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Saving Troubled Physicians (continued)

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The successful intervention

Arguably the most important thing to do is to enter the intervention with the proper mindset. “No physician wants to be a disciplinarian for a colleague they practice with,” attorney Stewart says. “But doing an intervention is an act of love and no one should forget that.” Psychiatrist Reid agrees and recommends that team members look at the intervention as the first step in a productive process that will lead to positive outcomes. Conducting the initial meeting in a non-judgmental, business-like manner seems to be most effective.

Experts recommend that at least two people meet with the identified physician, to keep the meeting focused on the behaviors of their colleague, to serve as witnesses, and to support each other. An encouraging development is that due to recent attention to the problem, more physicians are receptive to interventions from their peers.

Throughout the United States, hospitals and local medical boards have well-being committees that can offer expertise for those considering doing an intervention. They can provide background information, suggestions for gathering data, and even provide trained interventionists. In most cases, the interventionists are volunteer physicians. Private interventionists, such as James Tracy, can also be invaluable. They can handle all details from planning for the intervention meeting to actually conducting it, from building a bridge to the well-being committee of the medical board to making sure that there is an effective follow-up protocol in place.

The key to a successful intervention is planning. Working together, the intervention team typically first documents ways in which they have been forced to modify their practice to accommodate the impairments of the identified physician. Have they hesitated to call that person to cover for them? Do they constantly have to reschedule meetings with that person? Are patient complaints off the charts? When the identified physician hears how his behavior has affected those around him, he will often be more open to the intervention.

Tracy, who has been doing this work for fifteen years, uses an intervention model that avoids surprising the identified physician. Surprise meetings frequently backfire when the impaired person becomes enraged. Tracy alerts the identified physician of the meeting and strongly urges him to attend. Over the years he has had nearly 100 percent of physicians show up.

If the identified physician accepts the invitation and is receptive to the intervention, then having him self-report to an appropriate medical board is preferable, usually with one or more support persons attending. “The medical boards respond far better to people who self-report,” says Reid. “The great majority of self-reporters keep their licenses and do very well.”

How you frame the intervention session has a lot to do with whether or not the person accepts your recommendations. “If you present your recommendations as a threat, or focus on what they have to lose, they’re more likely not to take your recommendation,” says Tracy. “But if you frame it in terms of here’s what you have to gain by following our recommendations—for example, you’ll get to keep your license, to practice safely, to repair your relationships—they’re more likely

to accept your recommendations. If you frame it as a threat, only 22 percent are going to take your recommendation. If you frame it positively, 78 percent will go along with your recommendation.”

Kevin McCauley’s Navy experience makes him a walking testimonial to the positive intervention approach. “If you’ve got an alcoholic pilot, you get him into 30 days treatment. If he does well, on his first day back at the squadron, you fly him. The Navy’s not crazy. The idea is to return the alcoholic to the thing that gives his life meaning and use that as leverage against the alcohol. The program involves early surveillance, early identification, appropriate treatment, and return to duty with long-term monitoring. The same program has been phenomenally successful for doctors, pharmacists, and nurses. Recovery is attached to continued performance of their duties, but with the proviso that they are monitored and stay in recovery.”

But, what happens in cases where the identified physician rejects the intervention or even threatens to sue the group for suggesting he is impaired? Lawsuits typically do not get far, since the law protects physicians who act in good faith with an intervention. The thornier issue is resistance.

“You don’t back down,” warns Reid. “By and large physicians are pretty smart. They can think of all kinds of excuses for their behavior. They’ve already been using those excuses and lies to hoodwink their wives and their families and themselves and other people. The lies or rationalizations will just roll off their tongue. They may even sound logical to a person who is not a recovering user.”

That is why many interventions involve at least one recovering physician who knows the score and will not just blindly trust what the identified physician says. “You don’t have to get mad at him,” Reid says, “but you need to acknowledge his feelings and get past that and say, ‘Here’s what we’re going to need to do.’”

James Tracy and Kevin McCauley employ a family intervention model where possible, in which the family of the identified physician participates in the initial meeting. In that way, the impaired physician understands the full range of effect his behaviors have had but also feels the support of those he loves.

Once an intervention is engaged, the next step is usually an assessment of the physician’s impairment. “Our role is not to diagnose the person, but to see that they get evaluated at a center that is experienced with evaluating physicians specifically,” Tracy points out. “That’s usually a four day, multidisciplinary assessment where a four- or five-person team can examine the identified individual, go through all the data, and come up with a diagnosis and a suggested treatment plan.” Based on the assessment, the well-being committee of the medical board will finalize a treatment and follow-up monitoring plan that can preserve a physician’s ability to practice.

At the same time that medical boards have evolved away from punitive measures to a more balanced treatment model, insurance companies have become the major obstacle to an impaired physician’s reinstatement. In most cases, once a physician is placed on probation, they will drop that physician from their insurance panels, which can devastate a practice. This issue is currently being addressed by medical groups throughout the country, but as Tracy points out, that is an important reason to intervene early. In many states, working through a well-being committee avoids the public record and physician databases, so the physician in recovery can stay on insurance panels.

Follow-up

Rigorous follow-up is critical to a physician’s successful reintegration to medicine. Returning physicians must receive an extensive network of support and continual monitoring to prevent relapse. In cases of alcohol and drug abuse, periodic drug testing should be mandatory. In cases of mental illness, drug testing to ensure compliance with a medication regime, coupled with regular counseling and support group work is usually required.

“One of the key relapse problems with recovering physicians is that they tend to isolate themselves and drop out of the mainstream recovery community,” sats Tracy. “It’s critical to keep them actively involved. There’s nothing more powerful than for someone in recovery that has been intervened upon, to then sit on the other side of the table and help intervene on someone else.” It is a powerful experience not only for the recovering physician, but also for the other team members to see an example of successful reintegration into medical practice. That is precisely why so many intervention teams include at least one person in recovery.

Whatever the ultimate treatment and follow-up plan, the cornerstone of any intervention is to act at the first signs of trouble. Visible problems almost always percolate below the surface before erupting. “The best advice I can give is to call us,” says Stewart, who has been in recovery for 18 years. “If you’re lucky, the road of excess leads to the palace of wisdom. The truth is that you don’t get my kind of eyes unless you’ve suffered as I’ve suffered. Every physician knows how to get hold of people like me. We’re available to help through the diversion programs of medical boards. One call will help you get organized.”

Reid agrees and adds a sobering thought. “Those physicians whose impairment is not addressed, treated, and monitored are profoundly more likely to die within the next five years.” g

A Dozen Dos and Don’ts

No matter what the impairment—and there is a wide range—experts agree on one thing: It is a physician’s ethical responsibility to approach impaired colleagues early on and demand they be treated, both to protect patients and the well-being of the impaired colleague. Here are some suggestions, gleaned from best practices of interventionists

Seek help.
Most physicians lack skills in how to most effectively approach an impaired colleague. Reach out to the local well-being committee of your medical board or to a professional interventionist.

Intervene early.
“Early outreach is very important to avoid consequences,” says James Tracy, a professional interventionist. Early interventions can avoid throwing the proceedings into the public record and the physician databases. That will allow the physician to stay on insurance panels once he is in recovery.

Keep detailed notes
of times when you noticed your practice or patient care suffering from your colleague’s impairment. Presenting specifics at the initial meeting is helpful.

Stay positive.
Compliance is several times higher if the treatment alternatives are cast in a positive light than through threats. Help the identified colleague understand that he may keep his license and avoid public record if he agrees to enter treatment and work with the local well-being committee.

Follow up.
Make sure that the identified physician is seen by the well-being committee of the local medical board, is assessed, treated, and monitored.

Use prevention.
Addiction is a stress-induced disease and few professions experience as much stress as physicians. People under stress are more likely to take risks. Put in place programs and opportunities for health-care providers in your practice to exercise, stop smoking, and employ stress-reduction techniques.

Don’t

“buy into the myth
that addicts are bad people,” says Kevin McCauley, an addiction specialist. “Addiction is a disease and the patient should be treated like any other with a disease.”

Delay.
By avoiding a confrontation, you are increasing the danger to patients and to the impaired colleague. You also assume liability.

Moralize.
Addiction, mental illness, and disruptive behavior are indicators of disease. Focus on getting the colleague to treatment, not judging him.

“lose sight of why you are there,”
Psychiatrist William Reid reminds colleagues. “It’s to take care of a safety issue for the doctor and his patients, just as you would with a patient.”

Confront alone.
Having another colleague present will help you stay resolute and focused and can serve as a witness that your motives were to help the identified colleague and her patients.

Spring a surprise.
Experts like James Tracy and Kevin McCauley recommend letting the identified physician know that you need to meet with him on a matter of utmost concern. Setting that first meeting properly can avoid rage reactions and extreme defensiveness. g

Les Picker is a Maryland-based free-lance writer and a regular contributor to Unique Opportunities.

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