Saving Troubled Physicians
What do you do when a colleague is a
danger to himself or others?
This step-by-step guide helps you get an impaired doctor in
treatment and back on the job while protecting patients.
This step-by-step guide helps you get an impaired doctor in
treatment and back on the job while protecting patients.
Kevin McCauley, MD had an impressive
resume. A college degree, four years of medical school,
qualification as a Navy fighter pilot, and finally a dream job
as flight surgeon for a Marine F-18 Hornet squadron. His career
trajectory accelerated when he was about to be appointed flight
surgeon for the Navy’s elite Blue Angels precision flying
team. That was before federal agents arrested him one warm June
day in 1997 on multiple counts of drug abuse and prescription
violations.
McCauley’s
resume now includes serving hard time as federal prison inmate
number 76930 in Fort Leavenworth, Kansas.
Throughout the country,
medical boards are struggling to deal with the effects of
impaired physicians, which the American
Medical Association (AMA)
defines as “any physical, mental, or behavioral disorder
that interferes with the ability to engage safely in
professional activities.”
While media attention
focuses on less common impairments that doctors may exhibit,
such as disruptive behaviors, bipolar disorders, and
depression, by far the majority of physician impairments are of
a more common variety. “Most physician impairments,
I’d be very safe in saying upwards of 75 or 80 percent,
have something to do with substance abuse,” says William
Reid, MD, a clinical professor of psychiatry at the University
of Texas Health Science Center,
who has written widely on the issue.
Punitive actions
against physicians by medical boards, including license
suspensions, revocations, and probations, increased by 35
percent over the past decade, according to the AMA. In 2002,
there were an unprecedented 4,875 medical board disciplinary
actions for all causes. Health experts variously estimate the
percentage of impaired physicians at 10 to 15 percent of all
working doctors.
Roots of the problem
There is no doubt that technological and
societal factors have lured some physicians into making choices
they later regret. Prescribing over the Internet and the wide
availability of recreational drugs have contributed to problems
some physicians have had staying within ethical guidelines. At
least 27 of the nation’s 70 medical boards have censured
doctors for prescribing drugs over the Internet. Increased
media attention to medical errors has also forced medical
boards to heighten their scrutiny. A 1999 report by the
Institute of Medicine estimated that as many as 98,000 deaths
in hospitals occur annually as a result of errors from
physicians, pharmacists, nurses, and other caregivers.
The increased number of
physicians in the United States,
by definition, means increased
disciplinary measures by medical boards. In 1993 there were a
little more than 670,000 doctors in the country. Today, there
are more than 840,000.
 | ||
Other, subtler
influences have also contributed to the problem of impaired
physicians. In past decades, the rigors of college, medical
school, internship, and residency served to weed out many
people with impairments. But over the past two decades,
initiatives designed to keep students in the pipeline through
remediation and wellness programs have, in some cases, merely
delayed the onset of impairments until a physician begins to
practice.
“There are also
issues within the individual that can lead to
impairment,” says Reid, “like a propensity to a
particular mental illness, such as bipolar disorder, or to
substance abuse. Another is severe depression, which often
doesn’t present until midlife or later.” However, a
diagnosis of depression, for example, does not de facto mean
impairment. Many disorders can be treated successfully and not
affect a physician’s practice.
The very personality
factors that enable a physician to endure the rigors of medical
training may also work against him once an impairment begins.
Strong egos, issues of control, and fears of being wrong or
embarrassed propel impaired physicians toward the brink of
self-destruction before seeking help.
“Physicians
don’t seek help early enough in the process,” warns
Reid. “They believe either they can get away with it or
they can control it. They feel embarrassed or humiliated. They
think they will lose their license and lose face in the
community. Thus, they often postpone things until it is too
late.”
Getting personal
That was Kevin McCauley’s pattern
while in the Navy. Following a surgical procedure needed to
retain his qualifications as a fighter pilot, McCauley became
dependent on pain killers and wrote prescriptions to cover his
addiction, which progressed to intravenous Demerol and cocaine.
When he considered the Blue Angels flight surgeon position, he
tried to quit, but couldn’t.
While moonlighting at
a San Diego clinic, he stole Demerol from a supply cabinet.
After being confronted by colleagues, he finally sought help
from the state medical board. By then it was too late. The
Navy’s investigative agents were hot on his heels and
arrested him before he could arrange treatment. “I went
from the back seat of an F-18 Hornet to a maximum security
prison cell within weeks,” he says of his ordeal.
While in prison, McCauley
tried to learn everything he could about the physiology of
addiction. He was surprised at how sophisticated the field had
become. When he was released from prison after a year, he
entered an eight-month residential treatment program. He is now
the director of medical education at Sober
Living By The Sea Treatment Centers, a family of treatment facilities located in Southern
California, and he lectures widely on physician addiction.
McCauley doesn’t
buy into what he believes are myths about the psychological
profiles of addicts, nor does he approve of the punitive, moral
tone that the well-being committees of medical boards often
assume when dealing with doctors who abuse alcohol or drugs.
“Addiction is a stress-induced defect in the
brain’s ability to properly perceive pleasure. It
involves physiological changes in brain chemistry,” he
argues. As such, he believes addiction should be treated like
any other disease.
Although the details
vary, the majority of impaired physicians walk a path similar
to McCauley’s, whether toward alcohol and drug addiction
or toward mental illness or disruptive behaviors. The question
that plagues fellow practitioners is: How do I deal with
my impaired colleague?
Confronting the behavior
Virtually every expert on the subject
agrees on one thing: Intervene early and assertively. The
AMA issued guidelines for
dealing with impaired colleagues in 2002 that reminds doctors
of their ethical obligation to report. But, there are other
strong reasons to address a colleague’s impairment.
Reid recalls a
practitioner in a small clinic who finally confronted his
alcohol-abusing colleague about his lapses in medical judgment.
After strongly recommending that the colleague seek treatment
and threatening to report him to the county medical board if he
didn’t, the impaired physician assured him he would seek
treatment himself. It never occurred to the doctor to monitor
his colleague’s compliance. Weeks later, the impaired
physician committed suicide while intoxicated.
Statistics show that
impaired physicians are far more likely to commit suicide than
their peers. Intervening early and rigorously following up is
essential to rehabilitating the impaired physician—and
may even save her life. Doing so also protects patients from
potential injury and the reporting physician from liability in
cases where the impaired physician makes a medical error and is
sued. Robert Stewart, a Corte Modera, California attorney who
specializes in helping impaired physicians protect their
licenses—and their lives—by agreeing to
rehabilitation and monitoring programs, recommends that doctors
plan their approach carefully.
“When a
physician begins to observe signs of drug and alcohol use or
abuse in fellow docs, they should have a notebook that is kept
safe, in which they make notes, in some detail, of what
they’re observing,” says Stewart. “Frequently
the identified physician hopes that people will not have
anything specific that they can refer to. Specifics will move
the identified physician to accept the reality of their
situation much more readily.”
Unfortunately,
physicians do not receive formal training in confronting
colleagues about perceived impairments. They have a tendency to
avoid the problem in hopes that it will resolve itself. That is
why it is important to be proactive about impairment issues.
“In most medium to large group practices,” says
Stewart, “the group should identify one or two doctors,
or perhaps a rotating small group, who have as their
responsibility drug and alcohol issues or whatever other
impairments arise within the practice.”
Groups such as the American
Society of Addiction Medicine,
or local affiliates such as the California
Society of Addiction Medicine,
offer day-long, best-practices workshops on how to deal with
physician impairment, from assessment and intervention to
follow-up and reintegration within the practice.
The sheer magnitude of
the problem has spawned a specialty within the physician
community. If a practice finds it difficult to approach an
impaired colleague, they can call on the services of a growing
cadre of professional interventionists, like James Tracy, DDS.
Tracy, in recovery himself,
is also the professional community liaison for the William
J. Farley Center, a
residential, extended-care treatment center specializing in
health professionals and located in Williamsburg, Virginia.
“Early detection and intervention is most important and
most difficult to do,” he acknowledges. “People who
aren’t trained or experienced in this are terrified of
doing it. We’re good at taking care of others, but
we’re really lousy at taking care of ourselves and our
colleagues.”
If anyone should know
about the importance of early intervention, it is Tracy.
Twenty-one federal agents descended on his office on April 28,
1988 and arrested him on drug charges. “I ended up losing
everything,” he says without bitterness. “I had my
license revoked and a five year suspended prison sentence. No
one intervened on me.” Since his sobriety 16 years ago,
Tracy has become a national leader for interventions, lecturing
to physician groups, training well-being committees, and
frequently volunteering his time to help intervene with
impaired physicians and other health professionals.
