Dr. Jones is a popular and successful primary care doctor. Over the last few months, though, colleagues have noticed that he hasn’t seemed himself. He’s been seen in the hospital at odd hours, his normally professional demeanor has turned snappish, and at times he smells strongly of sweat and cigarettes. Patients have started complaining that he hasn’t been returning their calls and has shown up late for appointments. When the medical director asks Dr. Jones if everything is okay, Dr. Jones angrily replies, “Why shouldn’t it be?” and storms off. Finally, a patient complains that Dr. Jones slurred his speech during a visit, had tiny pupils, and looked like he was about to nod off. In the subsequent emergency staff meeting, the nurse manager reports narcotics and prescription pads have been disappearing from the office. In a panic, the medical director alerts senior management and calls the medical board to report Dr. Jones as an impaired physician.
Doctors and other health care providers are the last people you might suspect of being addicted to drugs or alcohol. Yet, substance abuse is estimated to afflict 10%–15% of physicians (Flaherty JH and Richman JA, Psychiatr Clin N Am 1993;16:189–195). This rate is higher than the rate for the general population, which is estimated at 8.4% (SAMHSA 2014 National Survey on Drug Use and Health). Nurses, dentists, and other health care providers are also particularly susceptible to substance use disorders (SUD).
Why? Perhaps it’s because health care providers have high levels of stress in their work lives. It has been well-documented that we suffer disproportionately from burnout and career dissatisfaction. We also have ready access to abusable pharmaceuticals and, of course, to alcohol. Together, these factors create a “perfect storm” that predisposes health care providers to SUDs.
An addicted coworker can cause a phenomenal amount of stress and disruption in your practice, and often represents a serious threat to the safety of your patients. By law, it is mandated that we report impaired colleagues to their professional boards, but many of us are reluctant to do so. We don’t want to ruin colleagues’ lives by subjecting them to stigma and discipline at the hands of the medical boards, which are perceived—not unjustifiably—as tending to shoot first and ask questions later. Consequently, you may not know what to do if you are confronted with an impaired colleague. The first step, of course, is learning how to recognize an impaired colleague in the first place.
Impaired colleagues Ideally, an SUD in a health care provider can be recognized as early as possible, before irreparable harm comes to the provider’s career, patients, or family. Overdose and suicide are not uncommon outcomes, and efforts must be focused on preventing these as well as protecting patients.
In Dr. Jones’ case, the diagnosis became apparent because there was a “smoking gun.” A patient witnessed that the doctor was clearly intoxicated. At that moment, all the clues fell into place, and it became obvious to the leadership that Dr. Jones was impaired. More often, however, the signs are subtler, and early recognition requires a high index of suspicion. In our vignette, colleagues and patients noticed tardiness, odd hours, mood swings, deteriorating hygiene, and isolative behavior long before Dr. Jones showed up with obvious signs of intoxication. These are often cardinal signs of an SUD. In fact, any time a professional demonstrates unexplained behavioral changes, substance use may be present. See our the table below.
Of course, it’s important not to jump to conclusions. Other conditions like depression or bipolar disorder—not to mention life stressors such as divorce—can precipitate similar changes. But behavior shifts can be caused by both things at once. SUDs in health care professionals often coexist with other psychiatric disorders, and this can present a confusing picture.
Referral and treatment The cornerstone of treatment for addicted physicians is referral to physician health programs (PHPs), also known as “diversion” or “alternative” programs. These are intended to provide a non-punitive, productive way to urgently address impaired caregivers, keeping the benefit of both physicians and patients in mind.
Referrals can come from a variety of sources. Some clients self-refer, either in desperation or at the recommendation (or threat) of a mental health provider or primary care doctor. Others are referred by their workplaces. Many are directed to PHPs by their newly hired attorneys, in response to a DUI or an episode of witnessed workplace impairment. Some are sent by the medical board after it learns of misconduct, as in the case of Dr. Jones.
Arguably, Dr. Jones’ medical director might have confronted him directly and urged him to contact his PHP himself. This approach can be surprisingly effective, especially when accompanied by a threat to call the medical board if the impaired professional doesn’t follow through. Alternatively, the medical director might have called the PHP instead of calling the medical board. This is also considered to be a credible way of discharging your responsibility as a “mandated reporter,” and is more likely to result in a focus on helping the physician rather than mere punishment.
Of course, if there is an imminent threat to patient safety, as there might be with an inebriated surgeon, then it is imperative to involve hospital or other appropriate administration immediately. The administration may need to call the board, hospital security, or even the police, depending on the acuity of the circumstance.
PHPs employ a multifaceted approach to treatment and monitoring of SUDs. Clients are intensively evaluated, and may be required to abstain from practicing their profession for a lengthy period of time. They must sign “monitoring contracts” lasting up to five years. These contracts, also known as “consent agreements,” may require frequent drug testing, attendance at peer support meetings, psychotherapy, and workplace monitors.
PHPs aren’t perfect. They have recently been criticized for having too much power over physicians and too little oversight. In my experience, this criticism is overblown. PHPs are a lifesaving resource for physicians that are suffering from SUDs, as well as other psychiatric disorders. For more information on PHPs, see this issue’s expert interview with Dr. Ziegler.
Outcomes and challenges Health care providers with SUDs tend to fare much better in treatment than almost all other addicts. Doctors have between a success rate in recovery of 70%–80% (McLellan AT et al, BMJ 2008;337(41):a2038). For addiction, this is astronomical.
On the other hand, many challenges remain in the treatment of impaired health care providers. Stigma is perhaps the most intractable of these. If providers are embarrassed and afraid to ask for help, their problems may remain undetected until irreversible damage occurs to their health, family, reputation, and career. As health care providers ourselves, we are in a unique position to make impaired colleagues more comfortable asking for and accepting help. It is important to spread the word about PHPs and other resources for impaired health professionals, so that lives and careers can be saved. It is critical that we care for our caregivers.