Physicians are a breed apart. Frequently hard-driving perfectionists who live a high stress life with disruptive schedules, continuous exposure to suffering and death, and dealing with the ongoing frustration of balky insurance companies and demanding patients, they tend to have trouble relaxing and often lack emotionally rich relationships. The personality, environment and access to drugs all contribute to a high risk for substance abuse and professional impairment.
Approximately 10% to 12% of physicians will develop a chemical dependency during their careers, with half choosing alcohol and 35% misusing opioids. The remaining 15% abuse stimulants, sedatives, marijuana or other drugs. Anesthesiologists, emergency medicine physicians and psychiatrists have the highest rate of addiction.1 Physicians in general may have higher rates of dysthymic temperament and obsessive-compulsive personality traits than the general population, with could also contribute to addictive behavior.
The AMA defines physician impairment as “any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities … .” In general, an addiction that affects a physician’s performance at work has already progressed significantly. As many addicted physicians obtain their drugs from their workplace, they strive to protect their source — their job — as long as possible.
Colleagues may note other signs well before work begins to suffer. These may include notable chaos in personal life, poorly explained accidents and injuries, troubled personal relationships, significant weight loss or gain, disheveled personal appearance, legal issues, severe mood swings or other changes in personality, financial stress or social withdrawal.
At work, increased tardiness or missed days, use of cologne, breath fresheners, dark glasses or long sleeves to hide signs of drug use, frequent disappearances during regular work hours, cognitive impairment, drug-seeking, and missing or misdocumented narcotics likely indicate a problem. Colleagues may question their suspicions or fear destroying a physician’s career by intervening, but compassionate referral for treatment and supervision through a hospital’s physician well-being committee or employee assistance program can create career and financial repercussions that may provide important motivation to maintain sobriety.
Hospital or employer groups that specialize in working with impaired physicians will generally require a comprehensive evaluation through a multidisciplinary assessment program that brings together an administrator to collect all the necessary data and releases, and then prepare the final report. Additional input may require a psychiatrist with expertise in addictions and perhaps a forensic psychiatrist if legal issues have become a problem. A psychologist administers a variety of psychological tests and assesses any cognitive deficits, while an addiction specialist performs a detailed substance use and abuse evaluation. An internist undertakes a thorough history and exam with appropriate lab work. A neurologist may conduct a clinical evaluation in the case of detected cognitive or motor skill impairment.
This comprehensive exam helps overcome the denial common among addicted professionals and rules out other causes for declining performance. They can also identify additional problems in social interactions or task performance that may indicate a personality disorder, major depression or a medical condition.
Physicians that are willing to enter treatment may be overseen by physician health programs or employee assistance programs that help the physician find and receive appropriate therapy, remain accountable, and reenter the profession. The programs coordinate care, support and ongoing monitoring to ensure abstinence.
Successful treatment for addicted physicians typically takes an integrated approach. Mind-body interventions such as meditation and spiritual counseling are combined with diet and exercise, education on healthy lifestyle choices as well as traditional therapeutic approaches. Many programs incorporate 12-step groups such as Alcoholics Anonymous as well.
Depending on the severity of the impairment, a physicians may be referred to a day or evening intensive outpatient program, a partial hospital program, inpatient rehabilitation or residential treatment. Treatment may be three or four hours a day for four to six weeks with three months of follow up to 24-hour care for several months. Some physicians may enter a residential program then step down to an outpatient program or half-way house setting. Programs tailored to medical professionals often include ongoing monitoring and support that continues for several years.
Recovery rates among medical professionals substantially exceed the average rate of 40% to 60% recovery after treatment seen in the general population. Physicians completing treatment have a five-year abstinence rate that approaches 80% with more than 70% remaining in the profession. The high rate of success may be related to the development of specialized addiction treatment programs with a range of intensities, peer groups that understand the challenges of the profession, ongoing therapy, extended monitoring, and potential loss of livelihood as a consequence of relapse.
With such good outcomes, there is no excuse for maintaining the conspiracy of silence that keeps impaired physicians from receiving the treatment that can return them to health, well-being, and the safe practice of medicine.
1. Angres DH. Physician Well-Being: Healing the Healer. Chapter 8. Proceedings of the AMA/CMS Physicians Wellness Conference. June 13-15, 2013.
2. AMA policy H-95.955 Physician Impairment.