Chapter 34: The impaired physician – healing the wounded doctor
|"A gem cannot be polished without friction, nor a man perfected without trials. "|
- Chinese Proverb.
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 doctors 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 isnt lying - its 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 its 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 ?