Physicians Under the Influence: Intervention & Treatment

Identifying physicians who are impaired can be difficult since the manifestations are varied and physicians are notoriously suppressive and able to deny any suggestion of a problem. Identification is essential, however, because patient well-being may be at stake and untreated impairment may result in loss of license, health problems, and even death for the physician.

We sat down with two leading authorities on the issue of impaired physicians: Ethan Bryson, MD, an associate professor of anesthesiology and psychiatry at Mount Sinai Medical Center in New York City, and Karen Miotto, MD, a clinical professor in the department of psychiatry and behavioral sciences at UCLA, where she is also chairman of the physicians’ wellness committee at the UCLA Medical Center. The discussion was moderated by Peter Salgo, MD, professor of anesthesiology and internal medicine at Columbia University in New York City.

Salgo: What are some of the warning signs for doctors to be aware of in detecting impairment in their colleagues? Dr. Miotto, what are some of the best practices for successful intervention? First of all, how do you find somebody who’s using?

Miotto: I think you don’t look in the workplace because, usually, what’s preserved is workplace function. I think what’s so important is that, when a physician has a substance use disorder, usually, it’s like a puzzle. And everybody has a piece of the puzzle, but no one can really put their finger on it. So it’s important to have, whether it’s your employee assistance program or your wellness committee, someone that could help and be the receptacle for multiple pieces of the puzzle.

Salgo: So how do you successfully intervene? How do you confront your colleague? Give me a road map, if you will.

Miotto: Well, I think, usually, what happens is people talk among their colleagues. What did you see? And who’s someone that’s close to them? And, of course, what’s important is you don’t walk up to them and say, “You need treatment.”

Salgo: That’s what I was getting at. You can’t just do that. You’re just going to get push back, right?

Miotto: Yes, so usually people say, “I’m concerned. You look tired. You need a break. You need a day off. You need to talk to your friend at the hospital down the road.” Small gestures are really important, and part of the small gestures in talking to each other are putting together the pieces of the puzzle: He didn’t finish the consult. He was lying on the floor in the call room. So you get the pieces of the puzzle. And then, if you’re in a hospital, going to your medical staff health committee or your wellness committee is a good next step.

Salgo: Isn’t there an ethical and a legal obligation upon physicians and hospitals and medical schools to deal with this forthrightly and to report impaired physicians, Dr. Bryson?

Bryson: Absolutely. I think the problem is, as physicians, we are very good at compartmentalizing everything, including our emotions, our response distress, our relationships. It’s very easy to keep our problems at home separate from problems at work. So, just as Dr. Miotto was saying, you will see problems at home develop long before you see problems at work. But the people at home don’t really have access to the people at work and vice versa. The addict will keep them separate. They will do everything they can to maintain this façade that everything is just fine. And denial is not just limited to the addict. Every single one of us who has experienced a colleague in that situation and, in retrospect, behavior which was obvious, but which we weren’t willing to call them on, is just an example of how denial affects us as observers, as well as the addicted physician.

Salgo: But it’s not just denial. There’s a legal obligation to do this, isn’t there?

Bryson: I believe there is. Absolutely, and there’s an ethical obligation to do so.

Miotto: It varies by state. In some states, it’s actually legal, and it’s written into the code. And, in other states, it’s stated as an ethical obligation.

Bryson: What we do not have is consistent policy from state to state. And what we absolutely do not have is an adequate level of education, everywhere from medical school to residency, even through practicing physicians, to give them the tools that they need to be able to identify and to know what to do when they suspect their colleague has a problem. As you mentioned earlier, you absolutely cannot confront someone by yourself. That’s only going to make the problem worse. There have been documented cases of physicians committing suicide after it became obvious that they would be found out very shortly. So this is something that has to be handled very carefully. It has to be done by professionals who know what they’re doing. And everybody in the group needs to know what sort of behaviors are suspect and then what to do when they see them.

Salgo: We screen for lots of diseases. What about random drug testing for physicians? Is this done anywhere now, and is this ethical?

Miotto: Many hospitals and facilities have pre-employment drug testing. And most hospitals have drug testing, for cause, if a physician is suspected of being under the influence. Some medical schools are actually talking about random drug testing of students and residents.

Salgo: But isn’t there a sense among physicians of society just beating us up? Isn’t there this victimization feeling among the medical community, and won’t that just add to it, Dr. Miotto?

Miotto: I think the approach that’s been discussed of education and destigmatization is so essential, and the public health

campaign that we need to embrace as physicians to take care of each other, to look out for each other, to be more concerned about our well-being, is so important. And so, starting out with the random drug testing misses such an important ingredient in combating this disease or addressing this disease in physicians.

Salgo: What am I missing? If it’s a medical disease, why don’t we just come out in the open, admit that it’s a medical disease, and admit we’re going to screen people for it?

Miotto: But there is a stigma attached. It’s the same argument as, should all high school students be drug tested: Who should have access to the information? What does a positive test mean? Should we kick them out of high school? Should we kick them out of medical school? Should we kick them out of the med staff of a hospital if a test comes back positive? So without putting into place a real campaign to understand and evaluate and embrace our colleagues who struggle with this disorder, I would worry it would turn into a witch hunt.

We want to hear your opinion on the issue of impaired physicians:

• Have you encountered an impaired physician during your career? How was the situation resolved?
• Do you believe drug and alcohol testing should be mandatory for physicians?
• Do you believe patients have a right to know if their physician has undergone treatment for substance abuse?
• What can medical societies, hospitals, and the government do to combat this problem?