Introduction

Medicine has always been a high reward, high stress occupation. But with the currently deteriorating healthcare climate, physicians are placed under even greater burdens. From mounting fears of malpractice suits, decreased respect from the public, financial worries – including pressure to treat more patients and the need to adapt to technological advances, physicians are under more stress than ever. This stress takes a tremendous toll on physicians’ well being, all the while increasing their risk of psychiatric disorders, addiction and stress-related medical illnesses. In addition, physicians are working longer hours, which only compounds these issues.

The American Medical Association defines physician impairment as “any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities….”[1] Recognition of the impaired physician began to emerge only in the 1970s, and led to the development of physician health programs (PHPs) (Gastfriend 2005).[2] And for decades, these physician assistance programs, like those sponsored by state medical societies and others at the hospital level, have been critical in the identification, triage, treatment and monitoring of physicians who may suffer from a number of maladies. Greater support and cooperation from licensing boards and hospital medical disciplinary entities have greatly assisted in this process, while a ‘tough love’ approach that helps physicians but holds them accountable has brought these issues into the foreground where they can be openly addressed. Physicians and patients have both been positively impacted by these efforts, as physicians’ professional engagement, the quality of care they provide, and their tendency to become overwhelmed all depend on the fulfillment they find in work (Gunderman and Brown 2006).[3] In the past, addiction was the primary issue with which these organizations dealt, but over the years this effort has expanded. Comprehensive addiction programs specializing in treating physicians and other health care professionals have also contributed to excellent abstinence rates and responsible transition to the workplace.[4]

This article will focus on the various mechanisms involved with helping the distressed physician. Addiction will be highlighted, but attention will be given to other areas of potential impairment.

II.     Unique Features of Physicians in General

The environmental factors that can impede physician well-being include the stress of high expectations, the need to make life and death decisions, sometimes with limited experience, and disruptive life styles due to demanding and inconsistent schedules.

Studies suggest that physicians tend to be compulsive perfectionists, a particular personality trait that has been shown to increase the risk for anxiety and depressive disorders, both of which are linked to addiction.[5]Along with this insight, Glen Gabbard M.D. from Menninger Clinic describes maladaptive tendencies that include difficulty engaging in leisure activities or taking vacations from work activities, a tendency to be satisfied with a low level of intimacy, such as the type between physician and patient, and a need to assume control of uncontrollable events.

Difficulty setting limits was also noted, along with guilty feelings relative to the pursuit of personal pleasure. Physicians also demonstrate a tendency to seek marital partners who are skilled at maintaining family relationships and household responsibilities, yet may have difficulty connecting on a deep emotional level with their partners because they are satisfied with a low level of intimacy they typically feel at the workplace.

With regard to the medical marriage, social status and financial stability are the rewards, but the bond often feels empty and delayed gratification is common. Future studies may suggest that the combination of high levels of stress, without a commensurate level of emotional intimacy and connection, enhance the physician’s vulnerability to substance use. It has been established that increased accessibility to drugs does increase the likelihood of abuse or addiction in physicians.

III.    Physicians and Personality Styles

Knowledge of the common traits of professionals with addictive disorders can facilitate the clinician’s formulation of effective individualized treatment plans. In terms of health-care professionals, research studies suggest that physicians tend to be compulsive perfectionists. Gabbard used observations from a workshop setting on the role of compulsiveness in the normal physician and related case examples to illustrate the impact of these behaviors on the professional, personal and family life of the typical physician. Maladaptive implications include difficulty engaging in leisure activities or taking vacations from work activities, problems allocating appropriate time for family functions, and a tendency to assume control of uncontrollable events. Difficulties in setting limits were also noted, along with guilty feelings relative to the pursuit of personal pleasure which set up a lifestyle of “delayed gratification.” Participation in a competitive and high-profile profession may serve to mitigate long-term feelings of poor-self-esteem and to please or impress an internalized parent; similarly, the “impostor phenomenon”, “which occurs when high achieving individuals chronically question their abilities and fear that others will discover them to be intellectual frauds,” also factors in the road to physicians’ addictions.[6]

Certain specialties among healthcare professionals have demonstrated increased risk of addiction and drug of choice (Angres, Healing the Healer). In addition to anesthesia, emergency medicine and psychiatry may have higher rates of drug abuse that may be impacted by the baseline personalities of these physicians.

There are any number of personality styles, features, traits and disorders in addicted professionals. Career choice, drug of choice, gender, age of addiction onset, trauma and a host of other factors can influence personality. In addition to obsessive tendencies and the minimizing or indirect seeking of dependency needs in professional populations, one study published in the Journal of Affective Disorders suggested that physicians and lawyers have higher rates of dysthymic temperament and obsessive-compulsive personality traits when compared with the control group of outpatients in various other professions. Needless to say, the causes of practitioners’ distress are numerous, and range from a loss of control over their work spaces to unmanageable workloads and frequent experiences with human suffering and death. (Shanafelt and West, 2007)

In the future articles I will discuss Identification, Intervention, and Assessment of Addiction in the Workplace; Comprehensive Evaluation; an Integrative Approach to Treatment; Levels of Care; Specialized Treatment for Professionals; Monitoring and Support Systems; Hospital Wellbeing Committees; Physician Health Programs; and  Stress Management.

IV.    Identification, Intervention and Assessment of Addiction in the Workplace

Most studies suggest physicians are not at greater risk than the general population for substance use disorders –approximately 10% to 12% will develop chemical addictions during their careers (Berge, Seppala, and Schipper 2006). They tend to use prescription drugs more often than the general public and are more likely to have access to drugs in the workplace or through personal prescription. A survey conducted by DuPont et al. found that the most common drugs of abuse were alcohol (50%) and opioids (35%). The other 15% included stimulants, sedatives, marijuana, and other substances. Across PHPs, 31% of physicians had problems with both drugs and alcohol, with nearly half (48%) also qualifying for psychiatric disorders and/or pain problems. (DuPont, McLellan, Carr, et al, 2009)

A.    Identification in the Workplace

The addicted professional has unique features and tendencies as compared to the general population. Proper identification is essential for the treatment of addiction in the professional. The workplace is often the last place addiction is exposed, so if there are signs at work, the disease is usually progressed. There is increasing emphasis on educating professionals about the course of addiction in themselves and their colleagues. This has been driven in part because of addiction now having a disease status—chemical dependency falls under the category of a disability with legal ramifications for employers—and due to the high prevalence of abuse and addiction in our society. Addiction costs billions of dollars as well as considerable pain and suffering, and prevention is preferable to treatment. Proper identification results from adequately educating those around the addicted professional about the disease of addiction and its manifestations. Education in the work place is critical in determining if a colleague is addicted, and should include discussions about the potential liability and legal ramifications of drug diversion and drug abuse.

There are a number of signs that can typify addiction in the workplace and having some knowledge of the disease can facilitate proper identification. These include:

1)    Chaotic personal and professional life.

2)    Frequent tardiness and absenteeism.

3)    Poorly explained accidents and injuries.

4)    Relationship discord: martial, family, professional.

5)    Deterioration in personal appearance.

6)    Significant weight loss or gain.

7)    Long sleeves and tinted glasses inappropriate for the setting.

8)    Overuse of cologne and breath fresheners.

9)    Legal problems; i.e. DUI’s or arrests for possession, disorderly conduct or in the case of health care professionals, inappropriate prescribing of controlled substances.

10)  Severe mood swings unrelated to situations or exaggerated mood responses, dramatic change in personality.

11)  Increased isolation due to shame and fear.

12)  Withdrawal from family, friends and coworkers; i.e., always refuses social invitations.

13)  Frequent disappearances during work hours.

14)  Overt evidence of addiction at work such as the smell of alcohol on the individual’s breath during working hours.

15)  Cognitive impairment.

16)  Spending too much time with narcotics or missing narcotics (specific for healthcare).

17)  Dilated or pinpoint pupils.

18)  Asking physicians for prescriptions for mood altering substances at a healthcare workplace.

19)  Increase in physical complaints.

20)  Financial strain.

21)  A negative or apathetic attitude.

22)  Working extra shifts (in order to obtain substances).

These changes can be gradual or sudden, and an individual usually exhibits several signs from the above list. The professional usually takes care to conceal the addiction from the workplace because he or she prioritizes his or her professional identity and, again, the workplace is often the last place the addiction is noticed.

Another reason that the professional life is the last to deteriorate is because the workplace is often where the health professional acquires his or her substances. Protecting his or her source of drugs becomes paramount to the addicted professional. When overt evidence of addiction in the workplace is apparent, this often represents a progressed condition. Simply stated, addiction can be detected by observing the professional’s work performance. Often, regularly scheduled performance evaluations will illustrate a decline in productivity and quality of work. There is a dire need for a pre-existing policy for handling discovery of addiction problems because addiction has become not all that uncommon. A lack of pre-existing policies may result in medical or legal liabilities, but also perpetuates the ongoing addiction, which can have catastrophic consequences for the addicted physician and the innocent people that individual comes into contact with in the workplace.

Whatever the means of identification, it is imperative to verbalize suspicions in an appropriate manner. When overt evidence of addiction in the workplace is apparent, this often represents a progressed condition. The employer or colleagues often feel the need to avoid confrontation or question their observations. This can create a “conspiracy of silence” that will only allow the addiction to progress with possible adverse effects on the addict and the workplace. If employers and colleagues could think of an intervention as a compassionate and necessary step for the addict, it would benefit everyone. An intervention is often implemented by intervention professionals under an employee assistance program or an outside consultant trained in professional interventions. A planned intervention has the greatest success.

Points to Remember

•      Identification of an addicted peer requires knowledge of signs and symptoms of addiction and the ability to compassionately and effectively implement an intervention.

•      A “conspiracy of silence” is common in professions, but ineffective and reckless for the safety of the addict and others.

•      There are compassionate and effective ways to intervene, such as the use of an employee assistance program within the organization.

B. Intervention

If chemical dependency is suspected, an intervention is the next appropriate step. An intervention occurs when the professional suspected of abusing drugs and/or alcohol is initially confronted, and it is usually an extremely stressful event for both the suspected professional and the individual doing the intervening.[7] Therefore, it is helpful to have a policy in place for these types of scenarios that will facilitate a successful approach.

It is important to discern whether the employee’s impairment is the result of mood altering substances or some other stressful event in his life. The presence of an addiction problem can be elucidated with an effective intervention.

There are a number of ways to intervene on an addict, from informal confrontations to formal professionally facilitated interventions. However, the author cautions employers and colleagues regarding informal confrontations because of the strength of denial in the addict and the risk of an unsuccessful outcome; as Cicala notes, “a hallmark of substance abuse is a remarkable denial on the part of the abuser that there is no problem, even as they go to great lengths to hide the symptoms of the problem.” [8]

An informal intervention can be effective in circumstances where there is a high degree of trust and a receptive attitude on the part of the individual suspected of being an addict toward a colleague or supervisor. More likely though, this individual will feel embarrassed, defensive and even betrayed in these circumstances and refuse help. It is crucial that the professional not be directly accused of diverting drugs or asked to stop using drugs. This is an inefficient means of intervening which will most likely result in the denial of drug use or the occurrence of a desperate act such as suicide.[9]

A formal intervention involves a trained interventionist. A trained interventionist understands the disease of addiction, knows referrals for treatment, and employs an attitude of compassion and is nonjudgmental in approach. An employer or colleague may consult with an interventionist and then proceed with the process on their own, too.

Utilizing an employee assistance program (EAP), human resource department, or, ideally a non-disciplinary process within the work setting like a hospital physician wellness committee, will reap the most successful results in interventions. The advantages of a workplace initiated intervention over family interventions are the influence of potential workplace consequences, which are important for the financial and professional survival of most individuals. It is the potential or actual consequences of addiction that initially convince an addict to get help.

A compassionate intervention is the ideal situation, but this author is well aware that many addicted professionals are terminated prior to any intervention. There are consequences to this action, such as passing on an unfit individual to another workplace, losing the possibility of a grateful and loyal employee in recovery, and becoming part of the “conspiracy of silence” that threatens our society with active addiction.

Points to Remember

•      There are informal and formal interventions. The most effective approach is a formal intervention via EAP personnel or trained interventionist.

•      The advantage of workplace interventions are the influence and consequences that are important to most professionals. They have more success in implementing and maintaining sobriety in an individual.

C.    Assessment

The assessment typically is done upon admission to a program for the treatment of addictions. An initial and brief assessment can be provided by the EAP or PHP and thereby give the individual a choice of treatment options based on certain criteria mentioned below. In cases where there is resistance, lack of clarity of the problem or continued denial on the part of the professional, a mandatory, comprehensive assessment is often necessary and can be instituted by the employer with the consequence of termination if the individual does not comply.

V.     Comprehensive Evaluation

This evaluation routinely uses a team of trained professionals with differing areas of expertise. This is sometimes described as a Multidisciplinary Assessment Program (MAP) in one setting and is generally 48 hours or more in duration. A typical MAP team includes:

•      MAP clinician/administrator: Responsible for scheduling and organizing the MAP as well as collecting collateral data after obtaining informed consent. Obtaining this collateral data is essential for this type of evaluation. The MAP is generally required because there is significant resistance and/or confusion about the source of any suspected impairment. This collateral data is obtained with written consent from the individual being assessed. There are typically multiple personal and professional sources that are contacted for collateral data. This clinician/administrator is also responsible for organizing and summarizing the final report.

•      Psychiatrist: Responsible for performing a comprehensive psychiatric evaluation. This psychiatrist has expertise in addictions and fitness for duty issues. At times, a forensic psychiatrist is necessary, especially where legal issues predominate. These legal issues may include multiple DUI offenses, prescribing offenses including suspicion of, or allegations related to, trafficking of controlled substances or even allegations of boundary violations (e.g. sexual harassment). All legal issues, past and present, must be revealed to determine the appropriate treatment for the individual.

•      Psychologist: Responsible for administering and interpreting psychological testing such as the Millon (MCMI-III) and the Minnesota Multiphasic Personality Inventory (MMPI). Screening with an instrument such as the Wechsler Aptitude Screening Instrument (WASI) is often necessary to rule out deficits in cognition that can occur with substance abuse or for other reasons such as dementia. In cases where cognitive deficits are identified or suspect, neuropsychological treatment is performed by an additional neuropsychologist. In these cases, consultation with a neurologist and imaging studies like Magnetic Resonance Imaging (MRI) are required to rule out a neurologic disorder such as a tumor or degenerative disease (i.e. Multiple Sclerosis) or degeneration from alcohol of other substances. This component is obviously important in assessing the high accountability professional and his or her ability to safely do his or her job.

•      Addictions Specialist: Responsible for performing an in-depth substance use and abuse evaluation.

•      Internist: Responsible for a thorough history and physical including necessary lab work to fully assess medical health.

•      Senior Supervising Psychiatrist: Responsible for reviewing the report and recommending any necessary changes to insure completeness of final report.

The MAP is, by far, the most thorough way to evaluate a professional with impairment from addiction or for any other reason.

Points to Remember

•      Identification of the professional with addiction in the workplace is important for several reasons. It provides the opportunity for an addicted individual to recover, allows the workplace to retain a valuable member of the team, recognizes addiction as a disease which avoids legal ramifications for the workplace and perpetuates the need for compassionate and early intervention in fighting addiction.

•      The natural inclination for employers and colleagues is to avoid the situation and address the problem by terminating the addict, so professionals must be educated and encouraged to participate in the identification, intervention and assessment of the addicted colleague.

•      There is a formal process for intervention and assessment that increases the accuracy of diagnosis and appropriate referral for help. It reduces the risks involved in the “conspiracy of silence” that drives addiction underground and increases the dire consequences of active addiction on others in the workplace and society.

A.   Vignette

1.     Simply More Depressed than Usual

Jerry was a promising young single general surgeon. Jerry was highly regarded by his peers and the hospital in which he practiced.

It therefore came as a shock when, after about 6 years of solid practice, he began to dramatically change. He started missing work and when he did show up, he looked disheveled and sad. When friends and office staff asked if he was alright, he would be dismissive and curt, saying he had a cold or was working too hard. Eventually he escalated to the point where his staff was concerned about him and his patients. After missing two consecutive clinic days, and being unreachable by phone, two of his staff went to his apartment and had to get security to let them in. Jerry was in bed and difficult to arouse. He eventually agreed to go to the emergency room to be evaluated and it was determined he was under the influence of hydrocodone and antidepressants. Jerryexplained to the E.R. staff that he had injured his back a year ago and became depressed. He assured them that he was taking his medications as prescribed and was simply more depressed than usual. He was reported by the E.R. staff to the Physician Well-Being committee of the hospital. The committee in turn required Jerry to receive a comprehensive evaluation despite his insistence to see a psychiatrist in the community. Since there were potential patient safety issues, the committee had the authority to require an independent comprehensive evaluation. The evaluation determined that Jerry had an addiction problem and was recommended to a professional’s treatment program for addiction and depression.

2. Intervening

This was a difficult situation for Jerry’s coworkers. He was such a competent and caring doctor, and he was valued by the hospital. His reputation made it particularly difficult to accept the change in behavior and potential harm he posed to himself and his patients. However, when he missed two clinic days without any communication, his staff became worried. They insisted he go to an emergency room, which gave all of his coworkers an opportunity to intervene. In this case a formal intervention was avoided but the recommendation was still difficult for the hospital. This was an acute, potentially dangerous situation and his caring staff did the right thing by going to his apartment. In other cases, a family member can be contacted and assist in the process. This was not possible for Jerry, who was single and lived alone. The ER staff was also correct in letting the Well-Being Committee know about Jerry’s situation.

B.    The role of Well-Being Committees

Hospitals are required by the Joint Commission to provide services that can assist in cases of suspected impairment of medical staff. This is often in the form of Well-Being Committees that are separate from the disciplinary entities of the hospital. These committees can facilitate the intervention and assessment of a suspected impaired physician in a way that is firm but caring. This entity can use the disciplinary alternatives (e.g. report to the medical disciplinary wing of the medical staff) as a tool to facilitate the physician following recommendations. In cases like Jerry, where he followed the recommendations, the Medical Staff Office can be made aware of his situation and defer to the Well-Being Committee. The committee will also be available to internally monitor the physician after treatment along with the treatment program and in many cases, the state professional assistance program. In cases where there are reportable events, such as diversion of narcotics from the hospital, the hospital may need to report the incident to the state licensing board. The board will carry out its own investigation and typically support re-entry to practice under certain conditions, like a consent order or probationary license. If there is non-compliance, for example, if Jerry refused to be assessed, he would be subject to disciplinary action taken by the hospital and the licensing board. Even in these cases, hospital and licensing boards will attempt to direct the person to assessment.

C.    The Comprehensive Assessment

In Jerry’s case, a comprehensive assessment was necessary. He did not initially admit to addiction, and rationalized his drug use by reporting his problems with pain and depression. He pushed for a less comprehensive evaluation by a psychiatrist in the community. The comprehensive evaluation determined that it was valuable to rule out addiction in a formal setting that utilizes professional input, collateral data and a hair analysis. These are examples of elements that are typically part of a comprehensive evaluation such as a MAP. Although Jerry had an addiction problem, often these comprehensive assessments are also used to evaluate behavior problems like sexual harassment, chronic charting problems or excessive tardiness or absences. These other behaviors fall under the title of the “disruptive physician or professional” where addiction may not be present as the source of the difficulties, but not the only problem. In these cases, a psychiatric diagnosis, such as a personality disorder or major depression, may be the underlying issue. In certain cases, a cognitive deficit from a neurological condition or medical problem may be the core issue. In any case, the comprehensive evaluation is best suited to flush out the problems and give appropriate recommendations for the necessary follow-up.

Points to Remember

•      Hospitals like many businesses are required to have intervention and support mechanisms within their organization.

•      A comprehensive multidisciplinary assessment is of great value in cases where the individual in question is not forthcoming and/or there are serious behavioral concerns.

•      Disciplinary action should be used as a backup plan when necessary to facilitate necessary treatment.

•      In most cases, licensing entities will support successful rehabilitation and re-entry.

VI.    An Integrative Approach to Treatment

There is a growing trend to promote wellness within a context of an integrative mental health care paradigm along with increasing evidence for its effectiveness. The broad array of alternative treatment modalities includes mind-body interventions such as meditation and spiritual counseling, as well as an emphasis on exercise, diet and lifestyle changes. Now a body of research supports the efficacy of these approaches in treating addictions. This integrative mental health paradigm does not need to diminish the importance of medications and traditional therapeutic approaches, but rather enhances and supplements them. Furthermore, a respect for the benefits and contributions of Alcoholics Anonymous and other 12-step groups needs to be acknowledged and maintained while increasing efforts to explore other evidence-based approaches to improve outcomes.

A.    Use of Mindfulness and Meditation

The technique of mindfulness can facilitate calming the mind and assist the patient in observing his or her thoughts, thereby enhancing the opportunity for subconscious thoughts to emerge. After the mind is steadied and the patient can practice an observing-ego stance, the result is an increase in self-aware consciousness by simply learning to be present in the moment. Learning how to be present can have significant benefit for addicts. The disease of addiction has neurobiological and psychological underpinnings that can be identified as “the addictive drive,” which is quiescent in recovery, but remains ubiquitous. An individual in recovery is often thought of as someone whose disease is in remission. That is why sober addicts are in “recovery,” never “recovered.” This addictive drive, however, can represent a unique opportunity. When this drive presents itself in recovery in its various forms, such as craving or feelings of deprivation, these feelings can remind one of the need to continue, and even intensify, a meditative practice along with other recovery activities vs. giving in and suffering a relapse. Through sublimation, the addictive drive can be fuel for transcendence. The sober addict can achieve and maintain higher states of consciousness and an improved relationship with self, others, and a higher power. For the sober addict, this simple yet profound practice can reduce stress, craving, improve mood and even create a capacity for experiencing higher and ultimately profoundly rewarding states of consciousness. This translates into recovery. For the clinician, incorporating mindfulness in his or her practice can be highly beneficial for both therapist and patient; indeed, researchers in a 2008 study found that when those who meditated heard the sound of human suffering during controlled experiments, there was more activity in their temporal parietal junctures, the part of the brain tied to empathy, than those who did not meditate.[10]

VII.  Levels of Care

The treatment of the addict or alcoholic is not a simple recommendation. Treatment has different levels of intensity and recommendations are based on a variety of factors; i.e. legal issues, financial constraints, type of professional, number of previous treatments, etc.

The following summarizes the typical abstinence based program structures:

A.    Day or Evening Intensive Outpatient Programs (IOP)

•      Averages four days or nights a week, three to four hours a day or night and four to six weeks in duration

•      Small group therapy plus didactic and experiential groups

•      Family involvement

•      12-step involvement expected during and after treatment

•      Typically three months of weekly continuing care

B.    Partial Hospital Programs (PHP)

•      Averages five days a week, six to eight hours/day for four to six weeks

•      Small group therapy plus didactic and experiential groups

•      Family involvement

•      12-step involvement and aftercare as above

Independent (supervised) living programs (ILPs) can accompany PHP (PHP with ILP or “boarded partial”). This is common in programs that treat professionals and allows for more structure, intensity and an opportunity for exposure to a therapeutic community as compared with more standard PHP’s.

C.    Residential Treatment

•      Same elements of PHP with ILP except the patient is in a “under one roof” 24-hr. supervised setting.

This level of care can provide more structure for patients with significant co-morbidities and/or history of repeated relapses following the above-mentioned levels of care. It is often more expensive than a PHP with ILP, but at times necessary for those that require more restrictions (i.e. adolescents have a greater success rate in residential treatments).

It is important to note the above-mentioned levels of care can vary in structure, length of stay and program emphasis. Also, various levels of care can be combined to provide a continuum for some patients. (For example, a patient who completes a residential program may step down to a PHP or IOP level of care. Also, many patients require continuation in a half-way or three quarter-way house following treatment).

Professional programs often offer more specialized programming, such as Caduceus groups, along with extended aftercare (i.e. 2-5 years for physicians and nurses).

VIII. Levels of Care Specialized Treatment for Professionals

Outcomes for general populations have been anywhere from 40% to 60% recovery following treatment. Extended studies beyond 6 to 12 months are not well documented in any case in the general population.

Treatment for professionals has demonstrated a much better outcome than treatment in the general population. Research suggests that factors such as voluntarily seeking treatment and the confidentiality of engagement in treatment have an impact on recovery.

In a recent article by McClellan, et al., it was noted that addicted physicians (n. 902) demonstrated high rates of complete abstinence over a five-year period. This included 78% abstinence over that period and 71% remaining in their profession.[11] Similar sobriety rates were noted in Healing the Healer.[12] McClellan and his group wanted to discover what the essential ingredients were in these excellent outcomes. They recognized that “physicians enjoy educational, employment, financial, and social benefits that are not typical of the population at large or of the population of addicted individuals in treatment. Some of these advantages are characteristic of the physicians themselves, but an additional advantage is health insurance and personal resources that make high-quality care possible for extended periods.” They also recognized essential elements that could be available to all addicted people. This included extended treatment and monitoring along with clear consequences for non-compliance. They concluded that it was not one of these elements but all of them combined that contributed to these excellent outcomes.[13]

There are some advantages that physicians and other professionals seemingly have. One is that they have a lot to lose, so they have an increased incentive for staying sober. However, in comparison, it has been noted that in the court system if someone were monitored and would relapse and consequently go right back to jail, the prospect of returning to jail does not result in very good outcomes. As many as 50% or more would return to the prison system, suggesting consequences alone are not a strong enough incentive.

One would argue, too, that professionals have a greater degree of access to better treatment. This may be true; however, there are a number of wealthy, non-professional individuals who do not have documented good outcomes, despite expensive and extensive treatment programming. Again, better treatment alone is not enough.

It seems logical, then, that the better outcomes in physicians, as well as other licensed professionals, have to do with a variety and combination of treatment and monitoring options. Those would include specialized addiction programs, either residential or boarded partial programs, that are extended; that is, anywhere between two to three months on average. These programs typically have staffs that are conversant with the various risks and problems associated with professionals, including over-identification with career, overwork and some of the occupational risks associated with reentry. Specialty groups within a treatment setting offer a peer group setting that is essential to minimize the amount of “specialness” that can be associated with the professional, and can offer real empathy. The sense of community and shared experiences are essential in any program, and this is particularly the case for professionals. Extended monitoring following treatment is also critical, and includes urine monitoring. Also essential is the contractual relationship with the addict and the employer and/or medical society that would include potential consequences of relapse or noncompliance in an aftercare program. There are also other important ingredients in long-term success rates of professionals; such as involvement in 12-step recovery with sponsorship and continuing peer support in aftercare such as Caduceus groups. Typically, individual counseling and monitoring by a primary physician and/or psychiatrist who understands addiction, is part of the aftercare for the recovering professional. If all of these entities and professionals are given permission to communicate with one another by the recovering addict, he or she is able to benefit from the integrated and holistic approach to the healing process.

The level of treatment can be determined by certain factors. On one hand, professionals can be treated on an outpatient basis if, in particular, their disease did not affect their workplace and they have appropriate support at home. However, if there is workplace involvement (i.e., evidence of use or impact of use while working or legal problems, etc.) and/or there are poor or absent support systems in the home, then a residential or boarded partial extended program is almost always necessary. All levels of treatment should be followed by extended aftercare and monitoring.

IX.    Levels of Care Specialized Treatment for Professionals Monitoring and Support Systems

Aftercare monitoring groups provide ongoing peer support and monitoring following treatment for as long as two years from the treatment program and five years for state-sponsored programs for licensed healthcare professionals. Involvement with peer groups for all recovering professionals following treatment is imperative. Other professionals offer their own support groups, such as the Lawyers’ Assistance Programs for attorneys and Peer Assistance Networks for nurses.

Addicted physicians have one of the more elaborate intervention, assessment and reentry systems known today for those who suffer from addiction. As previously mentioned in McClellan’s article describing the various “ingredients” that appeared to demonstrate excellent outcomes in this population, physicians are encased in a broad interlocking network of relating elements that both support the physician towards recovery and hold him or her accountable in the reentry monitoring process.

X.     Levels of Care Specialized Treatment for Professionals Monitoring and Support Systems Hospital Wellbeing Committees

It has been a relatively recent development that the Joint Commission now requires that each hospital have an independently functioning wellness committee that can work with physicians who struggle with addiction or other types of impairment. Although these committees can have responsibilities to general medical staff and disciplinary committees, they operate to some degree autonomously and exercise a more supportive stance towards the struggling physician. These committees are typically composed of those who have an interest and experience working with physicians, and tend to be individuals interested in the identification, appropriate assessment, rehabilitation and reentry of these physicians back to the workplace and medicine.

In addition, these committees often institute wellbeing strategies in the hospital for all physicians, such as “fun runs” and other activities that can promote wellness and balance amongst the physician population in that hospital setting. They are critical in identifying possible impairment in their medical staffs and making the necessary referral for assessment. It is imperative that these committees do not actually assess the suspicious individual themselves, but are simply available to intervene and make necessary referrals. They are also a necessary element for the continued monitoring of the physician when he or she is returned to the medical staff.

XI.    Levels of Care Specialized Treatment for Professionals Monitoring and Support Systems Hospital Wellbeing Committees Physician Health Programs

Most states in the USA have PHPs that generally operate as part of the state medical society in that particular state. Some of these programs have a direct relationship with the licensing board in that state while others have total independence and autonomy. These committees, in any case, act as “diversion” programs. That is, they can take responsibility for helping to educate, identify, refer, and facilitate reentry and monitoring for the affected physician. They can do this with some degree of autonomy and still hold the physician accountable for their recovery. They are a critical element in the process of the identified excellent outcomes in this population.

Typically, the PHPs monitor the physician for a minimum of five years, in some states even longer. They interface with treatment programs, wellness committees at the hospitals, sometimes the licensing board if necessary, as well as other entities that may be involved with the treatment, aftercare and monitoring of the physician. They are the point program to facilitate all of the various elements that are involved in the ongoing support monitoring of the physician; often including treating psychiatrists, individual therapists, and even family support. They are also instrumental in the urine monitoring or hair analysis that is critical to both document ongoing abstinence and to identify relapse. The PHPs are a critical component of the superior outcomes of addicted physicians completing professionals’ programs.

A.    Caduceus Groups

These groups were started by G. Douglas Talbott in the 1970’s. Dr. Talbott, a pioneer in the field of treating the addicted physician, identified the Caduceus emblem for medicine as a way to create a peer group for physicians. Although there have been many types of Caduceus groups, today they mostly describe the specific aftercare that is specialized for the addicted physician in recovery, and have come to include other addicted professionals. The importance of a peer group is not only evident in the treatment process, but also in the ongoing aftercare support and monitoring for the healthcare professional.

B.    The American Medical Association Physician Wellness Program

The American Medical Association (AMA) has been active in supporting the health and wellness of all physicians, including the appropriate identification, rehabilitation and reentry of all physicians, whether or not they are AMA members. The AMA has sponsored physician wellness conferences over the last several decades to actively support this initiative.

C.    State Licensing Boards

State licensing boards are entrusted to maintain public safety in regards to physician practice. Over the years, licensing boards have appreciated the logic that it is better to openly work with, and identify, impairment rather than to be purely disciplinarian or punitive. The latter stance has historically driven the problem underground, which actually is more risky for the addict and the public. This is known as “the conspiracy of silence” and only exacerbates the problem. The addict continues to use and has more opportunity to hurt him or others when the problem of addiction is not addressed. Licensing boards are responsible for public safety by monitoring the licensed professional. They do not necessarily get involved in the cases of impairment unless there are disciplinary actions taken at the hospital, or there is public evidence of impairment such as a driving-under-the-influence charge.

Licensing boards, in many states, will defer to the PHPs, treatment providers, and monitors in regards to managing cases. However, they do investigate cases and have hearings in regards to licensure status when necessary. There are a number of licensure status conditions, including consent agreements (less formal), consent orders, suspension and even revocation. Licensing boards have generally been supportive of those physicians who have followed up responsibly with the various treatment recommendations of the entities involved with their recovery.

D. Employee Assistance Programs

EAPs are essential in cases where hospitals utilize EAP services. EAPs are composed of staff who are well versed in understanding addiction and other impairments, along with the clinical and reentry issues. EAPs can act as intermediaries, much like the PHPs, and often work in conjunction with the other treatment entities for the physician.

E.    Physician impairment independent of addiction

Physicians who struggle with conditions other than addiction that can cause impairment such as psychiatric disorders, chronic pain or other physical conditions, and cognitive impairment, can benefit from many of the same intervention, assessment and monitoring entities mentioned. Whereas treatments here may substantially differ, such as individual therapy for a depressed physician, some of the support and monitoring strategies mentioned above may need to be accessed if the physician’s condition has in any way shown itself in the workplace. Prevention, assessment, treatment and monitoring is critical in these instances, especially with conditions like depression that can increase an already higher risk of suicide in physicians as a whole.[14]

XII.  Levels of Care Specialized Treatment for Professionals Monitoring and Support Systems Hospital Wellbeing Committees Physician Health Programs Stress Management

With all the advances in mental health and the science of well being we still have some relatively simple and basic time tested ways to live better, including meditation (as outlined earlier), exercise and proper diet. The research on the benefits of meditation, exercise and healthy diet are indisputable. The cost to the individual and society for not living better are also clear and disturbing. It is estimated that 70% of all medical problems are associated with stress, poor diet, substance abuse or inactivity. The costs of unhealthy living are not only seen in the physical realm, but also reflected in increasing rates of depression and anxiety within our society. And yet, these simple activities can make all the difference.

XIII. Summary

The identification, support and monitoring of physicians who suffer from potentially impairment producing conditions have evolved substantially in the past few decades. A climate of openness, compassion and accountability has assisted both the physician and public they serve and it is critical that this trend continue. There has been some backsliding in recent years where political and other pressures have created a somewhat more punitive climate. If we are to continue to benefit from the entities outlined in this paper, we must move forward not backwards lest we recreate a dangerous and toxic environment that again drives the problem underground. If this backsliding continues it will not reduce the problems of impairment or make the public safer; quite the opposite will be the result, placing all involved at greater risk.

References

Angres, D., Talbott D. Bettinardi-Angres, K. Healing the Healer Psychosocial Press, 1998

Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009 Jul;84(7):625-31.

Cicala Roger. Substance abuse among physicians: what you need to know. Hosp Physician. 2005;39-46

Lutz Antoine, Brefczynski-Lewis Julie, Johnstone Tom et al. Regulation of the neural circuitry of emotion by compassion meditation: Effects of Meditative Expertise. PLoS ONE. 2008;3(3): e1897.

Schernhammer E. Taking Their Own Lives—The high rate of physician suicide. N Engl J Med. 2005. 352;2473

West Colin, Shanafelt Tait. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA.2011; 306(9):952-960.

 

 

 

[1] See AMA policy H-95.955 Physician Impairment, which can be accessed at https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fdoc%2fPolicyFinder%2fpolicyfiles%2fHnE%2fH-95.955.HTM.

[2] Gastfriend David. Physician substance abuse and recovery: What Does It Mean for Physicians—and Everyone Else? JAMA. 2005;293(12):1513-1515.

[3] Brown S, Gunderman RB. Viewpoint: Enhancing the professional fulfillment of physicians. Acad Med. 2006 Jun;81(6): 577-82.

[4] Angres, D., Talbott D. Bettinardi-Angres, K. Healing the Healer, Psychosocial Press, 1998.

[5] Henning, K., Ey, S., Shaw, D. Perfectionism, the impostor phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Medical Education.1998;32(5): 456–464.

[6] Henning, K., Ey, S., Shaw, D. Perfectionism, the impostor phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Medical Education.1998;32(5): 456–464.

[7] Berge K.H., Seppala, M.D., Schipper, A.M. Chemical dependency and the physician. Mayo Clin Proc. 2009 Jul;84(7):625-31.

[8] Cicala, Rr. Substance abuse among physicians: what you need to know. Hosp Physician. 2005;39-46

[9] Berge K.H., Seppala, M.D., Schipper, A.M. Chemical dependency and the physician. Mayo Clin Proc. 2009 Jul;84(7):625-31.

[10] Lutz, A., Brefczynski-Lewis, J., Johnstone, T., et al. Regulation of the neural circuitry of emotion by compassion meditation: Effects of Meditative Expertise. PLOS ONE. 2008;3(3): e1897.

[11] DuPont R.L., McLellan T., Carr G., et al. How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment 2009; 37 1–7.

[12] Angres, D., Talbott, D., Bettinardi-Angres, K. Healing the Healer Psychosocial Press, 1998.

[13] DuPont R.L., McLellan T., Carr G., et al. How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment 2009; 37 1–7.

[14] Schernhammer, E. Taking Their Own Lives—The high rate of physician suicide. N Engl J Med. 2005. 352;2473.