Physician Impairment Research Articles

Experiences of Physicians Investigated for Professionalism Concerns: a Narrative Review.

Growing attention is being paid to physician health and behavior, including the occurrence of mental health issues and burnout in medical providers, physician impairment, and alleged disruptive behavior in physicians. In any of these areas, a physician may become the subject of an investigation. Studying the experience of investigated physicians is important to identify and mitigate any potential adverse personal and practice impacts, which in turn can hinder patient care. The purpose of this review is to (1) summarize the published scientific literature to date regarding the experiences of physicians who have been investigated, and (2) based on these findings consider strategies to mitigate any adverse effects of the investigatory process for physicians. A search of the databases PubMed and Ovid MEDLINE was conducted in June 2023 using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 16 articles were identified and reviewed. Physicians in multiple countries who had been investigated commonly described short-term (feelings of anger, depression, anxiety, shame, powerlessness, isolation, being betrayed, less confidence in clinical decision-making) and long-term (increase in defensive practice, retiring early) impacts of the investigatory process. Physicians found the most difficult aspects of the investigation process to be the length of time involved, lack of transparency/communication regarding the process, feelings of isolation, and dealing with vexatious complaints. While complaints about physicians have the potential to portend constructive individual practice and systemic changes, research suggests that the investigatory process for physicians is associated with negative short- and long-term emotional and practice impacts. Strategies to mitigate the unintended adverse effects of investigatory processes are proposed. Further research is warranted to clarify the investigation experience for physicians, including physicians underrepresented in medicine, and to systematically assess the effectiveness of strategies to mitigate unhealthy or disruptive components of the investigatory process.

Letter to the Editor

I write following my reading with great interest the published article “Physicians and Cognitive Decline: A Challenge for State Medical Boards,” in the Journal of Medical Regulation.1I express my opinion based on my own personal experience as an active practicing physician for 47 years across several states.I agree with the article’s author that “older physicians benefit from their many years of experience and the skills they have developed over decades of practice…,” but feel that the use of the generalization that these physicians “may be at risk of cognitive decline, with job performance deficits…,” may be biased and inaccurate. Such a conclusion could raise concern as not based on significant statistical facts and/or factual finding.We cannot and should not generalize, otherwise our opinions become skewed and invalid.State Medical Boards and Peer Review Boards have their own internal review procedures for checks and balances. They are the regulatory and monitoring authorities overseeing physician performance practices, treatment outcomes, physician patient satisfaction, medical errors, negligence, reporting of patient loss, including outcome of claims litigation.2,3,4Having an outside source beyond internal affairs of State Medical Boards and Peer Review Boards mingle and interfere with their internal and intrinsic procedures, proceedings, legislation, and medical staff by-laws seems like an intrusion by telling assigned medical organizations how to oversee, regulate, and proceed in these matters that are akin to physicians telling state bars how to regulate their member lawyers.2,4,6State Medical Boards do identify, monitor, and pursue physicians who show cognitive decline. These bodies already do a good amount of regulating and overseeing of Quality Assurance, as is the case of the Medical Board of California, following their legal state mandate and ethical obligation to the public and its trust.7Many State Medical Boards and Medical Associations have adopted certain methodology to establish such programs. They also have the wisdom to screen and monitor physicians to establish such programs, and the wisdom to screen and monitor physicians’ late impairment through specific Medical Specialty Tests and comprehensive follow-up tests to best identify any such issues.2,4,6There is no set or agreed upon age when such physicians’ testing program should commence. Due process and its protections are paramount for the process of identifying physician impairment and performance below the standard of care, so that the process can be fair, reasonable, and equitable to all.State medical societies already institute public relations campaigns geared to build support among clinicians and other professional medical organizations, as its relevance also applies to State Medical Boards, who are tasked with regulating and overseeing medical and health care providers as well.5Cognitive decline is not exclusively or only inherent to medical practitioners. It also applies to all in the work force, across the board. The dos and the don’ts are ultimately a matter of due process and the law.Given the current physician shortage crisis we are facing in the US, along with the demographic trends, more primary care providers are likely to be needed to meet the increasing needs of the older population, and the need to avoid forced early retirement of aging, elder physicians in this country.5Ultimately, competence rather than mandatory retirement due to age per se should be the deciding factor regarding whether physicians should be able to continue their practice.4Physicians recognize that they are not alone, and the visible leadership by influential national organizations and accrediting bodies (eg, National Academy of Medicine, American Medical Association, Association of American Medical Colleges, Accreditation Council for Graduate Medical Education, the Joint Commission, American College of Physicians, Accreditation Council for Continuing Medical Education) engaging regulators, payers, and other organizations may provide optimism for meaningful change.Respectfully Submitted,Isaac E. Jakubowicz, MD, MPHBeverly Hills, CAgreatpediatrician@yahoo.com

AMA Opposes Use of Ketamine, ‘Excited Delirium’ for Law Enforcement Purposes

AMA Opposes Use of Ketamine, ‘Excited Delirium’ for Law Enforcement Purposes

The opioid-impaired provider: A call for national guidance to maximize rehabilitation while protecting patient safety.

The opioid-impaired provider: A call for national guidance to maximize rehabilitation while protecting patient safety.

Special Perioperative Considerations in Anesthesiology

Anesthesia providers are faced with increasing work stressors and challenges that affect both patient care and the health of providers. Most physicians cope with stressors by relying on situational and personal characteristics. Addiction remains a relatively common maladaptive response. Anesthesiologists tend to abuse more potent medications than the general population and have a higher mortality rate than other practitioners with substance use disorder. Distractions from personal stressors, combined with a myriad of distractions in the operating room, can jeopardize vigilant practice. How can we better provide for the safety of our patients and satisfaction within our own lives? 1) Mindful practice can lead to an internal state of personal wellness. 2) Intentional design of clinical processes can simplify our workflows and increase resilience to errors. 3) Adoption of performance improvement techniques and error reduction strategies can focus on identifying deviations from practice. 4) Checklists and standardized workflows, along with structured communication and team training can improve shared understanding and the reliability of our work. Adoption of such interventions can reduce the burden of our work and improve outcomes for both the practitioner and the patient. This review contains 2 figures, 6 tables, and 55 references. Keywords: burnout, disclosure of mistakes, distractions, malpractice, mindfulness, performance improvement, physician impairment, safety, substance use disorder

Medical malpractice in Iran: A systematic review.

Background: Medical malpractice represents a serious problem in the health system and is one of the risk factors for patient safety which damages the patient and increases costs for the patient and the health care provider. The importance of these complaints against physicians is that litigation may continue for a long time and become problematic for patients and physicians. The objective of this study was to investigate the complaints of medical malpractices which were referred to Iran Medical Council to provide solutions to reduce the complaints and improve service delivery. Methods: Embase, PubMed/MEDLINE, ISI/Web of Science (WOS), Scopus, and Iranian databases, such as MagIran, SID, and Irandoc, were searched from 01/01/1990 to 07/01/2018. Also, the grey literature (via Google Scholar) was searched. Studies written in English or in Persian were searched, and keywords used included malpractice, negligence, medical malpractice, physician impairment, Iran, and professional impairment. Results: Nearly 1455 complaints (36%) of the total number of 3977 complaints were proved to be medical malpractice, and physicians were acquitted in 2542 (64%) cases. Most complaints were from gynaecologists, accounting for 43% of all complaints, followed by orthopaedic specialists who ranked second with 21.4% of the total complaints. The most type of failure was due to lack of skill (30.4%), followed by negligence (29.2%). Imprudence or indiscretion (26.3%) and noncompliance with governmental requirements (14.1%) were also in the next ranks, respectively. Conclusion: Improving patient and physician relationships, observing medical ethics, increasing the scientific and technical skills of the medical staff, and following the guidelines and medical protocols will prevent medical malpractice. Therefore, health policymakers can reduce errors and failures by adopting continuing education on medical, ethical, and legal issues.

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress-Part 3 of 6: Physician Illness and Impairment.

Physicians suffer from most medical conditions at the same rate as their lay peers. However, physicians' self-care is often sacrificed for patient care. This third article in our series examines physician and trainee illness and impairment. Presenteeism, physician impairment, and substance use disorder (SUD) are defined. We call attention to the potential for harm of dated cultural norms, which often fuel physicians' neglect of their own health and development of ill-advised coping skills.Although any medical condition may become a functional impairment, the primary cause of physician impairment is SUD. Alcohol and prescription opioids top the list of substances used in excess by physicians. Although SUD is less prevalent in residency, we focus on the rise of marijuana and alcohol use in emergency medicine trainees. A nonpunitive model for the prevention and treatment of SUD in residency is described.Physicians are ethically and legally mandated to report any concern for impairment to either a state physician health program or a state medical board. However, recognizing physician SUD is challenging. We describe its clinical presentation, voluntary and mandated treatment tracks, provisions for protecting reporters from civil liability, prognosis for return to practice, and prevention efforts. We underscore the need to model healthy coping strategies and assist trainees in adopting them.In closing, we offer our colleagues and trainees today's to-do list for beginning the journey of reclaiming your health. We also provide resources focused on the practical support of ill and/or impaired physicians.

Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety: A Position Paper From the American College of Physicians.

Physician impairment, the inability to carry out patient care responsibilities safely and effectively, is a problem of functioning. However, the presence or treatment of a potentially impairing illness or other condition does not necessarily imply impairment. This American College of Physicians position paper examines the professional duties and principles that should guide the response of colleagues and the profession to physician impairment. The physician should be rehabilitated and reintegrated into medical practice whenever possible without compromising patient safety. At the same time, physicians have a duty to seek help when they are unable to provide safe care. When identifying and assisting colleagues who might be impaired, physicians should act on collegial concern as well as ethical and legal guidelines that require reporting of behavior that puts patients at risk. Health care institutions and the profession should support practice environments in which patient safety is prioritized and physician wellness and well-being are addressed. Physician health programs should be committed to best practices that safeguard patient safety and the rights of physician-patients.

How broad are state physician health program descriptions of physician impairment?

BackgroundPhysician health program websites in 23 states provide many descriptions of possible physician impairment. This study sought to determine whether these descriptions are so broad that almost everyone might potentially be suspected of being impaired given these descriptions.MethodsThe authors randomly selected 25 descriptions of impairment and then presented them anonymously online to members of the general population in full-time employment through Amazon’s Mechanical Turk (N = 199). Half of the respondents randomly received a narrowly worded version, and half received a broadly worded version of the survey questions.ResultsIn the narrowly worded version of the survey, 70.9% of respondents endorsed at least one description of impairment, and 59.2% endorsed more than one. In the broadly phrased version, 96.9% endorsed at least one description, and 95.8% endorsed more than one. These respondents endorsed a median of 10 out of 25 (40%) descriptions.ConclusionsThese findings call into question whether these descriptions really identify persons with poor performance or who pose a high risk of substantial, imminent harm to self or others in the workplace. They also demonstrate the extent to which these descriptions could potentially be misapplied and brand almost anyone as impaired.

Do state physician health programs encourage referrals that violate the Americans with Disabilities Act?

The websites of many physician health programs provide lists describing signs of impairment or indications to refer physician-employees for evaluation and possible treatment. This study aimed (1) to determine how many of these descriptions likely provide physicians' employers with sufficient evidence to legally request mental health examinations under the general regulations of the Americans with Disabilities Act (ADA); and (2) to find out who they described. The authors applied US Equal Employment Opportunity Commission guidance documents and sought expert legal advice to evaluate the descriptions for their consistency with the ADA. They used directed content analysis to review and code these descriptions into categories. Very few, if any, of the 571 descriptions appeared to provide sufficient evidence for employers to request an examination under the ADA. About 14%, however, could refer to physicians attempting to defend themselves, assert their ADA rights, or otherwise complain about the hospital; and 27% either described physicians who complain or else had discriminatory effects in one of several different ways. Leaders within the medical field should ensure that their policies and state laws pertaining to physician impairment comply with and incorporate the language of the ADA. They should also reevaluate the functions of these policies, laws, and physician health programs, and the implications for patient safety, physician wellness, suicide, and other important issues.

85 The Difference of Professionalism Between Emergency Medicine Residents and Faculty Physicians: Multicenter Cross-Sectional Analysis

Professionalism is one of the critical emergency medicine (EM) physician competencies and professional behavior affects patient satisfaction. Forty-five percent of EM program directors reported that there were two or more residents with unprofessional behavior in their programs per year. Another study reported that role model was the most influential factor. However, there is no evidence to support that there is difference of professionalism between EM residents and EM faculty physicians. Therefore, to investigate difference of professionalism between EM residents and EM faculty physicians may facilitate medical professionalism education. Thus, by using a cross-sectional multicenter survey, we aimed to analyze the responses to common challenges to medical professionalism for EM physicians and to survey the extent of education related to professionalism and satisfaction with it during the time attending medical schools. We conducted a survey of EM residents and EM faculty physicians at several teaching hospitals in Japan, using the Barry questionnaire. The Barry’s questionnaire is one of the assessment of professionalism tools widely used in the US and Japan. The questionnaire instrument contains 6 challenging cases to professionalism: acceptance of gifts; conflict of interest; confidentiality; physician impairment; sexual harassment; and honesty in the documentation. After completing all six scenarios, participants were asked, ‘Have you ever experienced formal educational courses about medical professionalism?’ on yes or no responses. We sent the Barry's questionnaire to 6 hospitals. In addition, we collected data at the Japanese biannual emergency medicine academic meeting. We analyzed the frequency of providing either the best or the second best answers to each scenario as a main outcome measure and compared those frequencies between physicians in EM residents and EM faculty physicians. The Fisher exact test and proportion comparison test with normal distribution approximation were used to analyze data, where appropriate. We collected data from 135 participants (61 EM residents and 74 EM faculty physicians). Capture rate was 87%. The most challenging scenario was the sexual harassment scenario, in which 46.7% provided the best or second best answers, followed by the confidentiality scenario with 71.1%. Table 1 compares the frequencies that the participants provided the best or second best responses between EM resident and EM faculty physician. The frequency of either the best or second best responses to the confidentiality scenario was significantly greater in EM residents than in EM faculty physicians (p= 0.01). There were higher rates of participants who received formal educational courses about medical professionalism in EM residents' group versus in EM faculty physicians' group (23.0% versus 5.4%, p=0.003). EM faculty physicians were unable to provide acceptable response to challenges to professionalism in confidentiality and few had received an education in professionalism during school curricula. The greater teaching of professionalism is needed in medical education for both EM residents and EM faculty physicians in Japan.

Physician Impairment: Exploring the Health Issues and Determinants

Physician impairment is a critical issue in health care setting. Physicians have an exaggerated risk of psychosocial problems. The most common psychiatric problems in the physician can be isolated psychiatric conditions or substance abuse. Physician impairment due to psychosocial problems, substance abuse, burnout or accidental health care hazards can result in adverse personal, social and professional consequences. Due to the nature of the work, physician impairment can result in significant compromise in patients’ health. It is absolute necessary to have a definitive set of programs within each health care facility to target physician impairment preserving the functionality and optimal health output of health care provider and the receiver.

Personal Drug Diversion of Narcotics by Physicians:

Diversion of opioids and other controlled substances for personal use by physicians poses a risk to patient health, safety and welfare, as well as the health and well-being of the physicians themselves. This type of diversion places patients at risk for infectious disease transmission, substandard patient care, and/or denial of medication. State medical boards (SMBs) have an obligation to ensure that the highest quality of care is provided to all patients, which includes a multifaceted role in investigating, monitoring and disciplining physicians and a responsibility to make concerted efforts to prevent harm to patients. Thus, SMBs are an integral part of the process when a physician is suspected of being impaired. Implementation of both preventive and responsive measures is crucial in attempting to not only avoid physician drug diversion, but to effectively address drug diversion when it occurs. In April 2011, the House of Delegates of the Federation of State Medical Boards (FSMB) adopted its Policy on Physician Impairment. The policy provides guidance for state medical and osteopathic boards on the inclusion of physician health programs (PHPs) to facilitate evaluation, recovery and rehabilitation and monitoring of physicians, as well as to protect the public from impaired physicians. This article reviews the problem of controlled-substances diversion by physicians and its adverse effect on public and personal safety, and it demonstrates how SMBs or other parties can use the FSMB Policy on Physician Impairment as a guide to develop their own professional assistance programs to ensure public safety.

Narrative Texts and Issues in Medical Humanities

AbstractMedical Humanities began in the late 1970s as an attempt to supplement the emphasis on technology and science in medical education with renewed attention to the role of personal care. Today, more than 80% of all medical schools offer courses in Medical Humanities. Most of these courses emphasize fiction and nonfiction by physicians and patients that depict the experience of disease and care. This essay surveys foundational works in the field as well as relevant recent narratives of physicians, patients, caregivers, and families. The agenda of Medical Humanities is to explore how these interrelated and competing narratives can improve health care. Narrative is regarded as a necessary tool in medical practice, supplementing other components of evidence‐based medicine. The field has begun to be theorized by physicians who use narrative to describe how physicians and patients think and feel and how they reflect on their experience. Texts described in this essay address major issues in medicine, including multicultural medicine, access to care, death and dying, pain, empathy, medical mistakes, and physician impairment.

Prevalence of Drug Testing Among Family Medicine Residents and Students: Much Needed Data.

Prevalence of Drug Testing Among Family Medicine Residents and Students: Much Needed Data.

The Impaired Radiologist

Radiologists are faced with ever-increasing challenges in the needs of the practice, in both private and academic settings. Targeted information about protecting and maintaining the physical, mental, and emotional health of the radiologist is highly limited. Impairment is a functional classification that implies that the individual affected by a disease is unable to perform specific activities. Radiologists can suffer from the same illnesses as any human being, which include substance abuse and addiction, as well as chronic infectious diseases such as human immunodeficiency virus, hepatitis B and C, and tuberculosis. This article is intended to educate radiologists and leaders about various forms of physician impairment. It provides discussion of the challenges related to such impairment and provides tools and resources to address the impaired radiologist.

Identification of Physician Impairment

When a critical event occurs in most high-risk industries (such as airlines, nuclear power, or railways), a detailed investigation examines a variety of system and individual factors (such as fatigue and substance abuse) that caused or contributed to the event. Directly involved individuals are commonly tested for alcohol and other drugs. Airplane pilots and truck drivers are tested following crashes and near misses.1 Some law enforcement officers are tested following fatal shooting incidents.

Physician Impairment and Professionalism

W543 process, the loss of motor skills, or the excessive use or abuse of drugs, including alcohol.” In this article, we will focus primarily on impairment related to substance abuse, but many of these principles apply to other causes of impairment as well. An estimated 6% of physicians have a drug use disorder, and 14% have an alcohol use disorder—figures roughly comparable to rates of addiction in the general population [4]. Signs and symptoms vary but may include tardiness, unusual work hours, decrease in quality of care, secrecy, decreased productivity, conflicts with colleagues, irritability, signs of intoxication, and a history of changing jobs frequently [5]. Detecting and dealing with issues of impairment are important aspects of professional responsibility. The status of medicine as a profession rests in part on the commitment of physicians to participate actively in self-regulation, “including remediation and discipline of members who have failed to meet professional standards” [6]. Although confronting such issues may be unpleasant, physicians are expected to put the welfare of patients and the public first [6]. When this ethical responsibility has not been upheld, physicians and the profession of medicine have come under harsh criticism for “inappropriately protecting the careers and reputations of colleagues at the expense of the health and well-being of the public” [3]. Although, the public generally respects the right of the medical profession to regulate itself, due to the complex skills and knowledge of physicians and the sensitive nature of the doctor-patient relationship, this respect is not so great that patient and public welfare can be jeopardized. If the medical profession has fallen short in addressing physician impairment, part of the problem may stem from cognitive dissonance— more specifically, a conflict between physicians’ beliefs and their behavior when it comes to issues of impairment. In the abstract, most Physician Impairment and Professionalism

Cause for Pause After a Perioperative Catastrophe

Cause for Pause After a Perioperative Catastrophe

Disruptive Physician Behavior: Use and Misuse of the Label

ABSTRACT Beginning in 2009, The Joint Commission (TJC) requires medical leaders to address disruptive behaviors in accreditation organizations and this includes addressing disruptive physician behaviors. The Federation of State Medical Boards (FSMB) has acknowledged the importance of addressing disruptive physician behavior as reflected in the 2000 Report of the Special Committee on Professional Conduct and Ethics and in the 2011 Policy on Physician Impairment. This article provides in-depth information about disruptive physician behavior, including discussion of the causes and contributing factors, strategies to manage such behavior, formulation of medical staff policies, and appropriate and inappropriate use of the disruptive label. Although not a diagnosis, the disruptive label is useful in screening for disruptive physician behaviors. However, the disruptive label should not be applied to physicians just because they present controversial ideas or offer criticism of the medical system.