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The Impaired Resident


Depression is a highly treatable illness. The aim of treatment is complete remission ... Depression and Suicide in Physicians ... – PowerPoint PPT presentation

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Title: The Impaired Resident

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

  • Definitions and the context
  • Suicide
  • Depression
  • Alcohol and Drug Use/Abuse/Dependence
  • Sexual Harassment
  • The Problem Resident
  • Fatigue and Burnout
  • Psychological Health
  • Health Approaches to Physician Stress
  • Conclusion/Recommendations/Assignment

The Impaired Resident
  • Part I
  • Definitions
  • and
  • The Context

Who is the Impaired Resident
  • AMA Council on Mental Health (1973) physician
    impairment is the inability to practice medicine
    adequately by reason of physical or mental
    illness, including alcoholism or drug dependence
  • Although most residents experience high levels of
    stress during training, about 10 will become
    seriously impaired
  • Potentially remediable physician problems may
    lead to less than optimal patient care

The Context Residency Training
  • Sleep deprivation and fatigue
  • Limited time for family/friends and
    social/recreational activities
  • Common obsessive-compulsive style of the house
  • Emphasis on professional development at the
    expense of personal growth
  • Financial pressures/medical school debts
  • Assumption of the responsibilities of marriage
    and parenting

The Context Residency Training
  • Geographical relocation with loss of friendships
    and the support of close family
  • Transition from the student role to that of
    physician (responsibility for patient care)
  • Difficulty asking for help
  • Access to addictive substances

(No Transcript)
The Impaired Resident
  • Part II Suicide

Suicide Among Physicians
  • Suicide rates among physicians may be twice that
    of the general population
  • Scarce data on suicide among residents
  • Suicide rate among male physicians in the US is
    similar to that for all white males 25 years
  • Female physicians commit suicide at 3-5 times the
    rate of the white female population25 years
  • Kirsling Kocher, Psychological Reports 1989

Suicide Among Physicians
  • Very similar suicide rates for male and female
    physicians (approx 40/100,000)
  • Suicide rates may increase with age for male
    physicians but decrease with age for female
  • 20 of physician suicides are associated with
    drug abuse
  • 40 are associated with alcohol abuse

Suicide Among Physicians
  • Aggregate suicide rate ratio for male physicians
    compared to the general population 1.41 (1.21,
  • For female physicians, the ratio was 2.27 (1.90,
  • Schernhammer Colditz Am J Psychiatry 2004 151

Suicide Among Physicians
  • AMA/APA profile of the suicide-prone physician
  • Prior suicide attempt
  • Suicidal verbalization
  • Self-prescribed psychoactive drugs
  • Financial losses
  • History of treatment for emotional or
    psychiatric problems
  • Depression
  • Social problems related to alcohol abuse
  • Difficult childhood

Suicide Among Physicians
  • The most frequent precursor to suicide is
    depression (75 of all physician suicides may be
    attributable to depression and/or alcoholism)
  • Potential preventive measures
  • Be vigilant for depressive symptoms and
    alcohol/drug abuse among residents
  • Maintain an open and supportive attitude for
    residents who may need referral for evaluation
    and treatment
  • Work closely with the residency program director

The Impaired Resident
  • Part III
  • Depression

Depression Among Residents
  • Prevalence of depressive symptoms has been
    reported to be 29 among residents and 33-35
    among interns specifically
  • Be familiar with depressive signs and symptoms
  • Depressed mood/feeling sad or empty/tearfulness
  • Diminished interest or pleasure in activities
  • Change in appetite/weight loss or gain

Depression Among Residents
  • Insomnia or hypersomnia
  • Psychomotor retardation or agitation
  • Fatigue or loss of energy
  • Feelings of worthlessness/excessive or
    inappropriate guilt
  • Diminished ability to think or concentrate/indecis
  • Thoughts of death or suicidal ideation

Depression Among Residents
  • Early clinical and behavioral signs may be
    difficult to recognize, especially given the
    context of residency training
  • Depression is a highly treatable illness
  • The aim of treatment is complete remission

Depression Suicide in Physicians
  • Consensus recommendation
  • Transform professional attitudes
  • Change institutional policies to encourage
    physicians to seek help
  • As physicians remove barriers and confront
    depression and suicidality in their peers, they
    are more likely to recognize and treat these
    conditions in patients
  • Support any resident who seeks help.

Depression and Suicide in Physicians
  • Chief of Service or his/her representative may
    request Physical and Psychiatric/Psychological
  • Seek help from Employee Assistance Program (EAP)
    or the JMH Health Office
  • Physicians on the JMH Health Plan may call UMBH
    to arrange a private and confidential appointment
    with a psychiatrist or psychologist (on campus or
    off campus available)305-355-7270

The Impaired Resident
  • Part IV
  • Alcohol and Drug Use/Abuse/Dependence

Alcohol Drug Abuse
  • Complex social, behavioral, psychological and
    biological dimensions
  • Product of heredity and environment
  • Stress has been documented to be an important
    contributory factor
  • Commonly characterized by denial or failure to
    recognize the problem

Alcohol and Drug Abuse
  • National Survey of 3,000 3rd year residents drawn
    from the AMA physician master file 60 response
    rate (n1785)
  • 5 reported daily alcohol use
  • 7 reported marijuana use in the past month
  • 3.7 reported benzo use in the past month
  • 1.4 reported cocaine use in the past month
  • Hughes et al JAMA 1991 2069-2073

Alcohol and Drug Abuse
  • 80 of substance users began use in college, high
    school or earlier
  • Only benzo and opiate use were initiated during
    residency by a sizable portion of users (31.4
    and 23.1, respectively)
  • Self treatment for medical purposes (to relieve
    tension or to relax)was the primary use of
    prescription drugs, amphetamines were used to
    improve performance and alertness.

Alcohol and Drug Abuse
  • Compared to adults of similar age, residents were
    less likely to use 8 of 11 substances surveyed.
  • Higher past month rates of alcohol and
    benzodiazepine use

Alcohol and Drug Abuse
  • The early clinical and behavioral signs may be
    difficult to recognize, especially when use is
    intermittent and the resident is not yet
    dependent or impaired
  • In addition to overt manifestations (e.g. smell
    of alcohol on breath) clues may include
    behavioral changes, deterioration in
    performance, tardiness, irresponsibility
  • Anesthesiology, emergency medicine and psychiatry
    residents may have higher rates of substance use

Alcohol and Drug Abuse
  • Risk factors
  • Family history of addiction
  • Access to psychoactive drugs
  • domestic breakdown or relationship problems
  • Unusual stresses at work
  • Programs for physicians impaired by alcohol/drugs
    provide accessible early intervention and
    treatment that is not punitive and that advocate
    rehabilitation for continuing medical practice

Alcohol and Drug Abuse
  • It is a physicians ethical responsibility to
    take cognizance of a colleagues inability to
    practice medicine adequately by reason of
    physical or mental illness, including alcoholism
    and drug dependence. (AMA 1972)
  • The profession has a responsibility to preserve
    societys trust by monitoring itself and helping
    impaired colleagues.

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

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

The Impaired Resident
  • Part V
  • Sexual Harassment

Sexual Harassment
  • 1.802 U.S. family practice female resident
    phys9cians surveyed 51 responded
  • 32 reported unwanted sexual advances
  • 48 reported use of sexist teaching materials
  • 66 reported favoritism based on gender
  • 36 reported poor evaluation based on gender
  • 37 reported malicious gossip
  • 5. 3 reported punitive measures based on gender
  • Yudovich, Violence Victims 1996 11 175-180

Sexual Harassment
  • 2.2 reported sexual assault during residency
  • 32 of respondents reporting sexual harassment
    experienced negative effects including
  • Poor self esteem
  • Depression
  • Psychological sequelae requiring therapy
  • In some cases transferring training programs
  • Maintain an open attitude toward the reporting of
    sexual harassment

The Impaired Resident
  • Part VI
  • Fatigue and Burnout

Fatigue and Burnout
  • Burnout is a syndrome of emotional exhaustion and
    a sense of low personal accomplishment
  • Little is know about burnout in residents or its
    relationship to patient care

Fatigue and Burnout
  • Cross-sectional study using an anonymous mailed
    survey to Internal Medicine residents (n115) at
    a university based residency program
  • 87/115 (76) met the criteria for burnout
  • Compared with non-burnout residents, more likely
    to self report providing at least one type of
    sub-optimal patient care at least monthly (53 vs
  • Thomas, JAMA 2004 29228802889

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The Impaired Resident
  • Part VII
  • Psychological Health

Psychological Health
  • Physical and psychological health of 178 family
    practice residents in South Carolina
  • Excellent coping skills, with clinically
    significant psychological symptoms noted in only
  • Despite the rigors of residency training,
    residents are likely have average physical health
    and better-than-average psychological health,
    according to age-adjusted population norms

Psychological Health
  • 350 Family Practice residents from seven programs
    in South Carolina
  • Reported less anxiety and anger across most
    dimensions compared with general adult
  • Michaels et al, Academic Med 2003 7869-70

Psychological Health
  • Residents reported a higher frequency of hassles
    than did normal populations but they did not
    consider these hassles severe.
  • Social and emotional in-house support,
    attention to stress-management skills and
    personality characteristics of Family Practice
    residents may explain these encouraging findings

The Impaired Resident
  • Part VIII
  • Healthy Approaches to Physician Stress

Healthy Approaches to Physician Stress
  • Interpersonal relationships
  • Health diet
  • Adequate sleep
  • Physical activity/exercise
  • Personal time
  • Play/recreational activities
  • Religious/spiritual connection
  • Vacation
  • Effective prioritization/time management

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

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The Impaired Resident
  • Recommendations
  • Conclusions
  • Assignment

  • Despite the rigors of residency training
    residents may have average physical health and
    better-than-average psychological health
  • Early remediation and program support during
    training may significantly reduce the potential
    for resident impairment

  • Be vigilant for depressive symptoms
  • Be vigilant for alcohol/drug abuse
  • Perceived sexual harassment may be a common
    occurrence among residents during training
  • Burnout is common among residents physicians and
    is associated with suboptimal patient care

  • For problem residents, work closely with the
    Residency Director and rotation attendings the
    resident should be involved in every step of the
  • For problem residents more frequent feedback
    sessions, assigning a mentor for structured
    supervision, probation, professional counseling,
    strict behavioral guidelines and remedial
    didactic curricula

  • Residents need vacation time. Dont let your
    residents skip vacations
  • Residents need time not on-call. Dont let your
    residents insist on covering calls for their
    patients when not on call
  • Actively promote help-seeking
  • Actively promote introspection/reflection.
  • Work closely with the Residency Program Director
    early in the course of a problem

  • Encourage mentorship with seasoned, thoughtful
  • Remind residents of the opportunity for
    confidential access to psychotherapy or
    interventions for depression or substance abuse

  • Locate and review your institutions policy on
    counseling and support services.
  • When a resident needs private counseling or
    professional assistance to address an issue which
    may effect his/her ability to live or work
    productively, assistance is available through
  • Employee Assistance Program
  • Health Office
  • Direct call to UMBH 305-243-7270

Reporting Impaired, Incompetent or Unethical
  • Physicians responsibities to colleagues who are
    impaired by a condition that interferes with
    their ability to engage safely in professional
    activities include timely intervention to ensure
    that those colleagues cease practicing and
    receive appropriate assistance from a physician
    health programthe duty to reportstems from
    physicians obligation to protect patients from

  • Florida statute requires that you report ANY
    health care professional that you think is
  • Internal MEC, Department Chair, Managing
  • Professionals Resource Network (800-888-8776)
  • Florida Board of Medicine (850-245-4131)
  • Department of Health, Consumer Services