Counseling impaired docs: Help programs may need retooling as hospitals expand physician employment

The surgeon was moody.

He seemed drowsy at work.

He was secretly an alcoholic.

The situation could have led to patient harm, the loss of his license and malpractice lawsuits. But none of that happened.

Instead, a member of the hospital's wellness committee, after speaking with the doctor, connected him with the Positive Sobriety Institute in Chicago. Such programs often work with hospitals to assess potentially impaired physicians, refer them for treatment and monitor their progress.

“Hospitals aren't staffed or funded or have the expertise to manage these cases, and we do,” said Dr. Brad Hall, president-elect of the Federation of State Physician Health Programs and executive medical director of the West Virginia Medical Professionals Health Program.

The Positive Sobriety Institute, which employs addiction specialists, diagnosed the surgeon as suffering from alcohol dependence, referred him for intensive treatment in a residential detoxification program and monitored his progress.

Two months later, the general surgeon was back to work at his Midwestern hospital. He's now been sober and practicing for several years.

“You want to be able to demonstrate that there's a fair approach, that physicians, if they comply, will be given a fair opportunity to get help and come back,” said Dr. Daniel Angres, the Positive Sobriety Institute's medical director. Taking an overly punitive approach will only “drive a problem that's always going to be there underground.”

As hospitals expand their ranks of employed physicians, they will likely find themselves more frequently confronted with an issue that has always plagued the medical profession: practicing physicians with substance abuse and mental health problems. Medical pioneers such as Dr. William Stewart Halsted, the father of American surgery, and Dr. Sigmund Freud, who developed psychoanalysis, wrestled with cocaine addiction.

While estimates vary, about 15% of physicians will be impaired at some point in their careers because of psychiatric illness, alcoholism or drug dependency, according to a 2001 article in the American Journal of the Medical Sciences.

The Joint Commission began requiring hospitals in 2001 to create processes to facilitate confidential diagnosis, treatment and rehabilitation. But the Joint Commission standard mostly describes the issues that hospital processes must address without telling hospitals exactly how to do it. Experts say there is wide variation in hospital performance.

Hospitals without good processes may lose skilled providers, expose patients to potential harm and face malpractice lawsuits, experts say.

Healthcare organizations with impaired physicians may also have to deal with the cost of employment contract buyouts or payoffs, lost productivity from staff as they attempt to compensate for the impaired physician and increased costs because of sexual harassment or other toxic work environment complaints and litigation, according to a 2013 article published in the Journal of Workplace Behavioral Health.

The Joint Commission standard requires hospitals' processes for handling potentially impairing physician health issues to be separate from actions taken for disciplinary reasons.

The processes often allow impaired physicians to report themselves to a hospital's wellness committee, or colleagues can report them. The wellness committee then talks with the physician.

The committee may urge the physician to get evaluated, treated and monitored, often through an outside program such as the Positive Sobriety Institute or a state physician health program. In most instances, if the physician agrees, the issue can remain confidential. But if the physician refuses to cooperate and the hospital has to take disciplinary action, the situation may be reported to the state medical board, which can take action against a doctor's license, or the National Practitioner Data Bank.

It's a process meant to protect patients and doctors. But not all hospitals have strong frameworks in place, experts say. Hospitals without robust processes may risk pushing the problem deeper into the shadows.

“There's a great deal of variability as far as the sophistication of what they have and the effort put into it,” Angres said. “These standards can be met in different ways, and some people are better at it or more committed than others.”

Charleston (W.Va.) Area Medical Center has been proactive in identifying and helping impaired physicians. “I would like to think all hospitals are enlightened and that these programs are viewed consistently across them,” but it's likely the range of attitudes inside hospitals is not much different from those in society at large when it comes to mental illness and addiction, said Dr. Pinckney McIlwain, the center's chief medical officer.

Dr. Ana Pujols McKee, executive vice president and chief medical officer of the Joint Commission, said there's likely a great deal of variation for a number of reasons when it comes to how hospitals deal with impaired physicians. The types of services available to physicians may differ, as well as who delivers those services.

She said organizations with good leadership, fair structures and a commitment to protecting patients as soon as any sort of physician impairments are recognized are more likely to have better outcomes than organizations without such frameworks.

“The processes are important. But what's even more important is leadership's commitment to do the responsible thing,” McKee said. “You could have the best processes in place, but if leadership is ignoring this problem and not addressing it, it doesn't work.”

Dr. Stephen Loyd, chief of medicine at Mountain Home (Tenn.) VA Medical Center, has seen firsthand the best and the worst of how such issues are handled. Eleven years ago, Loyd was addicted to prescription painkillers, taking 500 milligrams of opiate narcotics a day at his lowest point.

At first, his work didn't suffer, Loyd said. But after he started losing weight, feeling tired, keeping odd hours and not completing his medical records, his father confronted him. He self-reported to a West Virginia physician health program.

The program kept his problem confidential. His practice told the hospital where he worked at the time that he was on leave of absence for an illness. Less than four months later, he returned to work.

“I was certain as soon as I told someone about my problem I would get immediately fired and lose my medical license,” Loyd said. “Little did I know I was in one of the best states in the country for physician health programs.”

Most states—California, Nebraska and Wisconsin are the exceptions—have physician health programs that hospitals can work with to evaluate, refer and monitor impaired physicians. But hospitals don't always make use of the programs when they should.

Loyd has seen instances where a hospital heard about an impairment issue and took disciplinary action instead of helping the physician. One hospital he worked at fired a talented cardiothoracic surgeon with a painkiller addiction.

“Looking back on it, it really made me angry because the surgeon was one of the best surgeons in the state and probably is to this day,” Loyd said. He is now recovered and practicing at a different hospital.

Experts say it's in hospitals' best interests to be proactive in helping potentially impaired physicians get help. It could lower the risk of malpractice claims, for instance. Doctors who went through a Colorado physician health program showed a 20% lower risk of malpractice claims than other doctors, according to a 2013 study published in the journal Occupational Medicine.

Physicians are valued commodities at many hospitals. “We have an obligation to our community to maintain our medical manpower,” McIlwain said. “It's a whole lot more efficient and effective to recognize and treat than it is to start all over again.”

Physicians spend too long in training, and hospitals invest too much in them to dismiss them so easily, some hospital leaders say. “It just comes down to recognizing that these people are tremendous assets for us and that once they get the recovery they need they can continue to be great assets,” said Dr. James Berry, chairman of the practitioners' health committee at West Virginia University Hospital in Morgantown and an addiction psychiatrist. “We would hate to see us lose their expertise and compassion and strong work ethic based on the fact they were suffering from a disorder that could be treated.”

Part of the Joint Commission's standard requires that hospitals educate physicians about wellness in hopes of avoiding actual impairment. “Illness can predate impairment, often by a period of years, so the goal is actually earlier detection, intervention and treatment of potentially impairing illnesses prior to overt impairment,” said Hall of the West Virginia Medical Professionals Health Program.

Some hospitals are taking that approach.

Mercy Regional Medical Center in Durango, Colo., recently began deploying spiritual-care counselors for doctors after upsetting events, such as the death of a patient. “Many times physicians feel they just need to go on with their work, just to see the next patient and never really deal with what they're experiencing,” said Dr. Bill Plauth, chief medical officer at Mercy.

The good news is that while doctors suffer from addiction at about the same rate as the general population, they have better success in recovering from substance-abuse disorders. After years of sweating through medical school and residencies, they have a lot at stake, said Terri Keville, a partner at law firm Davis Wright Tremaine.

Studies have shown abstinence rates of 78% to 90% for addicted doctors who go through physician health programs, which often monitor doctors for five years.

“Physicians, like other people in the general population, can develop a whole range of physical and mental and social problems in the course of their lives that can affect their work,” Keville said. “It is part of the human condition, and hospitals have to be prepared to deal with that.”