I have blogged and lectured about handling impaired physicians several times in the past; however, this issue continues to arise with regularity in my practice. As President Trump has stated, there is an opioid crisis in this country. Physicians, nurses and other caregivers are not immune to the addictive nature of opioids and other drugs, especially because many healthcare providers have greater access to drugs compared to the general population. What safeguards does your practice have in place to confront a provider who may be impaired? How do you track the appropriateness of prescriptions being generated? How do you handle the return to work by a previously impaired provider?
Consider the following scenario: A longtime physician in the practice suddenly advises you that he is checking himself in to a rehab program for drug and alcohol addiction. The practice owners are completely surprised, as the physician did not show any outward signs of an addiction issues and has been a successful member of the practice and upstanding citizen for many years. However, it turns out there may have been many signs: increase in patient complaints, lack of calls being returned, showing up late for work multiple times, nonsensical medical record entries, etc. What many may have thought to be signs of stress, distraction, fatigue, etc., may also be signs of addiction. Has this occurred or could it be occurring in your practice?
What can a practice really do to address addiction within their workforce?
1. Consider practice training/find out where to seek assistance should a provider show a change in behavior or other signs that create concern. Knowing the triggers to look for may also be helpful to allow for early intervention. For example, people may be more likely to turn to addictive behavior, or relapse, in times of particular stress (recent death in the family, divorce). Additionally, triggers might include a recent surgery or injury where medications were taken for pain relief. Your local hospital medical staff may have support for the practice and the provider as needed.
2. Understand the practice's rights to order random drug testing. Is it legal in your state? Does it need to be included in your contracts? What are the repercussions for a provider who refuses to cooperate? Discussion with the practice's counsel is advised.
3. How do you handle a provider taking time off related to an addiction? Depending on the circumstances, the provider's illness may implicate the Family Medical Leave Act (FMLA), disability laws and potential contractual protections. Terminating a provider under such circumstances opens the practice to liability and legal counsel should always be consulted before any decisions are made. I also always recommend the practice review the prescriptions previously written by the impaired provider for signs of self-medication or falsification. Legal issues, as well as reportable offenses (DEA), may exist, which could be grounds for termination.
4. What conditions are placed on a provider returning to work? An important requirement under the FMLA is a certification from the provider's healthcare giver regarding their return to work. What needs to be included in the certification to satisfy the practice? What ongoing support or treatment is the provider required to seek? How can this be assured?
5. When a provider returns to the practice, what limitations may legally be placed on prescription and drug access? Should there be review and approval of prescriptions written?
6. Is there a requirement for the provider to self-report under state law or for the practice to report the provider to the state licensing board, the state Department of Health, the malpractice carrier, the DEA, the medical staff(s) on which they provider has privileges or other third parties? Some of these answers are dictated by law, and others by contract. Legal counsel should be consulted before any action is taken, but failure to meet contractual or legal requirements can have implications for the provider's license and the practice.
7. Should the charts of the impaired provider be reviewed? Depending on the particular situation, there may be incomplete medical records, missed patient follow-ups, inappropriate prescriptions, incorrect or missed diagnoses, etc. It is possible for a lawsuit to come out of the period of time during which a provider was impaired and a chart review may minimize such risk.
There may be other issues which your legal counsel believes are appropriate for your particular practice and in your particular state. Knowing in advance the steps to be followed can streamline the process of handling an impaired provider in your practice and allow the focus to be on helping the provider and protecting the business.