Initial Warning Signs

1
Physician Impairment Substance use during
residency and implications for career development
in EM
Brian McBeth, M.D. University of California, San
Francisco Terry Kowalenko, M.D. University of
Michigan
Felix Ankel, M.D. Regions Hospital/University of
Minnesota Karl Nibbelink, M.D. Temple University
Medical Center
SAEM Annual Meeting New Orleans, LA May 14, 2009
2
Alcohol is the anesthesia by which we endure the
operation of life. George Bernard Shaw
Physician, heal thyself. Luke 423, New
Testament
3
Epidemiology

• Anonymous self report survey February 2006 of
  EM residents nationally (n2,397)
• Use of most illicit substances was low
• Increasing rates of regular marijuana use
  among residents (past-year use increased from
  8.8 to 11.8 past-month use from 2.5 to 4.0
  p lt 0.001)
• Alcohol use is increasing
• Daily drinkers from 3.3 to 5.0 of all residents
  (plt0.001)
• More residents are reporting that their alcohol
  consumption is increasing during residency (from
  4 to 12.6) (Plt0.001)

McBeth BD, Ankel FK, Ling LJ, Asplin BR, Mason
EJ, Flottemesch TJ, McNamara RM, Substance use
in emergency medicine training programs,
Academic Emergency Medicine. 15(1)45-53, 2008
Jan.
4
Epidemiology
McBeth BD, Ankel FK, Ling LJ, Asplin BR, Mason
EJ, Flottemesch TJ, McNamara RM, Substance use
in emergency medicine training programs,
Academic Emergency Medicine. 15(1)45-53, 2008
Jan.
5
Epidemiology
McBeth BD, Ankel FK, Ling LJ, Asplin BR, Mason
EJ, Flottemesch TJ, McNamara RM, Substance use
in emergency medicine training programs,
Academic Emergency Medicine. 15(1)45-53, 2008
Jan.
6
Epidemiology
McBeth BD, Ankel FK, Ling LJ, Asplin BR, Mason
EJ, Flottemesch TJ, McNamara RM, Substance use
in emergency medicine training programs,
Academic Emergency Medicine. 15(1)45-53, 2008
Jan.
7
Epidemiology

• Survey of EM residency directors in 1994 (67 of
  86 responding)
• 49 - suspected chemical dependency in a
  resident at least once
• 33 - identified a chemically dependent
  resident
• Residency directors in this survey estimated
  that only 1 of their current residents were
  impaired by alcohol (concurrent resident survey
  showed 12.5 of current EM residents scoring 1 or
  higher on CAGE questions)

McNamara RM, Margulies JL. Chemical Dependency
in Emergency Medicine Residency Programs
Perspective of the Program Directors, Annals of
Emergency Medicine, 23(5)1072-1076, May
1994. Yao DC, Wright SM. National survey of
internal medicine residency program directors
regarding problem residents. Journal of the
American Medical Association, 284(9)1099-1104,
2000.
8
Identification

• Has typically been hindered by several factors
• Denial by impaired individual
• Fear by impaired resident that disclosure of a
  substance abuse problem in training will
  permanently affect or end career
• Lack of willingness by other residents to bring
  problems to the attention of the administration
  out of a sense of camaraderie or desire to
  protect fellow residents

McNamara RM, Margulies JL. Chemical Dependency
in Emergency Medicine Residency Programs
Perspective of the Program Directors, Annals of
Emergency Medicine, 23(5)1072-1076, May 1994.
9
Identification

• Has typically been hindered by several factors
• Late manifestation of symptoms in the workplace
• Acceptance of substance use as an appropriate
  means of dealing with the stress associated with
  residency training
• Assumption by the administration that the
  problem does not exist or underestimation of its
  prevalence

McBeth BD, Ankel FA. Dont Ask, Dont Tell
Substance Use by Resident Physicians, Academic
Emergency Medicine, 13(8)893-5, June 2006.
10
Research Future Projects

• National Survey of Substance Use
• by Physicians in Training
• Annual survey of resident physicians to monitor
  changing epidemiology of substance use
• Web-based data gathering, possibly in conjunction
  with the annual resident survey by the ACGME
• Project philosophy similar to Monitoring the
  Future research by the Institute of Social
  Research (ISR)
• Better understanding of changing trends in
  substance use by residents will lead educators
  and residency directors to earlier identification
  and treatment of impaired residents

11
Alcohol helped in the House of God, and I think
of my best friend, Chuckwho was never without a
pint of Jack Daniels in his black bag for those
extra-bitter times when he was hurt extra bad
Samuel Shem, The House of God, 1978

• Email contact brian.mcbeth_at_emergency.ucsf.edu

12
Initial Warning Signs

• Tardiness
• Trading (into afternoon shifts ) and missing
  shifts (calling in very late ) especially on
  Mondays and Fridays
• Delinquency with regards to non-clinical
  professional responsibilities
• Late charting
• Conference attendance
• Duty-hour recording
• Attending residency-wide meetings

13
Initial Warning Signs

• Complaints from staff, patients, colleagues
• Frequent illness/injury
• Long bathroom breaks
• Object of gossip/rumors
• Personality changes
• Frequent emotional crisis

14
What You are Not Likely to See Early

• Appearing hung over
• Appearing unkempt
• Smelling of ETOH
• Unprofessional behavior in the clinical arena

15
Who are the Residents who have Problems

• Very smart
• Hard working/driven
• Strong interpersonal skills
• Very social (life of the party)
• Physically fit

16
Late Warning Signs

• Missing shifts or very late without calling in
• Appear hung over
• Appear unkempt
• Socially isolated
• Relationship problems
• Financial problems

17
If You Suspect

• Convene a meeting as soon as you see problems
• Especially if delinquent with non-clinical
  professional responsibilities
• Do not accuse
• Be supportive
• Ask the question directly
• Let him/her know answers are confidential
• Let him/her know about potential consequences and
  how they can be avoided

18

• Let him/her know about recovery
  programs/resources (they may access these without
  telling you)
• Resident must know you are in their corner
• Expect them to deny it

19
If They Deny It

• Reiterate potential consequences and how they can
  be avoided
• Inform them of resources especially if
  substance abuse problem (employee assistance
  program, mental health, health recovery programs,
  etc.)
• Let them know this does not mean they will loose
  their license (at this stage)

20

• Set clear expectations regarding performance
  clinical and non-clinical
• Let them know you will be monitoring their
  behavior
• Set clear time-line
• Set up next meeting
• 1st in 2 weeks then can extend (no gt 1 month)

21
If They Admit It

• Immediately release from clinical duty until
  assessed by mental health (substance abuse)
  professional
• Reiterate confidentiality within institutional
  guidelines
• May need to inform GME, OCA, etc.
• Immediately encourage enrollment in HPRP
• Volunteer to be site monitor
• Be supportive!
• Let them know this does not mean they will loose
  their license (at this stage)

22
What Should You Expect

• Obvious signs will be late
• Other residents will cover for him/her
  (protect)
• Resident will deny the problem
• Resident will think they will be kicked out of
  the program or lose their medical license
• Resident will hit rock-bottom before they seek
  help

23
What Should You Not Expect

• Other residents to report suspicions to you
• Resident will admit to the problem early on

24
What Did I Learn

• If you suspect, you are probably right
• Delinquency in non-clinical performance may be
  predictor
• Residents will protect their peers
• Chiefs will protect their peers
• Obvious signs are very late
• HPRPs are wonderful programs with high success
  rates

25

• Licensing bodies trust HPRPs
• This is a serious disease that is difficult to
  cure
• Relapses are not uncommon (close monitoring must
  continue)
• Educate your faculty and residents on early and
  late signs
• Let residents know that protecting the
  residents (especially early) significantly
  increases the chances that they will hit
  rock-bottom and any delay in reporting results in
  a delay in treatment and significantly decreases
  their chances at full recovery

26
What Should You Do

• Educate residents and faculty on early and late
  warning signs
• Develop confidential means for residents and
  faculty to report suspicions
• Educate residents on consequences and success of
  recovery programs
• Reinforce confidentiality
• Reinforce your support to their success

27

• Know your institutions rules/guidelines
• Know your resources and have them easily
  accessible if you need them
• As soon as you suspect a problem, set up a meeting

28
Incidence Among Residents

• Siegel BJ, Fitzgerald FT W J Med, 148, 1988
• 10 Classified as possible alcoholics by MAST
• 4 Alcoholics
• Lewy R NYS J Med, 88, 1988
• 13 Suspicion or presumptive DX of alcohol abuse
• Hurwitz TA, et.al. Canadian J Psych, 32, 1987
• 14 Pathologic alcohol use
• 3 Social / occupational impairment
• 3 DSM III criteria
• Ikeda, et. al., (1989)
• EPs 2.9 of all CA physicians, but 6.5 of all
  in treatment programs
• General Population 7 DSM IV alcohol abuse /
  dependence
• 23 binge drinking

29
Drug Abuse Among Residents

• Opiates and Benzodiazepines - Frequently begin in
  residency (self-medication)
• 31.5 Benzodiazepine users began in residency
• 23 Opiate users (not heroin) began in residency
• 30-100x General population

JAMA, 265(16), 1991
30
Epidemiology

• Anonymous survey of all Emergency Medicine
  residents following ABEM In-Service Exam 1992
• Response rate 78
• Alcoholic or risk for alcoholism 12.5 (CAGE)
• Cocaine 23 ever 1 in last year
• Marijuana 52.3 ever 8.8 in last year
• Heroin 0.9 ever 0 in last year

AEM, 1(1),1994
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Epidemiology

• Hughes PH, et.al. JAMA, 265(16), 1991
• Survey of 1754 random residents
• Alcohol
• 87 used in past month
• 5 daily
• Marijuana 7 in past month
• Benzodiazepines 3.7 in past month
• Cocaine 1.4 in past month
• Opiates 0.8 in past month

32
Epidemiology

• Hughes PH, et.al. AM J Psych, 149(10), 1992
• Emergency Medicine and Psychiatry residents
  highest rates of lifetime use of marijuana,
  cocaine, benzodiazepines, LSD, other
  hallucinogens
• Emergency Medicine residents
• Cocaine 8 in last month 14 last year
• Marijuana 29 in past year
• Psychiatry residents
• Marijuana 34 in past year
• Benzodiazepines 27 in past year

33
Epidemiology

• Survey EM Program Directors in 1994 (67 of 86
  responded)
• 49 Suspected chemical dependence at least once
• 33 Identified chemical dependence at least once
• Program Directors estimated 1 of current
  residents impaired by alcohol
• Concurrent resident survey 12.5 gt 1 on CAGE
  questions

Annals Em Med, 23(5), 1994 JAMA, 284(9), 2000
34
Barriers to Identification Colleagues /
Administration

• Workplace symptoms manifest late
• Acceptance as means of dealing with stress
• Administration underestimates
• Addiction is mental illness cannot happen to
  professional
• Minimize obvious effects
• Rationalize change in performance, behavior,
  appearance
• Camaraderie
• Cover up errors / omission (protect)
• Unaware of assistance network

Annals Em Med, 23(5), 1994
35
Reporting The Law

• Know your states law
• Review your states definition
• Most require reporting by other licensees
• Potential penalties for not reporting
• Many have good faith liability protection

36
Intervention Who ?

• Friends, Family?
• Colleague?
• Chief Resident?
• Program Director?
• Hospital Committee?
• State Medical Society?
• Intervention Team - Recommended

37
Intervention How, When and Where?

• How?
• Be non-judgmental
• Supportive and caring
• Emphasize desire to help
• Anticipate denial
• When?
• Early as possible
• Not while intoxicated
• Where?
• Quiet, non-threatening location

38
Intervention

• Gather irrefutable evidence about specific times,
  dates, places, and events
• Team should exercise appropriate coercion
• Threat of reporting to medical board or state
  authorities
• Dismissal from Program
• Identify clear goal / outcome
• Trained psychiatrist or substance abuse specialist

Ann Int Med, 116, 1992
39
Health ProfessionalRecovery Program

• Alternative to regulatory (Board) discipline
• Voluntary
• Confidential (not subject to disclosure under
  discovery, subpoena)
• Directed by private sector contractor
• Assistance to obtain evaluation, treatment,
  aftercare and monitoring
• Maintain professional license
• Opportunity to continue working
• Documentation of recovery

40
National Practitioner Data Bank

• Reporting required for
• Loss of clinical privileges or standing
• Disciplinary actions against professionals
  license
• Malpractice judgments
• NOT Diagnosis / treatment of S.U.D.

41
Treatment Physicians

• Immediate intervention
• Evaluation and triage to appropriate facility
• Uninterrupted therapy
• Rehab/group/structured living situation/AA/NA
• Family involvement
• Rapid reentry into practice
• Close monitoring
• Disaster plan contingency

Substance Abuse A Comprehensive Textbook
42
Relapse Risk Factors

• Continued denial
• Dishonesty/emotional concealment
• Dysfunctional family
• Isolation/failure to actively participate in
  AA/NA
• Cross-addiction to other chemicals
• Holiday syndrome
• Severe withdrawal

JAMA, 293(12), 2005 Med Cl N Amer, 81(4), 1997
43
Relapse Risk Factors

• Unresolved guilt/shame/anger
• Use of IV narcotics
• Occupational/legal problems
• Multiple relapses
• Concurrent medical/psychiatric disease
• Poor monitoring
• Family history

JAMA, 293(12), 2005 Med Cl N Amer, 81(4), 1997
44
Monitoring

• Reentry initially part-time
• Gradual return to full clinical responsibilities
• Direct observation of patient care
• Prescriptions
• Surveillance
• Professional qualified in managing impairment
• On-site monitor
• Outpatient treatment (NA, AA) for minimum of 2-3
  years
• Random drug screens

45
Drug Abuse Among Residents

• Opiates and Benzodiazepines - Frequently begin in
  residency (self-medication)
• 31.5 Benzodiazepine users began in residency
• 23 Opiate users (not heroin) began in residency
• 30-100x General population

JAMA, 265(16), 1991
46
Depression

• 30 of PGY-1s
• Of these 25 suicidal ideation
• 18 suicidal plan
• 37 marital difficulties
• Typical symptoms not apparent early on

47
Suicide

• Second leading cause of death among medical
  students
• 200 physicians / year
• MDs lt 40 y.o. 3 x risk of general population
• Substance abuse involved in 20-50

48
Summary

• You will see health professional impairment
• Professional performance one of last things
  affected
• Early detection / treatment improves outcomes
• Enabling delays!
• Diagnosis of CD, SA and/or MI does not
  necessarily mean impairment
• Treatment is effective

49
Physician Impairment Substance Use during
Residency and Implications for Career Development
in Emergency Medicine

• Felix Ankel, MD
• Residency Director
• Regions Hospital
• Ankel001_at_umn.edu
• SAEM National MeetingNew Orleans, LAMay 14,
  2009230-320pm

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To describe the goals and methods for supporting
a healthy residency environment with regards to
alcohol and drug use

• Culture
• Emotion
• Environment

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To describe the goals and methods for supporting
a healthy residency environment with regards to
alcohol and drug use

• Culture
• Emotion
• Environment

57
Physician Impairment Substance Use during
Residency and Implications for Career Development
in Emergency Medicine

• Felix Ankel, MD
• Residency Director
• Regions Hospital
• Ankel001_at_umn.edu
• SAEM National MeetingNew Orleans, LAMay 14,
  2009230-320pm