by Edgar P. Nace, MD
Physicians are as vulnerable to psychiatric illness – including substance use disorders – as the general population.
In the course of a lifetime, 8 to12 percent of physicians can be expected to develop a problem with either substance abuse or substance dependence.
Male physicians are approximately five times more likely to develop a substance use disorder than female physicians, a ratio that closely mirrors the trends in the general population.
Has there been an increase in physician impairment from substance use disorders in the last decade? The data, although limited, does not suggest that. Some data does indicate that, in the past, a physician may have had a substance abuse problem for up to six years before it was recognized. Today, we see an increased awareness of the potential for physician impairment and a tendency to intervene on doctors who show early signs of behavioral disruption.
It is likely that we are finding and arresting substance use or other psychiatric disorders at an earlier stage.
Peers who recognize early signs of impairment – changes in behavior, mood swings, irritability, increasing complaints from staff or patients or a change in work quality or productivity – are the key to assisting a doctor who is developing a substance or other psychiatric disorder. A physicians’ health committee, mandated by JACHO, should investigate complaints about a physician and assist him or her in obtaining a proper assessment. Following the assessment, an individual treatment plan – if necessary – should be implemented.
We are fortunate in Texas to have many highly skilled physicians’ health committees at the county medical society level, as well as at the hospital level.
However, the quality is spotty across the state. Too often, a physicians’ health committee may become the arm of the hospital administration and fail to properly advocate for a doctor.
Physician health committees function best if they include doctors who wish not only to protect patient safety but also to assist their colleagues in overcoming practice and personal difficulties ranging from excessive stress through burnout to specific clinical diagnoses. Because experience counts in forming the skills and judgment to assist colleagues who present with problems, a physicians’ health committee also does best if it doesn’t have a high turnover rate.
Fortunately, adequate treatment resources are available for physicians. Just a decade or two ago, most doctors would be sent automatically to a long-term inpatient rehabilitation program. We now know that this is inappropriate and that treatment must be individualized. Many, if not most, physicians can be treated on an outpatient basis if linked with the proper professional resources and an effective monitoring program.
Some physicians do best, of course, if they are placed in inpatient settings from 30 to 90 days, but this requires a judgment call and a careful assessment of the physician’s needs. It is of utmost importance to assess, for every doctor, whether or not he/she actually meets criteria for a substance use or other psychiatric disorder. Further, any additional medical problems should be identified and each physician mandated to consult his/her own personal physician rather than attempt to treat himself or rely on “curbside consultations.” Factors determining the treatment setting include the possible need for detoxification, and strong resistance to treatment and/or denial of the illness.
The environment in which the person lives and works is another consideration affecting whether inpatient or outpatient treatment is warranted. That is, physicians in a stable family situation who will take time off from work to pursue intensive outpatient and/or office-based treatment with a positive attitude are good candidates for treatment in their local environment. However, the physician who may have experienced prior relapses is potentially noncompliant, or may be burdened with comorbid psychiatric and substance use disorders is probably best served by a residential or inpatient setting, followed by aftercare planning and monitoring.
Texas has capable, experienced physicians who can carry out an intervention with a colleague. However, some see a recent alarming trend for some physicians’ health committees or hospital-based physician executive committees to insist that a physician immediately report to the Texas Medical Board even though no danger to patient care is
evident. Or, alternatively, they may attempt to suspend or
otherwise discipline the colleague without first conducting psychiatric and other medical assessments and giving the physician a chance to benefit from a course of treatment.
Typically, the physician experiencing the problem is expected to pay for the treatment. However, the Texas Medical Association Physician Health and Rehabilitation Committee has funds available to assist those who are in serious financial straits. In some cases, hospitals will fund the initial assessment process.
The TMA Physician Health and Rehabilitation Committee has an extensive educational series designed to help physicians, their family members and medical peers to recognize psychiatric impairment and/or substance use disorders in themselves or colleagues. These programs are available online and provided to hospital medical staffs in the form of lectures or seminars.
It is hoped that physicians will develop skills to “self-assess” whether or not they are experiencing behavioral changes, reactions to stress that are out of character or the symptoms of burnout. Burnout refers to a tendency to become increasingly withdrawn and apathetic regarding one’s professional work and/or irritable and cynical regarding the practice of medicine.
Fortunately, the prognosis for physicians receiving treatment is excellent. Physicians with substance use disorders typically have a recovery rate exceeding 75 percent and physicians who are treated for mood, anxiety or other psychiatric disorders can be expected to have optimal outcomes. Relapses are more likely to occur in doctors with a history of major opiate abuse (e.g., fentanyl, meperidine, morphine) combined with a psychiatric illness. If a positive family history of substance use disorder is added to the latter two variables, the relapse risk increases substantially.
A key to the successful treatment of the physician is to have a monitoring program where failure to comply or a relapse is detected early.
Regrettably, in our society a stigma remains for those who suffer from substance use or other psychiatric disorders. It is incumbent on us as medical professionals to mature past such unfortunate attitudes and to recognize that we, as well as so many of our patients, are vulnerable to biopsychosocial processes that lead to such disorders. The continuing education courses available through the TMA Physicians Health and Rehabilitation Committee are a valuable step in this direction.
Dr. Nace, a board certified psychiatrist with added qualifications in addiction psychiatry and forensic psychiatry, has done research in substance abuse and personality disorders, comorbidity and treatment outcome. He has published more than 65 articles in scientific literature and authored three books. Dr. Nace has chaired TMA’s Physicians’ Health and Rehabilitation Committee (six years) and the Texas Society of Psychiatric Physicians Task Force on Addiction Disorders. He is a clinical professor of psychiatry at UT-Southwestern Medical Center in Dallas and in the private practice of adult psychiatry.
