The Impaired Physician

What's the Prognosis for Impaired Physicians?

Neil Chesanow

Disclosures

February 25, 2015

In This Article

Helping a Sick Colleague

In rare instances, a physician with a problem with alcohol or addictive drugs will self-refer to a physician health program (PHP). PHPs are available in most states.

But most often, when a physician has a substance abuse disorder, an employer, colleague, hospital medical director, medical board, judge, or spouse needs to intercede on the sick physician's behalf. If the physician wants to get well and save his or her career, entering treatment is typically the only option.

What happens to an addicted doctor in a treatment program? Let's take a look.

Discovering the Root of the Problem

"Treatment really starts with a conversation lasting 1 to 3 hours about what brought the doctor to my attention," says P. Bradley Hall, MD, a family physician and addiction medicine specialist. Dr Hall is executive medical director of the West Virginia PHP in Bridgeport and president-elect of the Federation of State Physician Health Programs (FSPHP).

The goal of that initial conversation is to help physicians with a substance use disorder "see the situation more accurately from the outside in, rather than from their own perspective," Dr Hall explains.

He recalls an alcoholic physician who only drank at night to help himself sleep. He didn't realize how much he drank. He was never intoxicated at work, but his employers could smell alcohol on his breath the next day. They spoke to him about it. So he bought a home breathalyzer to test himself before going to work. However, the device wasn't properly calibrated. Eventually, he did test positive for alcohol on the job.

"In my discussions with him, it was the first time he had ever thought that needing to use a home breathalyzer is not normal social drinking behavior," Dr Hall says. "You could call it denial, which it is, but it's almost more like delusional thinking, and you have to borrow someone else's brain to see it more clearly."

At the Colorado PHP, the process is similar. "After completing a 20-minute health screening questionnaire, the physician has a 90-minute to 2-hour interview with the medical director and a master's-level clinician," says psychiatrist and addiction medicine physician Doris C. Gundersen, MD. Dr Gundersen is the PHP's associate medical director and president of the FSPHP.

"We focus on the presenting problem, summarize our preliminary ideas and recommendations, and arrange for additional evaluation if the physician needs it," she says. "We then assist the physician in obtaining treatment in the community with a provider who is comfortable with treating and also competent to treat other physicians."

How extensive the treatment is depends on the degree of impairment. But if a physician has a seriously debilitating or even life-threatening addiction—say, to fentanyl, a synthetic opioid that's far more potent than other opiate drugs, Dr Gundersen says—residential treatment is prescribed.

The Residential Treatment Experience

Residential treatment typically lasts 30-90 days, although for some physicians who have relapsed and are very ill, it may last 6 months to 1 year, Dr Gundersen says. Physicians are evaluated on a case-by-case basis. A 3-month stay is common.

Insurers rarely pay for residential treatment. The cost, which can be substantial, is generally borne by the impaired physician.

Three months isn't an arbitrary number, Dr Gundersen points out. "We have some research now demonstrating that this kind of intensive treatment, coupled with monitoring, allows physicians to achieve recovery rates that are much greater than those in the general population," she says.

"Physicians have more to prove than just that they're abstinent," Dr Gundersen adds. "They're in 'safety-sensitive employment.' We have to ensure that they can go back and treat patients safely. So programs designed to treat healthcare professionals are more intensive."

Some residential programs include only other physicians. Others include a mix of professionals, such as attorneys and pilots, as well.

"If they're in groups with other professionals, they're more likely to be confronted on any rationalizations or denial about their illness, whereas if they're with a mix of people who look up to the doctor as a power figure, the physician won't work on his own work," Dr Gundersen explains. "He will attend to the other individuals in the group. The importance of having a professionals group is that the physician is more likely to be confronted by his peers."

"Typically, when physicians go to a treatment center, there is a lot of group therapy," Dr Hall elaborates. "There's also one-on-one therapy. They also see psychiatrists. They get neurocognitive and neuropsychiatric testing that tells us a lot about underlying issues of personality and psychiatric illness that may or may not need to be addressed. And then we address multiple comorbid issues that they may encounter in a safe environment among their professional peers, who are learning the same things."

"During the day, it's a lot of education, group therapy, and one-on-one therapy, and in the evenings, they do other recovery-related activities, including live with each other, usually in an apartment-type setting," Dr Hall says.

Group therapy at many PHPs is based on 12-step models. At Alcoholic Anonymous (AA), six of the 12 steps make reference to God or call for declarations of subservience to a higher being.[1] What about physicians who are nonbelievers?

"What I tell those folks is, 'Don't worry about what God is,'" Dr Hall says. "'Just don't be your own for a while and you'll be all right.'"

Therapy sessions may be led by healthcare professionals who are nonphysicians. Are doctors able to take advice from, say, psychologists and psychiatric social workers as equals, when some doctors may perceive them as being lower in status, intellect, and professional attainment?

"Once you get them used to the treatment milieu, get them through some of the typical leadership personality traits of a physician, and get them to realize they're human beings like everyone else, they become more open-minded," Dr Hall says. "They start feeling better. They start recognizing that there's some things they don't know. And they actually like it. But it takes them a while to get there," he concedes. "They didn't get where they're at by asking people for help and listening to others. It becomes a new theory for them."

"A lot of attention is paid to family dynamics," Dr Gundersen adds. "Addiction is often considered a family disease. Families may enable addictive behavior. So the family participates in treatment. Toward the end of treatment, a lot of attention is paid to managing risks, preventing relapse, and transferring care into the community. So there's good continuity between residential treatment and the physician's community, where he or she will receive outpatient treatment."

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