Case Scenario

I recently joined a busy practice that includes a physician who is well-respected and almost revered by his patients. Over the past couple of months, the staff and I have noticed changes in his behavior. He has been more withdrawn, disengaged, and short-tempered. Also, he has been late for his office hours on many occasions, and has made untypical charting and prescribing errors. We are concerned that he may have a substance abuse problem, but want to protect him and his patients. How can I further identify if this is the cause and what can I do to help this situation?

Commentary

In 1973, the American Medical Association defined the impaired physician as one who is unable to fulfill professional and personal responsibilities because of a psychiatric illness, alcoholism, or drug dependency.¹ Physicians face the challenge of being able to identify impairment in their colleagues and, most importantly, in themselves. In many cases, substance abuse problems can remain undetected for several years before being brought to attention and treatment undertaken. Impaired physicians can usually function at an adequate level until their problem becomes more advanced and their ability to care for their patients deteriorates.

The prevalence of substance abuse and chemical dependence among physicians is difficult to ascertain. Conservative estimates are that 8 to 12 percent of physicians will develop a substance abuse problem at some point in their careers.² Within the medical specialties, persons in anesthesiology and emergency medicine appear to be at the highest risk.³ It is unclear whether it is the particular specialty that increases the risk of abuse, or that the already at-risk physician is more likely to choose that specialty.

Alcohol is the most commonly abused substance among physicians. Compared with the general population, physicians have higher rates of prescription drug abuse, particularly benzodiazepines and opioids.⁴ This is because of the common practice of self-treatment and the ease of access to many drugs.

Most risk factors for abuse that are seen in physicians parallel those of the general population, such as a family history of substance abuse or the presence of a mood disorder. The increased risk for physicians is likely to develop during the training period. Resident physicians are often unable to cope with the demands of training, such as long work hours, heavy patient loads, and the lack of emotional support. In studies involving residents, psychiatry residents were more likely to self-medicate with benzodiazepines than residents in other specialties, and emergency medicine residents used more cocaine than other groups surveyed.⁵ The strongest physician-specific predispositions that have been suggested are: self-treatment with prescription medications; high stress levels or long hours of practice; and easy or constant access to controlled substances.⁶

Impairment can be very difficult to identify in physicians. Problems are usually identified at home before they are noticed on the job. Family members are usually the first to experience the harmful effects of addiction. A distressed family can show different reactions, such as denial, overprotection, and avoidance. Marriages usually suffer and can lead to separation or divorce.

At work, impaired physicians make every attempt to conceal their symptoms, making it challenging for others to detect a problem. If their workplace provides access to drugs, they may work long hours to stay close to the source of their addiction. Behaviors that might signify a problem would include unpredictable behavior to the staff or patients, often late to or absent from the office or rounds, lack of availability when on call, and careless medical decisions. Some impaired physicians will isolate themselves—they may close or lock their office door often or make hospital rounds at odd hours.

Impaired physicians seeking employment may present with red flags on their resume, such as unexplained lapses between jobs, frequent job changes, multiple relocations, and vague letters of reference.

It is a duty and obligation to immediately report any good faith suspicion or concern about an impaired physician. Many states have a legal requirement to report any physician that may be practicing while impaired. It may seem tempting to privately question or confront the physician about the possibility of a problem, but this often results in denial and can cause more harm than good. Once the physician becomes aware that others may know of the problem, there is the potential for self-harm.

Virtually all state medical societies and licensing boards have a Physician Health Program (PHP) for dealing with impaired physicians. Nine states have legislated impaired physician programs administered by state medical boards, independent agencies, or medical societies through contracts with medical boards. All other state programs are administered by medical societies.⁷ The Federation of State Physician Health Programs is a nonprofit organization that serves as a forum for information exchange among these various state programs.

All shared information is treated confidentially and can be made without fear of retaliation. It may seem difficult to report a colleague, but failing to do so puts the patients of the impaired physician at risk. The PHP can serve as an advocate for the physician before the medical board. The potential consequences of licensure suspension and revocation for the physician are greater if they are reported to the board without involvement with the PHP.

After the initial contact is made with the PHP, they will arrange for a comprehensive assessment of the physician to help identify a substance abuse problem or psychiatric illness. If the PHP determines that an intervention is needed, a small group consisting of representatives for the PHP or local physician wellness committee and, sometimes, colleagues will meet with the physician and recommend a formal evaluation be done to determine if any treatment is necessary. The physician can voluntarily follow the recommendations of the committee. If the physician chooses not to, he or she could be reported to the state board and face serious consequences.

The treatment of physicians with substance abuse problems is different than the treatment of the general public. Short-term outpatient therapy relapse rates are greater than 60 percent, which is unfavorable, considering physicians will be returning to a workplace where judgment must not be compromised.⁸ Extended treatment that lasts three to four months and takes place in a center with other impaired physicians has better success rates.⁹

Treatment usually begins in a hospital setting in order to focus on the physical consequences of withdrawal and overcoming initial drug cravings. This may take a few days to a couple of weeks. During this time, psychological therapy, behavior modification, and education are initiated. The intermediate and late phases take place in a recovery setting where physicians can gain insight by interacting with others that are further along in their recovery.

A nine-year study of physicians in the New Jersey PHP reported a recovery rate of 83.8 percent, with no relapses at the end of two years.¹⁰ Including those who had one relapse (13.8 percent), the success rate was 97.6 percent.¹⁰ Most relapses occur during the first two years after treatment. A structured aftercare program can increase the success rate and help identify a relapse. Typical monitoring is usually done for the following five years, but longer periods may be chosen.