Physician Well Being: Healing the Healer, Part 2

This multi-part series of articles will examine medical professionals and addiction in depth. The first article looked at the unique features of physicians in general and physicians and personality styles.

This second installment will look at the identification, intervention, and assessment of addiction in the workplace; comprehensive evaluation; an integrative approach to treatment; and levels of care.

Identification, Intervention, and Assessment of Addiction in the Workplace

Most studies suggest physicians are not at greater risk than the general population for substance use disorders—approximately 10% to 12% will develop chemical addictions during their careers (Berge, Seppala, & Schipper 2006). They tend to use prescription drugs more often than the general public and are more likely to have access to drugs in the workplace or through personal prescription. A survey conducted by DuPont et al. found that the most common drugs of abuse were alcohol (50%) and opioids (35%). The other 15% included stimulants, sedatives, marijuana, and other substances. Across PHPs, 31% of physicians had problems with both drugs and alcohol, with nearly half (48%) also qualifying for psychiatric disorders and/or pain problems (DuPont, McLellan, Carr, Gendel, & Skipper, 2009).

 

Identification in the Workplace

The addicted professional has unique features and tendencies as compared to the general population. Proper identification is essential for the treatment of addiction in the professional. The workplace is often the last place addiction is exposed, so if there are signs at work, the disease is usually progressed. There is increasing emphasis on educating professionals about the course of addiction in themselves and their colleagues. This has been driven in part because of addiction now having a disease status—chemical dependency falls under the category of a disability with legal ramifications for employers—and due to the high prevalence of abuse and addiction in our society. Proper identification results from adequately educating those around the addicted professional about the disease of addiction and its manifestations. Education in the work place is critical in determining if a colleague is addicted, and should include discussions about the potential liability and legal ramifications of drug diversion and drug abuse.

There are a number of signs that can typify addiction in the workplace and having some knowledge of the disease can facilitate proper identification, including:

  1. Chaotic personal and professional life.
  2. Frequent tardiness and absenteeism.
  3. Poorly explained accidents and injuries.
  4. Relationship discord: martial, family, professional.
  5. Deterioration in personal appearance.
  6. Significant weight loss or gain.
  7. Long sleeves and tinted glasses inappropriate for the setting.
  8. Overuse of cologne and breath fresheners.
  9. Legal problems, e.g., DUIs or arrests for possession, disorderly conduct or in the case of healthcare professionals, inappropriate prescribing of controlled substances.
  10. Severe mood swings unrelated to situations or exaggerated mood responses, dramatic change in personality.
  11. Increased isolation due to shame and fear.
  12. Withdrawal from family, friends and coworkers, e.g., always refuses social invitations.
  13. Frequent disappearances during work hours.
  14. Overt evidence of addiction at work, such as the smell of alcohol on the individual’s breath during working hours.
  15. Cognitive impairment.
  16. Spending too much time with narcotics or missing narcotics (specific for healthcare).
  17. Dilated or pinpoint pupils.
  18. Asking physicians for prescriptions for mood altering substances at a healthcare workplace.
  19. Increase in physical complaints.
  20. Financial strain.
  21. A negative or apathetic attitude.
  22. Working extra shifts (in order to obtain substances).

These changes can be gradual or sudden, and an individual usually exhibits several signs from the above list. The professional usually takes care to conceal the addiction from the workplace because he or she prioritizes his or her professional identity and, again, the workplace is often the last place the addiction is noticed.

Another reason that the professional life is the last to deteriorate is because the workplace is often where the health professional acquires his or her substances. Protecting his or her source of drugs becomes paramount to the addicted professional. When overt evidence of addiction in the workplace is apparent, this often represents a progressed condition. Simply stated, addiction can be detected by observing the professional’s work performance. Often, regularly scheduled performance evaluations will illustrate a decline in productivity and quality of work. There is a dire need for a pre-existing policy for handling discovery of addiction problems because addiction has become not all that uncommon. A lack of pre-existing policies may result in medical or legal liabilities, but also perpetuates the ongoing addiction, which can have catastrophic consequences for the addicted physician and the innocent people that individual comes into contact with in the workplace.

Whatever the means of identification, it is imperative to verbalize suspicions in an appropriate manner. The employer or colleagues often feel the need to avoid confrontation or question their observations. This can create a “conspiracy of silence” that will only allow the addiction to progress with possible adverse effects on the addict and the workplace. If employers and colleagues could think of an intervention as a compassionate and necessary step for the addict, it would benefit everyone.

An intervention is often implemented by intervention professionals under an employee assistance program or an outside consultant trained in professional interventions. A planned intervention has the greatest success.

 

Intervention

If chemical dependency is suspected, an intervention is the next appropriate step. An intervention occurs when the professional suspected of abusing drugs and/or alcohol is initially confronted, and it is usually an extremely stressful event for both the suspected professional and the individual doing the intervening (Berge, Seppala, & Schipper, 2009). Therefore, it is helpful to have a policy in place for these types of scenarios that will facilitate a successful approach.

It is important to discern whether the employee’s impairment is the result of mood altering substances or some other stressful event in his life. The presence of an addiction problem can be elucidated with an effective intervention.

There are a number of ways to intervene on an addict, from informal confrontations to formal professionally facilitated interventions. However, the author cautions employers and colleagues regarding informal confrontations because of the strength of denial in the addict and the risk of an unsuccessful outcome; as Cicala notes, “a hallmark of substance abuse is a remarkable denial on the part of the abuser that there is no problem, even as they go to great lengths to hide the symptoms of the problem” (Cicala, 2003).  

An informal intervention can be effective in circumstances where there is a high degree of trust and a receptive attitude on the part of the individual suspected of being an addict toward a colleague or supervisor. More likely though, this individual will feel embarrassed, defensive, and even betrayed in these circumstances and refuse help. It is crucial that the professional not be directly accused of diverting drugs or asked to stop using drugs. This is an inefficient means of intervening which will most likely result in the denial of drug use or the occurrence of a desperate act such as suicide (Berge, Seppala, & Schipper, 2009).

A formal intervention involves a trained interventionist. A trained interventionist understands the disease of addiction, knows referrals for treatment, and employs an attitude of compassion and is nonjudgmental in approach. An employer or colleague may also consult with an interventionist and then proceed with the process on their own.

Utilizing an employee assistance program (EAP), human resource department, or, ideally a non-disciplinary process within the work setting like a hospital physician wellness committee, will reap the most successful results in interventions. The advantages of workplace-initiated interventions over family interventions are the influence of potential workplace consequences, which are important for the financial and professional survival of most individuals. It is the potential or actual consequences of addiction that initially convince an addict to get help.

A compassionate intervention is the ideal situation, but this author is well aware that many addicted professionals are terminated prior to any intervention. There are consequences to this action, such as passing on an unfit individual to another workplace, losing the possibility of a grateful and loyal employee in recovery, and becoming part of the “conspiracy of silence” that threatens our society with active addiction.

 

Assessment

The assessment typically is done upon admission to a program for the treatment of addictions. An initial and brief assessment can be provided by the EAP or PHP and thereby give the individual a choice of treatment options based on certain criteria mentioned below. In cases where there is resistance, lack of clarity of the problem, or continued denial on the part of the professional, a mandatory, comprehensive assessment is often necessary and can be instituted by the employer with the consequence of termination if the individual does not comply.

Comprehensive Evaluation

This evaluation routinely uses a team of trained professionals with differing areas of expertise. This is sometimes described as a Multidisciplinary Assessment Program (MAP) in one setting and is generally 48 hours or more in duration. The MAP is generally required because there is significant resistance and/or confusion about the source of any suspected impairment. This collateral data is obtained with written consent from the individual being assessed. There are typically multiple personal and professional sources that are contacted for collateral data. A typical MAP team includes:

  • MAP clinician/administrator: Responsible for scheduling and organizing the MAP as well as collecting collateral data after obtaining informed consent. Obtaining this collateral data is essential for this type of evaluation. This clinician/administrator is also responsible for organizing and summarizing the final report.
  • Psychiatrist: Responsible for performing a comprehensive psychiatric evaluation. This psychiatrist has expertise in addictions and fitness for duty issues. At times, a forensic psychiatrist is necessary, especially where legal issues predominate. These legal issues may include multiple DUI offenses, prescribing offenses including suspicion of, or allegations related to, trafficking of controlled substances or even allegations of boundary violations (e.g., sexual harassment). All legal issues, past and present, must be revealed to determine the appropriate treatment for the individual.
  • Psychologist: Responsible for administering and interpreting psychological testing such as the Millon (MCMI-III) and the Minnesota Multiphasic Personality Inventory (MMPI). Screening with an instrument such as the Wechsler Aptitude Screening Instrument (WASI) is often necessary to rule out deficits in cognition that can occur with substance abuse or for other reasons such as dementia. In cases where cognitive deficits are identified or suspect, neuropsychological treatment is performed by an additional neuropsychologist. In these cases, consultation with a neurologist and imaging studies like Magnetic Resonance Imaging (MRI) are required to rule out a neurologic disorder such as a tumor or degenerative disease, or degeneration from alcohol of other substances. This component is obviously important in assessing the high accountability professional and his or her ability to safely do his or her job.
  • Addictions Specialist: Responsible for performing an in-depth substance use and abuse evaluation.
  • Internist: Responsible for a thorough history and physical including necessary lab work to fully assess medical health.
  • Senior Supervising Psychiatrist: Responsible for reviewing the report and recommending any necessary changes to insure completeness of final report.

The MAP is, by far, the most thorough way to evaluate a professional with impairment from addiction or for any other reason.

 

The Role of Well-Being Committees

Hospitals are required by the Joint Commission to provide services that can assist in cases of suspected impairment of medical staff. This is often in the form of Well-Being Committees that are separate from the disciplinary entities of the hospital. These committees can facilitate the intervention and assessment of a suspected impaired physician in a way that is firm but caring. This entity can use the disciplinary alternatives (e.g., report to the medical disciplinary wing of the medical staff) as a tool to facilitate the physician following recommendations.

When the physician or medical professional follows the recommendations, the Medical Staff Office can be made aware of his or her situation and defer to the Well-Being Committee. The committee will also be available to internally monitor the physician after treatment along with the treatment program and in many cases, the state professional assistance program.

In cases where there are reportable events, such as diversion of narcotics from the hospital, the hospital may need to report the incident to the state licensing board. The board will carry out its own investigation and typically support re-entry to practice under certain conditions, like a consent order or probationary license. If there is non-compliance, the person would be subject to disciplinary action taken by the hospital and the licensing board. Even in these cases, hospital and licensing boards will attempt to direct the person to assessment.

The Comprehensive Assessment

In addition to an addiction problem, comprehensive assessments are often also used to evaluate behavior problems like sexual harassment, chronic charting problems, or excessive tardiness or absences. These other behaviors fall under the title of the “disruptive physician or professional,” where addiction may not be present as the source of the difficulties, but not the only problem. In these cases, a psychiatric diagnosis, such as a personality disorder or major depression, may be the underlying issue. In certain cases, a cognitive deficit from a neurological condition or medical problem may be the core issue. In any case, the comprehensive evaluation is best suited to flush out the problems and give appropriate recommendations for the necessary follow-up.

An Integrative Approach to Treatment

There is a growing trend to promote wellness within a context of an integrative mental health care paradigm along with increasing evidence for its effectiveness. The broad array of alternative treatment modalities includes mind-body interventions such as meditation and spiritual counseling, as well as an emphasis on exercise, diet and lifestyle changes. Research supports the efficacy of these approaches in treating addictions. This integrative mental health paradigm does not need to diminish the importance of medications and traditional therapeutic approaches, but rather enhances and supplements them. Furthermore, a respect for the benefits and contributions of Alcoholics Anonymous and other 12-step groups needs to be acknowledged and maintained while increasing efforts to explore other evidence-based approaches to improve outcomes.

 

Use of Mindfulness and Meditation

The technique of mindfulness can facilitate calming the mind and assist the patient in observing his or her thoughts, thereby enhancing the opportunity for subconscious thoughts to emerge. After the mind is steadied and the patient can practice an observing-ego stance, the result is an increase in self-aware consciousness by simply learning to be present in the moment.

Learning how to be present can have significant benefit for addicts. The disease of addiction has neurobiological and psychological underpinnings that can be identified as “the addictive drive,” which is quiescent in recovery, but remains ubiquitous. An individual in recovery is often thought of as someone whose disease is in remission—sober addicts are in “recovery,” never “recovered.” When the addictive drive presents itself in recovery in its various forms, such as cravings or feelings of deprivation, these feelings can remind one of the need to continue, and even intensify, a meditative practice along with other recovery activities, versus giving in and suffering a relapse.

For the sober addict, this simple yet profound practice can reduce stress, craving, improve mood and even create a capacity for experiencing higher and ultimately profoundly rewarding states of consciousness. This translates into recovery. For the clinician, incorporating mindfulness in his or her practice can be highly beneficial for both therapist and patient; indeed, researchers in a 2008 study found that when those who meditated heard the sound of human suffering during controlled experiments, there was more activity in their temporal parietal junctures, the part of the brain tied to empathy, than those who did not meditate (Lutz, Brefczynski-Lewis, Johnstone, & Davidson, 2008).

 

Levels of Care

The treatment of the addict or alcoholic is not a simple recommendation. Treatment has different levels of intensity, and recommendations are based on a variety of factors—legal issues, financial constraints, type of professional, number of previous treatments, etc.

Typical abstinence based program structures are summarized below.

Day or Evening Intensive Outpatient Programs (IOP)

  • Averages four days or nights a week, 3 to 4 hours a day or night and 4 to 6 weeks in duration
  • Small group therapy plus didactic and experiential groups
  • Family involvement
  • 12-step involvement expected during and after treatment
  • Typically 3 months of weekly continuing care

Partial Hospital Programs (PHP)

  • Averages 5 days a week, 6 to 8 hours per day for 4 to 6 weeks
  • Small group therapy plus didactic and experiential groups
  • Family involvement
  • 12-step involvement and aftercare as above
  • Independent (supervised) living programs (ILPs) can accompany PHP (PHP with ILP or “boarded partial”); commonly in programs that treat professionals and allow for more structure, intensity, and an opportunity for exposure to a therapeutic community as compared with more standard PHPs.

Residential Treatment

  • Same elements of PHP with ILP except the patient is in an “under one roof” 24-hour supervised setting.
  • This level of care can provide more structure for patients with significant co-morbidities and/or history of repeated relapses following the above-mentioned levels of care.
  • It is often more expensive than a PHP with ILP, but at times necessary for those that require more restrictions (e.g., adolescents have a greater success rate in residential treatments).

It is important to note that these levels of care can vary in structure, length of stay, and program emphasis. Also, various levels of care can be combined to provide a continuum for some patients. (For example, a patient who completes a residential program may step down to a PHP or IOP level of care. Also, many patients require continuation in a half-way or three-quarter-way house following treatment.)

Professional programs often offer more specialized programming, such as Caduceus groups, along with extended aftercare (2 to 5 years for physicians and nurses).

 

Summary

The identification and levels of care of physicians who suffer from potentially impairment-producing conditions have evolved substantially in the past few decades. A climate of openness, compassion, and accountability has assisted both the physician and public they serve and it is critical that this trend continue. There has been some backsliding in recent years where political and other pressures have created a somewhat more punitive climate. If this backsliding continues it will not reduce the problems of impairment or make the public safer; quite the opposite will be the result, placing all involved at greater risk.

The next article in this series will discuss monitoring and support systems, hospital well being committees, physician health programs, and stress management.

 

 

Daniel H. Angres M.D.

Daniel H. Angres M.D.

 

 

References

Angres, D., Talbott, D., & Bettinardi-Angres, K. (1998). Healing the healer. Psychosocial Press.

Berge, K. H., Seppala, M. D., & Schipper, A. M. (2009). Chemical dependency and the physician. Mayo Clinic Proceedings, 84(7), 625-631.

Cicala, R. S. (2003, July). Substance abuse among physicians: What you need to know. Hospital Physician, 39-46.

DuPont, R. L., McLellan, A. T., Carr, G., Gendel, M., & Skipper G. E. (2009). How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment, 37, 1-7.

Lutz, A., Brefczynski-Lewis J., Johnstone, T., & Davidson, R. J. (2008). Regulation of the neural circuitry of emotion by compassion meditation: Effects of meditative expertise. PLoS ONE, 3(3), e1897.

Schernhammer, E. (2005). Taking their own lives—The high rate of physician suicide. New England Journal of Medicine, 352(24), 2473-2476.

West, C. P., & Shanafelt T. D. (2011). Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA, 306(9), 952-960.