Reprinted from the "Workplaces" issue of Visions Journal, 2009, 5 (3)
Unrecognized or untreated substance use disorders and mental illness in physicians have the potential to cause serious patient harm. Because of this, medical professionals who are struggling with mental health or substance use issues should be of concern to us all.
These illnesses haven’t been talked about much within the physicians’ profession. Once we have an MD after our names, we start to believe that we are immune to the illnesses that affect our patients. Patients get ill, not we health care providers. In addition, the stigma and guilt associated with diagnoses of mental health and/or addiction reduces our ability to ask for help. This is ironic, since we know that a wait-and-see approach is potentially very dangerous.
Traditionally, our profession has focused on the end stage of these illnesses, when the person is very impaired in their ability to practice medicine safely. At that point, the only option appears to be involving a licensing body. This could result in the physician, potentially, losing their hospital privileges, their licence or even their livelihood. Ironically, fear of losing one’s medical licence, plus the shame associated with addiction or mental illness, tends to drive physicians underground with their illnesses.
Over the last couple of decades, however, we have realized there must be a better way to help the sick physician, while protecting the public. It became obvious that, as professional peers, we owe it to our sick colleagues—and their patients—to step in earlier.
The goal of peer assistance is to offer support and advocacy that focuses on getting the physician well, rather than getting them into trouble. Peer assistance must also protect the well-being of the physician’s patients. And, peer support does not hide the problem away, thereby enabling it to continue.
Current peer support initiatives and trends
Physician Health Programs (PHPs)
These began in the US in the 1970s and now exist in 50 US states and all Canadian provinces. They have emphasized probation and rehabilitation of addicted or mentally ill physicians, rather than discipline. They also emphasize a firm but caring approach.
While most PHPs have been typically restricted to physicians and medical students, a growing number are providing service to other health care professionals such as pharmacists, nurses and dentists. PHPs support colleagues, families and health care administrators by:
facilitating interventions if necessary
coordinating a multidisciplinary evaluation of medical professionals who have problems that might be related to inappropriate alcohol or drug use
referring medical professionals for comprehensive primary treatment
rigorously monitoring their compliance with accepted long-term treatment recommendations
Currently, most US programs operate independently of the professional licensing college. To protect public safety, the sick physician is encouraged (some people would say coerced!) to follow prescribed comprehensive treatment.
Sick physicians don’t always want to do what is good for them and frequently need a certain amount of “the carrot and the stick.” PHPs offer support in the form of encouragement and advocacy. But they also hold physicians and medical students accountable when it comes to following recommended treatment plans, as determined by a treating physician with expertise in physician health. A treatment plan might prescribe, for example, residential treatment and relapse prevention and monitoring agreements for a set period of time (usually five years).
Several US programs have an arrangement with their local licensing body that protects the physician—a “carrot” of sorts. The identity of the physician does not have to be disclosed by the PHP to their licensing body as long as the individual continues to comply unconditionally with the terms of their recommended treatment plan. If, however, they fail to comply fully, the licensing body will be notified (the “stick”). There is broad recognition that affected physicians and medical students, as well as their colleagues, are more likely to refer to such programs—often at an earlier stage in the illness.
In Canada, there is some form of PHP in every Canadian province, though not in the territories. The first Canadian program began in British Columbia in 1979 and continues to this day. At the time this article was written, only the PHP of the Ontario Medical Association officially had an arrangement with their provincial licensing authority where reporting a potentially impaired colleague is not mandatory—as long as the physician is completely compliant with all treatment recommendations.
Physician health and wellness committees
Many hospitals in the United States have developed a local resource to address the physical, emotional and social needs of physicians on their staff. These physician health and wellness committees provide resources to help physicians achieve a balanced life, such as peer-coach opportunities, wellness symposiums, regular newsletters, access to counselling and more.
Members of such committees accept self-referrals from physicians with addiction or mental health issues. They may also have processes for accepting and following up reports from colleagues who have concerns about a physician. Typically, these committees will work with PHPs to coordinate the needs of the sick physician in confidence. That is, however, unless the physician is not complying with treatment recommendations or if patient safety might be at risk.
Increased education for awareness
The provision of care to health professionals is increasingly being seen as a specialized field in medicine. Health professionals can be difficult patients to care for. They tend to have a long history of self-reliance and are reluctant to adopt the traditional patient role.
There are very few health care providers willing—or trained—to deal with a sick, addicted or mentally ill health provider. More and more, however, educational initiatives for medical students and physicians are including topics such as self-care, stress management, burnout prevention, and managing substance use disorders and mental illness in physician colleagues. This can only improve the situation for the sick physician and benefit their patients in the long run.
About the authorPaul is an Occupational Health Consultant with HealthQuest Occupational Health Corporation. He is also an Associate Clinical Professor in Family Practice at the University of British Columbia. A former executive director of the Physician Health Program of British Columbia, Paul currently serves on the Canadian Medical Association’s expert advisory committee on physician health