Evidence-Based Reviews

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

Current Psychiatry. 2010 June;9(6):11-20

References

1. Breiner SJ. The impaired physician. J Med Educ. 1979;54:673.-

2. Talbott GD, Gallegos KV, Angres DH. Impairment and recovery in physicians and other health professionals. In: Graham AW, Schultz TK, eds. Principles of addiction medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:1263-1277.

3. American Medical Association Council on Mental Health. The sick physician: impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA. 1973;223:684-687.

4. Talbott G, Wright C. Chemical dependency in healthcare professionals. Occup Med. 1987;2:581-591.

5. Baldisseri MR. Impaired healthcare professional. Crit Care Med. 2007;35:S106-116.

6. Mansky PA. Physician health programs and the potentially impaired physician with a substance use disorder. Psychiatr Serv. 1996;47:465-467.

7. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322:31-36.

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10. Gallegos KV, Browne CH, Veit FW, et al. Addiction in anesthesiologists: drug access and patterns of substance abuse. QRB Qual Rev Bull. 1988;14:116-122.

11. Hughes PH, Brandenburg N, Baldwin DC, et al. Prevalence of substance abuse among U.S. physicians. JAMA. 1992;267:2333-2339.

12. Vaillant GE, Clark W, Cyrus C, et al. Prospective study of alcoholism treatment. Eight year follow-up. Am J Med. 1983;75:455-463.

13. LoboPrabhu SM, Molinari VA, Hamilton JD, et al. The aging physician with cognitive impairment: approaches to oversight, prevention and remediation. Am J Geriatr Psychiatry. 2009;17:445-454.

14. U.S. General Accounting Office. Alzheimer’s disease: estimates of prevalence in the United States. Washington, DC: U.S. General Accounting Office; 1998:98. Publication GAO/HEHS-98-16.

15. American Medical Association. Physician characteristics and distribution in the U.S., 2006. Washington, DC: American Medical Association; 2006.

16. Blasier R. The problem of the aging surgeon. Clin Orthop Relat Res. 2009;467:402-411.

17. College of Physicians and Surgeons of Alberta. Physician Achievement Review (PAR) Program. Available at: http://www.cpsa.ab.ca/Services/PARprogram/Overview.aspx. Accessed March 27, 2010.

18. The Age Discrimination in Employment Act. (Vol. Pub. L. No. 90-202, 81 Stat. 602 (Dec. 15, 1967), codified as Chapter 14 of Title 29 of the United States Code, 29 U.S.C. § 621 through 29 U.S.C. § 63), 1967.

19. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Int Med. 2007;147:795-802.

20. Shouten R. Impaired physicians: is there a duty to report to state licensing boards? Harvard Rev Psychiatry. 2000;8:36-39.

21. Mass Gen Laws ch 112 § 5F.

22. NY PHL § 230 (11) (e).

23. Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.

24. Alpern F, Correnti CE, Dolan TE, et al. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.

25. Gallegos KV, Lubin BH, Bowers C, et al. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.

26. Reid W. Evaluating and treating disabled or impaired colleagues. J Psychiatr Pract. 2007;13:44-48.

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;^23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.⁵

Risk factors for relapse include:

denial of illness
poor stress-coping and relationship skills
social and professional isolation
inability to accept feedback
complacency and overconfidence
failure to attend support group meetings
dysfunctional family dynamics
feelings of self-pity, blame, and guilt.⁵

Treating an impaired colleague. Reid²⁶ recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Clinical Point

Advise an impaired physician who seeks treatment related to license or other legal concerns to seek legal counsel

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Related Resources

Disruptive physicians

Samenow C, Swiggart W, Spickard A Jr. Consequence of physician disruptive behavior. Tenn Med. 2007;100(11):38-40.
Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
Linney BJ. Confronting the disruptive physician. Physician Exec. 1997;23:55-59.

Physician evaluation

Anfang SA, Faulkner LR, Fromson JA, et al. The American Psychiatric Association’s resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005;33:85-88.
Harmon L, Pomm R. Evaluation, treatment, and monitoring of disruptive physicians’ behavior. Psychiatr Ann. 2004; 34:770-774.

Other resources

Federation of State Physician Health Programs. www.fsphp.org.
Federation of State Medical Boards: Directory of Physician Assessment and Remedial Education Programs. www.fsmb.org/pdf/RemEdProg.pdf.
The Center for Professional Health, Vanderbilt University Medical Center. www.mc.vanderbilt.edu/cph.
Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.
Alcoholics Anonymous. www.aa.org.
Narcotics Anonymous. www.na.org.

Drug Brand Name

Oxycodone/acetaminophen • Percocet

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.