Physician Health Program Statistics Can Inform Our Fitness for Medical Duty Evaluations
State boards of medicine have recently developed physician health programs (PHPs) dedicated to the early identification of substance abuse or dependence, medical and mental health disorders that impair the ability of physicians, physician assistants, anesthesiologist assistants, and licensed perfusionists to safely practice. Forensic psychiatrists are frequently called upon to evaluate these professionals at some point in the rehabilitative process. PHPs publish statistics that can inform our fitness for medical duty evaluations. The author has evaluated healthcare providers in this context, including a surgeon who could no longer draw a clock face, several cases of inappropriate prescribing, an anesthesiologist who developed opioid drug addiction, an angry physician with poor social skills and several others who were accused of boundary violations. Recently, the North Carolina Medical Board through its publication, Forum, provided a statistical analysis of its 2010 referral sources and types of associated disorders in healthcare providers in an article written by the new president of the North Carolina Medical Board, Dr. Janice Huff.
Dr. Huff’s article was written for the purposes of raising awareness of the North Carolina Physician Health Program (NCPHP), to urge healthcare providers to seek help early and to remind professionals of the Board's position that licensees have an obligation to act when a colleague is suspected of being impaired or otherwise incompetent to practice. Referrals to the physician health program can be made anonymously. To a large extent, the NCPHP is funded through license renewal fees and related donations. The healthcare program hopes to assist physicians through early identification and appropriate intervention and treatment before harm comes to the general public and to the hard-won career of the healthcare provider. Generally, the confidentiality of the provider who is in need of help can be maintained if treatment occurs before an arrest for DUI or loss of hospital privileges. However, confidentiality regarding the Board and the identity of the physician in need of help is lost if it is determined that the provider is an imminent danger to the public or to himself. Healthcare providers who have acted in a sexually inappropriate manner will not remain anonymous before the Board concerning the PHP. PHPs deal with substance abuse, depression and any other disorder that causes behavioral difficulties resulting in disruptive behavior or danger to patients and others.
Entry into PHPs often requires a contract, a binding non-practice agreement, which must be complied with in order to remain anonymous before the medical board. Unfortunately, the vast majority of licensees who are referred to the NCPHP come as part of a remediation plan ordered by the medical board. Dr. Huff invoked the analogy of Odysseus and the Sirens to illustrate the frequently seen conflict of immediate gratification and the risk of irreparable harm and danger found in these cases.
In 2010 the NCPHP received 176 referrals of which 88, half, came directly from the North Carolina Medical Board, 26 were self-referred, 21 were from a hospital administrator or chief of staff, 15 from an employer, 12 from a residency physician program director, and 5 were from attorneys. The types of impairment and their relative proportions are instructive. Fifty seven percent of the cases were due to chemical dependency and another 4% presented with a dual diagnosis, 15% were related to in Axis I diagnosis of depression or anxiety, 10% were due to personality disorders, 13% were caused by some other disorder, and 1% were the result of professional sexual misconduct. Cognitive impairment related to age and dementia probably accounted for the 13% “other” category.
When the program reviewed treatment results for substance abuse and dependency, 91% of physicians and 59% of physician’s assistants had a good outcome. Keeping a medical license is a powerful motivator. Monitoring helps ensure that the progress is maintained. Some physicians in recovery elect to change specialties and treat substance abusers, a very good outcome considering the rate of substance dependency in the general public.
Forensic psychiatrists appreciate the Odysseus illustration and are curious about excessive risk takers and their appetites as it relates to harm. We are called upon to evaluate medical colleagues by boards of medicine. Data from PHPs enhance our evaluations for medical fitness and for the closely related topic of private insurance disability evaluations and the monetary issue of whether a physician can resume practice. The summary follows:
- Keep abreast of your state’s PHP statistics, and identify new trends
- The statistics concerning how cases are referred as well as those regarding the types of disorders present can inform our subsequent evaluations for fitness for duty
- Threats to loss of licensure are a powerful motivator for change
- The most frequent encountered condition is substance abuse and dependence
- Dual diagnosis disorders are common
- Dementia related conditions may increase in frequency as physicians age
- Medical colleagues have a duty to report their impaired healthcare coworkers
- It is important to understand conditional issues of confidentiality, and you should review the contracts signed by impaired physicians upon their entry into PHPs
- The more damage a physician has done to his or her career including patient safety, the greater the need for reevaluation, monitoring, and long-term follow-up. After an impaired physician has been found by the Board to be capable of returning to practice, his or her private disability insurer will expect that individual to return to practice. Some physicians will elect to begin new training and become substance abuse specialists.
Robert S. Brown, Jr., M.D.
Copyright, www.forensicpsychiatry.com, 2011