ACP Guidance on Physician Impairment Emphasizes Rehabilitation

Marcia Frellick

June 03, 2019

The American College of Physicians (ACP) issued a position paper on how clinicians and health systems should respond to evidence or suspicions of physician impairment.

The authors emphasize that illness does not always mean impairment and that rehabilitating physicians and reintegrating them into practice should be the goal whenever possible.

The guidance — authored by Philip J. Candilis, MD, director of medical affairs at Saint Elizabeths Hospital in Washington, DC, and colleagues on behalf of the ACP's Ethics, Professionalism and Human Rights Committee — includes a rationale for each recommendation and suggestions on how to implement changes. The guidance was published online today in the Annals of Internal Medicine.

The authors distinguish between "functional impairment and potentially impairing illness." Underlying medical or mental health conditions resulting from profound fatigue, the aging process, or substance abuse do not always lead to impairment and often can be treated, they note.

Because licensure questions may be a barrier to reporting or seeking help, the ACP recommends that such questions ask only about current status regarding illness and impairment, rather than past history, and not distinguish between physical and mental health.

The ACP makes clear that when physicians do become impaired and cannot practice competently, they have a duty to seek help and make sure their patients get proper care. When they can't or don't do this, other physicians and the medical profession must step in to safeguard patients' welfare and assist physicians in getting the help they need.

Culture of Silence

Referring impaired colleagues has been a long-standing problem in the profession, the authors note. They cite a 2010 survey of 2938 physicians in which "almost a third with knowledge of an impaired or incompetent colleague did not report this to a relevant authority, and more than a third did not agree that physicians should report colleagues at all."

That silence also figures into other areas that threaten patient safety. For example, a recent perspective in the Journal of General Internal Medicine highlighted underreporting of sexual abuse of patients by physicians.

An author of that article said, "When it does happen, physicians and administrators have a responsibility to advocate for patients, to properly investigate cases, and to bring offending physicians to justice, including ending their practice."

Consider Threat to Patients

Colleagues should judge the threat level to patients when they suspect impairment, the ACP advises. If patients are not likely to be harmed, a direct but sensitive conversation starting with the physician may be in order. If there is potential for patient harm, the suspicions must be reported to clinical supervisors or licensing boards.

Physicians should act with personal concern for their colleagues as well as carrying out their ethical responsibilities, Candilis and colleagues note.

The medical profession helps impaired physicians primarily through state physician health programs (PHPs), but the programs have very different structures. Forty-six states and the District of Columbia have them and almost all are nonprofit.

However, funding for PHPs varies greatly, according to the authors. For example, a national survey in 2009 found that annual budgets ranged from $21,250 to $1.5 million.

The authors write that PHPs should look for funding from diverse sources and work to avoid conflicts of interest in referral to treatment programs or monitoring laboratories.

More studies are needed to discover which PHPs are most successful and why, they say.

Meanwhile, national efforts by the Federation of State Physician Health Programs are underway to help ensure consistency in accountability and quality of PHPs.

Well-Being as Quality Marker

The authors point out that clinician wellness should be a priority at the organizational level.

"As part of the medical profession's social contract, physician well-being should be identified as a quality marker for healthy organizations and physician communities," they say. "The greater the emphasis on well-being, the greater the effect on physician recruitment and retention."

Reasonable accommodations should be made, the authors suggest, to support recovering physicians and make sure they have what they need to competently care for patients. That might include time off for appointments, support group meetings, or medical tests, as well as offering flexible shifts or gradual returns to work.

Jeffrey H. Samet, MD, MA, MPH, of Boston University Schools of Medicine and Public Health and Boston Medical Center in Massachusetts and Jane Liebschutz, MD, MPH, with the University of Pittsburgh School of Medicine (UPMC) and UPMC Health System in Pennsylvania suggest in an accompanying editorial that the guidelines should further define what constitutes impairment and should emphasize that physicians need to be assessed individually to determine whether the care they provide is less than ideal or if there is evidence of impairment.

The editorialists highlight the ACP's emphasis on changing the view of impairment as something that requires disciplinary action to a condition for which rehabilitation is the goal.

They applaud the authors for communicating that "the community benefits when, instead of being asked to heal themselves during periods of impairment, these talented professionals are supported and treated as needed."

Support for the paper came from the ACP operating budget. Candilis reported fees from ACP for consulting on and coauthoring the manuscript, expert fees from the Michigan Board of Medicine and the Michigan physician health program, and holding stock in Pfizer and Merck. His coauthors' financial conflicts are reported in the abstract. Editorialists Samet and Liebschutz have disclosed no relevant financial relationships.

Ann Intern Med. Published June 3, 2019. Abstract, Editorial

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