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Under the influence
Substance abuse on the wards
By Charlotte Huff
As the director of the University of Colorado School of Medicine's remediation program, Jeannette Guerrasio, MD, sometimes meets with medical students or residents who have a problem with alcohol or substance abuse. But students aren't the only ones who run into this trouble, said Dr. Guerrasio, an ACP member and hospitalist, as well as an associate professor of medicine.
Dr. Guerrasio has raised substance abuse worries with a physician colleague twice in her career. Those conversations weren't particularly comfortable, she said. One doctor she suspected of diverting narcotics “got fairly upset with me” when asked about it. “I said, ‘If I was doing this to be punitive, I could have called the licensing board.’ “
Photo by Deborah Gowen and Michael Ripca. Model: Remo Simone.
In both cases, Dr. Guerrasio passed along her concerns to a state-run physician health program, confident that they would appropriately and discreetly follow up if needed. To this day, she doesn't know what happened.
But such stories can have a happy ending, for both the physician involved and patient care, she said. “With appropriate monitoring, I really do believe that people who struggle with substance abuse, or who have struggled with it in the past, can do very well,” she said.
Difficult to detect
In general, doctors don't appear to be significantly more prone to abusing alcohol or illegal substances than people working outside of medicine, according to studies and those working in the field. And they can exhibit the same warning signs of addiction detailed in any medical school textbook: tardiness, changes in appearance, emotional volatility and a tendency toward isolation from loved ones, among other red flags.
Yet substance abuse can be more difficult to detect in physicians, said Mark Gold, MD, chairman of the department of psychiatry at the University of Florida, who has researched physician substance abuse for more than three decades.
Given their medical knowledge, doctors can be savvier about camouflaging the warning signs, he said. Plus, they may protect their work performance at all costs, even as the rest of their life unravels. As a result, Dr. Gold said, “they tend to come for help late in the addictive disease process, often at a time of extreme crisis.
“Many times, it appears like they should have been able to ask for help before,” he continued. “But they didn't because they were afraid that they would not be able to leave work, that they could lose their career. They were hopeless and thought there was no treatment for them.”
Treatment is not only available, it can often be provided confidentially—if oversight and monitoring are complied with—through a network of physician health programs. Forty-four states offered such a program as of early 2012, according to the Chicago-based Federation of State Physician Health Programs.
The programs don't provide treatment themselves, but they conduct oversight and monitoring in conjunction with treatment, working with physicians who sign binding contracts to undergo treatment. Recent data involving 904 physicians indicate that the programs can be highly effective, in part due to random drug testing after treatment ends.
The retrospective analysis, which focused on physicians who entered a physician health program during a five-year period ending September 2001, found that 78% didn't have a single positive drug test for alcohol or drugs during post-treatment monitoring. (The mean time period for monitoring was 54 months; the average number of tests was 83.) That success rate exceeds results in other populations, including the U.S. military and random testing in the general workplace, according to the study, published in 2009 in the Journal of Substance Abuse Treatment.
Physicians as a profession are no more likely to have used illegal drugs than the general population, according to one frequently cited study. But they do report a higher frequency of alcohol or recreational prescription drug use, according to a survey of 5,426 doctors published in 1992 in the Journal of the American Medical Association.
Overall, alcohol was the most frequently used substance. As for prescription drugs, the physicians were asked about drug usage that hadn't been prescribed for a medical condition. The questionnaire focused on specific classes of drugs, such as opiates, benzodiazepines and amphetamine-type drugs. The physicians most frequently reported use of minor opiates and benzodiazepines.
Although risk factors for drug abuse among physicians are still being understood, it's believed that some specialties may be more vulnerable. One key study, published in 1987 in the Journal of the American Medical Association, found that these problems were far more common among anesthesiologists than the general physician population.
That study, which looked at 1,000 physicians treated through Georgia's impaired physicians program, found that 12% of those in treatment were anesthesiologists. Yet that specialty comprised just 3.9% of all doctors, according to American Medical Association data. General/family practice physicians also were overrepresented, making up 25% of those in treatment versus 12.4% of the workforce, perhaps in part because those doctors work in relative isolation, the study authors suggested.
Of course, the same risk factors for substance abuse that affect non-clinicians can lead to problems of abuse by physicians, including a family history of abuse, self-medication for underlying mental health issues like depression or anxiety, and personal and professional stressors.
Some risks, though, are more pertinent to physicians, such as relatively easy access and exposure to drugs, said Lisa Merlo, PhD, MPE, a clinical psychologist and director of research for Professionals Resource Network, one of Florida's two programs for impaired health providers. “What I've heard from many different physicians who have used illicit drugs is that they started with alcohol or prescription drugs, then branched out,” she said.
In the case of anesthesiologists, one theory is that their vulnerability to addiction might stem in part from workplace exposure to low doses of opioids, such as fentanyl, or anesthetics, such as propofol, Dr. Merlo said. She was involved with research, published in 2008 in the Journal of Addictive Diseases, which found that the drugs were not only detectable in the air, but also on operating room services.
A physician also might become intrigued once he or she sees the physiological impact that a prescription drug has on patients, Dr. Merlo said. For instance, a psychiatrist might experiment with a benzodiazepine, she said. Another risk: Physicians may deceive themselves into thinking that their own medical expertise is somehow protective, since they know how these drugs work.
“For example, if you have someone who is trained in anesthesiology, they [think they] know exactly what doses they can take and try to be safe,” Dr. Merlo said. “Obviously, that's not always the case.”
Sometimes the signs of an impaired physician are overt, such as the disappearance of drugs from the hospital or repeatedly showing up for work late, said Gregory Skipper, MD, an internist and addiction medicine specialist who directs professional health services at the Promises Treatment Centers in Los Angeles.
Alcohol sometimes can literally be smelled on a doctor's breath, said Dr. Skipper, who prior to his current job worked for more than a decade as medical director of the Alabama Physician Health Program. “I can tell you who smells it the most is nurses. I don't know if nurses have better noses or what,” he said.
When Dr. Skipper lectures at hospitals about impaired physicians, he bluntly tells clinicians to trust their gut. If you think a physician has a drug or alcohol problem, “there probably is,” he said. “Denial is contagious—you don't want to think that about somebody.”
Recent data, though, indicate that even if physicians spot an abuse problem in a colleague, they are reluctant to speak up. In a 2009 survey involving 1,120 physicians, 17% reported personally interacting with an impaired or incompetent physician during the prior three years. Two-thirds, or 67%, reported the physician. Among those who didn't, the three most frequently stated reasons were belief that someone else would take care of the problem, belief that nothing would result from the report and fear of retribution.
Group-style interventions, such as gathering a group of colleagues together, are the typical approach to dealing with an abuse problem, at least in movies and television. But Dr. Skipper, who estimates that he's been involved with some 3,000 interventions over three decades, discourages that approach with physicians. Feeling cornered and embarrassed, the doctor likely will refute everything with unproductive results, he said. “You just end up with a lot of arguing.”
In his role as medical director, Dr. Skipper fielded many calls from hospital administrators or chiefs of staff who had been notified about a potentially impaired physician. Uncomfortable and uncertain of what to do, they called the Alabama program.
Dr. Skipper, once he reached the doctor in question, said the typical conversation went like this: “I would say, ‘People are concerned that you may have a problem with alcohol. Do you have a problem?’”
Pretty much universally, the physician would deny any such problem, Dr. Skipper said. Then he would suggest that the doctor get tested to lay the concerns to rest. He also had leverage. In Alabama, as long as physicians cooperate with the physician health program including treatment and monitoring if needed, they aren't reported to the state medical board. Rather than risk being reported, even resistant physicians usually agreed to a screening test, Dr. Skipper said. “I rarely had anyone that didn't cooperate.”
The specifics of physician health programs vary from state to state, including whether the program is required to call the medical board if the physician doesn't comply with a testing request, according to Warren Pendergast, MD, an addiction psychiatrist and president-elect of the Federation of State Physician Health Programs, as well as medical director and CEO of the North Carolina Physicians Health Program.
If a physician resists testing, pressure can be exerted in other ways, he said. For example, if the doctor who is reported to the program is affiliated with a particular hospital, the doctor might be told that his credentialing is at risk if he does not comply.
Above all, one shouldn't take a doctor's word that he or she will change and leave it at that, Dr. Skipper said. It's also inadvisable to allow a physician to self-refer to a psychiatrist, perhaps someone sympathetic, which prevents any independent evaluation or monitoring.
Still, either of those missteps is better than no action, Dr. Skipper stressed. “I think the worst thing is to ignore it and not do anything,” he said. “It's a shame not to get somebody help for a very treatable disorder. It can wreck a career. It can kill a patient. To not act is very irresponsible.”
Returning to practice
If a doctor is being monitored by a physician health program, the oversight will continue after treatment is wrapped up. The monitoring, which typically includes random drug testing, may extend one to five years depending upon the severity of the individual's drug or alcohol dependence, Dr. Pendergast said.
In North Carolina, the follow-up includes a workplace monitor—someone who regularly interacts with the doctor and can report any worrisome signs or risks, such as stress at home or unexplained variations in work habits. “The idea is that if things aren't going well, the system can catch it before it gets to actual relapse,” Dr. Pendergast said. “We are moderating absolutely for abstinence, but we're also monitoring for recovery.”
Hospital leaders can do their part by working closely with the physician health program and the doctor involved, Dr. Pendergast said. Depending upon the situation, the doctor might return to practice part-time or her schedule might be modified in some other way to ease the transition.
A hospitalist who previously worked at night might benefit from working a day shift with less isolation and more interaction with colleagues, Dr. Pendergast said. A swing shift also may be riskier during recovery. Shifting work hours can disrupt vital sleep or interfere with the doctor's recovery support, such as attendance at Alcoholics or Narcotics Anonymous meetings.
Dr. Merlo also emphasized the importance of adjusting schedules and reducing access to narcotics. In addition, hospitals that don't have access to a physician health program, or agree to work with a doctor outside of one, could also implement random drug screening as a condition of a return to employment, Dr. Merlo said. Random testing can help keep recovering doctors on track. “It's like driving with a policeman behind you,” she said.
It's far from an ideal situation for a hospital administrator to provide the sole oversight for a physician's recovery, however, Drs. Merlo and Pendergast said. The administrator or chief of staff involved is not likely to be an addiction specialist. Plus, it's time consuming. As an outside entity, a physician health program also can protect the hospital against conflict-of-interest allegations, Dr. Pendergast said.
Compared with doctors working in small practices, hospital-based physicians have one built-in advantage as they begin their post-treatment lives: plenty of company.
“There is some benefit of working in teams,” said Dr. Guerrasio. “I would be more worried about the physician who worked in solo practice than a hospitalist. I think if something is off, I think it's much more likely to get picked up.”
Charlotte Huff is a freelance writer based in Fort Worth, Texas.
Physician Health Programs
Nearly every state has some type of physician health program. To find out more about what your state offers, go to the Federation of State Physician Health Programs website and click on the drop-down menu.
The North Carolina Physicians Health Program lists numerous behavioral and relationship signs that indicate a potentially impaired physician. Among the physical changes and work-related signs:
- Loss of appetite or reduced level of exercise
- Looks tired; admits to insomnia
- Personal hygiene deteriorates
- Physical problems are self-treated
- Misses appointments
- Make rounds at unusual hours
- Can't be reached when on call
- Sloppy charting
- Smell of alcohol on breath during the day
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