Early interventions can make an impact
■ A column that answers questions on ethical issues in medical practice
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted May 2, 2005.
What are the essential elements of a successful intervention for those with substance use or other problems?
A doctor who was a participant in our physicians' health program telephoned me. He was concerned about a colleague who was his superior. The concern was about his superior's use of alcohol and benzodiazepines. There were incidents in which his superior had behaved inappropriately at a hospital function, had uncharacteristically berated someone from the nursing staff, and had not performed up to his usual high standards. There were a few other occasions when someone smelled an "alcohol-like" odor on this physician's breath.
It is very important to have solid facts and dates available when one meets with such a physician. The intervener should be able to approach the physician with facts and concerns in a nonthreatening and nonjudgmental fashion. The meeting should occur in a neutral place where it cannot be terminated prematurely or controlled by the subject of the intervention.
A plan of action, one that will ultimately resolve the concern, should be ready beforehand with preparations for amelioration in place. Lastly, the intervener should be ready to explain the unpleasant consequences if the physician is in fact impaired and is a risk to himself or herself and to the public safety and welfare of patients.
I arranged to meet with the physician on a Monday morning as his first appointment. Monday mornings are usually good times to meet someone who may have a substance use problem because he or she may be recovering from the effects of use from the weekend. The physician was cordial but also visibly shaking and emitted a faint alcohol-like odor. I reviewed with him that I had received a concern about his health and that I was there to offer him some help and assistance if he needed it and chose to accept it. I went over the specific dates, places, and incidents that led to my visit.
The doctor, as is usual in many cases, had explanations for each incident and offered that "they" were out to get him.
I then pointed out his physical presentation, the tremors in his hands, his perspiration, and the alcohol-like odor emanating from him. I told him about denial and validated his fear of consequences.
Then I offered him the confidential track our state provides for physicians who self-report and enroll into our program. I also pointed out that enrollment in our program would provide him with advocacy once he entered into recovery and would make it more difficult for "them" to get him. He entered into treatment for alcohol and benzodiazepine dependence, and has been in documented continuous recovery for more than 10 years.
The intervention was successful because the approach was honest, straightforward, fact-filled, and done with care. No issues of power or control were introduced into the process, and a reasonable outcome was discussed beforehand.
Two other key elements to the successful outcome were the offer of confidentiality and the recognition by the doctor that refusal to engage in the process would be self-destructive inasmuch as our state has a "duty to report" requirement for all licensees if a colleague is suspected of being impaired.
Since the Institute of Medicine's "To Err is Human" report on medical errors was released in 1999, the American public and the health care industry have become more concerned about impairment among physicians. How many of the estimated 45,000 to 100,000 annual deaths reported to occur from medical errors were directly related to physician error? The conservative estimate is that 10% to 15% of licensed physicians in the United States may have an impairing condition, whether from drugs, alcohol, psychiatric illness, or another physical or medical condition.
As physicians, we are compelled by our ethical standards and, in most cases, by state law and regulation, to engage in professional self-regulation when it comes to physician impairment. We owe it to the profession and to the patients that we have vowed to care for under the Hippocratic Oath.
Although many states have implemented programs to address physician impairment, nothing seems to be more effective than one physician intervening with another.
Louis E. Baxter, MD, Executive medical director of the Physicians' Health Program of the Medical Society of New Jersey; medical director for the Division of Addiction Services, New Jersey Dept. of Health.
By speaking openly, honestly, and respectfully to those physicians who do seem troubled, we may help save a career -- or even a life.
In one such case, administrators at a small community hospital received information from a third-party payer that a young internist on staff had been receiving multiple prescriptions for controlled substances from a large number of the hospital's providers over a relatively short period of time. The physician had been taking considerable time off for treatment of multiple illnesses and interacting poorly with colleagues.
The chief and the administrator met with the physician and confronted him regarding the report of multiple prescriptions, and the physician immediately became defensive. He adamantly denied any addictive problem, insisting that all of the medications were legitimately prescribed by physicians and that any suggestion that he had a "problem" would result in legal action against the hospital. The hospital decided to place the physician on medical leave status and refer him to the state physician health program.
At his first PHP interview, the physician, infuriated at having been accused of being a "drug addict" by his hospital, steadfastly denied having any problems, and focused on his multiple legitimate illnesses, including chronic pain and a metabolic disorder. He stated that he had a primary care doctor who was aware of these conditions and that because this doctor was often unavailable, he occasionally had no choice but to seek pain medications from colleagues. He also noted that he had underlying depression secondary to family and marital problems for which he was self-prescribing antidepressants.
The physician was asked to participate in an extensive evaluation. Meanwhile, he lost his credentials with a third-party payer, and the hospital was considering disciplinary sanctions, a report to the state licensing board for violation of regulations, or both.
The PHP recommended the physician sign a contract to support him and monitor his substance use. As part of this contract, he agreed to have a single prescribing physician. Other physicians could provide care and specialized treatment, but they would then communicate any prescription needs to the designated primary care physician.
The contract provided for monitors in the workplace who were willing to alert the physician and the PHP to any apparent changes in behavior that might indicate a recurrence of problems. The physician agreed to attend peer support meetings and to work with a therapist to address the personal challenges that he had been facing and attempting to self-treat.
Over the following weeks, the physician's antagonism lessened. He became more aware that his actions did suggest he had a problem. Although it took time, he did recognize the need for improved monitoring of his illnesses and the need to address his pattern of abuse of prescription medications. The physician did well the next several months, except for one incident that required additional action.
The physician has now been monitored under PHP contract for more than four years. He has stopped all pain medications and feels his illnesses are better controlled than ever. He also is now fully employed at another hospital and has risen in the ranks of that academic institution.
Confronting a physician regarding early signs or symptoms of behavioral change may lead to early recognition of health problems including substance abuse, emotional problems, or medical illnesses. Had some of his colleagues refused to provide prescriptions, he may not have established the drug-seeking pattern that eventually developed. Had his colleagues been more attentive to the apparent changes in his behavior in the workplace, perhaps he could have received help before he lost his hospital job.
In the end, he was one of the lucky ones. He did get help. His pain is now managed safely and effectively. He has not harmed any of his patients and has not lost his license to practice. As a physician in recovery recently said, "I wish someone had reached out to assist me sooner, not for me, but for my patients."
We have an ethical obligation and a loyalty to our profession to protect our patients by assisting our peers in need.
As difficult as it may seem, timely recognition and intervention by colleagues can save a physician's career and even a life.
Luis T. Sanchez, MD, director, Physician Health Services, a Massachusetts Medical Society corporation
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.