Physician ImpairmentPhysician Impairment

John Schorling, M.D.

Physician WellnessPhysician Wellness

Overall physician health statusBurnout and its causesPhysician impairmentHealthy approaches to stress

Physician Well-BeingPhysician Well-Being

Leading a life that’s balanced in body, mind and spirit

Physicians’ Health StatusPhysicians’ Health Status

Overall mortality rates are half that of age-matched general population

Lower rates are due to decreased rates of cardiovascular disease, lung cancer and other diseases related to smoking

Smoking Prevalence in the Smoking Prevalence in the U.S.: 30 Year TrendsU.S.: 30 Year Trends

0

10

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30

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1965 1975 1985 1995

MenWomenPhysicians

Some of the factors involved in our Some of the factors involved in our becoming doctors contribute to a lack of becoming doctors contribute to a lack of

balancebalance

Family of origin issues

Compulsive personality traits

Psychology of postponement

“ “ Engrossed late and soon in Engrossed late and soon in professional cares you may find, too professional cares you may find, too late, with hearts given way, that there late, with hearts given way, that there

is no place in your habit-stricken is no place in your habit-stricken souls for those gentler influences souls for those gentler influences

which make life worth living.”which make life worth living.”

William Osler, Address to medical students, 1899

Physician BurnoutPhysician Burnout

Marked by emotional exhaustion, cynicism, depersonalization

Seems to be increasing- affects up to 65% of residents

Factors Leading to Burnout Factors Leading to Burnout

Family of origin issuesWork stress- lack of controlPersonality factors- compulsive traits

– Doubt– Guilt feelings– Exaggerated sense of self-importance

Family stressors

(Spickard et al, JAMA 2002;288:1447)

Physician Use of Opiates and Physician Use of Opiates and SedativesSedatives

Depending on age and gender, 6-23% of physicians had used non-prescribed opiates or sedatives in the past year

These substances were used by 1-4% of the general population

Most use of these substances by physicians was for self-treatment of symptoms

Substance Use by PhysiciansSubstance Use by PhysiciansPhysicians less likely to use cigarettes and

illicit substances than the general publicPhysicians more likely to use alcoholPhysicians much more likely to use minor

opiates and benzodiazepinesOverall, 8% of physicians reported ever

having a substance abuse or dependence problem(Hughes, et al. JAMA 1992;267:2333)

Clinical CaseClinical Case

A 41 yo male MD had a long history of self prescribing sedatives to treat anxiety and insomnia. His drug use gradually escalated to the point it was interfering with his work and home life. He tried repeatedly to control his use on his own, but without success. He began seeing a psychiatrist who felt he had a mood disorder, and did not directly address the substance abuse.

Clinical Case- ContinuedClinical Case- Continued

He began to feel his life was intolerable and discussed suicide with his wife, although he did not disclose a plan. He subsequently died in a “hunting accident” of a self-inflicted gunshot wound to the head.

Physician SuicidePhysician Suicide

Male physicians appear to commit suicide at about the rate of the general population, while the rate among female physicians may be two to four times higher

The rate of suicide attempts among women physicians is lower than the general population- are physicians who attempt suicide more likely to be successful?

(JAMA 1987;257:2949, Frank and Dingle. Am J Psych 1999;156:12)

Potential Factors Leading to Potential Factors Leading to ImpairmentImpairment

Personality traits of physicians: “If I only work harder, I will be loved”

Difficulty expressing emotionsDifficulty seeking and accepting helpWork stress / harassmentFamily history / family of origin issues DepressionSelf-medication

Clues to Physician ImpairmentClues to Physician Impairment

Self-prescribing of controlled drugsUse of large quantities of alcoholDriving under the influenceDomestic difficultiesNeglect of responsibilitiesOutbursts of angerDepressed mood

Drugs of Choice Among Impaired Drugs of Choice Among Impaired Physicians in Virginia 1998-2000 Physicians in Virginia 1998-2000

(n=151)(n=151)Alcohol 42%

Opiates 36%

Cocaine 10%

Benzodiazepines 4%

Other 3%

Multiple 5%

Approach to Impaired Approach to Impaired PhysiciansPhysicians

Formal interventions may be required with referral to specialized treatment centers

We may not act due to concerns about the potential impact on the impaired person- failure to intervene is likely to have greater consequences

In Virginia, the Health Practitioner Intervention Program should be involved http://www.dhp.state.va.us/levelone/hpip.htm or 1 - 866 - 206-4747

Health Practitioner Health Practitioner Intervention ProgramIntervention Program

Established by Virginia General Assembly in 1997 (Code of Virginia 54.1-2515)

Available to all licensed, certified, or registered health care practitioners

Practitioners who are impaired by mental or physical illness or by substance abuse problems may participate

Health Practitioner Health Practitioner Intervention ProgramIntervention Program

Disciplinary action may be stayed if:– There is no violation of law except diversion

for personal use– The practitioner entered with a written contract– Disciplinary action has not previously been

stayed– The practitioner remains in compliance– The Program has consulted with the appropriate

regulatory board

Treatment of Chemical Treatment of Chemical Dependency among PhysiciansDependency among Physicians

Most are referred to specialized treatment programs

Costs are often not covered by insuranceInitial treatment- 28-96 days

– Evaluation and stabilization– Intensive outpatient treatment– Mirror image placement

Extended Aftercare Treatment Extended Aftercare Treatment and Monitoringand Monitoring

Assigned to staff person to coordinate careEstablish contract - usually for 5 yearsMust have a primary care physicianRequired 12-step program and Caduceus

attendance Worksite monitorRandom drug screens

Outcomes of Substance Abuse Outcomes of Substance Abuse Treatment among PhysiciansTreatment among Physicians

In general, treatment outcomes are better for physicians than others

Treatment usually includes long-term monitoring

On average, 70-80% of physicians completing initial treatment and signing long-term contracts maintain abstinence

Most physicians are able to reenter practice

Approach to Impaired Medical Approach to Impaired Medical Students at UVAStudents at UVA

Voluntary referral to Student Health can lead to medical leave of absence

Individuals with suspected problems can be discussed with Dean Pearson or Dr. Turner

Referral for further assessment may be required to continue in school

Individuals determined to be impaired can be mandated to seek treatment and participate in aftercare

The Rest of the StoryThe Rest of the Story

"You got to be careful if you don't know where you're going, because you might not get there. " - Yogi Berra

Healthy Approaches to Physician Healthy Approaches to Physician StressStress

Increase self-awareness– Spiritual pursuits- religion, meditation – Psychotherapy

Share feelings and responsibilities– Protect time with family and friends– Participate in group social activities outside of

medicine– Participate in formal experiential groups(Quill and Williamson. Arch Intern Med 1990;150:1857)

Healthy Approaches - IIHealthy Approaches - II

Promote self-care– Attention to work scheduling– Express feelings– Pursue interests outside of medicine– Regular exercise

Develop a personal philosophy– Develop realistic short and long-term goals– Prioritize goals– Develop a time management system

“Physicians need to accept responsibility for muchof the stress they perceive. Our own achievement orientation, our drive to excel, and our exaggeratedsense of responsibility and self importance may leadus to think that we are helpless victims of awesome and uncontrollable stresses, the only solution for which is the comfort and refuge of alcohol or drugs.We as physicians need to cultivate a life that is not only “dedicated” but also balanced and healthy in mind, body, and spirit.”

Collins. Cleveland Clinic J Med 1998;65:106.