The Impaired Physician

Impairment Among Physicians is Growing: Why?

Neil Chesanow

Disclosures

February 24, 2015

Self-referrals Are Growing

Physician health programs (PHPs) across the country report a rise in the number of doctors whose treatment they are overseeing. Some of these doctors were reported by a concerned colleague, employer, hospital medical director, state medical board, or judge, but other physicians referred themselves.

Physicians with alcohol and drug abuse problems rarely enter a program without external pressure. Doctors who self-refer typically have other problems, ranging from burnout to behavioral problems or physical illnesses, such as cancer, stroke, diabetes, hypertension, and Alzheimer disease.

"In any given year, we engage with approximately 400 unique individuals, which includes people who are referring themselves and those who have been referred to us by someone else," says Steven Adelman, MD, a psychiatrist, addiction medicine physician, and director of Massachusetts Physician Health Services, the state's PHP. "However, if you look at the past year vs the previous year, the number of self-referrals to our PHP has doubled. And the number of self-referrals in our last year was over 30% of the total referrals. That's a sign of positive cultural change."

Still, 400 unique individuals are only a tiny fraction of Massachusetts physicians. Over 31,300 physicians are professionally active in the state.[1] The incidence of alcoholism and drug addiction alone in physicians nationwide is about the same as in the general population: 10%.[2] That doesn't include doctors afflicted with mental health problems, behavior problems, physical illness, or burnout.

Is Being a Doctor So Difficult?

Why are more physicians referring themselves for help?

"A medical career is like running a marathon over 30 or 40 years," Dr Adelman says. "As doctors proceed through their careers, the marathon gets more difficult for a number of reasons. For one, there's way more to do for physicians as time goes on, because there's more medical knowledge. There are more regulations. There's more complexity on the business side."

In addition, "we're victims of our own success, in the sense that as we help patients live longer, they get sicker and sicker, so the job of taking care of people gets more difficult," Dr Adelman observes. "The money is tighter. There's less margin in delivering healthcare, especially in a world of universal coverage."

This puts many physicians under mounting, sometimes unbearable, stress.

"As the doctor runs this marathon, where the course is getting trickier and trickier and more uphill as time goes on, doctors develop their own medical problems," Dr Adelman says. "We develop our own family problems. At a time when we need to be running harder and faster just to keep up with the stress and strain of the profession, we're actually facing our own challenges. So that's one piece of it."

Dr Adelman ascribes a second piece of the problem to the "physician mindset." "The mindset of physicians is we're rugged individualists," he says. "We are problem-solvers. We know what's best for people, including ourselves. We can sometimes be sure of ourselves to a fault. And we're super-busy. That mindset often contributes to a personal attitude of inadequate self-care."

"Many doctors, by our very nature, don't take particularly good care of ourselves," Dr Adelman reflects. "We do a lot of what I would call haphazard, freestyling care: Talk to the guy in the next office, talk to the guy in the hallway, get a prescription from a friend, and keep it to ourselves when things are bothering us."

"There's a mindset of, 'I can figure this out. I can take care of myself,'" Dr Adelman continues. "Then there's this cultural piece: We're super-human. As the marathon gets more and more difficult, the culture and this problematic mindset lead people to delay taking care of their problems earlier on. As a result, by the time a lot of doctors end up getting help, they're crashing and burning. It's an eight- or nine-alarm fire. Most doctors don't know what they ought to be doing to put out the fires when they are one- and two-alarm fires."

Although physicians with substance use disorders get the most press, Dr Adelman doesn't view drugs and alcohol as the primary problem. "Easy access to controlled substances is a risk factor for doctors who become addicted to controlled substances," he says. "But I think addiction to controlled substances, while significant, is a small part of what afflicts physicians."

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