Physician Well Being: Healing the Healer, Part 3

 

This multi-part series of articles has examined medical professionals and addiction in depth. The first article looked at the unique features of physicians in general and physicians and personality styles. The second installment looked at the identification, intervention, and assessment of addiction in the workplace; comprehensive evaluation; an integrative approach to treatment; and levels of care.

This third and final article in this series discusses monitoring and support systems, hospital well being committees, physician health programs, and stress management.

 

Specialized Treatment for Professionals

Outcomes for general populations have been anywhere from 40% to 60% recovery following treatment. Extended studies beyond 6 to 12 months are not well documented in any case in the general population.

Treatment for professionals has demonstrated a much better outcome than treatment in the general population. Research suggests that factors such as voluntarily seeking treatment and the confidentiality of engagement in treatment have an impact on recovery. Professional programs often offer more specialized programming, such as Caduceus groups, along with extended aftercare (from 2 to 5 years for physicians and nurses).

In a recent article by McClellan et al., (2009) it was noted that addicted physicians demonstrated high rates of complete abstinence over a 5-year period. This included 78% abstinence over that period and 71% remaining in their profession (DuPont, McLellan, Carr, Gendel, & Skipper, 2009). Similar sobriety rates were noted in Healing the Healer (Angres, Talbott, & Bettinardi-Angres, 1998).

McClellan and his group wanted to discover what the essential ingredients were in these positive outcomes. They recognized that “physicians enjoy educational, employment, financial, and social benefits that are not typical of the population at large or of the population of addicted individuals in treatment. Some of these advantages are characteristic of the physicians themselves, but an additional advantage is health insurance and personal resources that make high-quality care possible for extended periods.” They also recognized essential elements that could be available to all addicted people, including extended treatment and monitoring along with clear consequences for non-compliance. They concluded that it was not one of these elements but all of them combined that contributed to these excellent outcomes (DuPont, McLellan, Carr, Gendel, & Skipper, 2009).

There are some advantages that physicians and other professionals seemingly have. One is that they have a lot to lose, so they have an increased incentive for staying sober. One could argue, too, that professionals have a greater degree of access to better treatment. This may be true; however, there are a number of wealthy individuals who are not medical professionals who do not have documented good outcomes, despite expensive and extensive treatment programming. Again, better treatment alone is not enough.

It seems logical, then, that the better outcomes in physicians, as well as other licensed professionals, have to do with a variety and combination of treatment and monitoring options, including specialized addiction programs, either residential or boarded partial programs, that are extended, that is, last from 2 to 3 months on average. These programs typically have staff members that are conversant with the various risks and problems associated with professionals, including over-identification with career, overwork, and some of the occupational risks associated with re-entry. Specialty groups within a treatment setting offer a peer group setting that is essential to minimize the amount of “specialness” that can be associated with the professional, and can offer real empathy. The sense of community and shared experiences are essential in any program, and this is particularly the case for professionals. Extended monitoring following treatment is also critical, including urine monitoring. Also essential is the contractual relationship with the addict and the employer and/or medical society that would include potential consequences of relapse or non-compliance in an aftercare program.

There are other important ingredients in long-term success rates of professionals, such as involvement in 12-step recovery with sponsorship and continuing peer support in aftercare such as Caduceus groups. Typically, individual counseling and monitoring by a primary physician or psychiatrist, or both, who understands addiction is part of the aftercare for the recovering professional. If all of these entities and professionals are given permission to communicate with one another by the recovering addict, he or she is able to benefit from the integrated and holistic approach to the healing process.

The level of treatment can be determined by certain factors. On one hand, professionals can be treated on an outpatient basis if, in particular, their disease did not affect their workplace and they have appropriate support at home. However, if there is workplace involvement (i.e., evidence of use or impact of use while working or legal problems, etc.) and/or there are poor or absent support systems in the home, then a residential or boarded partial extended program is almost always necessary. All levels of treatment should be followed by extended aftercare and monitoring.

 

Monitoring and Support Systems

Aftercare monitoring groups provide ongoing peer support and monitoring following treatment for as long as 2 years from the treatment program and 5 years for state-sponsored programs for licensed healthcare professionals. Involvement with peer groups for all recovering medical professionals following treatment is imperative. Other professionals offer their own support groups, such as the Lawyers’ Assistance Programs for attorneys and Peer Assistance Networks for nurses.

Addicted physicians have one of the more elaborate intervention, assessment, and re-entry systems for those who suffer from addiction.

 

Hospital Well Being Committees

A relatively recent development is that the Joint Commission now requires each hospital to have an independently functioning wellness committee that can work with physicians who struggle with addiction or other types of impairment. Although these committees can have responsibilities to general medical staff and disciplinary committees, they operate autonomously to some degree and exercise a more supportive stance towards the struggling physician. These committees are typically composed of those who have an interest and experience working with physicians, and tend to be individuals interested in the identification, appropriate assessment, rehabilitation, and re-entry of these physicians back to the workplace and medicine.

In addition, these committees often institute well-being strategies in the hospital for all physicians, such as “fun runs” and other activities that can promote wellness and balance in the physician population in that hospital setting. Wellness committees are critical in identifying possible impairment in their medical staff and making the necessary referrals for assessment. It is imperative that these committees do not actually assess the suspicious individual themselves, but are available to intervene and make necessary referrals. They are also a necessary element for the continued monitoring of the physician when he or she is returned to the medical staff.

 

Physician Health Programs

Most states in the United States have Partial Hospital Programs (PHPs) that generally operate as part of the state medical society in that particular state. Some of these programs have a direct relationship with the licensing board in that state while others have total independence and autonomy. PHPs act as “diversion” programs. That is, the PHP can take responsibility for helping to educate, identify, refer, and facilitate re-entry and monitoring for the affected physician. It can do this with some degree of autonomy and still hold the physician accountable for his or her recovery. PHPs are a critical element in the process of the identified positive outcomes in this population.

Typically, the PHPs monitor the physician for a minimum of 5 years, longer in some states. They interface with treatment programs, wellness committees at the hospitals, sometimes the licensing board if necessary, as well as other entities that may be involved with the treatment, aftercare and monitoring of the physician. They are the point program to facilitate all of the various elements that are involved in the ongoing support monitoring of the physician, often including treating psychiatrists, individual therapists, and even family support. They are also instrumental in the urine monitoring or hair analysis that is critical to both document ongoing abstinence and to identify relapse. The PHPs are a critical component of the superior outcomes of addicted physicians completing professionals’ programs.

Caduceus Groups

These groups were started by G. Douglas Talbott in the 1970s. Dr. Talbott, a pioneer in the field of treating the addicted physician, identified the caduceus emblem for medicine as a way to create a peer group for physicians. Although there have been many types of Caduceus groups, today they mostly describe the specific aftercare that is specialized for the addicted physician in recovery, and have come to include other addicted professionals. The importance of a peer group is not only evident in the treatment process, but also in the ongoing aftercare support and monitoring for the healthcare professional.

The American Medical Association Physician Wellness Program

The American Medical Association (AMA) has been active in supporting the health and wellness of all physicians, including the appropriate identification, rehabilitation and re-entry of all physicians, whether or not they are AMA members. The AMA has sponsored physician wellness conferences over the last several decades to actively support this initiative.

State Licensing Boards

State licensing boards are entrusted to maintain public safety in regards to physician practice. Over the years, licensing boards have appreciated the logic that it is better to openly work with, and identify, impairment rather than to be purely disciplinarian or punitive. The latter stance has historically driven the problem underground, which is more risky for the addict and the public. The addict continues to use and has more opportunity to hurt him or others when the problem of addiction is not addressed. Licensing boards are responsible for public safety by monitoring the licensed professional. They do not necessarily get involved in the cases of impairment unless there are disciplinary actions taken at the hospital, or there is public evidence of impairment such as a driving-under-the-influence charge.

Licensing boards, in many states, will defer to the PHPs, treatment providers, and monitors in regards to managing cases. However, they do investigate cases and have hearings in regards to licensure status when necessary. There are a number of licensure status conditions, including consent agreements (less formal), consent orders, suspension, and even revocation. Licensing boards have generally been supportive of those physicians who have followed up responsibly with the various treatment recommendations of the entities involved with their recovery.

Employee Assistance Programs

EAPs are essential in cases where hospitals utilize EAP services. EAPs are composed of staff who are well-versed in understanding addiction and other impairments, along with the clinical and re-entry issues. EAPs can act as intermediaries, much like the PHPs, and often work in conjunction with the other treatment entities for the physician.

Physician Impairment Independent of Addiction

Physicians who struggle with conditions other than addiction that can cause impairment, such as psychiatric disorders, chronic pain, or other physical conditions, and cognitive impairment, can benefit from many of the same intervention, assessment, and monitoring entities discussed. Whereas treatments here may substantially differ, such as individual therapy for a depressed physician, some of the support and monitoring strategies mentioned above may need to be accessed if the physician’s condition has in any way shown itself in the workplace. Prevention, assessment, treatment, and monitoring are critical in these instances, especially with conditions like depression that can increase an already higher risk of suicide in physicians as a whole (Schernhammer, 2005).

 

Stress Management

With all the advances in mental health and the science of well being we still have some relatively simple, basic, and time-tested ways to live better, including meditation, exercise and proper diet. The research on the benefits of meditation, exercise, and healthy diet are indisputable. The cost to the individual and society for not living better are also clear and disturbing. It is estimated that 70% of all medical problems are associated with stress, poor diet, substance abuse, or inactivity.

The costs of unhealthy living are not only seen in the physical realm, but also reflected in increasing rates of depression and anxiety within our society. And yet, simple activities can make all the difference.

 

Summary

The identification, support, and monitoring 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 physicians and public they serve and it is critical that this trend continue. There has been some backsliding in recent years, when political and other pressures have created a more punitive climate. If we are to continue to benefit from the entities outlined in this discussion, we must move forward not backward, lest we recreate a dangerous and toxic environment that again drives the problem underground. If this backsliding continues it will not reduce the problems of impairment or make the public safer—quite the opposite, which will placing all involved at greater risk.

 

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