Management

Management of physicians who are chemically dependent includes identification, intervention, referral for treatment, and help with reentry. Having established mechanisms in place facilitates dealing with an impaired colleague.^[185]

Identification

Identification of a chemically dependent physician does not usually occur until the disease is in its late phases, when performance at work becomes significantly impaired. Although none of its signs and symptoms are diagnostic, an awareness of the usual sequence of events may help identify an ill colleague in the earlier stages of the disease ( Table 88-3 ).

Normally, withdrawal from outside interests is the first sign ( Table 88-4 ). Examples include giving up athletics, community activities, church, and getting together with friends. Next comes increased turmoil at home. Domestic arguments, sexual problems, and lack of interest in family matters are common. Third is the appearance of frequent unexplained illnesses, personality changes, multiple jobs, and frequent moves between cities. This progression,

TABLE 88-3 -- Signs and symptoms of chemical dependence seen in the hospital

1. Unusual changes in behavior (e.g., wide mood swings, depression, anger, euphoria)

2. Gossip by others

3. Progressive increase in apparent narcotic use for anesthetic management

4. Careless charting

5. Preference for working alone

6. Frequent requests for bathroom breaks

7. Unusual willingness to provide relief for others

8. Inappropriate willingness to take calls

9. Often appears in the hospital when not on call

10. Frequent unexplained absences

11. Difficult to find when on call

12. Excessive postoperative pain in patients cared for by an individual

13. Commonly wears long-sleeved gowns (to prevent chills often seen in early withdrawal and to hide needle tracks)

14. Pinpoint pupils

15. Weight loss

16. Found comatose

17. Found dead

18. Witnessed self-administration (the only pathognomonic sign)

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The last activity to be affected is usually job performance. Page operators and nurses may be the first to recognize behavioral changes. Record keeping may become sloppy. Excessive use of certain drugs becomes apparent, perhaps accompanied by an unusual compulsion to explain the need for these drugs in patient management. Colleagues may note similar changes. Direct observation of self-administration confirms the diagnosis, but it is not common.^[186]

Denial is a keystone of the disease. Impaired physicians disclaim their illness by using superficially logical reasons to explain their bizarre patterns of behavior. Colleagues, too, use denial. Typically, they would rather accept these explanations than consider that a friend is a drug addict. For these reasons, the diagnosis is not usually made until its manifestations are clear. Only when the pieces of the puzzle have been assembled is the picture obvious.

Intervention

The appropriate initial response to a chemically dependent physician is to seek help. A call to a person experienced in managing chemically dependent physicians initiates the next steps.^{[169] [187]} In the United States, all state medical societies have committees on impaired physicians to act as advocates for sick physicians. Advocacy continues as long as the physician cooperates with the committee's recommendations. These committees serve as a buffer between the physician and the medical board or licensing agency. They also provide advisers to aid in confirmation of the diagnosis and to intervene and refer impaired physicians to appropriate treatment centers. Although laws vary, the committees are usually required to notify the board of a physician's recalcitrance at any stage of treatment. In many states, the board does not censure impaired physicians who comply with the committee's recommendations.

Intervention is the process of demonstrating to chemically dependent persons that they are ill and need treatment.^[188] Interventions should never be attempted with less than two concerned persons and ideally should be directed by a person with previous experience, frequently a member of a state committee. The key is to be caring and compassionate in spite of the patient's arguments, but to be persistent. Addicted physicians are superb con artists. They are able to counter all ploys attempted by a single individual and usually give a group of people a good workout. Hours of preparation are needed to collect information, to assemble appropriate participants (including coworkers, family, friends, and a recovering physician, if one is available), and to rehearse. Pertinent pharmacy records, anesthetic records, and other documentation of the illness should be gathered. All involved must be prepared to present their nonjudgmental observations in as much detail as possible. Many suggest that each participant prepare written notes to be used for reference during the intervention. The objectives are to present irrefutable proof of the addict's symptoms, describe the disease, and get the addict to an appropriate treatment facility. It is not a kangaroo court but rather a caring act of compassion for an ill colleague who is unable to recognize the illness. A recovering physician at the intervention is invaluable as a role model for the patient. Arrangements for treatment and travel, should they be required, must be made before the intervention.

In spite of meticulous planning, it is important to realize that an intervention may be like a football play in a downpour—although it may sound great in the huddle, once the ball is snapped, the play may go awry. Just as in football, the interveners must anticipate the "broken play." They may need to improvise during the intervention, but they must keep the goal of referral for evaluation and treatment (if needed) continually in sight.

When all is in order, the patient is invited into a room in which the other participants are already seated. Each in turn should express concern for the colleague's wellbeing and, without passing judgment, should describe the aberrant behavior that has been seen personally. If necessary, the documents at hand can be shown. The basics of the disease and its treatment should be explained, and the patient should be urged to accept the proposed plan. If the patient refuses, as many do initially for fear of losing control, the patient should be told that the ultimate decision regarding therapy will not be made until after a thorough evaluation by a group of specialists at the facility.^[187] If the evaluation does not confirm the diagnosis, the patient will be discharged. Otherwise, formal treatment, perhaps lasting several months, will start. If still reluctant, the individual should be advised that the interveners must, by law, report that person to both the medical board and the controlled substance authorities. Although acceptance of treatment does not provide legal immunity, it is looked on favorably by many courts.

After the intervention, someone should stay with the patient continuously, not only to prevent the possibility of self-inflicted injury but also to provide friendship.

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Principles of Treatment

Treatment consists of an in-depth evaluation, which is usually followed by both inpatient and outpatient therapy. Formal therapy may last as long as several months,^{[168] [187]} but on the basis of the initial workup, some programs permit a recovering physician to continue practicing medicine during what may be several years of outpatient care. ^[169] Though debated by some, physicians often fare better if treated at a facility experienced in managing physicians. On admission, many feel guilty, ashamed, and totally alone. Just seeing that other physicians share their disease is therapeutic. Philosophies of treatment vary between programs, but the common goal is to provide a recovering physician with the ability to remain sober. The physician is assisted in developing a strong relationship with peer support groups such as Alcoholics Anonymous and Narcotics Anonymous. In the last stage, the physician may become involved in evaluating new patients. Such involvement permits personal reflection on one's own course, referred to by some as "mirror imaging." As understanding of the biology of addiction expands, specific pharmacologic treatment may become more common.^[151]

Reentry into the Workplace

Return from treatment is a difficult process for a recovering physician. The comprehensive treatment program has provided a structured environment that is much different from the workplace. During treatment, each person has learned a great deal about the disease, but those with whom the person interacts after discharge are far less knowledgeable and perhaps fearful of both the individual and the disease. For this reason, reentry is greatly facilitated by understanding, compassionate peers who are willing to provide emotional support to the recovering physician. Gradual return to work, perhaps with others initially managing narcotic administration, is important. Without this support, the likelihood of relapse may be much greater.

In many states, the committee on impaired physicians plays a vital role in recovery. At discharge from formal treatment, the committee prepares an "aftercare contract" with the physician, who agrees to be bound by the committee's recommendations. The contract usually stipulates the number and the type of meetings that the physician must attend, the name of a "monitoring physician," the requirement for random urine samples on demand, and the procedures to be used in the event of a relapse.^{[168] [171] [189]} Many recovery programs insist on the use of naltrexone or disulfiram, or both, for 6 months or more after returning. Novel treatments with drugs such as acamprosate, bromocriptine, selective serotonin reuptake inhibitors, and buspirone are under investigation.^[190] As long as physicians adhere to the contract, the committee continues to serve as their advocate.

Federal law in the United States (the Americans with Disabilities Act [ADA]) provides limited protection against employment discrimination for recovering individuals.^[191] Although persons who are currently using drugs are not protected by this law, those who have been successfully treated and are otherwise capable of working are considered to be "qualified individuals with a disability." The ADA defines a history of chemical dependence as a disability. Although it does not require an employer to provide for treatment, the ADA may require that "reasonable accommodation" be made for a qualified individual who wants to return to practice. For a recovering physician, such accommodation might include a modified work schedule, such as no call for several months and assistance with administration of narcotics. An employer is not required to make accommodation if "undue hardship" for the employer would result. For example, it could be argued in court that the accommodations needed to permit a recovering physician to return might have a negative impact on other employees or could result in prohibitive costs for the employer. Whether the ADA can be used also depends on the type of employer-employee relationship between an individual and a hospital or group practice. Clearly, any person who seeks the support of the ADA needs competent legal guidance.