Physician Impairment: When Should You Report?

Article excerpt

Dear Dr. Mossman:

Lately, a physician colleague has been arriving late for work. He seemed drunk a couple of times, and he's been making some careless but minor mistakes. When would I have a duty to report him for suspected impairment? He is a longtime friend, which makes me uncomfortable with the prospect of having to report him.

Submitted by "Dr. Z"

Holding ourselves to ethical guidelines and standards of conduct sometimes is hard, but when we become responsible for our colleagues' behavior, things can get awkward. Yet the responsibilities of practicing medicine include professional self-regulation. (1) Failure to monitor ourselves and each other would put the reputation and integrity of the medical profession at risk--not to mention the safety of our patents. Despite this, many physicians are understandably reluctant to report colleagues who appear impaired.

To decide whether you should report a colleague, you must:

* know what behaviors constitute impairment

* understand the duty to report impaired colleagues

* realize reporting colleagues often creates emotional conflict

* understand recovery options and resources available for impaired practitioners.

After we examine these matters, we'll see what Dr. Z should do.

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Impairment defined

Physician impairment is a public health issue that affects not just physicians but their families, colleagues, and patients. In this context, "impairment" means a physical, mental, or substance-related disorder that interferes with a physician's ability to undertake professional activities competently and safely. (2)

Although many mental conditions can cause impairment, we focus here on substance abuse, a condition that often leads to functional impairment. Physicians develop addictions at rates at least as high as those in the general population. (3) Physicians-in-training--including psychiatric residents--are at particularly high risk for developing stress-related problems, depression and substance misuse. (4), (5)

Occupational demands, self-criticism, and denial of one's own distress are common failings among physicians (5) as is self-treatment, which may help explain the high rates of substance misuse among physicians. (6) Behaviors that suggest a colleague may be abusing substances and experiencing occupational impairment appear in Table 1 (page 67) (7)

Reporting duties

Table 1

Signs of physician impairment

Deteriorating personal hygiene

Increased absence from professional functions or duties

Emotional lability

Appearing sleep-deprived

Increased professional errors (eg, prescriptions, dictations, clinical judgment)

Not responding to pages or telephone calls

Decreased concern for patient well-being

Citing unexplained 'personal problems' to mask deficits in concentration or patient care

Increased patient complaints about quality of care and bedside manner

Many 'accidental' injuries (possibly contrived to obtain narcotic prescriptions).

Source: Reference 7

Doctors and physician health programs have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. This obligation appears in professional guidelines (Table 2) (2), (8) and in laws and regulations governing the practice of medicine. Laws and regulations are similar in spirit across jurisdictions, although the exact wording varies from state to state (Table 3). (9-11) Physicians are responsible for being familiar with reporting requirements in states they practice and complying accordingly.

Table 2

Medical associations' official positions on
reporting impairment

American Medical   'Physicians have an ethical obligation to
Association         report impaired, incompetent, and unethical
(Policy             colleagues. …