Prevent, recognize impairment
Professional duties require physicians to recognize and address physician illness and impairment, but it is often difficult to recognize a colleague's condition and find an appropriate way of reporting and resolving it.
Alisa Duran, MD, FACP, had been promoted to her dream job as residency program director and was having one of the most successful times of her career. But after a couple of years, she was starting to lose control outside of work.
More and more, the stress of the job led Dr. Duran to drink alcohol to ease her anxiety at the end of the workday. Colleagues had no idea it was becoming a problem. “It was totally innocent,” she said. “You never, of course, have an intent to develop any type of an issue with it.”
Physicians have a reputation for being superhuman, but like the general population, about 8% to 13% of them have substance use disorders, said addiction medicine subspecialist Chwen-Yuen Angie Chen, MD, FACP. Rates of alcohol use disorders are even higher among female compared to male physicians, at 21.4% versus 12.9%, according to a study published in March 2015 by the American Journal on Addictions.
“Physicians are equally, if not more, susceptible to addictions and mental health disorders and need to be diagnosed and treated,” said Dr. Chen, a clinical assistant professor at Stanford University School of Medicine in California.
Substance use disorders and other health issues can cause a physician to become impaired, or unable to carry out patient care responsibilities safely and effectively. In these cases, physicians should be rehabilitated and reintegrated into medical practice whenever possible without compromising patient safety, according to a recent ACP position paper, published in June by Annals of Internal Medicine.
Although there are barriers to recognizing impairment, physician health advocates underscored the importance of seeking help and talking about the stigmatized causes, such as substance use disorders, mental health diagnoses, and age-related cognitive decline.
Professional duties require physicians to recognize and address physician illness and impairment, according to the position paper, which was developed by ACP's Ethics, Professionalism, and Human Rights Committee. Of importance, the distinction between functional impairment and potentially impairing illness should guide identification of and assistance for the impaired physician, the paper said.
But it is often difficult to recognize a colleague's substance use disorder, Dr. Chen said. “Often, the first symptoms are family life that is suffering,” she said. “It has to get fairly dysfunctional before the workplace is affected. Physicians often try to hold it together, at least at work.”
While this was true for Dr. Duran, she was able to address the problem before it impacted her patient care by recognizing the signs of addiction and the fact that she had a family history. “I think it is important to recognize the signs early, before a physician reaches the point of impairment,” she said.
Early warning signs of a substance use disorder can include missed work, unusual interpersonal struggles or unprofessional behavior, social isolation, and withdrawal and may co-occur with increasing anxiety and depression, although they are not always indicative, noted Dr. Duran, now an associate professor of medicine at the University of Minnesota in Minneapolis. “We're trained professionals,” she said. “We can recognize these signs and symptoms in our patients. We certainly can recognize them in each other. … People should reach out and ask, ‘Are you OK? Is something going on, and can I help?”
However, the factors that often stop physicians from reporting impairment in colleagues include fears of professional consequences, interpersonal issues, and being wrong, said Philip A. Masters, MD, FACP, ACP's Vice President of Membership and Global Engagement.
In addition, substance use disorders are strongly associated with mental health conditions, which are often stigmatized. Some medical licensure questions may also be a barrier to recognizing physician impairment because they neglect to determine the functional impact of mental health diagnoses, the ACP paper said. After all, illness does not necessarily indicate impairment.
Literature hasn't shown that having a mental health diagnosis affects a physician's care of his or her patients, said Eileen Barrett, MD, MPH, FACP, an ACP Regent who has advocated for modernizing licensing questions as they relate to physician health. Often, these questions (which vary by state) do not even ask whether the illness has affected one's practice, she said. ACP recommends that licensure questions address current status (rather than history), not distinguish between mental and physical health, and elicit objective information about functional status.
These questions can affect physicians' plans to seek help due to concerns about ramifications to their medical licensure, noted Dr. Barrett, a hospitalist at the University of New Mexico in Albuquerque and an ACP Well-being Champion. One study asked 5,829 practicing physicians if they would seek mental health care if they needed it, and nearly 40% said they would be reluctant to do so. Physicians were less likely to say that they would seek help in states where they are asked about mental health diagnoses on licensure application forms, according to results published in the October 2017 Mayo Clinic Proceedings.
Answers to these questions may not even be accurate. Another survey study of 2,106 female physicians found that almost 50% believed they had met criteria for mental illness but had not sought treatment. Only 6% of those with a formal diagnosis or treatment of mental illness had disclosed it to their state, according to results published in the November-December 2016 General Hospital Psychiatry.
ACP's position paper is a step in the right direction to help practices and state medical boards remove stigmatizing questions from job and credentialing and recredentialing applications, said Dr. Barrett. “Physicians and patients want the same thing. We're not at odds when we want to destigmatize physician help-seeking; patients want healthy physicians, as well,” she said.
Another cause of physician impairment is age-related cognitive decline. However, it is not clear how patient care may be affected by the complex changes in cognitive function over time, said Dr. Masters.
Research shows that as physicians get older, their way of thinking changes. On one hand, they incorporate less new knowledge in their practice and may be less flexible in diagnostic decision making; on the other, their accumulated wisdom and judgment may be better than that of younger doctors, he said. “And probably the biggest thing is that it's highly variable from one person to another.”
As with other causes of impairment, age-related cognitive decline is underreported, Dr. Masters said. “If you talk to the Federation of State Medical Boards, they don't get a lot of complaints about cognitive impairment,” he said. “Generally, whenever they see them, it's gotten to the point where … some incident has occurred, as opposed to getting reports proactively.”
Some health systems have started to use general assessments of cognitive function in older physicians (at age 70 years, for example), but these measures do not necessarily correlate with the ability to practice medicine, said Dr. Masters, who in 2016 represented the College as part of an American Medical Association (AMA) meeting on senior physician assessment. “A lot of institutions and organizations are saying we should be doing something about this, but … there are no standardized ways of assessing cognitive concerns, so it can be very inconsistent,” he said.
Peer evaluation is another way to assess performance. “It's easier to determine effect on practice when there are physical signs, such as if it's a surgeon who has a diagnosis such as Parkinson's because you can see their tremor,” said Dr. Barrett. “But this highlights the role of us doing … ongoing professional evaluations of our peers” as required by The Joint Commission. However, in practice settings where individuals may be more independent with less direct collegial interaction, peer assessment is often less formal and may be based simply on indicators such as whether a physician attends medical staff meetings or follows up on consult requests, Dr. Masters noted.
The AMA meeting concluded that while physicians should be allowed to remain in practice as long as patient safety is not endangered, evidence-based guidelines should be developed for any potential screening programs and for assessing senior and late-career physicians for whom there is concern. “But it's harder than it seems. What are you going to require to assess somebody's cognitive competency?” said Dr. Masters. “And not everybody who's [cognitively impaired] is old.”
Several U.S. professions have mandatory retirement ages—commercial airline pilot (65 years), Federal Bureau of Investigation agent (57 years), National Park Service ranger (57 years), air traffic controller (56 years), and lighthouse operator (55 years)—but physicians do not, a February 2019 JAMA viewpoint noted. ACP is opposed to arbitrary rules that would cancel or limit the hospital privileges of physicians based on the age of 65 years or more unless there is good evidence to do so, a 2017 Board of Regents resolution stated.
Getting help, healing together
While cognitive detriments may lead to noticeable changes in practice, Dr. Barrett said physicians with substance use disorders or mental health diagnoses often continue to provide excellent care. “Their lives may be falling apart around them,” she said. “Their marriages may be falling apart, their interpersonal relationships may be strained, and yet their care may be unaffected because physicians are highly dedicated to our patients.”
Of course, this was true with Dr. Duran's experience as well. “I was not at a point where I was in any way impaired in my clinical practice, but I recognized it early and got help,” she said. Dr. Duran took a leave of absence for about two months while she sought outpatient treatment and later joined Minnesota's Health Professionals Services Program.
Programs like these vary by state. As of July 2019, 45 states and the District of Columbia have programs that are members of the Federation for State Physician Health Programs (FSPHP). A physician health program is a confidential resource for physicians, other licensed health professionals, and trainees who have addictive, psychiatric, medical, behavioral, or other potentially impairing conditions, according to the FSPHP. Studies have shown these programs, which coordinate detection, evaluation, treatment, and continuing care monitoring, to be effective, especially for those with substance use disorders. In one 2008 study of 904 physicians admitted to 16 programs, about 79% of physicians were still licensed and working after five years of follow-up, compared to six-month relapse rates of 40% to 60% in general addiction treatment programs, according to results published in The BMJ.
The high success rate with these programs is partly due to how they support clinicians, said Dr. Duran. The way they interact with licensing agencies is highly variable from state to state, “But here in Minnesota, I felt supported,” she said, adding that she interacted directly with her state's program. “You are not required to report anything about your substance use on your licensing documents. They handle that process, so it really does take some of the fear out of that situation,” Dr. Duran said.
In California, it's a different story, said Dr. Chen, who treats and consults on physicians with substance use disorders in the state. “There's no physician health program that's set up by the medical board,” she said. “It's still a rather punitive process and not something that encourages treatment as first line; it can often be suspension of licensures or severe monitoring and litigation.”
For example, one physician went through a physician health program for alcohol use disorder in another state and wanted to move to and practice in California. For five years, the physician had remained abstinent and sober and had passed all drug testing. Despite the physician's recovery, California issued a probationary license, which hampers the job search and, if a physician appeals or turns it down, converts to a denial of licensure, said Dr. Chen, who has called for standardization through ACP's Council of Early Career Physicians. “Why would we treat a physician differently in this state versus another state?”
When physicians are impaired due to substance use disorders, it is important to not simply fire them or report them to the medical board, exposing them to long, costly legal battles in order to retain their licenses, she added. “It is essential to encourage and support treatment and then reintegrate the physician back into practice.”
By the time Dr. Duran got involved with her state's health program, she had about six months of recovery under her belt. “I was going to [mutual help group] meetings almost every day. I would go at 6:30 in the morning before I went to work so it wouldn't impact my job,” she said. Joining the program took her efforts up a notch by adding quarterly reports to a case manager, a worksite supervisor, and random urinalysis monitoring.
About a year and a half into recovery, Dr. Duran made the difficult decision to step down from her role as program director. “It was very clear to me that I needed to prioritize my health. The program director job was so busy, you never had down time,” she said, adding that she took on new teaching and research roles at the university and continued to see patients in the outpatient setting.
This December will mark six years in recovery for Dr. Duran. “Facing my issues with substance use really allowed me to take a look at some harmful patterns in myself with regard to perfectionism … and being kinder with myself and allowing myself some time and permission to create some space for relaxation,” she said. “I was a total workaholic, and I'm not anymore.”
ACP also advocates for the promotion of physician well-being among colleagues and learners. As Dr. Duran healed from her struggles with alcohol, she opened up during a wellness program for trainees, where she sat on a panel about physician wellness and burnout. “I did not go in there planning to share everything. … I started talking about how very slowly over time I was using alcohol to medicate stress and anxiety, and it all just came pouring out,” she said.
Afterward, trainees and colleagues started crying and having open discussions with each other. “I think in that moment, I realized how important it is for people who are health professionals, who are in roles where you're teaching and mentoring others, to really be vulnerable and share your truth,” Dr. Duran said.
Since then, she hasn't stopped sharing. After she wrote a January 2019 perspective piece about her experience in JAMA, physicians have contacted her from all over the world. “They've written me letters, they've written me emails, and it's made me realize how important it is to have these conversations,” Dr. Duran said.
Dr. Chen agreed that it's essential to ask and talk about substance use with colleagues and learners. “Especially alcohol, which is so ubiquitous and acceptable, and encouraged,” she said. “We particularly don't like to talk about alcohol. I'm probably perceived as a party pooper: I talk about it, and everybody walks away.”
Medical school and residency orientation is a particularly good time to address these issues, Dr. Chen said. In the anesthesiology department, where clinicians are disproportionately affected by opioid use disorders due to access, she and a colleague have given presentations about addiction to fellows and residents. “It's a very informal gathering, a retreat where we invite spouses and family members to come because it affects the whole family,” Dr. Chen said. “I advise them to be open and ask for help, that it will be held in confidence and to trust the in-house departmental process.”
For many physicians, it is difficult to be in a sick role, she noted. But those who go through addiction treatment and receive compassionate care may become even better doctors, Dr. Chen said. “They can pass all that information and experience of self-care and well-being on to their patients and disseminate that,” she said. “That's powerful.”
Retaining physicians in practice is especially important because the U.S. is projected to face a shortage of up to 122,000 physicians by 2032, according to estimates published in April 2019 by the Association of American Medical Colleges. “We can't afford to lose people,” said Dr. Duran. “Ideally, we want to get everybody back out into the community practicing and taking care of patients.”