Physician Impairment

CDR Dennis L Hufford, MC, USN

Faculty Development Fellowship

Madigan Army Medical Center

29 July, 1999

Introduction:

Scenario:

Your office mate, who you’ve known for about six months, has been acting strangely in the last few weeks. You’ve noticed that he has arrived a few minutes late each morning, usually missing all of morning report. He’s also been leaving a little early each afternoon. A stack of unfinished clinic charts from the last two days is piling up on his desk. He’s called in sick for one day each on two separate times in two weeks, each time leaving full clinics for you and the rest of the team to cover. His uniform appears a little wrinkled, as though he’s worn it several days in a row. He looks physically a little tired, with dark circles under his eyes (and occasionally bloodshot). You’ve noticed he’s been rather abrupt with his resident advisee, telling the resident to "get with the program", and "go look it up". The resident that took call with him last week grumbled that he "didn’t lift a finger to help". The PA on your team pulled you aside yesterday and asked, "is he OK"? These things seem to be out of character for this doctor, who has a good reputation otherwise. As you haven’t known him for very long, and you do not regularly socialize with him, you don’t know much about his personal life, except that he is married and has two teenage kids. Their pictures are on his desk.

What are some possible explanations for his behavior? What worries you most?

 How do you approach this doctor? What, if anything, do you say/ask?

Should you talk to anyone else? Who and why?

Definition: "Impair: to make worse, less, weaker; damage; reduce; deteriorate."

Doctors are at higher statistical risk than the general population for:

• Alcohol Dependency
• Drug Abuse/addiction…30-100X higher than general population, including self medication
• Mental Illness
• Depression
• Suicide

                Males: Twice the rate of other men.
                Females: FOUR times higher rate than other women!
                Physicians represent a rare population group in which the suicide rate is higher for women than men.

• OCD
• Marital Discord
• Various physical illnesses
• and delay in diagnosis of serious illnesses

Barriers to getting help:

• trained attitude: "Physician Heal Thyself"
• culture
• fear of losing:

            -license
            -esteem
            -confidence of self and others
            -source of income, status, rewards

• poor support mechanisms
• others:

Barriers to giving help:

• culture
• uncertainty
• denial
• fear of:

            -"Don’t go THERE!!"
            -self-exposure
            -commitment to a long process

Warning Signs (six D's):

• Dereliction
• Depression
• Destructive Behavior
• Distancing
• Distraction
• Disillusion

Intervention and Support (four A's):

• Active Listening, Intervention, and Referral
• Adjust duties
• Make time available for professional care and support (e.g. AA)

• Avoid enabling
• Assure confidentiality and dignity

References:

Butler DJ; Wolkenstein. Physician Impairment: Physicians' Exposure, Attitudes, and Beliefs. Fam Pract Res J 1991 Sep;11(3):327-33.

Physicians who've had group education and have experience with impaired physicians are more comfortable treating same. No surprise.

Carlson HB; Dilts SL; Radcliff S. Physicians with Substance Abuse Problems and Their Recovery Environment: a Survey. J Subst Abuse Treat 1994 Mar-Apr;11(2):113-9

Confirmation of prior study citing 12-step programs as the most important single factor predicting successful rehabilitation in impaired physicians.

Galanter M; Talbott D; Gallegos K; Rubenstone E. Combined Alcoholics Anonymous and Professional Care for Addicted Physicians. Am J Psychiatry 1990 Jan;147(1):64-8.

More support for conclusion that AA is most effective intervention in physicians

Gregory, Ian D., MD and Donald J. Smeltzer, MA. Psychiatry: Essentials of Clinical Practice. Boston: Little, Brown and Company, 1983.

Logan WS. The Evaluation of the Impaired Physician. New Dir Ment Health Serv 1989 Spring;(41):33-53.

Simons, Richard C., MD and Herbert Pardes, MD. Understanding Human Behavior in Health and Illness (2^nd ed.) Baltimore: Williams and Wilkins, 1981.

McDermott RM; Samkoff J. Help for Impaired Physicians. Physician Exec 1989 Jan-Feb;15(1):26-9.

What your boss might read in trying to deal with you if you become impaired. Overview of management from the top.

Return to Resource Center | Leadership/ Management