1 The Impaired Resident Presented by Richard M. Steinbook, M.D. Professor of Psychiatry & Behavioral Sciences And Director of Psychiatric Residency Training

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The Impaired The Impaired ResidentResident

Presented by Presented by Richard M. Steinbook, M.D.Richard M. Steinbook, M.D.Professor of Psychiatry & Professor of Psychiatry &

Behavioral SciencesBehavioral SciencesAndAnd

Director of Psychiatric Residency Director of Psychiatric Residency TrainingTraining

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OverviewOverview

• Definitions and the contextDefinitions and the context• SuicideSuicide• DepressionDepression• Alcohol and Drug Use/Abuse/DependenceAlcohol and Drug Use/Abuse/Dependence• Sexual HarassmentSexual Harassment• The Problem ResidentThe Problem Resident• Fatigue and BurnoutFatigue and Burnout• Psychological HealthPsychological Health• Health Approaches to Physician StressHealth Approaches to Physician Stress• Conclusion/Recommendations/AssignmentConclusion/Recommendations/Assignment

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The Impaired ResidentThe Impaired Resident

Part IPart I

Definitions Definitions

andand

The Context The Context

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Who is the “Impaired Who is the “Impaired Resident”Resident”

• AMA Council on Mental Health (1973): AMA Council on Mental Health (1973): physician impairment is “the inability to physician impairment is “the inability to practice medicine adequately by reason of practice medicine adequately by reason of physical or mental illness, including physical or mental illness, including alcoholism or drug dependence”alcoholism or drug dependence”

• Although most residents experience high Although most residents experience high levels of stress during training, about 10% levels of stress during training, about 10% will become seriously impairedwill become seriously impaired

• Potentially remediable physician problems Potentially remediable physician problems may lead to less than optimal patient caremay lead to less than optimal patient care

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The Context: Residency The Context: Residency TrainingTraining

• Sleep deprivation and fatigueSleep deprivation and fatigue• Limited time for family/friends and Limited time for family/friends and

social/recreational activitiessocial/recreational activities• Common obsessive-compulsive style of the Common obsessive-compulsive style of the

house officerhouse officer• Emphasis on professional development at Emphasis on professional development at

the expense of personal growththe expense of personal growth• Financial pressures/medical school debtsFinancial pressures/medical school debts• Assumption of the responsibilities of Assumption of the responsibilities of

marriage and parenting marriage and parenting

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The Context: Residency The Context: Residency TrainingTraining

• Geographical relocation with loss of Geographical relocation with loss of friendships and the support of close friendships and the support of close familyfamily

• Transition from the student role to Transition from the student role to that of physician (responsibility for that of physician (responsibility for patient care)patient care)

• Difficulty asking for helpDifficulty asking for help• Access to addictive substancesAccess to addictive substances

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Part II SuicidePart II Suicide

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Suicide Among Suicide Among PhysiciansPhysicians

• Suicide rates among physicians may be Suicide rates among physicians may be twice that of the general populationtwice that of the general population

• Scarce data on suicide among residentsScarce data on suicide among residents• Suicide rate among male physicians in the Suicide rate among male physicians in the

US is similar to that for all white males US is similar to that for all white males >25 years>25 years

• Female physicians commit suicide at 3-5 Female physicians commit suicide at 3-5 times the rate of the white female times the rate of the white female population>25 yearspopulation>25 years

• Kirsling & Kocher, Psychological Reports 1989 64:951-959Kirsling & Kocher, Psychological Reports 1989 64:951-959

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• Very similar suicide rates for male and Very similar suicide rates for male and female physicians (approx 40/100,000)female physicians (approx 40/100,000)

• Suicide rates may increase with age for Suicide rates may increase with age for male physicians but decrease with age male physicians but decrease with age for female physiciansfor female physicians

• 20% of physician suicides are 20% of physician suicides are associated with drug abuseassociated with drug abuse

• 40% are associated with alcohol abuse40% are associated with alcohol abuse

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• Aggregate suicide rate ratio for male Aggregate suicide rate ratio for male physicians compared to the general physicians compared to the general population 1.41 (1.21, 1.65)population 1.41 (1.21, 1.65)

• For female physicians, the ratio was For female physicians, the ratio was 2.27 (1.90, 2.73)2.27 (1.90, 2.73)

• Schernhammer & Colditz Am J Psychiatry 2004 151: 2295-Schernhammer & Colditz Am J Psychiatry 2004 151: 2295-23022302

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AMA/APA profile of the suicide-prone physician AMA/APA profile of the suicide-prone physician (1987)(1987)

• Prior suicide attemptPrior suicide attempt• Suicidal verbalizationSuicidal verbalization• Self-prescribed psychoactive drugsSelf-prescribed psychoactive drugs• Financial lossesFinancial losses• History of treatment for emotional or psychiatric History of treatment for emotional or psychiatric

problemsproblems• DepressionDepression• Social problems related to alcohol abuseSocial problems related to alcohol abuse• Difficult childhoodDifficult childhood

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• The most frequent precursor to suicide is The most frequent precursor to suicide is depression (>75% of all physician suicides depression (>75% of all physician suicides may be attributable to depression and/or may be attributable to depression and/or alcoholism)alcoholism)

• Potential preventive measures:Potential preventive measures:– Be vigilant for depressive symptoms and Be vigilant for depressive symptoms and

alcohol/drug abuse among residentsalcohol/drug abuse among residents– Maintain an open and supportive attitude for Maintain an open and supportive attitude for

residents who may need referral for evaluation residents who may need referral for evaluation and treatmentand treatment

– Work closely with the residency program directorWork closely with the residency program director

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Part IIIPart III

DepressionDepression

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Depression Among Depression Among ResidentsResidents

• Prevalence of depressive symptoms has Prevalence of depressive symptoms has been reported to be 29% among been reported to be 29% among residents and 33-35% among interns residents and 33-35% among interns specificallyspecifically

• Be familiar with depressive signs and Be familiar with depressive signs and symptomssymptoms– Depressed mood/feeling sad or Depressed mood/feeling sad or

empty/tearfulnessempty/tearfulness– Diminished interest or pleasure in activitiesDiminished interest or pleasure in activities– Change in appetite/weight loss or gainChange in appetite/weight loss or gain

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– Insomnia or hypersomniaInsomnia or hypersomnia– Psychomotor retardation or agitationPsychomotor retardation or agitation– Fatigue or loss of energyFatigue or loss of energy– Feelings of worthlessness/excessive or Feelings of worthlessness/excessive or

inappropriate guiltinappropriate guilt– Diminished ability to think or Diminished ability to think or

concentrate/indecisivenessconcentrate/indecisiveness– Thoughts of death or suicidal ideationThoughts of death or suicidal ideation

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• Early clinical and behavioral signs Early clinical and behavioral signs may be difficult to recognize, may be difficult to recognize, especially given the context of especially given the context of residency trainingresidency training

• Depression is a highly treatable Depression is a highly treatable illnessillness

• The aim of treatment is complete The aim of treatment is complete remissionremission

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Depression & Suicide in Depression & Suicide in PhysiciansPhysicians

• Consensus recommendationConsensus recommendation– Transform professional attitudesTransform professional attitudes– Change institutional policies to encourage Change institutional policies to encourage

physicians to seek helpphysicians to seek help• As physicians remove barriers and As physicians remove barriers and

confront depression and suicidality in confront depression and suicidality in their peers, they are more likely to their peers, they are more likely to recognize and treat these conditions in recognize and treat these conditions in patientspatients

• Support any resident who seeks help.Support any resident who seeks help.

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Depression and Suicide in Depression and Suicide in PhysiciansPhysicians

• Chief of Service or his/her representative Chief of Service or his/her representative may request Physical and may request Physical and Psychiatric/Psychological examination(s)Psychiatric/Psychological examination(s)

• Seek help from Employee Assistance Seek help from Employee Assistance Program (EAP) or the JMH Health OfficeProgram (EAP) or the JMH Health Office

• Physicians on the JMH Health Plan may Physicians on the JMH Health Plan may call UMBH to arrange a private and call UMBH to arrange a private and confidential appointment with a confidential appointment with a psychiatrist or psychologist (on campus or psychiatrist or psychologist (on campus or off campus available)305-355-7270off campus available)305-355-7270

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Part IVPart IV

Alcohol and Drug Alcohol and Drug Use/Abuse/DependenceUse/Abuse/Dependence

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Alcohol & Drug AbuseAlcohol & Drug Abuse

• Complex social, behavioral, Complex social, behavioral, psychological and biological psychological and biological dimensionsdimensions

• Product of heredity and environmentProduct of heredity and environment• Stress has been documented to be Stress has been documented to be

an important contributory factoran important contributory factor• Commonly characterized by denial Commonly characterized by denial

or failure to recognize the problemor failure to recognize the problem

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Alcohol and Drug AbuseAlcohol and Drug Abuse

• National Survey of 3,000 3National Survey of 3,000 3rdrd year year residents drawn from the AMA physician residents drawn from the AMA physician master file; 60% response rate (n=1785)master file; 60% response rate (n=1785)– 5% reported daily alcohol use5% reported daily alcohol use– 7% reported marijuana use in the past month7% reported marijuana use in the past month– 3.7% reported benzo use in the past month3.7% reported benzo use in the past month– 1.4% reported cocaine use in the past month1.4% reported cocaine use in the past month

• Hughes et al JAMA 1991 2069-2073Hughes et al JAMA 1991 2069-2073

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• 80% of substance users began use in 80% of substance users began use in college, high school or earliercollege, high school or earlier

• Only benzo and opiate use were initiated Only benzo and opiate use were initiated during residency by a sizable portion of during residency by a sizable portion of users (31.4% and 23.1%, respectively)users (31.4% and 23.1%, respectively)

• Self treatment for medical purposes (to Self treatment for medical purposes (to relieve tension or to relax)was the relieve tension or to relax)was the primary use of prescription drugs, primary use of prescription drugs, amphetamines were used to improve amphetamines were used to improve performance and alertness.performance and alertness.

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• Compared to adults of similar age, Compared to adults of similar age, residents were less likely to use 8 of residents were less likely to use 8 of 11 substances surveyed.11 substances surveyed.

• Higher past month rates of alcohol Higher past month rates of alcohol and benzodiazepine useand benzodiazepine use

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• The early clinical and behavioral signs may The early clinical and behavioral signs may be difficult to recognize, especially when use be difficult to recognize, especially when use is intermittent and the resident is not yet is intermittent and the resident is not yet dependent or impaireddependent or impaired

• In addition to overt manifestations (e.g. smell In addition to overt manifestations (e.g. smell of alcohol on breath) clues may include of alcohol on breath) clues may include behavioral changes, deterioration in behavioral changes, deterioration in performance, tardiness, irresponsibilityperformance, tardiness, irresponsibility

• Anesthesiology, emergency medicine and Anesthesiology, emergency medicine and psychiatry residents may have higher rates of psychiatry residents may have higher rates of substance usesubstance use

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• Risk factorsRisk factors– Family history of addictionFamily history of addiction– Access to psychoactive drugsAccess to psychoactive drugs– domestic breakdown or relationship problemsdomestic breakdown or relationship problems– Unusual stresses at workUnusual stresses at work– Programs for physicians impaired by Programs for physicians impaired by

alcohol/drugs provide accessible early alcohol/drugs provide accessible early intervention and treatment that is not intervention and treatment that is not punitive and that advocate rehabilitation for punitive and that advocate rehabilitation for continuing medical practicecontinuing medical practice

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• ““It is a physician’s ethical responsibility It is a physician’s ethical responsibility to take cognizance of a colleague’s to take cognizance of a colleague’s inability to practice medicine inability to practice medicine adequately by reason of physical or adequately by reason of physical or mental illness, including alcoholism mental illness, including alcoholism and drug dependence.” (AMA 1972)and drug dependence.” (AMA 1972)

• The profession has a responsibility to The profession has a responsibility to preserve society’s trust by monitoring preserve society’s trust by monitoring itself and helping impaired colleagues.itself and helping impaired colleagues.

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• The PHT and CIR recognize that The PHT and CIR recognize that employee substance and alcohol employee substance and alcohol abuse can have an adverse impact abuse can have an adverse impact on the Public Health Trust’s on the Public Health Trust’s operations, the image of employees operations, the image of employees and the general health , welfare and and the general health , welfare and safety of the employees and the safety of the employees and the general public.general public.

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• Employees reasonably believed to suffer from Employees reasonably believed to suffer from substance abuse may be referred at the Trust’s substance abuse may be referred at the Trust’s chief of Service’s discretion to the Employee chief of Service’s discretion to the Employee Assistance Program and submit to toxicology Assistance Program and submit to toxicology and alcohol testing designed to detect the and alcohol testing designed to detect the presence of any controlled substance, narcotic presence of any controlled substance, narcotic drug or alcohol. The Physicians Recovery drug or alcohol. The Physicians Recovery Network (PRN), is a primary resource for Network (PRN), is a primary resource for confidential housestaff post-treatment confidential housestaff post-treatment monitoring. Initial confidential evaluations and monitoring. Initial confidential evaluations and treatment will be coordinated by the resident’s treatment will be coordinated by the resident’s health insurance plan.health insurance plan.

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Part VPart V

Sexual HarassmentSexual Harassment

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Sexual HarassmentSexual Harassment• 1.802 U.S. family practice female resident 1.802 U.S. family practice female resident

phys9cians surveyed; 51% respondedphys9cians surveyed; 51% responded• 32% reported unwanted sexual advances32% reported unwanted sexual advances• 48% reported use of sexist teaching materials48% reported use of sexist teaching materials• 66% reported favoritism based on gender66% reported favoritism based on gender• 36% reported poor evaluation based on gender36% reported poor evaluation based on gender• 37 reported malicious gossip37 reported malicious gossip• 5. 3% reported punitive measures based on 5. 3% reported punitive measures based on

gender gender

• Yudovich, Violence & Victims 1996 11: 175-180Yudovich, Violence & Victims 1996 11: 175-180

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Sexual HarassmentSexual Harassment

• 2.2% reported sexual assault during 2.2% reported sexual assault during residencyresidency

• 32% of respondents reporting sexual 32% of respondents reporting sexual harassment experienced negative effects harassment experienced negative effects includingincluding– Poor self esteemPoor self esteem– DepressionDepression– Psychological sequelae requiring therapyPsychological sequelae requiring therapy– In some cases transferring training programsIn some cases transferring training programs

• Maintain an open attitude toward the Maintain an open attitude toward the reporting of sexual harassmentreporting of sexual harassment

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Part VIPart VI

Fatigue and BurnoutFatigue and Burnout

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• Burnout is a syndrome of Burnout is a syndrome of emotional exhaustion and a sense emotional exhaustion and a sense of low personal accomplishmentof low personal accomplishment

• Little is know about burnout in Little is know about burnout in residents or its relationship to residents or its relationship to patient carepatient care

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• Cross-sectional study using an anonymous Cross-sectional study using an anonymous mailed survey to Internal Medicine mailed survey to Internal Medicine residents (n=115) at a university based residents (n=115) at a university based residency programresidency program– 87/115 (76%) met the criteria for burnout87/115 (76%) met the criteria for burnout– Compared with non-burnout residents, more Compared with non-burnout residents, more

likely to self report providing at least one type likely to self report providing at least one type of sub-optimal patient care at least monthly of sub-optimal patient care at least monthly (53% vs 21%)(53% vs 21%)

• Thomas, JAMA 2004 292:2880:2889Thomas, JAMA 2004 292:2880:2889

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Part VIIPart VII

Psychological HealthPsychological Health

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• Physical and psychological health of 178 Physical and psychological health of 178 family practice residents in South Carolina family practice residents in South Carolina

• Excellent coping skills, with clinically Excellent coping skills, with clinically significant psychological symptoms noted significant psychological symptoms noted in only onein only one

• Despite the rigors of residency training, Despite the rigors of residency training, residents are likely have average physical residents are likely have average physical health and better-than-average health and better-than-average psychological health, according to age-psychological health, according to age-adjusted population normsadjusted population norms

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• 350 Family Practice residents from 350 Family Practice residents from seven programs in South Carolinaseven programs in South Carolina– Reported less anxiety and anger across Reported less anxiety and anger across

most dimensions compared with most dimensions compared with general adult populationsgeneral adult populations

Michaels et al, Academic Med 2003: 78:69-70Michaels et al, Academic Med 2003: 78:69-70

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• Residents reported a higher frequency Residents reported a higher frequency of hassles than did normal populations of hassles than did normal populations but they did not consider these hassles but they did not consider these hassles severe.severe.

• Social and emotional “in-house” Social and emotional “in-house” support, attention to stress-management support, attention to stress-management skills and personality characteristics of skills and personality characteristics of Family Practice residents may explain Family Practice residents may explain these encouraging findingsthese encouraging findings

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Part VIIIPart VIII

Healthy Approaches to Physician Healthy Approaches to Physician StressStress

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Healthy Approaches to Healthy Approaches to Physician StressPhysician Stress

• Interpersonal relationshipsInterpersonal relationships• Health dietHealth diet• Adequate sleepAdequate sleep• Physical activity/exercisePhysical activity/exercise• Personal timePersonal time• Play/recreational activitiesPlay/recreational activities• Religious/spiritual connectionReligious/spiritual connection• VacationVacation• Effective prioritization/time managementEffective prioritization/time management

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Healthy Approaches to Healthy Approaches to Physician StressPhysician Stress

• Young physicians who sacrifice their Young physicians who sacrifice their personal lives during training believing personal lives during training believing that they will reap the rewards of a that they will reap the rewards of a balanced life after graduation often balanced life after graduation often find themselves without skills to clarify find themselves without skills to clarify and prioritize values or to develop a and prioritize values or to develop a personal philosophy that integrates personal philosophy that integrates professional, personal and spiritual professional, personal and spiritual domainsdomains

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RecommendationsRecommendations

ConclusionsConclusions

AssignmentAssignment

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• Despite the rigors of residency Despite the rigors of residency training residents may have average training residents may have average physical health and better-than-physical health and better-than-average psychological healthaverage psychological health

• Early remediation and program Early remediation and program support during training may support during training may significantly reduce the potential for significantly reduce the potential for resident impairmentresident impairment

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• Be vigilant for depressive symptomsBe vigilant for depressive symptoms• Be vigilant for alcohol/drug abuseBe vigilant for alcohol/drug abuse• Perceived sexual harassment may be Perceived sexual harassment may be

a common occurrence among a common occurrence among residents during trainingresidents during training

• Burnout is common among residents Burnout is common among residents physicians and is associated with physicians and is associated with suboptimal patient care practices.suboptimal patient care practices.

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• For problem residents, work closely For problem residents, work closely with the Residency Director and with the Residency Director and rotation attendings; the resident should rotation attendings; the resident should be involved in every step of the processbe involved in every step of the process

• For problem residents: more frequent For problem residents: more frequent feedback sessions, assigning a mentor feedback sessions, assigning a mentor for structured supervision, probation, for structured supervision, probation, professional counseling, strict professional counseling, strict behavioral guidelines and remedial behavioral guidelines and remedial didactic curriculadidactic curricula

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• Residents need vacation time. Don’t let Residents need vacation time. Don’t let your residents skip vacationsyour residents skip vacations

• Residents need time not on-call. Don’t Residents need time not on-call. Don’t let your residents insist on covering calls let your residents insist on covering calls for their patients when not on callfor their patients when not on call

• Actively promote help-seekingActively promote help-seeking• Actively promote introspection/reflection.Actively promote introspection/reflection.• Work closely with the Residency Program Work closely with the Residency Program

Director early in the course of a problemDirector early in the course of a problem

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• Encourage mentorship with Encourage mentorship with seasoned, thoughtful mentorsseasoned, thoughtful mentors

• Remind residents of the opportunity Remind residents of the opportunity for confidential access to for confidential access to psychotherapy or interventions for psychotherapy or interventions for depression or substance abusedepression or substance abuse

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AssignmentAssignment

• Locate and review your institution’s Locate and review your institution’s policy on counseling and support policy on counseling and support services.services.

• When a resident needs private counseling When a resident needs private counseling or professional assistance to address an or professional assistance to address an issue which may effect his/her ability to issue which may effect his/her ability to live or work productively, assistance is live or work productively, assistance is available through:available through:– Employee Assistance ProgramEmployee Assistance Program– Health OfficeHealth Office– Direct call to UMBH 305-243-7270Direct call to UMBH 305-243-7270

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Reporting Impaired, Reporting Impaired, Incompetent or Unethical Incompetent or Unethical

ColleaguesColleagues• Physicians responsibities to colleagues Physicians responsibities to colleagues

who are impaired by a condition that who are impaired by a condition that interferes with their ability to engage interferes with their ability to engage safely in professional activities include safely in professional activities include timely intervention to ensure that those timely intervention to ensure that those colleagues cease practicing and receive colleagues cease practicing and receive appropriate assistance from a physician appropriate assistance from a physician health program…the duty to report…health program…the duty to report…stems from physicians’ obligation to stems from physicians’ obligation to protect patients from harm…protect patients from harm…

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• Florida statute requires that you report Florida statute requires that you report ANY health care professional that you think ANY health care professional that you think is IMPAIREDis IMPAIRED

• Internal: MEC, Department Chair, Internal: MEC, Department Chair, Managing PartnerManaging Partner

• Professionals Resource Network (800-888-Professionals Resource Network (800-888-8776) ANONYMOUS8776) ANONYMOUS

• Florida Board of Medicine (850-245-4131)Florida Board of Medicine (850-245-4131)• Department of Health, Consumer Services Department of Health, Consumer Services

(888-419-3456)(888-419-3456)

Documents

1 The Impaired Resident Presented by Richard M. Steinbook, M.D. Professor of Psychiatry & Behavioral Sciences And Director of Psychiatric Residency Training