Impaired physicians: How to recognize, when to report, and where to refer

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From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.¹ Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.^1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,⁴ and substance abuse is the most common form of impairment that results in discipline by a state medical board.⁵ An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.⁵ Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.⁶ An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).^7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.⁹ Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.^10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.^1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).^1,2,5 A doctor’s professional performance often is the last area to be affected.^1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.⁵

Table 1

Physicians and substance abuse: Predisposing factors

Table 2

Signs of substance abuse

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.¹³ The prevalence of dementia in individuals age ≥65 is 3% to 11%,¹⁴ and 18% of physicians are in this age group.¹⁵