Policy Playbook: Physician Impairment
- Aug 18th, 2021
- Kathryn Wiesendanger
Authors: Kathryn Wiesendanger (Medical Student, Royal College of Surgeons in Ireland, @k_wiesendanger) and Summer Chavez, DO, MPH, MPM (EM Attending Physician, The University of Texas Health Science Center at Houston) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
What is the issue?
Physician impairment, as defined by the American College of Emergency Physicians (ACEP), is when a physician becomes unable to practice medicine with reasonable skill and safety as a result of personal health problems or other stressors1. Disruptive behavior, on the other hand, is behavior that has the potential to negatively affect patient care or the ability to work with other members of the healthcare team2. Addiction is a familiar example of an illness that has the potential to cause both disruptive behavior and ultimately impairment3. While the exact definitions of physician impairment and disruptive behavior may differ slightly between organizational boards, one thing is certain; the mere presence of a personal health problem or illness (i.e. physical injury, burnout or substance abuse) does not necessarily constitute physician impairment1,3,4. These issues exist on a continuum, which is why a good understanding within the medical community and early intervention are essential to both physician and public safety.
Substance use disorder (SUD) is a well-known example of a potentially impairing illness, and can be further subdivided into substance abuse and substance dependence5. Substance abuse can lead to disruptive behavior in the workplace, and is often associated with adverse social consequences and legal problems. Substance dependence (i.e. addiction), on the other hand, results from a maladaptive pattern of substance use, often resulting in physiologic and behavioral problems5, and often coexisting with physician impairment. Multiple theories exist as to why physicians in particular experience SUD, and include achievement oriented personality traits, aversion to taking on the patient role, “professional invincibility,” high stress careers and easy access to controlled substances3,5,6.
Why does this matter?
It is estimated that approximately 15% of physicians will be impaired at some point in their careers, with emergency medicine being the second most common specialty affected after anesthesiology2,6. Alcohol is the most commonly abused substance by physicians, followed by benzodiazepines and opiates, and then fentanyl5. Carinci and Christo suggest this is likely a result of easy access and pharmacologic familiarity of these substances, possibly explaining why, contrarily, marijuana and cocaine are more commonly abused by the general public5.
There are many obstacles to a physician seeking treatment. Physicians are inherently solution driven, often plagued by the concept of “professional invincibility”5, and thus avoid taking on a patient role. Other risk factors include genetic and personality factors, denial and more logistical factors such as practice coverage, loss of licensure and fear of disciplinary action3. Thus, it is vital that we not only recognize when our colleagues display signs of impairment, but also intervene early before functional impairment occurs. Physician Health Programs (PHPs) were designed to play a crucial role in this process, and matter when it comes to protecting both the physician and the public. PHPs vary by state, but promote confidentiality and adopt a non-punitive approach to best support physicians toward resolution and recovery.
While we know what PHPs strive to provide, it isn’t exactly clear how beneficial they are or to whom they are most beneficial for. While there is a limited amount of literature regarding PHPs, success rates have been reported to be as high as 75%7. There have been criticisms surrounding PHPs when it comes to providing assistance to physicians suffering from impairment, and more research should be done regarding any given state’s PHP as there are currently no national standards or routine audits8,9. If a physician is referred by a colleague to a PHP for suspected substance abuse, for example, the physician in question may be required to undergo a several-day evaluation, comply with a 30-to-90 day inpatient stay followed by a monitoring agreement, random drug testing, weekly Alcoholics Anonymous or Narcotics Anonymous group meetings, and regular meetings with a PHP representative8. Failure to comply with any aspect of this process can affect a physician’s ability to hold a medical license and hospital privileges, so it is equally important to understand your state’s appeals process. Unfortunately, appealing a referral to a PHP similarly varies and is often criticized for being difficult or near-impossible9.
Because optimal physician health is critical to patient health, physicians must be able to access treatment as any other individual would. Additionally, seeking care should be encouraged rather than penalized. It is also recommended that credentialing agencies support and expand access to treatment programs. When it comes to healthcare professionals who develop addiction, evidence suggests that treatment usually results in remission of disease and restored functioning, especially if appropriate continuing care is put in place10.
What can I do about it?
- Recognize when your colleague is having a problem. Physicians are experts in concealing concerning signs and symptoms, and deterioration in clinical performance is often last to present8. Warning signs relevant to the Emergency Department include frequent absences, conflicts with support staff, writing multiple prescriptions for family members, heavy drinking at hospital functions and defensive or anxious demeanor11.
- Challenge the “professional code of silence.” Physicians can be reluctant to report their colleagues at all, in many cases risking the safety of both their colleague and the public12,13. While 20% of US states enforce mandated reporting of suspected physician impairment14, the American Medical Association encourages physicians to reflect on their ethical obligation to patient safety when it comes to addressing impairment within their own institutions8.
- Become familiar with and advocate for your state’s PHP, including the right to a fair appeals process.
- Note the importance for PHPs to gain confidence of regulatory boards (through audits etc.) so that they can continue to provide a beneficial experience for physicians.
Helpful Resources & Links:
- Federation of State Physician Health Programs
- FSMB Policy on Physician Impairment
- ACEP Policy on Physician Impairment
- EMRA Wellness Guide
- ACEP Wellness & Assistance Program
- CORD guidelines for recognizing chemical dependency within residents
This post was a collaboration between EM Docs and the EMRA Health Policy Committee
- American College of Emergency Physicians. Policy Statement on Physician Impairment.; 2020.
- Johnson BA. Dealing with the impaired physician. Am Fam Physician. 2009;80(9):1007.
- Federation of State Medical Boards. Policy on Physicians with Potentially Impairing Illness. 2011:3-68. https://www.fsmb.org/siteassets/advocacy/policies/physician-impairment.pdf.
- Sorge R. Physician Impairment. In: Chung AS, ed. EMRA Wellness Guide.
- Carinci AJ, Christo PJ. Physician Impairment: Is Recovery Feasible? Pain Physician. 2009;12:487-491. www.painphysicianjournal.com.
- Boisaubin E V, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322(1):31-36. doi:10.1097/00000441-200107000-00006
- Candilis PJ. Physician health programs and the social contract. AMA J Ethics. 2016;18(1):77-81. doi:10.1001/journalofethics.2017.18.1.corr1-1601
- Boyd JW. Deciding Whether To Refer a Colleague to a Physician Health Program. Am Med Assoc J Ethics. 2015;17(10):888-893.
- Boyd JW. A Call for National Standards and Oversight of State Physician Health Programs. J Addict Med. 2015;9(6). https://journals.lww.com/journaladdictionmedicine/Fulltext/2015/12000/A_Call_for_National_Standards_and_Oversight_of.2.aspx.
- American Society of Addiction Medicine. Public Policy Statement on Physicians and Other Healthcare Professionals with Addiction. Rockville, MD; 2020. https://www.asam.org/docs/default-source/public-policy-statements/2020-public-policy-statement-on-physicians-and-other-healthcare-professionals-with-addiction_final.pdf?sfvrsn=5ed51c2_0.
- Breiner SJ. The impaired physician. Acad Med. 1979;54(8). https://journals.lww.com/academicmedicine/Fulltext/1979/08000/The_impaired_physician.21.aspx.
- McCall S V. Chemically dependent health professionals. West J Med. 2001;174(1):50-54. doi:10.1136/ewjm.174.1.50
- Farber NJ, Gilibert SG, Aboff BM, Collier VU, Weiner J, Boyer EG. Physicians’ willingness to report impaired colleagues. Soc Sci Med. 2005;61(8):1772-1775. doi:https://doi.org/10.1016/j.socscimed.2005.03.029
- Baldisseri MR. Impaired healthcare professional. Crit Care Med. 2007;35(2 Suppl):S106-16. doi:10.1097/01.CCM.0000252918.87746.96