The Impaired Surgeon

The Impaired Surgeon Ranjan Sudan, MD*, Keri Seymour, DO KEYWORDS Impaired Physician Alcohol Drugs KEY POINTS Impaired physicians commonly refers to those who suffer from substance use disorders (SUDs). The annual prevalence is approximately 10% to 12%. Treatment is available through physician health programs (PHPs). Prognosis for recovery and preservation of the ability to practice medicine are excellent for more than 70% of the participants. BACKGROUND According to the American Medical Association (AMA), an impaired physician is one whose physical or mental health interferes with their ability to engage safely in profes- sional activities.1 Such impairment can be the result of a substance use disorder (SUD), mental health issues, or physical health problems. Although by this definition “physician impairment” can be used broadly, it is more commonly used to describe a physician who has a SUD and is the focus of this article. Previously, substance abuse and substance dependence were 2 separate diagnostic categories. The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edi- tion), however, combined them into a single disorder that is measured on a continuum from mild to severe, and each specific substance use is addressed separately (eg, alcohol use disorder). To diagnose SUDs, 11 symptoms are assessed that relate to impaired control, social impairment, risky use, and pharmacologic criteria, such as tolerance and withdrawal. In general, a mild SUD is suggested by the presence of 2 to 3 symptoms, moderate by 4 to 5 symptoms, and severe by 6 or more symptoms. These include taking the substance in larger amounts and for longer period than intended; wanting to cut down or stop using the substance but not being able to; spending a lot of time getting or recovering from use of the substance; craving and urges to use the substance; not keeping up with work or school because of substance Disclosure Statement: The authors have nothing to disclose. Department of Surgery, Duke University Medical Center, Box 2834, Durham, NC 27710, USA * Corresponding author. E-mail address: [email protected] Surg Clin N Am 96 (2016) 89–93 http://dx.doi.org/10.1016/j.suc.2015.09.006 surgical.theclinics.com 0039-6109/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved. 90 Sudan & Seymour use; continuing to use the substance even when it is causing problems in relation- ships; giving up important social, occupational, or recreational activities because of substance use; using substances repeatedly even when it puts a person in danger; continuing substance use despite the knowledge that physical or psychological problems have been caused or made worse by the substance; and needing more substance to get the effect (tolerance) or the development of withdrawal symptoms. Prevalence In the United States, the 12-month prevalence of alcohol use disorder in the general population is estimated to be 8.5% among adults age 18 years and older with greater rates among adult men (12.4%) than among adult women (4.9%).2 Many studies es- timate that the rate of alcohol use disorder in physicians parallels that of the general community and the factors that predispose individuals to SUDs are similar among physicians and the general population. Certain factors are unique to physicians such as easier access, knowledge of the medications, and the ability to prescribe, which predispose to higher use of opioids, benzodiazepines, fentanyl, and propofol, particularly in certain specialties, such as anesthesia and psychiatry.3–10 Despite similar prevalences of SUDs among physicians and the general population, physicians are held to a higher standard because of the trust that society has placed in them to make critical life-and-death decisions for patients and their conduct has the potential to impact the quality and safety of health care delivered. Therefore, SUDs have far-reaching consequences not only for physicians and their own families but also on the work environment and the patients they treat. Impairment Is Treatable In recognition of the impact that impairment has on physicians and on their community, a landmark article was published in the Journal of the American Medical Associ- ation in 1973 by the AMA Council on Mental Health, “The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence.”11 The work of this council led the AMA to acknowledge physician impairment in 1974, recognizing alcoholism and other SUDs as illnesses and suggesting alternate ways of managing them other than through disciplinary actions, and eventually led to the development of physician health programs (PHP) in all states. Prior to that, the Federation of State Medical Boards identified drug addiction and alcoholism among doctors primarily as disciplinary problems and very few states had programs in place to treat impaired physicians. PHPs are now available in every state and are administered either by the state medical boards or the medical societies. The Federation of State Physician Health Programs is a forum for exchange of information among these various programs that seeks to standardize their goals and objectives. It is also engaged in advocacy for impaired physicians while at the same time safeguarding the public. A physician may either self-refer or be referred to a PHP by a colleague or a medical staff office. Entering a contractual agreement with a PHP helps impaired physicians get appropriate treatment confidentially, allowing them to keep their license and subse- quently practice, after completing treatment. Thus, formal disciplinary action is avoided while they obtain treatment. Typically, PHPs do not themselves provide treatment but they do provide early detection, assessment, evaluation, and referral to selected treatment facilities. Many of these facilities provide residential treatment for 60 to 90 days followed by a 12-step–oriented outpatient treatment program that includes frequent random drug and alcohol testing along with workplace monitors. The reports of these evaluations are then provided to appropriate credentialing authorities, such as hospi- tals, malpractice companies, and health insurance companies for 5 or more years. The Impaired Surgeon 91 This reporting system allows the participant to practice while simultaneously protecting patients and coworkers. Operating funds for a PHP come from state licensing boards, participant fees, state medical associations, hospital contributions, and malpractice companies. A mean of 34 physicians enter a PHP each year. On entering, the participant must sign a contract that provides the specifics of treatment and monitoring and the consequences of not adhering to this contract. PHPs do not have the authority to disci- pline physicians but they can make recommendations to state licensure boards that could result in severe disciplinary repercussions. Preservation of license and the ability to practice are, therefore, strong motivators for physicians to stay engaged in the program.12,13 Several studies have shown that more than 70% of the physicians going through a PHP were able to stay in practice 5 years later. IDENTIFYING AN IMPAIRED PHYSICIAN The AMA has now made it an ethical obligation to report impaired colleagues in accor- dance with the legal requirements of each state to ensure that impaired physicians cease practice and receive appropriate assistance from a PHP. Identifying an impaired colleague has its challenges, because physicians are good at hiding their substance use and often the problem has to be severe before it is discovered. Some authors have recommended mandatory testing for drugs and alcohol after a sentinel event such as after an accident in the airline or transportation industry.14 More often, deteriorating social and interpersonal behaviors are first noticed by friends and family. In the work environment, inaccessibility to patients and staff, unexplained absenteeism, frequent conflicts with coworkers, and frequent moves to different loca- tions for jobs may be warning signs.15 Certainly, the smell of alcohol on a person’s breath or impaired motor coordination at work cannot be ignored. Comorbid mental disorders are also common in physicians with SUDs and are associated with a higher relapse rate. Major depression, bipolar disorder, social phobia, generalized anxiety disorder, and antisocial personality disorder were among the more common diagno- ses identified in impaired physicians and may also predispose towards suicide.16,17 Although such symptoms are noticed by peers, they are reluctant to report an impaired colleague or a friend to the appropriate authorities. The desire to avoid confrontation or fear of damaging a physician’s career, especially when the signs and symptoms are subtle, is among the stated reasons for this reluctance.18 It is an ethical obligation, however, and in most states a legal requirement, that physicians report impaired colleagues to the state medical boards or PHPs. The PHPs then un- dertake suitable in-depth evaluation and make further recommendations. INTERVENING WITH AN IMPAIRED PHYSICIAN Colleagues should not diagnose or treat an individual with an SUD. Instead, they should record details of the behavior and performance suggestive of an SUD. Present- ing these facts becomes important when performing an ‘intervention’ with an impaired physician. An intervention is the formal process of presenting these facts and is led by an experienced individual. Friends, families, and coworkers can also

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