Identifying Impaired Physicians: How to address problem physicians quickly

Several health care professionals have witnessed how impaired physicians can adversely affect patient safety. Jane, a nurse with decades of hospital experience, has also experienced the problem from the patient’s point of view. Several years ago, Jane (not her real name) worked with a surgeon who had a drug abuse problem. When the abuse was discovered, the surgeon’s privileges were revoked by the health care organization. Years later, Jane developed kidney disease and went on the waiting list for a transplant at a different hospital. “When I woke up after the surgery, the first thing I noticed was that the subclavian line was on my breast,” she says. “I asked about it and was told simply that the surgeon had a problem.” She asked the surgeon’s name and was surprised to learn it was the same physician who had been dismissed from her hospital. In the following days, she developed several complications but never saw the surgeon on rounds. “Finally I said, ‘There was a problem, wasn’t there? He was taking drugs, wasn’t he?’ They didn’t deny it.” Jane went into transplant rejection and eventually had to have another kidney transplant.

“What I’m really angry about is that no one at the hospital had the courage to speak up,” she says. Jane believes organizations and caregivers both have a responsibility to protect patient safety. “As a nurse, I realize that drug abuse is a sickness,” she says. “The impaired person cannot make a good decision. That’s why the people who are not impaired need to make the decisions.”

Who Is An Impaired Physician?
In a paper published recently in the Annals of Internal Medicine, Lucian L. Leape, M.D., and John A. Fromson, M.D., define the term impaired as a “disability resulting from psychiatric illness, alcoholism, or drug dependence.”1(p.107) An impairment can be the result of mental and behavioral problems, including depression, anxiety, substance abuse, personality disorders, and disruptive behavior with colleagues, patients, and subordinates.1 Disruptive physicians are those who “exhibit abusive behavior that interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care.”1(p.107)

Leape and Fromson’s definition of an impaired physician does not specifically include age-related and disease-related cognitive impairment; however, this is certainly an issue for health care organizations as well. Organizations can consider the possibility of implementing “routine cognitive evaluations for older physicians”1(p.113) to identify whether a physician’s skills have deteriorated over time.

Common Problem
How common is impairment in physicians? Leape and Fromson examine several different causes of physician impairment, including depression, alcohol and drug dependence, physical illness, and skill dyscompetency. “When all conditions are considered, at least one third of all physicians will experience, at some time in their career, a period during which they have a condition that impairs their ability to practice medicine safely.”1(p.109) This means that in a 100-physician hospital, an average of 1 to 2 physicians will suffer an impairment every year.1

What are the root causes of physician impairment, and why is it so hard to address? Experts point to a complex mix of psychology, culture, and economics. Although impairment is not exclusively a physician problem, it is particularly unique to the physician personality. “Many physicians possess a strong drive for achievement, exceptional conscientiousness, and an ability to deny personal problems,” say Eugene V. Boisaubin, M.D., and Ruth E. Levine, M.D. “These attributes are advantageous for success in medicine; ironically, however, they may also predispose to impairment.”2 Several commentators also call attention to the increasing stresses on physicians—including financial stresses (large educational debt, decreasing reimbursement) and legal stresses (difficult malpractice environment).1

Most physicians are not directly employed by a hospital, so they enjoy a great deal of autonomy and independence within the hospital environment. Because physicians value their independence, many experts note their general reluctance to report colleagues—often personal friends—for impairment as physicians do not want to evaluate or judge a colleague.1 In addition, Leape and Fromson point out that the hospital may not be able to afford to lose a revenue-producing physician, even though he or she may have an impairment.1

Sidebar 1. Signs of Impairment Physical Appearance: Personality or behavior changes Deterioration of hygiene or appearance Frequent or unusual accidents Multiple prescriptions In the Office: Frequent or unexplained absences Complains of excessive work load Inaccessible (“locked door syndrome”) Excessive ordering of drugs or excessive personal drug use Complaints by patients or staff In the Hospital: Frequent trips to the restroom Frequently late, absent, or ill Desire to work alone or refusing work relief Lack of or inappropriate responses to pages or calls Decreasing quality of performance or patient care In the Community: Unreliability or neglect of commitments Isolation or withdrawal Unpredictable behavior Embarrassing behavior at social functions Arrest for DUI or other legal problems Source: Thomas Wallace, M.D., J.D., M.B.A., F.A.C.P.E., vice president and chief medical officer, Methodist Medical Center in Oak Ridge, Tennessee, and Joint Commission Resources consultant.

Set High Expectations
Although it is important for organizations to have systems in place to identify impaired physicians; first and foremost, they should create codes of conduct for all employees to follow. “If leaders set boundaries and parameters on what is acceptable, they will be more successful in consistently meeting those expectations,” says Thomas Wallace, M.D., J.D., M.B.A., F.A.C.P.E., vice president and chief medical officer, Methodist Medical Center in Oak Ridge, Tennessee, and Joint Commission Resources consultant. All staff members should uphold a professional competence, or the “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.”1(p.107)Those staff members who do not maintain professional competence must be held accountable for their actions and supported through a recovery plan, if necessary.

Options for Action
Although the causes of physician impairment are deep seated and the obstacles to addressing it are significant, ignoring the problem is not an option. In fact, the Joint Commission requires health care organizations to develop a systematic approach to physician impairment. Standard MS.4.80 reads: “The medical staff implements a process to identify and manage matters of individual health for licensed independent practitioners. This identification process is separate from actions taken for disciplinary purposes.”

Leape and Fromson propose a model system based on objectivity, fairness, and responsiveness to reduce the risk of impaired and disruptive physicians practicing within an organization.1They envision a four-stage process:

1. Adopting standards. The health care organization adopts “explicit performance standards of behavior and competence.”1
2. Requiring compliance. As part of the credentialing process, the organization requires all physicians to agree in writing to the standards and acknowledge that persistent violation will lead to loss of privileges.
3. Monitoring performance. Every physician undergoes a formal annual evaluation, using specified measures, including peer and coworker evaluations and investigation of patient complaints.
4. Responding to deficiencies. When monitoring reveals significant problems, the department chair takes steps to provide an appropriate response. Possible moves include additional evaluation, personal counseling, and referral for treatment. “In cases that threaten patient welfare, department chiefs and hospital leaders must take immediate action to limit practice during assessment and rehabilitation.”1

One hurdle to implementing this kind of system is developing objective measures for identifying impairment. Leape and Fromson say that one of the keys is basing evaluations on validated data, not “subjective judgments of personality, motivation, or character.”1(p.109) They note that some researchers have found analysis of patient complaints to be an effective way to identify physicians with interpersonal problems. Evaluation surveys (filled out by peers, coworkers, and patients) that compare individual to group results offer another possible measure. Apart from annual reviews, there are measures that can be used to monitor for physician impairment on an ongoing basis. Wallace says his organization uses several objective measures to monitor for impairment among anesthesiologists:

• Random checks to detect siphoning of anesthetic drugs
• Audits of patient charts and anesthesia forms to uncover drug diversion
• For-cause drug testing
• Use of dispensing software to detect abnormal drug
• usage patterns that can indicate abuse

Wallace, who serves as a consultant for Joint Commission Resources, says Methodist also tracks complication rates for surgeons. This helps the organization identify competency problems and, in general, monitor for impairment due to age.

TIP: Employ a Staff Psychologist. In 1996 Kamela K. Scott, Ph.D., joined the faculty of the Department of Surgery of the University of Florida Health Science Center in Jacksonville. A professional psychologist, Scott was brought on to provide counseling to trauma/critical care patients and their families. One unexpected consequence was that she became an unofficial resource for identifying and helping surgery residents with symptoms of impairment.3

“When you work on the front line with the faculty and the residents, you begin to develop camaraderie and a sense of trust,” says Scott. Because of that trust, colleagues frequently came to her with concerns about possible impairment in themselves and each other. She is able to provide immediate, confidential access to help.

Employing a staff psychologist may be one of the many solutions hospitals use to protect patients from impaired physicians. “In medicine, there is often a ‘man of steel’ attitude—that you aren’t affected by critical illness and death,” says Scott. “That’s a farce because we all have emotions.”

Wallace notes that physician impairment often manifests as disruptive behavior. At Methodist Medical Center, staff members and employees can anonymously report any abnormal or unacceptable behavior, using the organization’s Physician Behavior Report. This report automatically triggers an investigation and an appropriate administrative response. Wallace stresses the importance of having set policies and procedures for dealing with impairment issues. “If you get into court, the key questions will be ‘did you follow your process’ and ‘does it appear to be a reasonable process in terms of fairness.’”

One closely related issue is the importance of organizational culture. Jane, the nurse operated on by an impaired surgeon, believes hospitals must support individuals who call attention to potential problems. “This is very much a culture issue,” she says. “People in a hospital have to feel very secure when they speak up that there will be no recourse taken against them.”

Sidebar 2. How the Aviation Industry Protects You from Impaired Pilots Both health care and aviation are highly technical fields that depend on complex interactions between members of a team. When it comes to dealing with impairment, can health care organizations learn from aviation? Aviation safety expert Dennis Lessard, chair of the Aeronautical Science Department in the College of Aviation at Embry-Riddle Aeronautical University, says the commercial aviation industry has implemented several safeguards to protect air passengers from impaired pilots: Cross-checks. Crew members are trained to evaluate each other for signs of impairment before every flight. Authority to intervene. If a copilot believes the captain is not up to the task, he or she can cancel the take-off or even take over control of the plane. Nonpunitive processes. Pilots can report impairment concerns anonymously. This triggers an automatic inquiry process and can lead directly to medical examination or psychological assessment. Lessard says pilots are also subject to periodic medical exams and random substance testing. The lesson for health care leaders, Lessard believes, is the importance of building checks and balances into the system. “As humans, we can’t be on the top of our game all the time,” he says. “Checks and balances are very important in high-risk operations.”

Improving Assessment Programs
Because a physician’s competence level can often be an indicator or symptom of impairment, there is a need to improve the accuracy and reliability of assessment programs. Obviously, physicians are required to pass a standardized examination, but the examination only tests a physician’s knowledge and not his or her fine motor skills. “Simulator technology has not been developed enough to accurately test a physician’s overall competence,” says Wallace. “Until this type of technology is developed for the health care industry, there will be limitations on our assessment programs.”

Getting Help
One of the essential elements of an effective response to impairment is access to follow-up resources. In the United States, many resources are supplied by state physician health programs (PHPs), which are organizations that provide third-party assessment, treatment referral, and monitoring for impaired physicians.

“Most state programs started by providing services for alcohol and drug abuse,” says Yvonne Garber, L.C.S.W., C.E.A.P., executive director of the Federation of State Physician Health Programs. However, since their inception, many PHPs have widened their scope to include a broad range of health-related issues that have the potential to develop into impairments—mental health, medical illness, stress management, professional boundary issues, and unprofessional behavior issues. “If you are going to treat addiction,” says Garber, “often there are mental health issues that need to be treated as well.”

Garber says PHPs have very good success rates for enabling physicians with identified impairments to return to practice. (To find the PHP in your state, visit http://www.fsphp.org.) She makes a distinction between illness and impairment. “Just because a doctor has an illness does not mean that he or she is impaired to work,” says Garber. “Having a group like a PHP that can make that distinction and monitor the situation is critical.” Garber believes PHPs are an essential element of the patient safety culture. “We are safer when we acknowledge problems (making it safe to get assistance) than we are by brushing them under the carpet.”

References

1. Leape L.L., Fromson J.A.: Problem doctors: Is there a system-level solution? Ann Intern Med 144:107–115, Jan. 2006.
2. Boisaubin E.V., Levine R.E.: Identifying and assisting the impaired physician. Am J Med Sci 322:31–36, Jul. 2001.
3. Veldenz H.C., et al.: Impaired residents: Identification and intervention. Curr Surg 60:214–217, Mar.–Apr. 2003.

Source: Joint Commission Resources: Identifying impaired physicians: How to address problem physicians quickly. Patient Safety 6:1-13 Jul. 2006.