He’s been acting strangely of late: frequent tardiness, moody, a disheveled appearance. Your partner just doesn’t seem himself. Is it just stress? Or something more serious - and dangerous? Allowing denial to blind you to a partner’s substance abuse or other mental health problem could cost you, him, and his patients dearly.
Maybe you heard about the anesthesiologist stealing fentanyl from the drug cabinet? Or the pediatrician lacing his morning coffee with brandy to take the edge off his daily hangover? Thanks goodness nothing like that happens in your practice.
Or does it?
Experts estimate that about 6 percent of physicians have drug problems and one in seven have problems with alcohol. That’s about the same rate as the general population, but doctors are held by the public to a higher standard.
Of course, substance abuse isn’t the only reason some physicians may put patients, reputations, and medical licenses at risk. Personality disorders, psychiatric illnesses, and emotional problems also can lead physicians to endanger patients with substandard care. Your practice may never have to deal with these problems among its providers, but if it does, preparation and swift action can save a lot of time and a ton of trouble. You might even save a colleague’s career.
“There’s never an easy situation and they are all heartbreaking,” says Joan Roediger, a partner with the Philadelphia-based law firm Obermayer, Rebmann, Maxell & Hippel LLP. “The light at the end of the tunnel is that if you handle these things correctly, what could have been a horror story will end up with a successful outcome.”
Many recovery programs have been designed specifically for physicians. But getting to that successful outcome is a lot harder if problems aren’t detected and addressed early. Too often they are not. Physicians tell their patients how to spot the early signs of substance abuse, stress, depression, and other health issues. But as practice partners, they sometimes fail to recognize or acknowledge those signs in their colleagues. After all, it’s easier in the short run to stand back and hope the problem with a colleague will resolve itself.
“Every situation is different and there’s certainly no cookie-cutter solution, but two things are universally guaranteed: Avoiding the problem will not make it go away and the longer you wait, the more risk and pain your practice will suffer,” Roediger says.
The risks of delaying action can be high for the practice. Even if you do everything right, malpractice lawsuits frequently name the practice or practice partners.
Deny, deny, deny
Denial and secrecy aren’t just for substance abusers. Friends, families, and professional colleagues of substance abusers often refuse to acknowledge warning signs even when they are clear.
“Colleagues feel very uncomfortable confronting colleagues,” says Betsy White Williams, a psychologist and clinical program director of the Professional Renewal Center in Lawrence, Kan. “There may be obvious signs of the problem right in front of you, but it is human nature for people not to want to believe that something really bad like this is happening to them or a colleague.”
Williams says that when physicians do become patients at outpatient centers like the one where she works, it’s often because their drug or alcohol abuse was exposed involuntarily. Maybe it’s a flurry of complaints from patients or other physicians, she says. Or a payer’s chart audit turns up suspicious prescribing patterns. Sometimes, the physician is even arrested for drug possession or impaired driving.
“Smaller practices represent the best and the worst with these situations,” she says. “Physicians and staff are in close contact so they should be able to spot the signs of trouble early, but they don’t always have the experience to know what to look for or what to do.”
How to document
Williams says that changes in the physician’s behavior and appearance can give early clues that a problem exists.
Even with a sharp eye out for potential problems with colleagues, keep in mind that you are probably spotting the problem at an advanced stage, says Edward Krall, a psychiatrist with the Marshfield (Wis.) Clinic.
“The practice is the last place you’ll see the problem; the family sees it first,” says Krall, who also is director of the physician health committee at the 800-physician multispecialty practice. “The practice is protected domain and people go to great lengths to hide these problems in the workplace.”
Once suspicions are raised, Krall says to begin documenting the behaviors and incidents.
It will be harder for the substance abuser to deny or downplay a problem if confronted with solid evidence rather than vague impressions. Those notes will come into play when you take the next step, which is to confront the physician, usually through an orchestrated intervention. And yes, it will be a painful and uncomfortable experience for all concerned, he says.
“You tend to want to look the other way and hope it will resolve itself but it usually doesn’t,” Krall says. “Denial is often the biggest hurdle to get over.”
Don’t let worries about your notes becoming fodder for future lawsuits stop you from beginning the task of documenting the behavior, says Roediger. True, noting one’s suspicions for a year or two while doing nothing will pose a problem if a patient is injured. But you are headed for a mess either way, she says, so choose the path of action. “You should absolutely be documenting any issues you see because it prepares you to intervene,” Roediger says. “These situations can turn into very serious cases; you don’t want to get caught saying under testimony that you didn’t have any suspicions when, in fact, you did.”
Interventions that work
Krall and others recommend that interventions be rehearsed with a specific plan in mind. Those participating in an intervention should approach the physician with the facts about his or her behavior, express their personal concerns, and then make specific recommendations.
“You want to have your ducks in a row as you go into this because there is apt to be a fair amount of denial,” he says.
The intervention team should include the physician’s supervisor, such as the practice president or department chief, plus two or three close physician colleagues, and perhaps a family member. It may be helpful to include a recovering addict who is also a physician or other professional. Sound like a lot of planning for a dicey event that could go awry? You bet. That’s why Krall suggests getting expert advice to plan the intervention. One resource could be your state’s physician health program. Nearly every state has one of these independent nonprofit organizations that help physicians who want to recover from substance abuse and other problems without putting their license in danger.
Krall says interventions work best when attendees express sincere concern about the physician’s health and professional future. It’s best to have a clear plan of action to suggest, such as getting an evaluation and diagnosis by an outside physician.
“You make it clear you are not there to diagnose or treat or punish but to present your concerns out of a collegial spirit,” he says.
And yes, expect denial.
“These things never go really smoothly because usually the person doesn’t see it,” says Tom Weida, a family physician who is professor and medical director at Penn State Hershey Medical Center College of Medicine. “You have to help that person become aware that there is a problem by pointing out their performance, which is where you usually see the first red flags.”
Systems help the process
State physician health programs work with state medical boards to help physicians gain access to substance abuse treatment without risking their medical licenses - if they follow through with the prescribed treatment plans. The programs can be a vital source of support to smaller medical practices that may not be able to afford employee assistance programs or don’t have standing physician health committees.
Every practice, however small, should have a written zero-tolerance substance abuse policy in place, says Bergitta Smith, chief operating officer of the National Patient Safety Foundation. Clear language in the practice’s policy manual and in physicians’ employment agreements will help draw a clear line between what the practice considers acceptable and what it does not.
“Decision-making and critical thinking may not be optimal for someone who’s impaired and you don’t want to be in a position of having to tell that person they should have just known where the line was that you now say they shouldn’t have crossed,” Smith says.
Smith says keeping the lines of communication open between the administrator and the physician leadership can help uncover potential substance abuse, behavioral, and mental health problems early on. Administrators are quick to hear what staff members say about a physician’s behavior.
“Patients might not complain - they tend to just leave quietly when they don’t like something about a physician but the staff always knows,” she says. “Your staff figure out very quickly who the problem provider is.”
Smith advises checking with the practice’s attorney when dealing with a physician suspected of having a substance abuse problem. Don’t depend on your regular attorney who provides business and tax advice to know the ins and outs of handling these situations, Roediger says. Instead, ask your regular counsel to refer you to an attorney who has experience dealing with physician impairment issues.
Follow-up that works
For some physicians, outpatient treatment for several weeks may be in order. Others may require a stay in a residential facility for a few weeks. For all, the return to the practice can be the make-or-break test.
Follow-up should include informal support from colleagues but also a structured program that includes:
Krall says the physician returning to practice should be assigned work at first that can be easily supervised and does not present ample opportunities for patient endangerment. For example, assign the returning emergency physician to an urgent care center or clinic instead of to a hospital emergency department’s night shift.
Even if the returning physician is not permitted to practice medicine immediately, the recovery phase can still be productive. Smith recommends putting the physician to work developing new quality reporting rules, dealing with payer issues, or other critical tasks that need a physician’s input.
Williams adds that substance abuse is a chronic disease and recovery requires lifelong monitoring and care, not a quick fix.
“Think of every person in your practice as a resource and ask how you can work together to help that resource achieve and keep achieving its maximum potential,” she says.
Bob Redling has written on practice management topics for 10 years. He has been practice management editor for Physicians Practice, Web content editor and senior writer for the Medical Group Management Association, and a speechwriter for the American Academy of Family Physicians. He can be reached at email@example.com.
This article originally appeared in the February 2008 issue of Physicians Practice.