Special Population Series Impaired Healthcare Professionals Learning Objectives
Special Population Series Impaired Healthcare Professionals
Learning Objectives • Define impairment in Health Care Professionals (HCP). • Discuss the incidence of Substance Use Disorders (SUD) in HCP. • Describe contributory factors to SUD for HCPs. • Identify typical signs and symptoms of impairment in HCP. • Review treatment, monitoring and reporting issues for HCP with SUD.
William Halstead 1852 -1922 A noted surgeon at Johns Hopkins Hospital who championed the aseptic surgical technique. He experimented with cocaine as an anesthetic. He became addicted to cocaine, and then morphine, while continuing to practice.
American Medical Association (AMA) Impairment: "The AMA defines physician impairment as any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities and will address all such conditions in its Physician Health Program” AMA Policy H-95. 955 Physician Impairment
Incidence and Prevalence • Males > Females • 10 -15% of HCP misuse drugs and/or alcohol at some time during their careers. • Prevalence of SUD among HCP is the same as in the general population. • Substance dependence is the most common disabling illness among physicians. Baldisseri MR, 2007; Cottler LB, 2014
Risk Factors • Family history of SUD, mood disorder, and personality traits, are as much risk factors for SUD in HCP as they are for non-HCP. • Long work hours and easy access to drugs are not risk factors for SUD in HCP. • Easy availability and access to drugs accounts for types of substances used. Kenna GA and Lewis DC, 2008
Substances Used • Alcohol is the most commonly misused substance, followed by opiates and stimulants. • Rates of opiate and benzodiazepine use is five times higher among HCP compared to the general population. Hughes et. al. JAMA 1992; 267: 2333 -2339; Gold KB, 2010
Challenges in Screening and Case Finding • Adept at hiding signs and symptoms of substance abuse. • Difficulty admitting that they cannot control their substance use. • Self-diagnosis and self-treatment for SUD and other conditions without seeking help of colleagues. • Fear of losing medical license is a strong deterrent to disclosing use or seeking help. Kenna GA and Lewis DC, 2008; Baldisseri M. R. , 2007
Challenges to Identification by Colleagues • Warning signs of SUD are the same for HCP as for others, but excuses and explanations are more readily believed from a respected professional. • Deterioration in clinical performance is one of the last signs of SUD in HCP. • Colleagues of impaired providers believe someone else is dealing with the issue or that nothing will happen if they report the individual; others feared the individual would be excessively punished • Significant or unexpected changes in these areas should not be ignored. • Higher than average prescribing of benzodiazepines and/or opioid analgesics is associated with SUD, but is not predictive or necessary for SUD in HCP. Des. Roches CM 2010; Baldisseri M. R. , 2007
Brief Intervention • Early identification and intervention help to keep licensure, credentialing, and training legal and employment issues minimal. • Acceptance of SUD is a positive prognostic indicator. • High personal and internal motivation for abstinence and recovery is associated with better outcomes, as are supportive family and friends. • HCP who do not receive treatment place their patients and themselves at risk. Boisaubin E. V. and Levine R. E. , 2001
Recovery • Physicians show better rates of recovery from SUD than non-physicians, because of long term monitoring by Physician Health Programs (PHP). • Substance misuse recovery rates are 70 -90%. • As with the general population, there are higher relapse rates with opioid use and for those who have a family history of SUD Carinci, AG and Christo PJ, 2009, Domino KB 2005
Physician Health Programs (PHP) • Program does not treat SUD but assists physicians in navigating state systems. • 49 states have PHPs (Wisconsin’s was discontinued due to lack of funding) • Referrals given from colleagues, staff, and/or family to promote early identification of SUD for program. • Program coordinates treatment and aftercare monitoring from therapists, PHP trained physician volunteers, and/or drug tests. • Program provides supervision upon return to practice. Du. Pont RL, 2009; Krall EJ, 2012
Comparison
PHP Programs Also Address • Behavioral health problems • Stress management issues • Physical illnesses • Cognitive deficits • “Disruptive physician" conduct Federation of State Physician Health Programs (http: //www. fsphp. org/)
Aftercare and Monitoring Aftercare, monitoring, and follow-up are essential. Monitoring usually involves: • Random drug testing • Regular attendance at recovery-based meetings • Periodic evaluation of progress Boisaubin E. V. and Levine R. E. , 2001
Returning to Practice A written agreement or contract between the impaired HCP and supervisor, administrator, or Employee Assistance Plain (EAP) is devised, outlining: • Expectations for follow-up • Actions if relapse occurs Boisaubin E. V. and Levine R. E. , 2001
Reporting Substance Use • Misuse of drugs and alcohol by HCP is complicated by the HCP caregiver role. • There are significant ethical and legal ramifications in not reporting an impaired colleague. • Colleagues may be reluctant to report an impaired HCP be of: – Intimidation – Fear of occupational and financial reprisals – Belief that it is not their job or that someone else is dealing with the issue Des. Roches CM 2010
Reporting Requirements Legal • Only 20% of states have laws mandating reporting an HCP suspected of SUD. • Most states provide immunity from civil suit against reporters. • Pennsylvania reporting requirements: http: //www. hortyspringer. com/reporting-statutes-bystate/pennsylvania-reporting-statute/ • Ethical • AMA code of ethics: http: //www. ama-assn. org/ama/pub/physician-resources /medical-ethics/code-medical-ethics/opinion 9031. shtml
Avenues for Reporting • Medical School Dean’s Office • Residency program director and resident assistance program • Hospital/facility Medical Staff Office or EAP • County Medical Society • State Physician Health Program
Case 1: Byron is a 28 year old 2 nd year Emergency Medicine resident squeezed into your office schedule today at the request of his advisor. He did not show up for his last shift and did not call off. Reportedly, he has been increasingly late for shifts and has had several last minute call offs due to vague illnesses. He has appeared exceptionally tired and even somnolent. Byron reports having trouble adjusting his sleep schedule repeatedly to accommodate his rotational schedule. He has a history of depression, but is otherwise healthy. Byron did not complete the registration process and was not screened for SUD, because he was slipped into your schedule as a courtesy. He is tired and sad appearing but cooperative.
Case 1: Byron 1) How will you broach the subject of SUD with this patient? 2) Discuss specific assessment concerns in the situation of a possibly impaired physician. 3) Describe an appropriate follow up plan and discuss licensing and training implications for Byron.
Case 2: John is a 45 year old Internist in a large group practice. He was divorced in the past year and has a teenage son who lives with his ex-wife. Despite his good income he has been complaining of financial difficulties. Although He blames these on the amount of support he must provide his ex-wife. Since joining the practice, John has the highest rates of benzodiazepine and opioid analgesic prescribing compared to his partners. There has been a marked increase over the past year. John has always arrived for office hours without a minute to spare, but he is now routinely up to 45 minutes late. Today, a notice appeared in the paper that he was charged with a DUI. When you tell him you need to speak to him privately he is surprisingly calm and even blank in his expression.
Case 2: John 1) How would you approach your partner’s behavior using BI techniques? 2) What options are available for John and which would you recommend? 3) Discuss the role of the state Board of Medicine in John’s followup plan and what is your obligation?
Conclusions • Impairment is defined as the inability to fulfill professional or personal responsibilities because of psychiatric illness or substance abuse/dependency. • Substance dependence is the most common disabling illness among physicians. • Deterioration in clinical performance is one of the last signs of SUD in HCP. • Physicians demonstrate better rates of recovery from SUD than non-physicians secondary to longterm monitoring
- Slides: 24