Helping impaired physicians get back into practice
How one successful Tennessee program helps its doctors overcome addictions and psychiatric disorders
From the May 1998 ACP Observer, copyright © 1998 by the American College of Physicians.
By Jennifer Fisher Wilson
In his 15 years as director of the Tennessee Medical Foundation's Physician Health Program, David T. Dodd, MD, has helped thousands of physicians learn how to overcome addictions or cope with psychiatric disorders—and keep their medical licenses. The program's success rate in treating physicians with emotional disorders, mental disorders and chemical dependency problems is close to 90%, making the statewide project one of the most successful of its kind nationwide.
Dr. Dodd understands the problems that physicians face from personal experience. Before joining the Physician Health Program as director, he was a successful general surgeon who had his own problems with drugs and depression. He went through the program himself and only afterward decided to work full time helping others overcome similar problems.
For his work with impaired physicians, Dr. Dodd received ACP's William C. Menninger Award, which honors distinguished contributions to the science of mental health. Earlier this spring, he talked to ACP Observer about his work.
ACP Observer: What kind of person does your program typically treat?
Dr. Dodd: I learned in my early years of experience with chemically dependent physicians that most resort to chemicals for relief from emotional turmoil. Many physicians are so idealistic and perfectionistic and work-addicted in the name of healing everyone else that they don't know how to handle their personal and emotional lives. Much of this is a byproduct of the obsessive-compulsive traits engendered by the education and training process of medicine.
Many physicians have identities that are so obscured that they give themselves away in terms of helping others. All physicians probably have this dynamic to some degree. Their personalities need gratification from patients—the assertion that they're wonderful, they're great, that patients can't live without them. But when it reaches a certain threshold, then it's self-defeating.
Q: How does this compare to your own life?
A: For 20 years, I maintained a solo surgical practice that was highly successful in terms of volume and outcomes. But in 1982, when I was 55 years old, I suffered burnout. I became depressed and began self-prescribing antidepressants. I felt that I had nowhere to go to get help. Eventually, I did find help through the Tennessee Medical Association's Impaired Physician Program, as it was called then.
When I was given the chance to stop my practice and enter counseling, it awakened me to the reality that as a physician, I had not learned how to balance my life. I had not learned how to be a good physician and surgeon, and how to be a good husband, a good father and good to myself.
I had gotten caught up in a work ethic that I believed physicians were supposed to represent. When given the opportunity to re-evaluate my own life, I came to realize that I was not the only physician to suffer similar circumstances and similar outcomes.
Four months later, I reentered practice, but I wasn't being fulfilled by surgery. So when the position of director at the program opened up in 1983, I accepted it. Soon thereafter, I quit my practice and made the part-time position into a full-time one.
Q: How do you identify impaired physicians?
A: Identification is typically a telephone call to my office from anyone out there in the public—a fellow physician or other professional peer such as a pharmacist, a family member, a patient, a hospital or medical staff member—saying they're concerned about a possible problem with this physician and that they think he needs an assessment. It varies, but the most common calls are from fellow physicians.
Next, I have to verify the identification. I make necessary checks to assure that there's no malice going on, that there's no nasty divorce going on, that some irate spouse is not out to hurt the physician, for example. I check with members of the community, check with peers, and do a lot of research before I ever make that call to the physician.
Q: How do physicians react when you get in touch with them?
A: The truly impaired physicians are so protected by their denial systems that they don't recognize that they need help. So we have to deliver that help to them, sometimes against their wishes. The doctor frequently says, 'I don't need your help,' but we keep pushing. It's an offer that can't be refused.
Q: How do you treat physicians?
A: First and foremost, the program is anonymous and confidential. That's very important. When physicians are made aware of how our program works, many start calling for help voluntarily.
Each treatment is tailored according to the patient's needs and responses. We have learned that for rehabilitation to succeed, all chemically dependent physicians need a minimum of four months out of practice and in treatment. Often it's a combined inpatient and residential program.
We recommend places physicians can go to obtain the appropriate additional assessment, second opinions and treatment. If there's obvious chemical dependency, they go to a preferred treatment center for chemical dependency. If they have a psychiatric disorder, we recommend certain treatment clinics. If it's sexual misconduct, they go to sexual misconduct treatment centers.
Some don't need to go into inpatient treatment but need counseling. We have counselors who are capable of handling physician personnel. Physicians need tough therapists; the therapist has to have at least as strong a personality as the physician.
While a physician is in treatment, we also try to make sure that his practice is covered by colleagues, friends and peers. The community is usually very supportive. Patients are loyal to their physicians who go and get help.
Q: What happens after treatment is complete?
A: Once rehabilitated, re-entry is a big chore. When a physician leaves the workplace, there may be hostility, anger, fear, a lot of other emotions. We respond by trying to offer a forum for the people who are angry at their physician.
Once physicians finish with treatment, they enter an aftercare program. It's a widely dispersed, continuing-care monitoring and support system. Rehabilitated physicians are under contract to attend support group meetings for a minimum of two years.
Volunteer physicians facilitate these support group meetings. These are physicians who have been attending the support meetings for years. They are pretty knowledgeable about what's going on, and they report back to me if things are not going well.
We also created RAM teams, which stands for regional aftercare monitoring teams. These are made up of volunteer physicians in every area where we have support groups who act as the medical director's eyes and ears. Every re-entry physician who is under contract has to meet with a RAM team member regularly. If things are not going well, we might extend the physician's contract to three years.
Q: What makes your program different from other state programs for impaired physicians?
A: Many states have similar programs, but ours is different in its longevity and its broad spectrum of services. Most other state programs do not provide treatment for problems like sexual misconduct or psychiatric disorders. Besides chemical dependency treatment, we now offer services for physicians who have personality disorders, who are disruptive, or who have a mood disorder.
We have also addressed post-malpractice charge stress syndrome and are providing seminars across the state for that. We also are moving into the arena of providing treatment for inappropriate sexual behavior.
Additionally, we've been lucky to maintain the program as a physician-held and operated program with an internal peer-review process.
Q: Do you report physicians in the program to state authorities?
A: Most physicians don't get turned over to the Tennessee Medical Licensing Board. If we think that a physician is dangerous to the public and is not complying with our recommendations for rehabilitation, we may have to identify him to the medical board and leave it to the board to discipline the physician or revoke his license. And if physicians have a disease that is progressive and self-defeating, they will ultimately and unfortunately usually do something that will bring them to the attention of the medical board.
We have a good working relationship with the board of medical examiners and a malpractice insurance company. The malpractice insurance company has the advocacy of the Tennessee Medical Foundation, and agrees to provide recovering physicians with malpractice coverage so that they can progress in reentry to practice.
Of course, not all physicians lose their coverage. This is available for the few who need it. We usually work with physicians before it reaches that point, and the board works with us on this.
Q: What kind of results have you seen?
A: We started attaining 90% to 93% success rates early on and have maintained that. Success is defined as reentry, resuming the practice of medicine with no further complaints and no relapses in the case of chemical dependency.
Part of our success can be attributed to the effectiveness of using the aftercare monitoring program. It can also be attributed to tailoring treatment to each physician according to his needs.
Q: How long do you see yourself working with impaired physicians?
A: I'm in my 15th year, yet I still get excited over seeing miraculous outcomes and over providing physicians services that heretofore were not available, a safe forum in which to get well. I get to see physicians become not only functioning again as healers, but better healers than they were previously.
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