THE IMPAIRED CLINICIAN

Transcription

1 THE IMPAIRED CLINICIAN Azeemuddin Ahmed, MD, MBA Clinical Professor and Executive Vice Chair, Department of Emergency Medicine Emergency Medical Services (EMS) Fellowship Program Director Medical Director, Kinnick Stadium and Carver Hawkeye Arena University of Iowa Carver College of Medicine Disclosure Ahmed A, Graber M, Dickson EW. Evaluation of the adult with dyspnea in the emergency department. In UpToDate, Rose, BD (ed). UpToDate,

2 Objectives Medicine is a high risk business Can affect us, our colleagues, our trainees = no one is immune Reluctance to discuss or intervene Impaired provider alcohol addiction Depression, substances NOS, sedatives, alcohol, stressors NOS Can pose a patient safety risk People deserve an opportunity to receive proper treatment We must be vigilant to recognize, intervene and/or refer Global discussion I am not a psychiatrist 2

3 AMA Definition One who is unable to fulfill professional or personal responsibilities because of psychiatric illness, alcoholism or drug dependency Reality check = Virtually any significant medical illness or situation that affects judgement and performance could compromise the ability to provide correct medical care = impaired provider 3

4 Background William Halstead (father of modern surgery) had a cocaine addiction described in great detail by Sir William Osler 1958 State Medical Boards called for probation and rehabilitation programs for physicians 1973 AMA formally recognizes physician impairment 1990 Creation of State Physician Health Programs Some looseness regarding the definition of impaired physician that is being tightened up Incidence Data is not that good 10-15% of all healthcare professionals will misuse drugs in their career 6-8% of physicians have substance use disorder and up to 14% have an alcohol use disorder Mirrors general population 64,000 physicians = substance use disorder 112,000 physicians = alcohol dependence disorder Biggest cause of physician disability Seen as a huge problem because of the significant responsibilities entrusted to the provider 4

5 Additional Information Rates of abuse and dependence is similar to general population Rates of USE of drugs is 5X greater in physicians then rates of use in the general population Alcohol > opioids > stimulants Men > Women Healthcare providers = benzos, opioids; less marijuana and cocaine Anesthesiology, Emergency Medicine and Psychiatry = overrepresented in the data Contributing Factors Idealistic beliefs Perfectionist behavior High drive to achieve and excel at work Elements of OCD behavior Coping mechanism for stress, anxiety and pain Underlying psychiatric illness that is unmasked by the stress of training and practice Family history of substance abuse, stress at work and home, emotional problems, sensationseeking behavior 5

6 Signs and Symptoms Clinicians are pretty good at hiding signs and symptoms Well-established denial mechanisms professionals! Feelings of immunity Usually have deterioration of personal life first then eventually professional life is affected Warning Signs Baldisseri MR. Impaired Healthcare Professional. Crit Care Med 2007;35 (Suppl):S106-S116. 6

7 Physical and Behavioral Symptoms Baldisseri MR. Impaired Healthcare Professional. Crit Care Med 2007;35 (Suppl):S106-S116. What is Disruptive Provider? Practice PATTERN of personality traits that interferes with effective and safe clinical behavior It is NOT someone having a bad day have to be careful with labels Negative impact on others co-workers, patients, trainees Can potentially compromise the quality of health care provided Can be direct or passive aggressive Reynolds NT. Disruptive Physician Behavior: Use and Misuse of the Label. Journal of Medical Regulation. Vol 98. No. 1 7

8 Why Do Providers Become Disruptive? May have been trained by people who were disruptive these were their mentors so they were mentored in bad things as well! Have paid their dues now have special standing to behave this way not appropriate! May have a psychiatric problem Cultural or social conflicts External stressors Reynolds NT. Disruptive Physician Behavior: Use and Misuse of the Label. Journal of Medical Regulation. Vol 98. No. 1 Barriers to Intervention/Reporting the Impaired Clinician People are unwilling to report impaired colleague = complex Less supervision = fewer people can exert influence on person Social and financial concerns Intimidation Fear of reprisals Need to protect reputations Accused of over-reacting Fear of labeling someone an addict without evidence Code of Silence 8

9 Reporting Challenging to confront person about suspected illness AMA = ethical obligation to report impaired, incompetent and unethical colleagues Be familiar with institutional reporting mechanisms Legal aspects vary from state to state Few states have mandatory reporting requirements for impaired colleagues 9

10 State Medical Boards Physician Health Programs are usually different from State Medical Boards Encourage self-reporting Get referrals from State Medical Board Even with intervention from health programs substance abuse remains most common form of impairment sanctioned by State Medical Boards 10

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12 Iowa Physician Health Program Physically co-located with the Iowa Board of Medicine but separate operations. Overlap when needed on cases. Can be involved for up to 5 years in certain cases How do they get involved? Self reporting (preferable) Apply for licensure to the Board of Medicine (applicant has OWI, public intoxication arrests) Complaint to the Board of Medicine (disruptive behavior, intoxicated on the job) 12

13 Iowa Physician Health Program The IPHP gets involved with your case They refer you to a professional either within Iowa or outside of the state (based on your needs) for evaluation They receive the recommendations They ensure compliance with the recommendations through regular checks If you re compliant à things will probably go well If you re not compliant à board action Iowa Physician Health Program For physicians only (NPs, PAs, dentists, pharmacists have their own mechanisms and processes) The IPHP itself does not provide medical care The IPHP does not pay for your care (hospitals, practices, private insurance) Per the IPHP = would rather help you than investigate you 13

14 Contact AMY VAN MAANEN, LBSW IOWA PHYSICIAN HEALTH PROGRAM COORDINATOR IOWA BOARD OF MEDICINE 400 SW EIGHTH STREET, SUITE C DES MOINES, IOWA OFFICE: FAX: amy.vanmaanen@iowa.gov Treatment Growing recognition and decreasing stigma Need to get them a proper evaluation, treatment plan, continued monitoring and vigilance Protect patient and the provider Support the family Most impaired providers have a great potential to rehabilitate the strong skill sets that made them successful 14

15 Why? Moral obligation to assist our own colleagues in identifying and understanding their illness and getting treatment Protect the patients By helping impaired providers, we gain perspective and insights into our own lives and situations Discussion Questions What can be some initial steps in dealing with suspected impaired clinician? What would you do if you suspected that one of your colleagues arrived under the influence of a substance? How would you address that? Difference in approach for impaired clinician vs. disruptive clinician? What if the clinician in question is powerful, generates a lot of revenue and/or seems to be immune from administrative action? Other topics to discuss? 15

16 3/9/18 Conclusion None of us immune from becoming impaired no matter how awesome we are Look out for yourself and each other Understand your ethical obligations as well as institutional guidelines regarding impaired providers Self-reporting is better There is always light at the end of the tunnel becoming impaired is not necessarily a career ender Thank You! 16

17 References Boisaubin EV, Levine RE. Identifying and Assisting the Impaired Physician. Am J Med Sci 2001; 322(1): Baldisseri MR. Impaired Healthcare Professional. Crit Care Med 2007;35 (Suppl):S106-S116. Rose JS, Campbell M, Skipper G. Prognosis for Emergency Physician with Substance Abuse Recovery: 5-Year Outcome Study. West J Emerg Med. 2014;15(1): Berge KH, Seppala MD, Schipper AM. Chemical Dependency and the Physician. Mayo Clin Proc. 2009;84(7): Milling JT. Drug and Alcohol Use in Emergency Medicine Residency: An Impaired Resident s Perspective. Ann Emerg Med. 2005;46: