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Should You Report a Substance-Abusing Colleague to the State Licensing Board?

From: The Hospitalist, September 2011

by O’Neil Pyke, MD, SFHM, and Jeannette Guerrasio, MD

Dr. Pyke

PRO

Hospitalists’ moral obligation is to protect the patient

In this era of historic budget deficits, wars, and political strife surrounding healthcare reform, one might ask if we can afford to spend valuable time and energy on the issue of reporting physicians who abuse substances.

At first glance, I certainly had skepticism about the subject, but then I dug deeper. To my surprise (and likely yours), studies indicate that physicians develop substance-abuse problems as often or more than the general population does.¹ Recent reports detail horrific patient outcomes at the hands of health providers whose actions are compromised by drug use. With data showing the prevalence of substance abuse among physicians hovering around 10% to 12%, we must accept the reality that hospitalists are not exempt.^2,3,4,5

As medical doctors, our promise to our patients is to provide care in an ethical manner. Even if we try to live in denial, most of us would agree that with great blessing (or power) comes great responsibility. So when the question of reporting a fellow hospitalist who is abusing substances was asked, my response was unequivocally yes.

In my opinion, this discussion can be limited to two overarching principles: First, we are compelled to put our patients first. As hospitalists, we are blessed to be caring for some of the most frail and vulnerable in our society. Fortunately, an overwhelming number of us do so with pride, skill, and integrity.

The task of providing high-quality care to an empowered patient population is difficult enough with us being physically, emotionally, and mentally exhausted. But to add substance abuse to this is just a complete and utter violation of our patients’ trust. We must agree that putting our patients’ well-being beyond reproach requires us to report any colleague who is compromised.

Second, delayed help for a colleague in trouble with substance-abuse issues could be fatal—and for more than just that single colleague. At some point, we are compelled to do more than just raise an eyebrow and shake our head. Usually at the time of discovery, months if not years of substance abuse already have gone by undetected. Deferring to the next person is just not an option. There is too much at stake. It is our moral duty to help our colleagues who are unable to realize the danger they are posing to themselves, the team, and, most importantly, the patients.

Certainly, physicians do not need another lecture about the perils of substance abuse. Whether discussing prescription drugs, alcohol, marijuana, cocaine, or the like, we all have witnessed the devastating effects of abuse. The fact is, any substance that alters our ability to perform our trusted duty must be avoided.

Colleagues, the algorithm is simple: Be vigilant, observe, confirm, and report. It is our moral and ethical imperative.

Dr. Pyke is chief medical officer of Medicus Consulting, LLC.

Dr. Guerrasio

CON

Responsible, helpful action doesn’t always mean official involvement

Recognizing impairment in our colleagues is both difficult and ethically challenging. Despite national trends, medicine remains a largely self-regulated profession, and we have an ethical obligation to report impaired, incompetent, or unethical colleagues. Rarely are the indications for reporting or identifying a colleague clear.

As trained clinicians, we know the signs of substance abuse:⁶

• Frequent tardiness and absences;
• Unexplained disappearances during working hours;
• Inappropriate behavior;
• Affective lability or irritability;
• Interpersonal conflict;
• Avoidance of peers or supervisors;
• Keeping odd hours;
• Disorganized and forgetful;
• Incomplete charts and work performance;
• Heavy drinking at social functions;
• Unexplained changes in weight or energy level;
• Diminished personal hygiene;
• Slurred or rapid speech;
• Frequently dilated pupils or red, watery eyes and a runny nose;
• Defensiveness, anxiety, apathy, and manipulative behaviors; and
• Withdrawal from long-standing relationships.

Yet when it is a colleague, we are often in denial about their substance abuse. Certainly, simple seasonal allergies and allergy medications can cause a number of the above symptoms. We also are aware of and fear the potential impact of licensing board notification on a physician’s career. In fact, in a national survey of physicians, 45% of respondents who had encountered impaired or incompetent physicians had not reported them, even though 96% of those surveyed agreed that physicians should report impaired or incompetent colleagues.⁷

Similar to reporting child or elder abuse, you don’t want to be wrong.

At the same time, impaired physicians are disruptive. They negatively impact the lives of their patients, colleagues, and hospital staff.

It is possible to do both the responsible thing and not go directly to the licensing board. You are not responsible for diagnosing your colleagues, but rather recognizing possible impairment.

Check out the Federation of State Physician Health Programs’ website (www.fsphp.org) to identify a local physician health program. Call them and place a report of concern identifying your impaired colleague. While it’s possibly new to you, they have years of experience working with this situation. Trust these organizations, many of which are independent from licensing, to intervene responsibly and confidentially. They can evaluate your colleague and provide a treatment plan and monitoring, as needed. Their approach is rehabilitative rather than punitive, and they resist reporting to the medical board unless the physician-patient is noncompliant.

Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment.^8,9 Between 75% and 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^9,10

There is hope for your impaired colleague. Contact your local physician health program.

Dr. Guerrasio is a hospitalist and director of resident and medical student remediation at the University of Colorado Denver.

References

1. Hughes PH, Brandenburg N, Baldwin DC Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
2. Gold KB, Teitelbaum SA. Physicians impaired by substance abuse disorders. The Journal of Global Drug Policy and Practice website. Available at: http://www.globaldrugpolicy.org/2/2/3.php. Accessed June 27, 2011.
3. Wolfgang AP. Substance abuse potential and job stress: a study of pharmacists, physicians, and nurses. J Pharm Mark Manage. 1989;3(4):97-110.
4. Cicala RS. Substance abuse among physicians: What you need to know. Hosp Phys. 2003:39-46.
5. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
6. Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Curr Psy. 2010;9(6):11-20.
7. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147:795-802.
8. Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
9. Alpern F, Correnti CE, Dolan TE, Llufrio MC, Sill A. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
10. Gallegos KV, Lubin BH, Bowers C, Blevins JW, Talbott GD, Wilson PO. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.