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34-The impaired
physician – healing the wounded doctor
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"A gem cannot
be polished without friction, nor a man perfected
without trials. "
- Chinese Proverb. |
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A doctor’s life is extremely stressful, and doctors
have one of the highest suicide rates amongst professionals.
Some doctors start abusing drugs or become alcoholics when
they cannot cope with the stress they are under. However,
the medical profession tries to hide these impaired physicians,
and they usually remain medicine’s dirty little secret.
This is because most doctors would rather pretend that such
problem doctors do not exist. However, pretending that there
are no problem doctors just makes the problem even worse for
everyone: for the doctors who are having problems since they
have nowhere to turn to for help; for their patients , because
impaired doctors provide inadequate medical care and can cause
harm; for the profession’s public image, when these
problem doctors come to light; and for society at large, which
loses faith and confidence in the medical profession.
An impaired physician is defined as one who is "unable
to practice medicine with reasonable skill and safety to patients
because of physical or mental illness, including deterioration
through the aging process or loss of motor skill, or excessive
use or abuse of drugs, including alcohol." Impaired doctors
are not uncommon, and studies show that ten to fifteen percent
of physicians will have a problem affecting their ability
to practice medicine at some point in their careers. In fact,
such a high incidence should hardly be surprising, because
many of the personality traits which cause doctors to choose
medicine as a profession , also predispose them to abuse drugs.
These include: compulsiveness, conscientiousness, and the
need to retain control over their feelings. Easy access to
drugs of abuse just compounds the problem.
What is really remarkable about the problem is not that it
exists – but rather that we refuse to discuss it publicly
! The major difficulty in solving the problem of impaired
doctors is the conspiracy of silence which surrounds them–
and most colleagues of a problem doctor often refuse to acknowledge
that something is wrong, even when faced with evidence that
should arouse suspicion: alcohol on the doctor's breath, disheveled
appearance, an explosive temper, repeated failure to return
patient calls, or consistent tardiness. Why is it so hard
to report a problem doctor?
Doctors are groomed to think of themselves as a breed apart,
and this notion can lead to a dangerous arrogance. Doctors
have always been expected (and many treat themselves) to be
infallible – only one step below God. This is why many
doctors adopt denial as a defense mechanism when they feel
one of their colleagues is malfunctioning. Denial isn't lying
- it's an unconscious defense mechanism used to avoid facing
a fearful truth. For a doctor to acknowledge that a colleague
has a problem means the entire profession is vulnerable to
that problem – and it also emphasizes your own vulnerability.
Also , the professional bond is so strong, that doctors do
not want to report problems in their colleagues – they
do not want to be considered to be whistleblowers, because
they then run the risk of being ostracized by colleagues and
the medical community.
What are the clues which should lead you to suspect a colleague
may have a problem ? These are usually fairly obvious –
once you stop taking an “ostrich in the sand “
attitude. A physician who is impaired will go through subtle
personality changes as the disease progresses. Mood swings
will occur, ranging from irritability, outbursts of anger,
and paranoia to sudden euphoria and hyperactivity. He may
be frequently absent; behave badly with staff and patients;
give inappropriate orders; and his handwriting may deteriorate.
Physical symptoms of chemical dependence include declining
personal hygiene, multiple physical complaints, frequent hospitalization
or visits to physicians, and accidents. The physician may
withdraw from involvement in community activities and display
embarrassing behavior at parties.
Unfortunately, many of us compound the problem by inadvertently
enabling it. Many hospital doctors employ a strategy of protective
support towards their impaired colleague, and quietly shift
work away from him and do it themselves. This strategy may
protect his patients, but it's of no help to the physician,
who should be regarded as a patient himself—especially
if he has a chemical dependency. Ignoring an addiction problem
is a death sentence !
So what can you do if you suspect a friend has a problem ?
Please don’t ignore it or blame him for it – he
may be crying for help, and may not know where to turn ! You
can have an off-the-record session to let him know that there
are concerns about him – and that you are concerned
for him. Such a chat allows you to gather more information,
assess whether the doctor realizes he has a problem, and,
if appropriate, urge him to seek help.
In order to cope with this ever-increasing problem, many developed
countries have Physician Health Programs , which diagnose
impaired physicians, treat them or refer them to treatment
programs, and monitor them. The purpose of these programs
is rehabilitation, not witch-hunting. When they receive a
report on a potentially impaired doctor, they begin a discreet
inquiry. They assess the reliability of the reporting sources,
gather corroborating data and wait till they reach a critical
mass of information before they take action.
The best PHPs have been remarkably successful in helping impaired
physicians. The secret of most effective PHPs is a careful
monitoring program which includes 1) random urine or blood
screens for drug testing , 2) written reports from counselors,
3) self-reports written by the physician in recovery, and
4) written verification of attendance at self-help and support
group meetings. Doctors who relapse either are retreated,
subject to intensive monitoring, or reported to their medical
councils for disciplinary action in order to protect patients.
Indian doctors need PHPs too, and I hope that the Indian Medical
Association will take the lead and set these up. Till then,
you can take the initiative, and set up a peer assistance
committee in your own hospital or medical society. Peer assistance
committees consist of senior respected doctors (retired doctors
can be excellent members , because they often have the required
time, perspective and experience) who are interested in helping
their colleagues. However, serving on such a committee can
be very demanding, because working with problem physicians
can be an extraordinarily convoluted and difficult process.
Psychiatrists who have a special interest in treating addiction
problems can provide the needed technical expertise. Since
impairment coincides with an increased risk of professional
liability lawsuits, hospitals should have a vested interest
in setting up these committees, since they are an integral
part of risk management and preventing malpractice problems.
( It is a sad commentary on the state of the Indian medical
profession today , that no Indian hospital has such a service
for its doctors !) These committees also should be proactive
in fostering public confidence in the organized practice of
medicine, because they assure society that professional standards
are being seriously adhered to and public well-being is sincerely
served.
Peer assistance committees, when working effectively and efficiently,
provide education and preventative programs, and may identify
disorders before impairment develops – after all, early
identification, treatment, and rehabilitation of physicians
is in everyone’s best interests . Intervention should
be a well-planned, structured process in which the impairment
of the physician is dealt with in a caring, objective, non-judgmental
manner so that the physician receives a professional evaluation
. The key to a successful committee is the authority to effectively
act on received information, verify its accuracy, and seek
additional information as necessary to help determine a proper
course of action. The mission of a Peer Assistance Committee
is to help the doctor, and the primary role is physician advocacy.
These committees have to be completely confidential, so that
doctors feel safe reporting their colleagues – and impaired
doctors themselves should be comfortable asking for help ,
when they feel they need it for themselves. You can find more
information on how to help impaired doctors by going through
the valuable guidelines provided by the Texas Medical Association
at its website , http://www.texmed.org/cme/phn/ifp/default.asp.
The plight of the impaired physician has been described very
eloquently by Abraham Verghese, in his moving book, The Tennis
Partner.We need to learn to take care of wounded doctors–
they are our friends , colleagues, mentors, and classmates.
Timely assistance can help to save their careers, patients,
family – and even their lives – and who knows
which of us will need help in the future ourselves ? If we
don’t take care of each other, who will ?
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