Beyond the oath: the unaddressed challenge of physician impairment

Despite their idealized oath to do no harm, physicians are still human, and as such, mistakes, errors, and the unpredictability of life still occur. Although the stories that grab headlines are of doctors intentionally harming patients, such instances are exceedingly rare. Far more prevalent, however, are the cases of physicians who begin their careers with the best intentions, only to encounter challenges along the way. According to the American Medical Association, an “impaired physician” is defined as someone who cannot provide medical care with appropriate skill and safety due to physical and mental health-related issues that affect their performance.

Physicians become impaired due to three primary challenges: substance abuse, psychological issues, and physical health problems. The most common challenge is substance abuse, which includes alcohol as well as narcotics, depressants, and stimulants. Substance abuse, in particular, is further heightened by easy access to controlled substances. Psychological issues can also undermine a physician’s professional capabilities, including bereavement, divorce, or mental health disorders like depression or anxiety. Lastly, physical health issues, both acute and chronic, can impair a physician’s ability to practice effectively, including cognitive decline or musculoskeletal disorders like Parkinson’s.

Society often places doctors on a pedestal, believing they’re immune to the vulnerabilities that affect the rest of the population. However, there is no evidence that physicians experience any less incidence of mental health issues, addiction, or disease than anyone else working under similar circumstances. Although these challenges are “normal,” the concern arises when such issues start impacting professional duties, thereby directly jeopardizing patient health and safety.

Personal challenges impacting professional capabilities are not unique to the medical field, either. This extends to other high-stakes professions, such as pilots and CEOs, where personal difficulties can significantly affect professional judgment and actions. When individuals in these critical positions falter, the question arises: What policies and procedures are in place to address these harms or, better yet, to catch them before they happen?

The ineffectiveness of quiet interventions

In an ideal world, colleagues would promptly identify problematic behavior and report it to the medical licensing authorities, leading to swift action and investigation. However, with no clear procedure in place, this rarely happens, with months or even years passing before collective action is taken to address a problematic doctor. This inertia stems from various factors: the convenience of inaction, the lack of concrete evidence, personal relationships that encourage a gentler approach, or institutional reluctance to challenge a financially profitable physician. Commonly, co-workers engage in a process described by sociologists as a “Terribly Quiet Chat,” where they discreetly pull the physician aside to inquire about their well-being and to express their concerns. Sometimes, these informal chats help, but if not well-received, there is a lack of authority to effect real change.

I had a colleague who was confronted with this issue during her first week as a new attending trauma surgeon. A patient presented in extremis with unstable vital signs from a blunt injury to her abdomen from a motor vehicle accident. She instructed the team to move the patient quickly to the operating room for a trauma laparotomy. Suddenly, the long-time chair of the surgery department entered the room and barked at everyone to move the patient to the ICU for fluid and blood product resuscitation to stabilize the patient first instead. My colleague was new and junior and stepped out of the room with the chair to understand his thinking about not going straight into surgery. He said, “I have seen this situation a thousand times … trust me.” He was unwilling to listen to her concerns, and a contrary opinion was uninvited. Troubled by his overriding decision, she ran the case by other surgeons in the department only to receive shrugs or indifference.

Two hours later, the patient died of cardiac arrest in the ICU from a ruptured spleen despite massive blood product resuscitation. Going to the ICU instead of the operating room was wrong for this patient, a mother of two children. Distraught by this case, my colleague felt responsible for not being able to persuade the chair to go to the OR. Indeed, unbeknownst to her, the chair’s behavior had become a pattern over the last few years, and the following week, he left a clamp in a patient’s abdomen. Multiple colleagues had engaged in informal discussions with the chair to address concerns about his professional conduct. Despite these conversations, there was a collective failure to notice, acknowledge, or address the fact that he was evidently experiencing neurocognitive decline. This decline was impairing his judgment and his ability to safely care for patients, and he retired the following week.

Similar examples of physician impairment and professional decline were documented in depth in The New Yorker’s 2000 article titled “When Good Doctors Go Bad.” Overwhelmed by grief, depression, or stress, doctors erred or failed to act appropriately, and as a result, patients were injured. Some of these doctors recovered and improved, while others were pushed into early retirement; some colleagues confronted the impaired physician, while other colleagues stepped in and quietly made sure no patients were injured. A striking commonality in these cases was the absence of a clear protocol for hospitals to manage such situations.

While I’d like to think progress has been made in the two decades since my encounter with physician impairment, the reality is that there still lacks a comprehensive system to effectively address such situations. The “Terribly Quiet Chat” was limited and ineffective then and remains so today. Its informal nature means it carries no real force or obligation for the physician to enact change. More concerning is that these conversations are retrospective, usually occurring after a discernible pattern of patient harm has emerged. Despite increased awareness and dialogue around physician impairment and patient safety, a cohesive and proactive approach to identifying and managing the decline in a health care professional’s capabilities remains elusive.

Challenges and solutions in addressing physician impairment

As we approach the 25th anniversary of the landmark report “To Err Is Human,” we should reflect on the strides made in health care safety and the gaps that persist. This seminal work highlighted the systemic issues contributing to medical errors, sparking significant reforms to enhance patient safety across the health care spectrum. Yet, as we delve into the nuances of health care improvement, it becomes evident that one critical area has seen little evolution: the approach to managing and dealing with impaired physicians. Despite the advancements in protocols, technologies, and policies designed to safeguard patients, the dilemma of addressing the challenges faced by physicians struggling with mental health issues, addiction, or physical impairments remains largely unchanged.

Physicians have a fundamental duty to maintain their own health and to act with self-awareness as part of their professional commitment to patient care. This includes recognizing when their own physical or mental health might impair their ability to provide safe and effective care and taking necessary steps to seek assistance. Furthermore, physicians have an ethical responsibility to respond if they perceive a colleague might be compromised in their ability to practice safely. This involves intervening with respect and compassion, ensuring the colleague does not pose a risk to patients and receives appropriate evaluation and care. In cases where unsafe practices continue despite initial efforts, physicians are ethically obligated to take further action, including reporting if necessary, as part of the profession’s duty to self-regulate and uphold patient safety.

We should no longer depend on casual, informal discussions that carry little or no weight or obligation for change; instead, there should be specifically designed programs to tackle physician burnout, stress, mental health concerns, substance abuse, and other disorders. These programs should focus on immediate intervention and also provide a clear, documented path toward rehabilitation while carefully considering the physician’s potential for re-entry into practice or transition into retirement. By implementing robust support systems, health institutions can safeguard patient welfare while simultaneously providing the necessary care and support for their medical staff. Without such measures, health systems and their representatives risk perpetuating a cycle of patient harm.

Scott Ellner has been a general surgeon for over 20 years, and can be reached at PEAK Health. He has transitioned into health care executive roles due to his passion for patient safety, quality, and value-based care delivery. His authentic leadership style inspires team members to navigate challenging situations, such as resistance to change and innovation, in order to bring about meaningful transformation. Most recently, he served as the CEO of Billings Clinic, the largest health system in Montana. During his tenure, Forbes recognized the clinic as the best place to work in the state. It was also at that time that he formulated a strategic growth plan that included the development of a level 1 trauma network and a rural-based clinically integrated network.


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