Lecture X: Practitioner Impairment & Recovery

Question 1

Define the definitions and prevalence of impairment among practitioners.

a) physician impairment

Answer 1

a. Physician Impairment- “The inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness, including alcoholism or drug dependence.” “Impaired implies an enduring condition which, w/out effective treatment, is not amenable to remission, e.g. substance use disorders, mental illness and other medical conditions.” (JAMA)

Question 2

Compare risk of substance use disorders between practitioners and other populations

Answer 2

e. Alcohol and drug problems- Prevalence for physicians is thought to be similar to that of the general population
f. Physicians/Nurses use benzodiazepines, weaker opioids, and intravenous substances more frequently than the general population because of enhanced access.
g. Risk Factors for SUD in healthcare professionals
i. Work-related stress
ii. Things that the worker considers self-medication for: insomnia, pain, fatigue
iii. Emotional problems
iv. Availability
v. GENETIC RISK

Highest risk for anesthesiologists, rural family physicians, psychiatrists

Question 3

Substance Abuse

Answer 3

b. Substance abuse = continued use of a psychoactive substance despite repeated negative consequences of such use = Use + Consequences + Repetition

Question 4

Substance dependence

Answer 4

c. Substance dependence = Substance abuse + Neuroadaptation, leading to some or all of: Cravings, Compulsitivity in use, Preoccupation with obtaining the substance, Physical dependence (tolerance and/or withdrawal), and Loss of Control of Substance Use

Question 5

Depression

Answer 5

d. Depression - persistently depressed or anxious mood, decreased or increased sleep, decreased or increased appetite and weight, difficulty concentrating, decreased energy, sense of helplessness and hopelessness, anhedonia (lack of pleasure), social withdrawal

Question 6

Symptoms and signs of impairment due to substance abuse and depression

Answer 6

a. Isolation
b. Friction with colleagues.
c. Disorganization
d. Inaccessibility
e. Frequent absences
f. Inappropriate care or forgotten tasks
g. Slurred speech during off-hours calls.
h. Prescriptions for family members.
i. Rounding on patients at odd hours.
j. Overdose or suicide attempt.
k. mood swings
l. change in work habits
m. change in energy levels
n. increased complaints about work/martyrdom
o. complaints from other staff/patients

Question 7

Why do practitioners typically have high rates of recovery from substance abuse?

Answer 7

a. Physicians can afford intensive programs and lengthy follow-up.
b. Monitoring program
c. Physicians have a lot at stake
d. Intelligence is often a hindrance, because it can enhance rationalization and denial.
e. Some treatment programs are tailored for health care professionals
f. Health professional self-help group is cornerstone
g. At 1 - 2 yrs, recovery rates range from 64% to 100%, usually 80% to 90%.

Question 8

Arguments FOR reporting impaired peers:

Answer 8

i. Impaired physicians may hurt patients.
ii. Biomedical, psychological, family, legal (non-professional) consequences.
iii. Malpractice suit/settlement/judgment if impaired physician makes mistakes.
iv. Alcoholics and addicts often don’t realize how miserable they are until they get help. (Recovery is wonderful!)
v. Helping a colleague get help benefits them and many others.
vi. Even if a medical career is terminated, it’s better that lives are saved.
Impaired Physician Advocacy Programs
• Goals: Protect the public, and help impaired physicians get help and stay in practice
• Structured to encourage reporting
• Administered by State Medical Society, licensure board, or independent organization
• Relationship with the state licensure board
• Parallel programs in hospitals and medical schools

Question 9

Arguments AGAINST reporting impaired peers:

Answer 9

i. Suspension/loss of hospital privileges by impaired physician if someone tells on them.
ii. Discipline/revocation by state board if impaired physician found to be impaired.
iii. National Physician Databank Entry-Record will follow impaired physician forever.
iv. Lack of solid evidence that physician is impaired, depressed, using drugs, alcohol, etc… (i.e., What if I report this physician, who I think is impaired, but I’m wrong?).

Question 10

3. List barriers to identification and treatment of substance abuse in practitioners

Answer 10

a. Symptoms appear last in the workplace.
b. Denial and rationalization by the impaired physician; resistance to help.
c. Limited training in alcohol/drug problems and denial by others.