suicide relative risk: 1.1-3.4 in male docs • Suicide relative risk: 2.5-5.7 in female docs

Center et al., JAMA 2003; 289: 3161-3166

Struggling in Silence • 300-400 physicians die each year by suicide • Methods: OD, firearms • Risk factors: depression (90%), alcohol abuse • Higher completion/attempt ratio • In general population, completed suicides by men

is 4 x higher than women • In physicians, completed suicide by men = women

• American Foundation for Suicide Prevention

High risk for suicide MD profile (cont.)

• Physical symptoms (chronic pain, debilitating illness) • Change in professional status − threat to status,

autonomy, security, financial stability, recent losses, increased work demands

• Narcissistic injury • Access to means (legal medications, firearms)

Center et al., JAMA 2003; 289: 3161-3166

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Barriers to MDs seeking care Discrimination in: • Medical licensing • Hospital privileges • Professional advancement • Shift in professional attitudes & institutional • policies needed to support MDs seeking help

35% MDs have no regular healthcare provider

Center et al., JAMA 2003; 289: 3161-3166

Suicide Prevention • Typically organized once it affects a medical center or

organization (Airforce Blueprint): – Zero Suicide Initiative – Executive Support – Integrated Model

• Typically no anonymous central helpline within systems (require 24 hour staffing)

National Strategy for Suicide Prevention Life line: 800/273-8255

http://www.mentalhealth.samhsa.gov/suicideprevention/ 72

Example PWBC Outcomes • Major Michigan Medical Institution • >1200 providers • PWBC organized in 1980s

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Cases/Outcomes 2013 (60% success)

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Cases/Outcomes 2014 (85% success) Case Referral Intervention Outcome

1 Disruptive behavior multiple years Coaching, psych eval, therapy 2nd remediation – left system

2 Disruptive behavior and noncompliance charting

Therapy and coaching Successful retention – change in specialty

3 Performance Issue, ? eating disorder Coaching, therapy, medical eval Successful retention

4 Disruptive behavior Counseling, PULSE Successful retention

5 DUI eval DUI eval from different state Successful integration

6 Disruptive behavior, aging Counseling, coaching, retirement planning

Successful retention

7 DUI Medical and psych eval Successful retention

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Case Referral Intervention Outcome 1 Disruptive behavior – resident Coaching, psych eval 2nd remediation – left system

2 2nd victim secondary to unexpected patient death

Therapy and coaching Successful retention

3 Stress, disruptive behavior Coaching, therapy Left system

4 Disruptive behavior Counseling Successful retention

5 2nd victim, stress secondary to law suit Counseling, coaching Successful retention

6 Disruptive behavior Counseling, coaching, anger management, PULSE program

Successful retention

7 Stress reaction with decompensation, age/cognitive decline

Counseling, coaching, change in schedule and retirement planning

Successful retention

8 Disruptive behavior/unprofessional conduct with peers/? Substance use

Therapy, substance use eval Successful retention

9 Disruptive behavior Therapy Successfully retention

10 Noncompliance charting, substance use and no show

Therapy, HPRP Successfully reintegrated

Cases/Outcomes 2015 (80% success)

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Reason Number Percentage Total ETOH/substance use 7/31 23% Disruptive/inappropriate 16/31 51% Cognitive/aging 4/31 13% Stress/2nd victim 4/31 13%

Summary – Reasons for Referral SUMMARY PWBC OUTCOMES

• 2013 – March 2016 31 referrals 23/31 (74%) retention/reintegration rate Cost to replace a physician $500,000 - $1,200,000

~ $20,000,000 saved over 3.25 years

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Culture of Empathy

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CASE PRESENTATION #1: Physician Disclosure

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CASE PRESENTATION #2: RN

MOST IMPORTANT OBJECTIVE

Motivation to learn the process and improve it at your organization.

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Questions?

Thank you!

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Vita McCabe, MD Chair, Committee of Physician Wellness, Resilience and Well-Being, Trinity Health

Member, Physician Well-Being Committee, St Joseph Mercy Health System Michigan Board of Medicine Representative to HPRP

vita.mccabe@stjoeshealth.org