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Impaired Physicians

Overview | Clinical Scenarios | Additional Tips | References
By Richard Frierson, MD

OVERVIEW

Definitions

  • Impaired Physician: In 1973, the American Medical Association (AMA) defined an impaired physician as one who is unable to fulfill professional and personal responsibilities because of a psychiatric illness, alcoholism, or drug dependency.1 Other illnesses may also result in impairment, such as neurologic (dementia) or other medical conditions.
  • Regulatory Agency: Each state has established an agency to regulate physician practice and to oversee the assessment of potential physician impairment that could impact the safe practice of medicine. In general, this agency is referred to as either the medical board or board of medical examiners.2 However, most medical boards work in tandem with an established physician health program (PHP).
  • PHPs: A therapeutic alternative to disciplinary actions which provides care and treatment for physicians impaired by alcohol or other substances, mental illness, or other potentially impairing medical illnesses. PHPs coordinate detection, evaluation, treatment, and continuing care monitoring of physicians with these conditions.3

General Principles

The prevalence of chemical dependency among physicians in the United States is generally the same as for the general population, about 8% to 12%.4 Specialties such as anesthesia, emergency medicine, and psychiatry have higher rates of drug abuse, probably related to the high-risk environment associated with these specialties through availability of substances and physician stress and burnout.5 Impaired physicians may enter treatment and monitoring with a PHP voluntarily. However, there are barriers to seeking help for many physicians including denial of the disease and/or loss of performance, fear of stigma, the presence of psychiatric comorbidities, and fear of family, social, professional and economic negative consequences. However, it is also the ethical responsibility of physicians to interfere in a timely manner to ensure that impaired colleagues cease practicing and receive appropriate assistance from a PHP.6 In some states, reports of impaired physicians should be made to the medical board, while in other states reports may be made directly to the PHP. Most state laws provide immunity from liability to reporters who are acting in good faith.

Additionally, the average age of a licensed physician in the United States is 51, and over a quarter of all physicians are over the age of 60.7 Therefore, outside of impairment from chemical dependency, elderly physicians may be prone to the development of a neurocognitive disorder which could also impact their ability to safely practice medicine.

Jurisdictional Considerations

  • In most jurisdictions, state law creates and defines the duty of physicians to report impaired physician colleagues.
  • The threshold to report is generally low. For instance, in Wisconsin it is “reason to believe” which is similar to that for mandated reporters of child or elder abuse.
  • State law usually protects physicians from civil or criminal liability, when they report in good faith.
  • Physicians who voluntarily enter treatment with a PHP are entitled to confidentiality. However, if the PHP believes the physicians ability to practice is impaired, this may be reported to the medical board. Finally, if the physician is subjected to medical board actions or hospital privilege suspension while under investigation, these may be reported to the National Practitioner Data Bank (NPDB).

CLINICAL SCENARIOS

Scenario #1: An on-call 50 year-old surgeon is called to the hospital to evaluate an acute abdomen. Upon arrival, the ER physician treating the patient notices the surgeon smells of alcohol and is slurring his words. The surgeon admits to having a glass of wine earlier, but denies being impaired.

  1. In any event that a physician is concerned that a colleague is suffering from a substance use disorder that is or may impair safe medical practice, it is the physician’s duty to intervene to protect the safety of his colleague’s patients.
  2. The ER physician should intervene emergently, call for the assistance of a different surgeon, and report the incident to the chief of the medical staff.

Scenario #2: A colleague observes that a 70 year-old inpatient psychiatrist often forgets to finish his daily Electronic Health Record (EHR) charting, leaves daily patient notes halfway done and forgets to sign them, and forgets to order medications that are mentioned in the notes that he does finish. The psychiatrist also has an increasingly slow gait.

  1. Outside of an emergent situation, before intervening, physicians should familiarize themselves with relevant legal, professional, and institutional reporting requirements which may vary depending on jurisdiction.8
  2. It is a duty and obligation to report to the medical board any good faith suspicion or concern about a physician who may be impaired from cognitive decline.
  3. When privately confronting the physician results in denial, telling the physician you plan on making a medical board report and suggesting they self-report instead may be a useful strategy .

ADDITIONAL TIPS

  • The vast majority of impaired physicians return to work with no signs of relapse or malpractice for years after treatment.
  • A malpractice insurer may be able to provide risk management tips and resources to assist with intervention with an impaired colleague.
  • If they are known to the physician reporter, soliciting assistance and support from the impaired physician’s spouse or family may be a useful strategy in convincing a colleague to self-report.
  • Take appropriate steps to preserve a colleague’s privacy and reputation.

Documentation Tips

Physicians concerned about an impaired colleague should note and privately document behaviors that are concerning. Maintaining a record of specific aberrant behaviors, performance errors, and professional lapses may assist the PHP in making appropriate assessment and treatment requirements.

REFERENCES

  1. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA. 1973 Feb 5;223(6):684-7.
  2. Carlson D, Thompson JN: The role of state medical boards. Virtual Mentor, 2005, 7(4):311-314
  3. American Psychiatric Association Resource Document: Physician Health Programs and Treatment of Substance Use Disorders in Physicians. 2018. Available from: https://www.psychiatry.org/psychiatrists/search-directories-databases/library-and-archive/resource-documents
  4. Blondell RD. Impaired physicians. Prim Care. 1993 Mar;20(1):209-19.
  5. Baldisseri MR. Impaired healthcare professional. Crit Care Med. 2007 Feb;35(2 Suppl):S106-16.
  6. American Medical Association Code of Medical Ethics, Section 9.3.2 Physician Responsibilities to Impaired Colleagues. Available from: https://policysearch.ama-assn.org/policyfinder/detail/impaired%20physician?uri=%2FAMADoc%2FEthics.xml-E-9.3.2.xml
  7. Soonsawat A, Tanaka G, Lammando MA, Ahmed I, Ellison JM. Cognitively Impaired Physicians: How Do We Detect Them? How Do We Assist Them? Am J Geriatr Psychiatry. 2018 Jun;26(6):631-640.
  8. Federation of State Medical Boards. Policy on Physician Impairment. April 2011. Available from: https://www.fsmb.org/siteassets/advocacy/policies/physician-impairment.pdf

Additional Reading

  1. DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009 Mar;36(2):159-71.
  2. Vayr F, Herin F, Jullian B, Soulat JM, Franchitto N. Barriers to seeking help for physicians with substance use disorder: A review. Drug Alcohol Depend. 2019 Jun 1;199:116-121.
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