Psychiatric Annals

CME Article 

The Forensic Evaluation and Rehabilitation of the Impaired Physician

Daniel H. Angres, MD; Anish John, MD; Kathy Bettinardi-Angres, APN-BC, MS, RN, CADC; Gaurava Agarwal, MD

Abstract

Forensic, addiction, and occupational psychiatry have been the main subspecialties of psychiatry contributing to the assessment and treatment of impaired physicians. The assessment and rehabilitation of the impaired physician is a critical tool to achieving wellness for the affected physician. In addition, evaluating and treating physicians with disruptive behavior, professionalism concerns, substance use, and cognitive concerns help preserve a culture of wellness in the organizations and teams in which these physicians work. This article highlights the role of physician health programs, licensing boards, multidisciplinary comprehensive assessment teams, and treatment programs in the process of rehabilitating an impaired physician. It describes the components of a comprehensive evaluation of physicians that can accurately diagnosis the reason for impairment. Finally, key components of successful treatment programs and smooth re-entry to practice are highlighted. [Psychiatr Ann. 2019;49(11):487–491.]

Abstract

Forensic, addiction, and occupational psychiatry have been the main subspecialties of psychiatry contributing to the assessment and treatment of impaired physicians. The assessment and rehabilitation of the impaired physician is a critical tool to achieving wellness for the affected physician. In addition, evaluating and treating physicians with disruptive behavior, professionalism concerns, substance use, and cognitive concerns help preserve a culture of wellness in the organizations and teams in which these physicians work. This article highlights the role of physician health programs, licensing boards, multidisciplinary comprehensive assessment teams, and treatment programs in the process of rehabilitating an impaired physician. It describes the components of a comprehensive evaluation of physicians that can accurately diagnosis the reason for impairment. Finally, key components of successful treatment programs and smooth re-entry to practice are highlighted. [Psychiatr Ann. 2019;49(11):487–491.]

Significant progress in the identification, assessment, treatment, and monitoring of impaired physicians has been established in the past few decades,1 and physician health programs (PHPs) have been an essential resource in these endeavors. Stronger linkage between state licensing boards and PHPs have progressed in a constructive manner as medical boards are confident in the overall efforts of the PHPs, which promote the stated purpose in the American Medical Association (AMA) physician health programs act of 2016 “…to enhance the protection of the public by providing for a successful means of confidential and professional support of physicians and other health care professionals who have a potentially impairing substance use disorder, mental health condition, or other medical disease that may adversely affect the physician's or other health care professional's ability to safely and effectively treat patients.”2 As stated in the 2019 position paper from the American College of Physicians; “When physicians become impaired and are unable to practice competently, they should seek medical help and assistance in caring for their patients. When they cannot or do not do so, the profession and individual physicians have a responsibility to safeguard the welfare of patients and assist colleagues in obtaining help.”3 This is a collaborative process, one that leads to both restored lives for the affected physician as well as patient safety. It is important to note that the outcomes of physicians with addictions who are properly treated and monitored are substantially better than the general population,4 and the same success has been suggested with other illnesses.5 In 2011, the Federation of State Medical Boards created the “Policy on Impaired Physicians.”6 Included in that narrative was a notation of two tracks: (1) a voluntary track, which describes a confidential process of seeking assistance through a PHP, intended for detection prior to an illness becoming functionally impairing; and (2) a mandated track, in which a medical board requires participation in a PHP.6 A multidisciplinary comprehensive evaluation by someone experienced in physician health is most suitable in determining whether a physician can practice with reasonable skill and safety, as well as determining the steps necessary to promote rehabilitation and safe re-entry.

Assessing Impairment

Forensic, addiction, and occupational psychiatry have been the main subspecialties of psychiatry contributing to the assessment and treatment of impaired physicians.

When there is impairment, a speedy and accurate evaluation is imperative to help physicians and create and preserve a workplace culture of accountability and well-being for all the team members and patients.

It is important to briefly understand why physicians may be at risk of impairment and how the field of specialized physician evaluation and treatment developed. The forensic and legal issues are related to the fact the fact that physicians are in highly accountable roles and, if impaired, their actions can directly affect the safety of others, similar to the role of airplane pilots. The AMA acknowledged that there were impaired physicians or physicians that were not fit to practice medicine with reasonable skill and safety in a 1973 report, which led to the first PHPs.7 The AMA definition of impairment is “…one who is unable to fulfill professional and personal responsibilities because of psychiatric illness, alcoholism or drug dependency.”8 An impaired physician can also be a disruptive physician “who engages in personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care... that interferes with one's ability to work with other members of the health care team.”9 Burnout is another impediment to optimal functioning, and it can be contagious and demoralizing. In addition, it is correlated with risk factors for impairment such as disruptive behavior and substance use disorders. Hospitals are required by the Joint Commission on Accreditation of Healthcare Organizations to develop policies for impaired physicians. There are reporting mandates dictated by the National Practitioner Data Bank, and the licensing boards of every state can inquire about, suspend, or revoke the licenses of physicians for cause.

Two factors that can contribute to impairment include the medical work environment, which is demanding and stressful, and physician personalities. Physicians often exhibit compulsive traits, which can exacerbate unhealthy tendencies10 and place them at risk for behaviors that “take the edge off.” Other maladaptive tendencies in physicians (such as “medical marriage”) can include their satisfaction with a low level of intimacy that their workplaces provide, thereby shunning deeper intimacy offered by spouses and loved ones. Delayed gratification is another common coping mechanism in physicians, and as a result the temporary reward of a mood-altering substance or a compulsive behavior becomes acceptable. If the physician is genetically predisposed to substance use disorder, it can lead to the progression of the disease and the consequential behaviors that follow. Health care organizations recognize that physician impairment and disruption is a risk management problem.11 However, challenging unusual behavior can be difficult because physicians appear to be “given more latitude in eccentric behavior than would be tolerated in others.”11 Overt warning signs of impairment include deterioration in personal appearance, increased isolation, frequent tardiness and absenteeism, cognitive impairment, and burnout.12 Ancillary staff are more likely to report these signs than other physicians because of the “conspiracy of silence” among physicians; however, staff should be taken seriously and the physician confronted with a referral to a PHP or to hospital administration. If substance abuse is suspected, the health care organization is always advised to require a drug screen of the physician at the time of the intervention or discussion. The next step should be a multidisciplinary comprehensive assessment (MCA) implemented in a timely manner. The MCA is pivotal in accurately identifying and treating “problem” doctors.13 This evaluation can halt the progression of psychiatric diagnoses such as substance use disorder and depression, which is especially important because physicians have a higher rate of suicide than the general population.14

The evaluation process has evolved over the years, and the current gold standard is an MCA at a facility that is experienced and knowledgeable about physician well-being.15 The MCA begins with a referral source, usually a physician health program or a health care institution, referring a physician for an MCA. The referral sources are clear that there is a problem, they are not qualified to determine with certainty what that problem is, and they aspire to address the problem in an objective and concerted manner that is respectful to the physician and patients. The MCA is a 2- to 5-day evaluation, can be done on an inpatient basis, and the physician included in the patient population of the facility, or the MCA program can be done on an outpatient basis that allows the physician to reside in a neutral environment (ie, a hotel) while undergoing the assessment. The pros for the neutral environment are that the MCA implies objectivity and is respectful of independence, whereas the pros of the inpatient setting are that the person has opportunities to connect with other patients and possibly break through their denial.

The MCA is both a spiritual and scientific endeavor toward finding the truth versus assuming the truth and proceeding on a presumption. The process is similar in forensic psychiatry, especially as a spiritual practice, because the clinicians are giving witness to suffering; they are exercising empathy and compassion while seeking the truth.16 Norko16 states the necessary qualities of the evaluators must include curiosity, humility, active observation of both self and patient, willingness to set aside categories and prejudices, humility to tolerate one's areas of incompetence, and insight with compassion. The MCA allows this to occur because it differs from an intervention in allowing the person to show their best self, includes facts such as laboratory measures, communicates with people that know the physician personally and professionally, and offers solutions in terms of “recommendations.”

The MCA team always incorporates the disciplines of medicine, psychiatry, and psychology, and includes neurocognitive testing and psychological testing. Cognitive screening tools alone can be helpful and are easily administered; however, there are limitations such as their relatively lower sensitivity and typically should not be substituted for neuropsychological evaluation, especially if one is screening for impairment in a safety-sensitive role.17 Attention, executive function, memory, language, perception, visuospatial processing, psychomotor ability, and processing speeds are important cognitive domains to assess. In addition to substance use, psychiatric disorders, and medication effects, many conditions can affect neurocognition including genetic anomalies, maternal health issues, environmental factors, developmental anomalies, and other disease processes varying from diabetes to eating disorders. Therefore, it is vital to consider these results in a larger context aided by a detailed history and review of available records. There are ancillary mental health professionals that offer expertise in family systems, social work, substance abuse, eating disorders, trauma, and other compulsive behaviors such as sexual compulsivity and gambling disorders. A thorough MCA includes a medical assessment with laboratory measures, always with drug screens that include urine, hair or nails, and phosphatidyl ethanol (PEth), and specialty consultation to rule out medical problems when necessary. The PEth test is useful to quantify alcohol use over the past month whereas hair and nail tests can provide a more comprehensive use of substances in the prior 3 to 12 months.

Finally, collateral contacts should include those that know the impaired physician professionally and personally, especially the people that voiced concern, should be contacted to add their insights to the overall picture. Collateral information includes conversations, written documents, medical records, legal documents, and disciplinary hearings that are collected with the physician's consent. The clinician that gathers collateral information should have knowledge of hospital systems and the role of physicians in their specialties. When the collateral information is included in the final written report, it is best to document the information in generalities and add language such as “…the following people may or may not have been contacted” to protect the collateral sources and offer more freedom in sharing their experiences about the impaired physician. Collateral information is not always treated as fact, but it is important data in determining accurate diagnoses and recommendations. It is imperative that the impaired physician know they have a choice of treatment programs to avoid feeling trapped and later resenting the process, which can adversely affect treatment outcome. The final outcome must state whether the impaired physician is safe or unsafe to practice medicine with reasonable skill and safety.

The impaired physician is afforded the opportunity with treatment and the future support of a PHP to return to the practice of medicine. Unanimously, physicians highly value their medical career and will typically strive to mitigate the impact of impairment upon their career, so by the time impairment shows itself at the workplace their illness has been longstanding and is serious.1 Treatment for dual diagnoses and substance use disorder is ideally at a treatment program for professionals and that has been appraised by a state's PHP. A professional's program should have a substantial population of other health care professionals in the treatment program, as well as a dedicated addiction psychiatrist or addiction medicine physician and clinicians with experience in the treatment of physicians and other safety-sensitive workers. The treatment team should have extensive experience in re-entry and working with PHPs, licensing boards, and health care systems. It must be noted that many treatment programs will advertise that they are a professional's program because the field did not previously have a coordinated means to vet “professional's programs.” The Federation of Physician Health Programs has recently initiated the process of developing a provider accreditation program that can certify treatment programs that assess and treat physicians and other safety-sensitive workers.

Treatment for the Impaired Physician

Treatment consists of a period of approximately 6 to 12 weeks with a combination of a partial hospitalization program (full days) followed by an intensive outpatient program (half days). The variation in length of stay is often a topic of disagreement among the treatment providers and PHPs. However, success rates are similar for physicians in this range of 6 to 12 weeks.12 Treatment consists of assigning the impaired physician a primary counselor who leads a psychotherapeutic “small group.” This approach has been the most effective, along with concurrent individual therapy. Didactic and experiential groups that include cognitive-behavioral therapy, dialectical behavioral therapy, and acceptance and commitment therapy techniques, along with opportunities to learn nonchemical coping skills (ie, yoga, meditation, mindfulness) are incorporated into the program. An expectation of daily attendance at a 12 Step group or other support group (eg, Refuge Recovery) is imperative because the impaired physician will transition home to a local community of like-minded people for continued support. The family and loved ones of the impaired physician are strongly encouraged to participate in family programming, including a family week with education and group therapy and family sessions, which can ease the physician's transition to life at home. The home transition ideally includes one therapeutic leave while in treatment to uncover what will be obstacles to success and then address these obstacles prior to discharge. Some physicians will not return home to a loved one or a family, and the treatment team must consider whether this will be beneficial to the long-term success of the physician. To avoid isolation and loneliness, the treatment team may recommend a transition to local sober-living facility before returning home. Finally, the physician is guided toward re-entry to work, which may include communication from the treatment program to the workplace and back-to-work recommendations that will ease the transition (eg, no call, fewer hours) The re-entry also includes standard recommendations, such as a weekly physician support group known as Caduceus groups, consultation, and ongoing support and monitoring with their state's PHP for a minimum of 5 years, individual therapy, and continued participation in 12 Step community support groups. Aftercare in Caduceus groups is a minimum of weekly meetings for 2 years, but the time can be extended. The recommendations are standard because over time they have been known through peer-reviewed studies to be one of the most effective approaches to long-term sobriety and well-being.12

Re-Entry Issues

There are prognostic indicators that will determine whether a recovering physician will succeed, and these include acceptance of their diagnosis and discharge recommendations, supportive and educated loved ones, and a smooth re-entry to medical practice.1 Also, physicians have better access to the resources necessary for continued recovery (ie, financial ability to pay for services), and these factors improve their success rates. Success rates are approximately 82% at 5 years,12 although relapse can occur. This specialized area of medical practice (ie, the assessment, treatment, and aftercare of the impaired physician) is imperative because of the professional obligation of health care professionals to protect patients and support our professional peers. It is also effective compared to people in the general population,4 which has caught the attention of the treatment community hoping to improve rates of recovery and sobriety for all people that suffer with mental illness.

The most common reason for the high success rates of physician recovery is accountability, which is the PHP's monitoring of the physician's sobriety and compliance with aftercare recommendations. Impaired physicians are often referred to their state PHP for monitoring after a course of treatment. Monitoring by a PHP often combines case management and toxicology to ensure the physician continues to be fit to practice medicine with reasonable skill and safety after that physician complies with recommendations that result from the (ideal) initial intervention, which is the MCA. The average period of time of monitoring is 5 years, although in some cases the physician is advised to be monitored for the lifetime of their medical career (eg, after numerous relapses). PHPs advocate for the returning physicians and when recovering physicians succeed there is stigma reduction, which will hopefully ease the way for future physicians with impairment to seek help. Also, recent changes to the credentialing and licensing questions will hopefully increase the number of physicians who self-report and impede the progression of impairment before more harm comes to them or their patients.

References

  1. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322(1):31–36. https://doi.org/10.1097/00000441-200107000-00006 PMID: doi:10.1097/00000441-200107000-00006 [CrossRef]11465244
  2. American Medical Association. Physician health program act. https://www.fsphp.org/assets/docs/ama_physicians_health_programs_act_-_2016.pdf. Accessed October 9, 2019.
  3. Candilis PJ, Kim DT, Snyder Sulmasy Lfor the ACP Ethics, Professionalism and Human Rights Committee. Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians. Ann Intern Med. 2019;170(12):871–879. doi:10.7326/M18-3605 [CrossRef]31158847
  4. McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008;337:a2038. https://doi.org/10.1136/bmj.a2038 PMID: doi:10.1136/bmj.a2038 [CrossRef]189846322590904
  5. Knight JR, Sanchez LT, Sherritt L, Bresnahan LR, Fromson JA. Outcomes of a monitoring program for physicians with mental and behavioral health problems. J Psychiatr Pract. 2007;13(1):25–32. https://doi.org/10.1097/00131746-200701000-00004 PMID: doi:10.1097/00131746-200701000-00004 [CrossRef]17242589
  6. Federation of State Medical Boards. Policy on physician impairment. https://www.fsmb.org/siteassets/advocacy/policies/physician-impairment.pdf. Accessed October 15, 2019.
  7. Gastfriend D. Physician substance abuse and recovery: what does it mean for physicians and everyone else?JAMA. 2005;293(12):1513–1515. doi:10.1001/jama.293.12.1513 [CrossRef]15784877
  8. [No authors listed]. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA. 1973;223(6):684–687. doi:10.1001/jama.1973.03220060058020 [CrossRef]4739202
  9. Rondinelli RD. AMA Guides to the Evaluation of Permanent Impairment. 6th ed. Chicago, IL: American Medical Association; 2012.
  10. Gabbard GO. The role of compulsiveness in the normal physician. JAMA. 1985;254(20):2926–2929. PMID: doi:10.1001/jama.1985.03360200078031 [CrossRef]4057513
  11. Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA. 2002;287(22):2951–2957. https://doi.org/10.1001/jama.287.22.2951 PMID: doi:10.1001/jama.287.22.2951 [CrossRef]12052124
  12. Angres DH, Talbott DG, Bettinardi-Angres K. Healing the Healer: The Addicted Physician. Scotts Valley, CA: CreateSpace; 2012.
  13. Leape LL, Fromson JA. Problem doctors: is there a system-level solution?Ann Intern Med. 2006;144(2):107–115. https://doi.org/10.7326/0003-4819-144-2-200601170-00008 PMID: doi:10.7326/0003-4819-144-2-200601170-00008 [CrossRef]16418410
  14. Schernhammer E. Taking their own lives—the high rate of physician suicide. N Engl J Med. 2005;352(24):2473–2476. https://doi.org/10.1056/NEJMp058014 PMID: doi:10.1056/NEJMp058014 [CrossRef]15958803
  15. Reade JM. Impaired physicians: the role of the occupational psychiatrist. Psychiatr Ann. 2006;36(11):799–802.
  16. Norko MA. What is truth? The spiritual quest of forensic psychiatry. J Am Acad Psychiatr Law. 2018;46(1):10–22.
  17. Williams BW, Flanders P, Grace ES, Korinek E, Welindt D, Williams MV. Assessment of fitness for duty of underperforming physicians: the importance of using appropriate norms. PLoS One. 2017;12(10):e0186902. https://doi.org/10.1371/journal.pone.0186902 PMID: doi:10.1371/journal.pone.0186902 [CrossRef]290537365650180
Authors

Daniel H. Angres, MD, is the Medical Director, Positive Sobriety Institute; and an Adjunct Associate Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine. Anish John, MD, is the Associate Medical Director, Positive Sobriety Institute; and an Adjunct Assistant Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine. Kathy Bettinardi-Angres, APN-BC, MS, RN, CADC, is a Family Therapist, and the Coordinator, Multidisciplinary Comprehensive Assessment Program of Chicago, Positive Sobriety Institute. Gaurava Agarwal, MD, is the Director of Physician Well-Being, Northwestern Medical Group; and an Assistant Professor, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine.

Address correspondence to Daniel H. Angres, MD, Positive Sobriety Institute, 680 N. Lake Shore Drive, Suite 800, Chicago, IL 60611; email: Dangres@positivesobriety.com.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20191009-01

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