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AAOS Now

Published 5/1/2011
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Luis T. Sanchez, MD

Taking care of ourselves to better care for our patients

Heeding the adage,“Physician, heal thyself,” is no mean task

It seems that physicians are more frequently expressing the sentiment that their joy in the practice of medicine is vanishing. The pressures of practice, liability concerns, and increasing requirements and regulations are some contributory factors. How do we as physicians cope? How can we provide the best care for patients if we do not care for ourselves?

We physicians are often reluctant to seek help. We can become our own expert of what ails us. But ignoring the symptoms of substance abuse or denying it as a possibility can lead us to become isolated and fearful of discovery. Even those closest to us might not recognize a problem developing because of our secrecy and unwillingness to talk about ourselves.

Our value to society is clear. We possess medical knowledge and skill that others do not have. We are expected to be leaders and assumed to be medically and mentally fit. But because this is not always true, state physician health programs (PHPs) are available to provide assistance and support.

Almost every state has a functioning PHP, usually sponsored by the state medical society and approved by the state licensing board. The programs are uniformly confidential, provide for early intervention, have a mechanism to divert licensing board discipline or sanction if there is no patient harm, and can refer to professional treatment and offer monitoring agreements. Most PHPs assess and monitor mental health, behavioral problems, medical illnesses, and addictive disorders. Recent peer-reviewed studies attest to the high rates of success in these programs.

By preventing impairment and restoring physicians to good health, PHPs support patient and public safety. This risk management aspect has earned the support of liability insurance carriers, which help fund these nonprofit entities. The Federation of State Physician Health Programs (FSPHP), an organization that provides an educational and networking function for individual state PHPs and the Canadian provinces, has 47 members; for more information, visit its Web site, www.fsphp.org

Contributing factors
We as physicians are susceptible to the same illnesses and disorders as our patients. Neither a medical degree nor training can protect us. Our genetic and family background is more relevant. If a physician has a parent who is alcoholic, depressed, or has bipolar disorder, attention-deficit disorder, diabetes, or another inheritable medical problem, that physician is at increased risk of that condition.

Instead of enhancing our awareness of our own vulnerability, medical training more frequently teaches us to take care of patients and focus on their illnesses, rather than to care for ourselves. The rigors and stresses of our profession contribute to our unwillingness to provide self-care and can enhance the denial of early illness, including the onset of depressive symptoms, excessive alcohol intake, self-medicating with prescription medications, or behavior problems.

The stress of medical practice, if not recognized and managed, can lead to problems that affect patient safety and care. Potential stressors include financial, legal, family, medical, mental, and addictive issues. The phenomenon of burnout is particularly relevant, with some specialties experiencing high rates of dissatisfaction and frustration. Although one might expect that the physician would reach out for help, inform the spouse or family, or meet with a primary care physician for a diagnosis, treatment, and if needed, referral to a consultant or therapist, doctors seldom do this.

The role of state PHPs
Although each state PHP was individually developed, they all share the following common elements:

  • Confidentiality—Each program has confidentiality as a base, providing a level of protection for physician self-disclosure.
  • Assessment and referral—Physicians are initially assessed and given recommendations for referral to treatment if needed. Most programs do not treat the physician but will refer to professional treatment programs.
  • Early intervention—Programs encourage early intervention and involvement so that patient care is not affected.
  • Disciplinary protections—Protocols developed in conjunction with licensing boards protect physicians from disciplinary investigation if no violation of law or known patient harm has occurred.
  • Monitoring—All programs can monitor physicians under formalized contracts for an extended time, often 3 to 5 years or longer if needed.

If substance abuse is the problem, the contract allows for random substance screening and testing, in addition to regular meetings with program staff. Abstinence from all addictive substances is required; attendance at support meetings, therapy, and workplace monitors may be part of the contract. Compliance is regularly checked. Thorough monitoring enables timely intervention if the physician is noncompliant or has a relapse. Protocols allow for notification of the licensing board, which could lead to disciplinary action.

Most states also can monitor mental disorders and medical illnesses. State programs are developing expertise in assessing behavioral concerns such as workplace conflict issues, commonly referred to as disruptive behaviors. The programs also offer support and resources for stressful situations such as malpractice suits and medical errors.

Illness and impairment
Although PHPs are usually associated with impaired physicians, this term is often a misnomer and is misunderstood. Illness and impairment are commonly confused; all illnesses can be treated before they become impairing. Impairment implies an inability to practice medicine at an acceptable standard because of an illness or an injury. In addition, an impairment is not permanent. When a substance disorder has been treated and the physician is abstinent, as documented by compliance with a monitoring contract, the physician is no longer impaired.

The differentiation between illness and impairment is important. It would be unfair and disconcerting if a licensing board took action on a license because the physician disclosed a history of treated depression with no impairment.

The work of the PHPs can easily be seen as significantly contributing to the risk management of medical practice. Physicians who are aware of their style of practice, understand their personal vulnerabilities, have their medical problems promptly diagnosed, and have benefited from treatment are more likely to be empathic with patients and employ communication skills that benefit the patient-doctor interaction.

The literature is beginning to recognize these connections as physician health assumes a priority position. Recent articles attest to the importance of physician health on patient safety and outcomes.

PHPs are also becoming more cognizant of the role of systems of care in physician health, the health of other medical professionals, and the culture of hospitals or medical practice organizations. As of January 2009, Joint Commission standards outline the importance of recognizing and correcting disruptive behaviors and addressing conflict in the workplace to support quality care and patient safety.

Our mental and physical health, as physicians, is fundamental to our practice of medicine. Practicing healthy habits, being a team player, communicating well, and enjoying ourselves are goals we should all strive to reach. State physician health programs are available to support and assist us in attaining these goals.

Did you know…?

  • The physician health movement first began in the mid 1970s.
  • “The Sick Physician,” originally published in the Journal of the American Medical Association (1973 Feb 5;223(6):684-7), called for the establishment of state physician health programs (PHPs).
  • State PHPs provide a safe place for affected physicians to seek help, get treatment, and be monitored over time to enhance the chances of recovery and return to practice.

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor S. Jay Jayasankar, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

E-mail your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

Luis T. Sanchez, MD, is director of Physician Health Services, Inc., a subsidiary of the Massachusetts Medical Society, and immediate past president of the Federation of State Physician Health Programs. He can be reached at lsanchez@mms.org

Additional References:

  1. Dupont R, McLellan A, Carr G, Gendel M, Skipper G. July 7, 2009. “How are addicted physician treated? A national survey of physician health program.” Journal of Substance Abuse Treatment, Vol. 37, Issue.
  2. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA 1973; 223: 684-687.
  3. Frank E.  2004.  “Physician health and patient care.”  Journal of the American Medical Association, Vol. 291 (5), pg. 637.
  4. Frank E, Breyan J, Elon L. 2000. “Physician disclosure of healthy personal behaviors improves credibility and ability to motivate.” Archives of Family Medicine, Vol. 9. Pgs. 287-290.
  5. Joint Commission 2010 Hospital Accreditation Standards, Leadership Standards LD.03.01.01 and LD.02.04.01.