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Profile of an Impaired Physician

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Title: Profile of an Impaired Physician


1
Profile of an Impaired Physician
  • Melissa Lee Warner MD
  • Wm J Farley Center at Williamsburg Place
  • 800-582-6066

2
AAFP This Week (vol. 4, 36, 9/9/03)
  • Patients with drug or alcohol dependence or
    abuse problems will be hard to detect unless the
    physicians ask them about their use
  • 94 of the 22 Million people with these problems
    fail to recognize them themselves
  • Of the 362,000 people who sought treatment 354,00
    could not get help

3
Prevalence Rates
  • 10-15 General Population
  • Highest Rates in Hospital Trauma/Ortho Population
    (80)
  • AMA Discharge
  • Drug abuse, particularly alcohol and narcotic
    abuse, is the one common risk factor pervading
    all hospital settings
  • In 2002, the top 2 diagnoses related to AMA
    discharge were drug abuse disorders and alcohol
    abuse disorders
  • clinicians should maintain a high level of
    suspicion for potential drug and/or alcohol
    dependence when patients, particularly elderly
    patients, wish to leave AMA.
  • physician must address the patients concerns
    and, when necessary, convey a clear desire and
    ability to treat withdrawal symptoms.
  • Dostal, et al., 2006 Dept Emergency Med,
    Northwestern Univ.

4
Incidence of Addictive Disorders in Healthcare
ProfessionalsZiegler MD
  • Alcoholism- 11-12 lifetime prevalence (same as
    general population)
  • Other drug dependencies- 4-6 lifetime prevalence
  • Illicit drug addiction among healthcare
    professionals lower than general population
  • Prescription drug addiction higher

5
Profile
  • Can you tell by looking at them?

6
Find The Physician (Addict)
Rush Limbaugh Radio Host Prescription Narcotics
Congressman Patrick Kennedy Prescription
Narcotics
Brett Farve 3 time MVP Prescription Narcotics
Jim Flemming Comedian
7
  • How Do Physicians (with addiction) Present?
  • Univ of Chicago study in 1991 of 740 occupations
  • Highest social status
  • Most respected profession
  • Malpractice, Managed Care, Decrease in public
    opinion
  • M-Deity syndrome MDs looked on as Gods begin
    to assume that role
  • Problems with family life, medical marriage
  • Physicians are comforted by peers, patients
    effusive praise
  • Problems such as chemical dependency are ignored
    or enabled
  • Denial and shame increase, making it more
    difficult to disclose a problem
  • Conspiracy of silence
  • Chemical dependency is the same disease among
    physicians and non-physicians, but because of
    specific barriers, specific modifications to
    intervention, treatment and aftercare are needed
    in this population.

8
Risk Factors for Development of Addictive
Disorders
  • Genetics
  • Intoxicant Use
  • Stressors
  • Greatest Variable

9
At-Risk Diagnostic Categories(Treated with
intoxicating Medications)
  • Non-Malignant Chronic or Recurrent Pain
  • Musculoskeletal, HA, GI
  • Anxiety Syndromes
  • Sleep Disturbances
  • Weight Management
  • Attention/Concentration Problems
  • No Adult Onset ADHD

10
Intoxicating Medications
  • Opiates
  • Ultram
  • Benzodiazepines
  • Ambien, Sonata, Lunesta,Klonopin
  • Stimulants
  • Concerta, Adderall
  • Barbiturates
  • Fiorinal/cet, Esgic
  • Soma

11
Significant Historical Correlates
  • Family History of Addiction
  • Personal Use of Intoxicants
  • Nicotine Use
  • Early High Tolerance/ Tolerance of any kind
  • Co-Morbidity
  • Bi-Polar Disorder
  • Abuse History
  • Serious Mental Illness

12
5 FactorsPain Management
  • Family Hx of Addictive Disorder
  • Personal Hx of Addictive Disorder or Abuse
  • Psychiatric Disorder
  • Sexual Abuse History
  • Nicotine Dependence
  • 1st Cigarette w/in 1 Hour of Awakening

13
The Addicted Physician Manejwala MD
  • Typically, the hospital/ practice is the last
    place addiction manifests symptoms
  • Physicians hold the workplace sacred
  • Disruptions in family, personal health,
    community, social, spiritual and leisure life can
    all occur while the workplace remains relatively
    unaffected
  • Even very small intrusions of addiction into the
    workplace should be taken extremely seriously in
    physicians

14
Workplace Symptoms
  • Initially
  • Chaotic or labile personal and professional
    lifestyle
  • Poorly explained accidents and injuries
  • Family and marital discord
  • Long sleeves and tinted glasses
  • Deterioration in appearance/ hygiene
  • Significant weight change
  • Irritability or hostility when confronted
  • Increased use of cologne, perfume, breath
    fresheners
  • Resumption of tobacco use
  • Spending sprees, gambling, risky investments
  • Increasing medical problems and symptoms
    requiring medication

15
Subtlety
  • Any change from known practice/ personal style
  • Will be attributed to anything else (but
    addiction)
  • It could well be both (e.g.. Divorce and
    addiction)
  • Even very small intrusions of addiction into the
    workplace should be taken extremely seriously in
    physicians
  • Tip of the Iceberg

16
Workplace Symptoms (later)
  • Deterioration in handwriting and quality of
    record-keeping
  • Diction delinquencies
  • Nonresponsive on call
  • Failure to adhere to schedule
  • Late mornings, midnight rounds
  • Failure to follow patients appropriately and
    consistently
  • Failure to make appropriate referrals or to
    request consultation when appropriate
  • Altercations with patients, peers or hospital
    staff
  • Poorly explained complications and misdiagnosis
  • Change in prescribing habits Inappropriate and
    inconsistent telephone interactions
  • Change in type of controlled substances kept in
    the office, ordered from vendors, or requested
    from pharmaceutical reps

17
Common Presentation
  • Others saw symptoms but raised no concern
  • Mythology couldnt be addiction
  • am EtOH (first order kinetics)
  • withdrawal/intoxication
  • Stigma misdirected attempt to protect
  • Normalization of approach to screening/detection
  • Treatable illness that effects all

18
Even very small intrusions of addiction into the
workplace should be taken extremely seriously in
physicians Tip of the Iceberg
19
Common Handicap
  • No drug testing done at the time of concern
  • UDS
  • NIDA 5 vs. 12
  • Hair testing
  • EtG- ethyl glucaronide

20
Summary
  • 1/10 Physicians
  • Wont self-diagnose
  • Detectable/ Treatable
  • De-Stigmatize
  • Provide Protocols
  • Include testing
  • Even very small intrusions of addiction into the
    workplace should be taken extremely seriously in
    physicians

21
JCAHAO Directive
  • Physician Wellness Committees/ Protocols
  • Role of the Medical Board

22
Williamsburg Place The Wm. J Farley Center
  • Melissa Lee Warner M. D.
  • Family Practice/ Addiction Medicine
  • Omar Manejwala M. D.
  • Psychiatry/Addiction Medicine
  • 800.582.6066
  • www.farleycenter.com
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