Robert P. Bright, MD

Discuss this article at www.facebook.com/CurrentPsychiatry

Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism.

Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and “weak” to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to “carry his load.” Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence.

Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment.

Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher.¹ Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might:

• be reluctant to seek treatment
• attempt to diagnose and treat themselves
• seek and receive “VIP treatment” from other health care providers.

This article examines physicians’ risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles.

Not immune to depression

Rates of depression are higher in medical students and residents (15% to 30%) than in the general population.^2-4 A longitudinal study of medical students at the University of California, San Francisco showed that students’ rates of depression when they enter medical school are similar to those of the general population, but students’ depression scores rise over time; approximately one-fourth of first- and second-year students were depressed.³ Fahrenkopf et al⁵ reported that 20% of 123 pediatric residents at 3 U.S. children’s hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers.⁵ For more information on physicians-in-training, see “Treating depression in medical residents“.

After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women⁶; these rates are comparable to those of the general population. Firth-Cozens⁷ found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1).⁷ Although these stressors increase depression risk, Vaillant et al⁸ showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse.⁸

A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. Spouses and partners can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. Patient care and the physician’s professional standing can be endangered. Signs that suggest a physician may be suffering from depression or another mental illness appear in Table 2.⁹

Table 1

Predictors of depression in physicians

Table 2

Manifestations of mental illness in physicians

Increased suicide risk

A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.¹ A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population.¹⁰ There are no recent studies of suicide rates among U.S. physicians. A 1984-1995 study showed that white male physicians have a higher risk for suicide than other white male professionals.¹¹ A survey of 4,500 women physicians found that female doctors are less likely to attempt suicide than the general female population⁶; however, their attempts more often are lethal, perhaps because they have greater knowledge of toxicology and access to lethal drugs.¹²

The relative rate of suicide among medical specialties is unknown. Studies had indicated higher rates of suicide among psychiatrists and anesthesiologists, but these trials were methodologically flawed.¹²

Silverman¹² developed a profile of the physician at high risk for suicide: a workaholic white male age ≥50 or female age ≥45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression. He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). Physicians with chronic pain or illness or with a recent change in occupational or financial status also are at risk. Recent increased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.

Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.^13,14

Barriers to treatment

Physicians often are hesitant to seek mental health treatment.¹⁵ They may fear social stigma and could have trouble finding a local provider who they trust but is not a colleague. Physicians might be concerned about confidentiality and fear recrimination by colleagues, facilities where they work, or licensing boards.¹⁶ Givens and Tjia³ found that only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students reported that time constraints, confidentiality concerns, stigma, cost, and fear that their illness will be documented on their academic record were major barriers to seeking mental health care.

Licensing concerns. Physicians may be required to disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. Increasingly, medical boards are asking applicants if they have been treated for bipolar disorder, schizophrenia, paranoia, or other disorders.¹⁷ Credentialing bodies, clinics, and hospitals may make similar queries.

In an analysis of 51 medical licensing applications (50 states and the District of Columbia), Schroeder et al¹⁷ determined that 69% contained at least 1 question that was “likely impermissible” or “impermissible” in terms of compliance with the Americans with Disabilities Act (ADA). In 1993, a U.S. District Court found that the New Jersey State Board of Medical Examiners was in violation of the ADA because licensure application questions did not focus on current fitness to practice medicine but rather on information about a candidate’s status as a person with a disability (illness or diagnosis).¹⁸

In Alexander v Margolis,¹⁹ however, the court found that because patient safety is in question, medical licensing boards and credentialing bodies can solicit information about serious mental illness that could lead to impaired performance. Courts have ruled that questions regarding a history of treatment or hospitalization for bipolar disorder or schizophrenia and other psychotic disorders are permissible because they are considered “serious disorders” likely to interfere with a physician’s current ability to practice.²⁰ In a 2008 review of all U.S. -affiliated medical licensing boards (N=54), Polfliet²¹ found that 7 specifically asked applicants about a history of bipolar disorder or schizophrenia, paranoia, and other psychotic disorders. Polfliet²¹ also found that state medical boards’ compliance with ADA guidelines was not uniform and some questions were “just as broad, and potentially discriminatory, as they were before enactment of the ADA.”

Worley²² reported a successful appeal to the Arkansas State Medical Board to revise its licensure questions following a cluster of medical student and physician suicides. The Board changed the question “Have you ever, or are you presently, being treated for a mental health condition?” to “Have you ever been advised or required by any licensing or privileging body to seek treatment for a physical or mental health condition?”

Providing inaccurate information on a medical licensure application may result in denial or revocation,²³ but acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board. The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.

Bipolar disorder. The trend in psychiatry toward diagnosing bipolar II disorder and “soft bipolarity” in patients previously diagnosed with and treated for major depression presents a new challenge. Despite no change in their history or functioning, a physician whose diagnosis is changed from depression to bipolar II disorder might be moved from a non-reportable to a board-reportable diagnostic category. With the evolving understanding of bipolar spectrum disorders, medical boards may need to revise their screening questions to ensure that they are seeking information about impairment, not simply the presence of a medical disorder.

Seeking special treatment

Self-treatment. Physicians may attempt to treat their mood disorder with self-prescribed medications before seeking consultation from a psychiatrist. Others use alcohol or illicit drugs to try to alleviate mood disorder symptoms. Self-diagnosis and treatment are not advisable because it is impossible to be objective. Professional boards and state medical boards discourage or prohibit self-prescribing because of the need for ongoing evaluation and monitoring for adverse reactions.

‘VIP’ treatment. When a physician comes to a colleague for help with a mental health issue, both parties might underestimate the severity of the crisis.²⁴ Weintraub²⁵ reported a case series of 12 “VIP” psychiatric inpatients, 10 of whom he described as “therapeutic failures, “including 2 who committed suicide and 3 who left the hospital against medical advice. He observed that improvement occurred only after patients lost their VIP status/treatment.

In a literature review, Groves et al²⁶ found delays in pursuing diagnostic evaluation and treatment for physician patients. He described risks of VIP treatment (Table 3),²⁶ including the physician’s ability to circumscribe the care regimen to obtain “special treatment, “which can create conflict among care providers and other patients. The ailing physician might have trouble relinquishing control. Care providers might not give physician patients necessary information about the illness or treatment because they make assumptions about the physician’s knowledge or fear causing narcissistic injury. Providers’ identification with their peers, deference to their background, and desire to preserve these patients’ autonomy may lead to interventions that are different from those they would provide to other patients.

Treating physicians might underestimate the patient’s suicide risk and tend to not hospitalize a physician patient who faces an imminent risk of self-harm. Similarly, a physician patient might know what key words to use to deny suicidal ideation or avoid hospitalization. Providers assessing physician patients should provide the same interventions they would give to nonphysician patients with the same history and suicide risk factors. To do otherwise is to risk a fatal outcome.

Physician health programs provide confidential treatment and assistance to physicians with mental illness and/or substance abuse problems. Some programs are affiliated with licensing boards, some are branches of the state medical societies, and others are independent of the licensing agencies. Directories of these programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Physician health programs aim to help impaired physicians receive treatment and rehabilitation without censure or licensure revocation, provided they comply with treatment and monitoring requirements.

Table 3

Risks of caring for ‘VIP’ patients

Related Resources

• American Foundation for Suicide Prevention. www.afsp.org. 24-hour crisis line: 1-800-273-TALK (8255).
• Center for Patient and Professional Advocacy. www.mc.vanderbilt.edu/root/vumc.php?site=CPPA.
• Depression and Bipolar Support Alliance. www.dbsalliance.org.
• Federation of State Physician Health Programs, Inc. www.fsphp.org.
• National Alliance on Mental Illness. www.nami.org.
• Vanderbilt Center for Professional Health. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism.

Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and “weak” to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to “carry his load.” Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence.

Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment.

Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher.¹ Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might:

• be reluctant to seek treatment
• attempt to diagnose and treat themselves
• seek and receive “VIP treatment” from other health care providers.

This article examines physicians’ risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles.

Not immune to depression

Rates of depression are higher in medical students and residents (15% to 30%) than in the general population.^2-4 A longitudinal study of medical students at the University of California, San Francisco showed that students’ rates of depression when they enter medical school are similar to those of the general population, but students’ depression scores rise over time; approximately one-fourth of first- and second-year students were depressed.³ Fahrenkopf et al⁵ reported that 20% of 123 pediatric residents at 3 U.S. children’s hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers.⁵ For more information on physicians-in-training, see “Treating depression in medical residents“.

After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women⁶; these rates are comparable to those of the general population. Firth-Cozens⁷ found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1).⁷ Although these stressors increase depression risk, Vaillant et al⁸ showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse.⁸

A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. Spouses and partners can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. Patient care and the physician’s professional standing can be endangered. Signs that suggest a physician may be suffering from depression or another mental illness appear in Table 2.⁹

Table 1

Predictors of depression in physicians

Table 2

Manifestations of mental illness in physicians

Increased suicide risk

A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.¹ A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population.¹⁰ There are no recent studies of suicide rates among U.S. physicians. A 1984-1995 study showed that white male physicians have a higher risk for suicide than other white male professionals.¹¹ A survey of 4,500 women physicians found that female doctors are less likely to attempt suicide than the general female population⁶; however, their attempts more often are lethal, perhaps because they have greater knowledge of toxicology and access to lethal drugs.¹²

The relative rate of suicide among medical specialties is unknown. Studies had indicated higher rates of suicide among psychiatrists and anesthesiologists, but these trials were methodologically flawed.¹²

Silverman¹² developed a profile of the physician at high risk for suicide: a workaholic white male age ≥50 or female age ≥45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression. He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). Physicians with chronic pain or illness or with a recent change in occupational or financial status also are at risk. Recent increased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.

Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.^13,14

Barriers to treatment

Physicians often are hesitant to seek mental health treatment.¹⁵ They may fear social stigma and could have trouble finding a local provider who they trust but is not a colleague. Physicians might be concerned about confidentiality and fear recrimination by colleagues, facilities where they work, or licensing boards.¹⁶ Givens and Tjia³ found that only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students reported that time constraints, confidentiality concerns, stigma, cost, and fear that their illness will be documented on their academic record were major barriers to seeking mental health care.

Licensing concerns. Physicians may be required to disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. Increasingly, medical boards are asking applicants if they have been treated for bipolar disorder, schizophrenia, paranoia, or other disorders.¹⁷ Credentialing bodies, clinics, and hospitals may make similar queries.

In an analysis of 51 medical licensing applications (50 states and the District of Columbia), Schroeder et al¹⁷ determined that 69% contained at least 1 question that was “likely impermissible” or “impermissible” in terms of compliance with the Americans with Disabilities Act (ADA). In 1993, a U.S. District Court found that the New Jersey State Board of Medical Examiners was in violation of the ADA because licensure application questions did not focus on current fitness to practice medicine but rather on information about a candidate’s status as a person with a disability (illness or diagnosis).¹⁸

In Alexander v Margolis,¹⁹ however, the court found that because patient safety is in question, medical licensing boards and credentialing bodies can solicit information about serious mental illness that could lead to impaired performance. Courts have ruled that questions regarding a history of treatment or hospitalization for bipolar disorder or schizophrenia and other psychotic disorders are permissible because they are considered “serious disorders” likely to interfere with a physician’s current ability to practice.²⁰ In a 2008 review of all U.S. -affiliated medical licensing boards (N=54), Polfliet²¹ found that 7 specifically asked applicants about a history of bipolar disorder or schizophrenia, paranoia, and other psychotic disorders. Polfliet²¹ also found that state medical boards’ compliance with ADA guidelines was not uniform and some questions were “just as broad, and potentially discriminatory, as they were before enactment of the ADA.”

Worley²² reported a successful appeal to the Arkansas State Medical Board to revise its licensure questions following a cluster of medical student and physician suicides. The Board changed the question “Have you ever, or are you presently, being treated for a mental health condition?” to “Have you ever been advised or required by any licensing or privileging body to seek treatment for a physical or mental health condition?”

Providing inaccurate information on a medical licensure application may result in denial or revocation,²³ but acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board. The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.

Bipolar disorder. The trend in psychiatry toward diagnosing bipolar II disorder and “soft bipolarity” in patients previously diagnosed with and treated for major depression presents a new challenge. Despite no change in their history or functioning, a physician whose diagnosis is changed from depression to bipolar II disorder might be moved from a non-reportable to a board-reportable diagnostic category. With the evolving understanding of bipolar spectrum disorders, medical boards may need to revise their screening questions to ensure that they are seeking information about impairment, not simply the presence of a medical disorder.

Seeking special treatment

Self-treatment. Physicians may attempt to treat their mood disorder with self-prescribed medications before seeking consultation from a psychiatrist. Others use alcohol or illicit drugs to try to alleviate mood disorder symptoms. Self-diagnosis and treatment are not advisable because it is impossible to be objective. Professional boards and state medical boards discourage or prohibit self-prescribing because of the need for ongoing evaluation and monitoring for adverse reactions.

‘VIP’ treatment. When a physician comes to a colleague for help with a mental health issue, both parties might underestimate the severity of the crisis.²⁴ Weintraub²⁵ reported a case series of 12 “VIP” psychiatric inpatients, 10 of whom he described as “therapeutic failures, “including 2 who committed suicide and 3 who left the hospital against medical advice. He observed that improvement occurred only after patients lost their VIP status/treatment.

In a literature review, Groves et al²⁶ found delays in pursuing diagnostic evaluation and treatment for physician patients. He described risks of VIP treatment (Table 3),²⁶ including the physician’s ability to circumscribe the care regimen to obtain “special treatment, “which can create conflict among care providers and other patients. The ailing physician might have trouble relinquishing control. Care providers might not give physician patients necessary information about the illness or treatment because they make assumptions about the physician’s knowledge or fear causing narcissistic injury. Providers’ identification with their peers, deference to their background, and desire to preserve these patients’ autonomy may lead to interventions that are different from those they would provide to other patients.

Treating physicians might underestimate the patient’s suicide risk and tend to not hospitalize a physician patient who faces an imminent risk of self-harm. Similarly, a physician patient might know what key words to use to deny suicidal ideation or avoid hospitalization. Providers assessing physician patients should provide the same interventions they would give to nonphysician patients with the same history and suicide risk factors. To do otherwise is to risk a fatal outcome.

Physician health programs provide confidential treatment and assistance to physicians with mental illness and/or substance abuse problems. Some programs are affiliated with licensing boards, some are branches of the state medical societies, and others are independent of the licensing agencies. Directories of these programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Physician health programs aim to help impaired physicians receive treatment and rehabilitation without censure or licensure revocation, provided they comply with treatment and monitoring requirements.

Table 3

Risks of caring for ‘VIP’ patients

Related Resources

• American Foundation for Suicide Prevention. www.afsp.org. 24-hour crisis line: 1-800-273-TALK (8255).
• Center for Patient and Professional Advocacy. www.mc.vanderbilt.edu/root/vumc.php?site=CPPA.
• Depression and Bipolar Support Alliance. www.dbsalliance.org.
• Federation of State Physician Health Programs, Inc. www.fsphp.org.
• National Alliance on Mental Illness. www.nami.org.
• Vanderbilt Center for Professional Health. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article at www.facebook.com/CurrentPsychiatry

Dr. G, a second-year surgical resident, becomes depressed when his girlfriend abruptly ends their relationship. His phone calls and e-mails seeking an explanation go unanswered. Having long struggled with his self-esteem, Dr. G interprets this rejection as confirmation of his self-criticism.

Because of his work schedule, Dr. G feels that there is no way to see a therapist or psychiatrist and believes that asking for time off to do so would adversely affect his evaluations. He feels too embarrassed and “weak” to disclose his breakup and depression to his colleagues and attending physicians and senses that fellow residents would resent having to “carry his load.” Dr. G has spent the past 2 years moonlighting at the local emergency room and thinks it would be humiliating to go there for psychiatric help. His work performance and attendance decline until eventually his residency director forces him to take a medical leave of absence.

Dr. G feels that his pain will never end. He writes goodbye letters to his family, makes arrangements for his possessions and funeral, and hangs himself from the balcony outside his apartment.

Although the rate of depression among physicians is comparable to that of the general population, physicians’ risk of suicide is markedly higher.¹ Depression and other mood disorders may be under-recognized and inadequately treated in physicians because physicians might:

• be reluctant to seek treatment
• attempt to diagnose and treat themselves
• seek and receive “VIP treatment” from other health care providers.

This article examines physicians’ risk for depression and suicide, licensing concerns and other barriers to effective treatment, and what can be done to overcome such obstacles.

Not immune to depression

Rates of depression are higher in medical students and residents (15% to 30%) than in the general population.^2-4 A longitudinal study of medical students at the University of California, San Francisco showed that students’ rates of depression when they enter medical school are similar to those of the general population, but students’ depression scores rise over time; approximately one-fourth of first- and second-year students were depressed.³ Fahrenkopf et al⁵ reported that 20% of 123 pediatric residents at 3 U.S. children’s hospitals were depressed. These depressed residents made 6.2 times more medication errors than did their non-depressed peers.⁵ For more information on physicians-in-training, see “Treating depression in medical residents“.

After completing residency, the risk of depression persists. The lifetime prevalence of depression among physicians is 13% in men and 20% in women⁶; these rates are comparable to those of the general population. Firth-Cozens⁷ found a range of factors that predict depression among general practitioners; relationships with senior doctors and patients were the main stressors (Table 1).⁷ Although these stressors increase depression risk, Vaillant et al⁸ showed that they did not increase suicide risk in physicians who did not have underlying psychological difficulties when they entered college. Certain personality traits common among physicians, such as self-criticism and perfectionism, may increase risk for depression and substance abuse.⁸

A depressed physician might enter a downward spiral. Feelings of hopelessness and worthlessness frequently lead to declining professional performance. Professional and personal relationships are strained as internal dysphoria manifests as irritability and anger. Spouses and partners can feel overwhelmed and bewildered by changes in the depressed person’s behavior, which may lead to separation or divorce. Patient care and the physician’s professional standing can be endangered. Signs that suggest a physician may be suffering from depression or another mental illness appear in Table 2.⁹

Table 1

Predictors of depression in physicians

Table 2

Manifestations of mental illness in physicians

Increased suicide risk

A review of 14 studies found that the relative risk of suicide in physicians compared with the general population is between 1.1 and 3.4 for men and 2.5 to 5.7 for women.¹ A retrospective study of English and Welsh doctors showed elevated suicide rates in female but not male physicians compared with the general population.¹⁰ There are no recent studies of suicide rates among U.S. physicians. A 1984-1995 study showed that white male physicians have a higher risk for suicide than other white male professionals.¹¹ A survey of 4,500 women physicians found that female doctors are less likely to attempt suicide than the general female population⁶; however, their attempts more often are lethal, perhaps because they have greater knowledge of toxicology and access to lethal drugs.¹²

The relative rate of suicide among medical specialties is unknown. Studies had indicated higher rates of suicide among psychiatrists and anesthesiologists, but these trials were methodologically flawed.¹²

Silverman¹² developed a profile of the physician at high risk for suicide: a workaholic white male age ≥50 or female age ≥45 who is divorced, single, or currently experiencing marital disruption and is suffering from depression. He or she has a substance abuse problem and a history of risk-taking (high-stakes gambling, etc.). Physicians with chronic pain or illness or with a recent change in occupational or financial status also are at risk. Recent increased work demands, personal losses, diminished autonomy, and access to lethal means (medications, firearms) complete the profile.

Protective factors that lower the risk of completed suicide include effective treatment, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.^13,14

Barriers to treatment

Physicians often are hesitant to seek mental health treatment.¹⁵ They may fear social stigma and could have trouble finding a local provider who they trust but is not a colleague. Physicians might be concerned about confidentiality and fear recrimination by colleagues, facilities where they work, or licensing boards.¹⁶ Givens and Tjia³ found that only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students reported that time constraints, confidentiality concerns, stigma, cost, and fear that their illness will be documented on their academic record were major barriers to seeking mental health care.

Licensing concerns. Physicians may be required to disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. Increasingly, medical boards are asking applicants if they have been treated for bipolar disorder, schizophrenia, paranoia, or other disorders.¹⁷ Credentialing bodies, clinics, and hospitals may make similar queries.

In an analysis of 51 medical licensing applications (50 states and the District of Columbia), Schroeder et al¹⁷ determined that 69% contained at least 1 question that was “likely impermissible” or “impermissible” in terms of compliance with the Americans with Disabilities Act (ADA). In 1993, a U.S. District Court found that the New Jersey State Board of Medical Examiners was in violation of the ADA because licensure application questions did not focus on current fitness to practice medicine but rather on information about a candidate’s status as a person with a disability (illness or diagnosis).¹⁸

In Alexander v Margolis,¹⁹ however, the court found that because patient safety is in question, medical licensing boards and credentialing bodies can solicit information about serious mental illness that could lead to impaired performance. Courts have ruled that questions regarding a history of treatment or hospitalization for bipolar disorder or schizophrenia and other psychotic disorders are permissible because they are considered “serious disorders” likely to interfere with a physician’s current ability to practice.²⁰ In a 2008 review of all U.S. -affiliated medical licensing boards (N=54), Polfliet²¹ found that 7 specifically asked applicants about a history of bipolar disorder or schizophrenia, paranoia, and other psychotic disorders. Polfliet²¹ also found that state medical boards’ compliance with ADA guidelines was not uniform and some questions were “just as broad, and potentially discriminatory, as they were before enactment of the ADA.”

Worley²² reported a successful appeal to the Arkansas State Medical Board to revise its licensure questions following a cluster of medical student and physician suicides. The Board changed the question “Have you ever, or are you presently, being treated for a mental health condition?” to “Have you ever been advised or required by any licensing or privileging body to seek treatment for a physical or mental health condition?”

Providing inaccurate information on a medical licensure application may result in denial or revocation,²³ but acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board. The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.

Bipolar disorder. The trend in psychiatry toward diagnosing bipolar II disorder and “soft bipolarity” in patients previously diagnosed with and treated for major depression presents a new challenge. Despite no change in their history or functioning, a physician whose diagnosis is changed from depression to bipolar II disorder might be moved from a non-reportable to a board-reportable diagnostic category. With the evolving understanding of bipolar spectrum disorders, medical boards may need to revise their screening questions to ensure that they are seeking information about impairment, not simply the presence of a medical disorder.

Seeking special treatment

Self-treatment. Physicians may attempt to treat their mood disorder with self-prescribed medications before seeking consultation from a psychiatrist. Others use alcohol or illicit drugs to try to alleviate mood disorder symptoms. Self-diagnosis and treatment are not advisable because it is impossible to be objective. Professional boards and state medical boards discourage or prohibit self-prescribing because of the need for ongoing evaluation and monitoring for adverse reactions.

‘VIP’ treatment. When a physician comes to a colleague for help with a mental health issue, both parties might underestimate the severity of the crisis.²⁴ Weintraub²⁵ reported a case series of 12 “VIP” psychiatric inpatients, 10 of whom he described as “therapeutic failures, “including 2 who committed suicide and 3 who left the hospital against medical advice. He observed that improvement occurred only after patients lost their VIP status/treatment.

In a literature review, Groves et al²⁶ found delays in pursuing diagnostic evaluation and treatment for physician patients. He described risks of VIP treatment (Table 3),²⁶ including the physician’s ability to circumscribe the care regimen to obtain “special treatment, “which can create conflict among care providers and other patients. The ailing physician might have trouble relinquishing control. Care providers might not give physician patients necessary information about the illness or treatment because they make assumptions about the physician’s knowledge or fear causing narcissistic injury. Providers’ identification with their peers, deference to their background, and desire to preserve these patients’ autonomy may lead to interventions that are different from those they would provide to other patients.

Treating physicians might underestimate the patient’s suicide risk and tend to not hospitalize a physician patient who faces an imminent risk of self-harm. Similarly, a physician patient might know what key words to use to deny suicidal ideation or avoid hospitalization. Providers assessing physician patients should provide the same interventions they would give to nonphysician patients with the same history and suicide risk factors. To do otherwise is to risk a fatal outcome.

Physician health programs provide confidential treatment and assistance to physicians with mental illness and/or substance abuse problems. Some programs are affiliated with licensing boards, some are branches of the state medical societies, and others are independent of the licensing agencies. Directories of these programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Physician health programs aim to help impaired physicians receive treatment and rehabilitation without censure or licensure revocation, provided they comply with treatment and monitoring requirements.

Table 3

Risks of caring for ‘VIP’ patients

Related Resources

• American Foundation for Suicide Prevention. www.afsp.org. 24-hour crisis line: 1-800-273-TALK (8255).
• Center for Patient and Professional Advocacy. www.mc.vanderbilt.edu/root/vumc.php?site=CPPA.
• Depression and Bipolar Support Alliance. www.dbsalliance.org.
• Federation of State Physician Health Programs, Inc. www.fsphp.org.
• National Alliance on Mental Illness. www.nami.org.
• Vanderbilt Center for Professional Health. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Discuss this article

From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.¹ Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.^1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,⁴ and substance abuse is the most common form of impairment that results in discipline by a state medical board.⁵ An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.⁵ Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.⁶ An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).^7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.⁹ Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.^10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.^1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).^1,2,5 A doctor’s professional performance often is the last area to be affected.^1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.⁵

Table 1

Physicians and substance abuse: Predisposing factors

Table 2

Signs of substance abuse

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.¹³ The prevalence of dementia in individuals age ≥65 is 3% to 11%,¹⁴ and 18% of physicians are in this age group.¹⁵

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.¹³ In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.¹⁶

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.¹⁷ Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

• skill and knowledge
• psychosocial functioning
• management skills
• performance
• collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.¹⁸

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.¹³

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).¹³

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.¹⁹ Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.²⁰

Shouten²⁰ cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.^20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.²⁰

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.⁵

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;^23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.⁵

Risk factors for relapse include:

• denial of illness
• poor stress-coping and relationship skills
• social and professional isolation
• inability to accept feedback
• complacency and overconfidence
• failure to attend support group meetings
• dysfunctional family dynamics
• feelings of self-pity, blame, and guilt.⁵

Treating an impaired colleague. Reid²⁶ recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Related Resources

Disruptive physicians

• Samenow C, Swiggart W, Spickard A Jr. Consequence of physician disruptive behavior. Tenn Med. 2007;100(11):38-40.
• Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
• Linney BJ. Confronting the disruptive physician. Physician Exec. 1997;23:55-59.

Physician evaluation

• Anfang SA, Faulkner LR, Fromson JA, et al. The American Psychiatric Association’s resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005;33:85-88.
• Harmon L, Pomm R. Evaluation, treatment, and monitoring of disruptive physicians’ behavior. Psychiatr Ann. 2004; 34:770-774.

Other resources

• Federation of State Physician Health Programs. www.fsphp.org.
• Federation of State Medical Boards: Directory of Physician Assessment and Remedial Education Programs. www.fsmb.org/pdf/RemEdProg.pdf.
• The Center for Professional Health, Vanderbilt University Medical Center. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.
• Alcoholics Anonymous. www.aa.org.
• Narcotics Anonymous. www.na.org.

Drug Brand Name

• Oxycodone/acetaminophen • Percocet

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.

Discuss this article

From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.¹ Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.^1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,⁴ and substance abuse is the most common form of impairment that results in discipline by a state medical board.⁵ An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.⁵ Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.⁶ An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).^7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.⁹ Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.^10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.^1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).^1,2,5 A doctor’s professional performance often is the last area to be affected.^1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.⁵

Table 1

Physicians and substance abuse: Predisposing factors

Table 2

Signs of substance abuse

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.¹³ The prevalence of dementia in individuals age ≥65 is 3% to 11%,¹⁴ and 18% of physicians are in this age group.¹⁵

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.¹³ In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.¹⁶

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.¹⁷ Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

• skill and knowledge
• psychosocial functioning
• management skills
• performance
• collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.¹⁸

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.¹³

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).¹³

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.¹⁹ Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.²⁰

Shouten²⁰ cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.^20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.²⁰

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.⁵

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;^23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.⁵

Risk factors for relapse include:

• denial of illness
• poor stress-coping and relationship skills
• social and professional isolation
• inability to accept feedback
• complacency and overconfidence
• failure to attend support group meetings
• dysfunctional family dynamics
• feelings of self-pity, blame, and guilt.⁵

Treating an impaired colleague. Reid²⁶ recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Related Resources

Disruptive physicians

• Samenow C, Swiggart W, Spickard A Jr. Consequence of physician disruptive behavior. Tenn Med. 2007;100(11):38-40.
• Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
• Linney BJ. Confronting the disruptive physician. Physician Exec. 1997;23:55-59.

Physician evaluation

• Anfang SA, Faulkner LR, Fromson JA, et al. The American Psychiatric Association’s resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005;33:85-88.
• Harmon L, Pomm R. Evaluation, treatment, and monitoring of disruptive physicians’ behavior. Psychiatr Ann. 2004; 34:770-774.

Other resources

• Federation of State Physician Health Programs. www.fsphp.org.
• Federation of State Medical Boards: Directory of Physician Assessment and Remedial Education Programs. www.fsmb.org/pdf/RemEdProg.pdf.
• The Center for Professional Health, Vanderbilt University Medical Center. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.
• Alcoholics Anonymous. www.aa.org.
• Narcotics Anonymous. www.na.org.

Drug Brand Name

• Oxycodone/acetaminophen • Percocet

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.

Discuss this article

From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.¹ Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.^1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,⁴ and substance abuse is the most common form of impairment that results in discipline by a state medical board.⁵ An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.⁵ Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.⁶ An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).^7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.⁹ Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.^10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.^1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).^1,2,5 A doctor’s professional performance often is the last area to be affected.^1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.⁵

Table 1

Physicians and substance abuse: Predisposing factors

Table 2

Signs of substance abuse

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.¹³ The prevalence of dementia in individuals age ≥65 is 3% to 11%,¹⁴ and 18% of physicians are in this age group.¹⁵

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.¹³ In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.¹⁶

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.¹⁷ Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

• skill and knowledge
• psychosocial functioning
• management skills
• performance
• collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.¹⁸

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.¹³

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).¹³

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.¹⁹ Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.²⁰

Shouten²⁰ cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.^20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.²⁰

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.⁵

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;^23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.^24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.⁵

Risk factors for relapse include:

• denial of illness
• poor stress-coping and relationship skills
• social and professional isolation
• inability to accept feedback
• complacency and overconfidence
• failure to attend support group meetings
• dysfunctional family dynamics
• feelings of self-pity, blame, and guilt.⁵

Treating an impaired colleague. Reid²⁶ recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Related Resources

Disruptive physicians

• Samenow C, Swiggart W, Spickard A Jr. Consequence of physician disruptive behavior. Tenn Med. 2007;100(11):38-40.
• Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
• Linney BJ. Confronting the disruptive physician. Physician Exec. 1997;23:55-59.

Physician evaluation

• Anfang SA, Faulkner LR, Fromson JA, et al. The American Psychiatric Association’s resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005;33:85-88.
• Harmon L, Pomm R. Evaluation, treatment, and monitoring of disruptive physicians’ behavior. Psychiatr Ann. 2004; 34:770-774.

Other resources

• Federation of State Physician Health Programs. www.fsphp.org.
• Federation of State Medical Boards: Directory of Physician Assessment and Remedial Education Programs. www.fsmb.org/pdf/RemEdProg.pdf.
• The Center for Professional Health, Vanderbilt University Medical Center. www.mc.vanderbilt.edu/cph.
• Vanderbilt Comprehensive Assessment Program. www.mc.vanderbilt.edu/root/vcap.
• Alcoholics Anonymous. www.aa.org.
• Narcotics Anonymous. www.na.org.

Drug Brand Name

• Oxycodone/acetaminophen • Percocet

Disclosure

The authors report no financial relationship with the manufacturer of any product mentioned in this article or with manufacturers of competing products.