Warning signs of physician alcohol impairment

Scenario: Let’s say that like most people, and most physicians, you enjoy an alcoholic beverage from time to time. After work, you find that a drink relaxes you. You may not explicitly perceive ethanol’s pharmacological effects to allay fatigue and make your dinner taste better. But you notice that having one drink is now a daily occurrence, or you even have two each night. Instead of reading or working out, you prefer that evening cocktail.

Reply: The American Medical Association Code of Medical Ethics says physicians have the professional obligation to maintain and promote their own health and well-being. This means having a personal physician, seeing her or him, heeding recommendations and participating not only in disease prevention and health promotion but also pursuing self-care activities. No one wants to have a problem with alcohol, and nine in 10 practicing physicians do not have such a problem. But, short of addiction to alcohol, what is “problem drinking”?

Terminology in the alcohol field is admittedly confusing, and the upcoming revision to the American Psychiatric Assn.’s Diagnostic and Statistical Manual may confuse as much as it clarifies. Epidemiologists have come to understand that heavy consumption of alcohol is unhealthy, even if no “substance use disorder” is present.

According to the National Institutes of Health, the threshold for “unhealthy drinking” is more than 14 drinks a week for a man (not yet a senior citizen) and more than seven drinks a week for a woman who is not pregnant or attempting to become pregnant. Actuarially, unhealthy drinking is that which carries an increased likelihood of the development of an illness or an injury caused by alcohol. It gradually and almost imperceptibly may become illness with potential to lead to impairment. Harmful drinking includes patterns of consumption already associated with medical or other complications.

For any physician who notices that the use of alcohol or another drug is taking on a position of centrality in their lives — that choices to use alcohol are nudging out other activities one could pursue — then self-reflection is called for. Any physician who becomes aware that alcohol adversely has affected his or her general medical status or mental health status should take steps to alter patterns of use. Any physician who exceeds the guidelines for unhealthy drinking as set by the NIH is taking a risk that they would not want any of their patients to take — and that they should counsel their patients against doing. And a health maintenance or disease prevention intervention that is good enough to recommend to your patients is one worth following yourself.

The issue of having a drink — even one — when on duty or on call is a separate discussion. Various forums and surveys have shown that physicians have mixed feelings about this, but patients are unequivocal: They expect all physicians to be completely alcohol-free while on duty. But neither guilt nor concern for professionalism nor health concerns should lead a physician who is off duty to think that a drink, consumed in a socially appropriate context, is incompatible with the highest standards of personal or professional behavior or ethical conduct.

Finally, there is the issue of true addiction to alcohol, an illness that affects close to 10% of physicians. Medical ethics directs physicians to approach colleagues who they think are manifesting signs of an illness that could impair practice. At times, state statutes direct a physician who knows of another physician whose behavior is placing patients at risk of harm to report the “impaired physician” to an entity that can intervene.

Reporting to a physician health program, which is nondisciplinary, is generally considered preferable to reporting to an entity that can mete out discipline, such as a hospital credentials committee or a state licensure board. Physician health programs have the obligation to protect public safety, and they are obliged to notify licensure boards when they determine that a physician’s active health problem could put patients at risk, were the physician to continue to see patients.

The AMA says that when a physician has self-awareness of a health problem that could impair job performance, he or she has an ethical obligation to self-report. But the defense mechanisms that naturally come into play in such situations make it unlikely that physicians with active addiction will self-report.

Still, the existence of physician health programs makes it more likely that physicians will self-report for conditions of clinical depression or substance use disorder or even in cases of burnout where there is no diagnosable health condition. The best state physician health programs are reporting that more than 50% of program participants are self-referrals. The best programs, in my opinion, are those with the highest rates of participation of physicians, address the widest range of situations (i.e., health promotion and not just treatment monitoring) and are most trusted by potential referral sources to guarantee confidentiality and compassion in the way they work with program participants.

In a 2008 study of 904 doctors who had entered physician health programs in 16 states for alcohol or substance abuse, 72% successfully returned to the practice of medicine with unrestricted licensing and were abstinent at five-year follow-up. Ninety-one percent of those who completed the programs were able to continue practicing in some capacity.

Michael M. Miller, MD, medical director, Herrington Recovery Center, Rogers Memorial Hospital, Oconomowoc, Wis.; director, American Board of Addiction Medicine