Want Hospital Admitting Privileges? First Pass a Drug Test

May 16, 2013

Physicians seeking medical staff privileges at a hospital should first go into a bathroom and fill a small paper cup, all for the sake of patient safety, suggests an article published online April 29 in JAMA.

Requiring physicians to take a urine drug test as a condition of employment is already the norm at hospitals, but lead author Julius Pham, MD, PhD, and colleagues recommend that hospitals also screen medical staff applicants for possible impairment by substance abuse.

In addition, while they are at it, hospitals might want to subject their medical staff to random drug tests and test physicians involved in any mishap — a sentinel event, in quality-control parlance — that leads to a patient's death, writes Dr. Pham, an associate professor in the Armstrong Institute for Patient Safety and Quality at Johns Hopkins School of Medicine in Baltimore, Maryland. After all, airplane pilots are screened for drug use after a crash or near miss.

"Patients and their family members have a right to be protected from impaired physicians," write Dr. Pham and colleagues. "In other high-risk industries, this right is supported by regulations and surveillance. Shouldn't medicine be the same?"

Noting that alcohol, narcotic, and sedative addictions are as common among physicians as they are in the general population, the authors write that "physician impairment seems to be a possible contributor to patient harm."

In an interview with Medscape Medical News, Dr. Pham said that he lacks data to show that physicians with substance abuse problems are actually injuring patients. This lack of data, he said, is an argument for at least testing physicians with a role in an adverse event.

"That is a catch-22," Dr. Pham said. "If we don't test after adverse events, we don't know if substance abuse was involved."

Dr. Pham acknowledges the challenges inherent in drug testing, such as the danger of a false-positive ruining someone's reputation, but nevertheless advocates the practice. The push for patient safety "is moving medicine from an art to a science, something you can evaluate in a scientific way," he told Medscape Medical News. "Drug testing is a part of that."

At least one physician, however, questions the wisdom of requiring physicians to fill the paper cup to gain hospital admitting privileges, much less land a job. That physician, Martin Donohoe, MD, decries the invasion of privacy that he associates with a urine drug test.

"It's degrading," said Dr. Donohoe, a part-time hospitalist at Kaiser Permanente Sunnyside Medical Center in Clackamas, Oregon, and editor of the 2012 book Public Health and Social Justice. "If the head of my hospital wants access to the results of my drug test, I want access to the results of his or her drug test, too."

A Sign of Corporate Medicine

Urine drug tests are now routine for physicians seeking hospital employment, according to recruiters interviewed by Medscape Medical News.

"I'm not aware of any hospital that doesn't do it," said Tommy Bohannon, divisional vice president of the academic medicine division at Merritt Hawkins in Irving, Texas. To Bohannon, it is a sign of "the practice of medicine becoming more corporate."

"Hospitals are treating physicians like any other employee," added Lori Schutte, the president of Cejka Search in St. Louis, Missouri. Her company advises job-seeking physicians that hospitals typically will require them to pass a drug test. "We haven't had anybody push back."

Drug testing is not yet a standard practice in clearing physicians for medical staff privileges, but a growing number of hospitals do it, said Melissa Walters, president of the National Association of Medical Staff Services. Her group represents professionals responsible for credentialing physicians and other clinicians.

One of those hospitals requiring an initial urine drug test for its medical staff members is Johns Hopkins Hospital, said Dr. Pham. The policy also applies to its employed physicians.

Not Enough Professional Self-Regulation?

Drug testing for physicians has not gone unprotested. In 2005, the Journal of Clinical Ethics published an article punnishly titled "Urine Trouble" by Dr. Donohoe that called such tests "ill-justified."

"Tests are expensive, are based on poor science, represent an unwarranted invasion of privacy, and are unlikely to meet the purported goals of diagnosing functional impairment, improving patient safety, and enhancing quality of care," Dr. Donohoe writes.

Urine drug tests have a number of shortcomings, Dr. Donohoe told Medscape Medical News. They are prone to registering false-positives triggered by everything from poppy seeds to tonic water, but miss alcoholics whose weekend binge washes out of their system before they are handed the paper cup.

Administering drug tests after an unexpected patient death also poses problems, said Dr. Donohoe, because sometimes the sentinel event is not spotted until a month later in a quality review. A drug test at that point may not identify a case of substance abuse when the mishap occurred.

Dr. Donohoe told Medscape Medical News that a better way for hospitals to catch physician impairment born of substance abuse — or any other malady — is to periodically give physicians performance tests involving their reflexes, coordination, and memory. Another part of the solution, he said, is professional self-regulation.

"You have to have a willingness of physicians to report impaired colleagues," he said.

When it comes to blowing the whistle, there is considerable room for improvement. A study published in JAMA in 2010 reported that roughly 1 in 3 physicians do not believe it is their duty to report a colleague who comes to work hung over or otherwise impaired.

To Dr. Pham, this finding only buttresses his case for drug tests for physicians who want to join a hospital's medical staff.

Physicians take a Hippocratic oath to protect their patients from harm, but "we know that [physicians] fall through the cracks, and patients suffer," said Dr. Pham. "Now it's not good enough that you take the oath.

"We need more accountability."

Dr. Pham and coauthors have disclosed no relevant financial relationships.

JAMA. Published online April 29, 2013. Abstract

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