underperforming doctors

Easy access to prescription drugs and stress leads large numbers of US doctors to misuse alcohol and drugs. But rehabilitation programmes are widespread.

In the mid-1980s, the commissioner of health for New York State gave a talk in which he said that at least 15 per cent of the doctors in practice in the state were either substance or alcohol abusers. While the comment raised some eyebrows, no one challenged it, leading many to think that it might have been a conservative estimate. Since then, doctor impairment has become a bigger issue and every US state now has a programme to try to help doctors who have been identified as a threat to their patients or themselves.

Impairment generally refers to situations in which doctors are unable to perform their professional responsibilities adequately because of disease, psychiatric problems or substance abuse. A California study in the early 1980s found that mental illness accounted for only 6 per cent of reported doctor impairment, the remainder being due to a combination of alcohol and drug abuse.

It is thought that substance abuse starts before medical school and is consistent with drug use patterns in the wider community. Tranquilliser and opiate abuse seems to rise during house jobs and the start of practice because of increased exposure to drugs and prescribing privileges. Alcohol abuse is estimated at between 7-10 per cent of doctors, equal to its prevalence in the overall US population.

The problem of substance or alcohol abuse is not unique to doctors: other health workers are as likely to be abusers. Studies have noted that nurses in high-technology settings such as critical care units and emergency rooms are particularly at risk.

Many seem to think that the problem of drug abuse by doctors is exacerbated in medical school by the high pressure, dismal social life and lack of external support. In a study at a mid-western medical school, 11 per cent of medical students met the criteria for excessive drinking over six months and 18 per cent for alcohol abuse over a two-year period.

But substance abuse appears to have had little impact on academic performance since students who drink heavily get higher grades than those who do not. Nor did alcohol abuse have a negative impact on evaluations of clinical jobs in the latter part of medical schooling. These experiences may lead doctors to disregard warnings about abuse.1

Doctors resident in hospital are generally considered to be under greater stress than all other categories of doctors, given their long hours of work and increased responsibility. The use of chemicals or alcohol to help get through this period is therefore not unusual. Yet most house staff are unaware of the policies of their hospital on substance abuse even though 20 per cent know of a fellow resident who is an abuser. The problem has led the Association of Program Directors in Internal Medicine to adopt a strategy for recognising and handling house officers who are substance abusers, including better information sessions and assistance programmes.

There is a general agreement that substance abuse is difficult to identify in practising doctors. Indicators already mentioned include marital problems, behavioural changes, legal problems, physical signs of impairment and a worsening of job performance. Among the risk factors for doctor impairment are the greater availability of drugs, ignorance about milder forms of addiction, feelings of invulnerability, and overwork and stress.

The group of doctors thought to be most at risk of substance abuse are anaesthetists. A study in California found that 14 per cent of those referred to an impaired doctors programme were anaesthetists, while a study in Georgia found that 12 per cent were. Given that anaesthetists represent only 4 per cent of all doctors, their increased risk is evident. A particular problem of doctors is self-medication, because of their access to controlled substances. They have much easier access to opiates and other drugs than the rest of the population, through pharmaceutical company samples,office supplies, or raiding hospital pharmacies.2

It is difficult to identify doctors who are substance abusers. Doctors are good at hiding the more classic signs of alcohol and drug abuse, and colleagues who might suspect a problem are reluctant to talk directly to the doctor or report it to someone else. Typically, the problem is identified only after some harm has been done to a patient or to the doctor. More recent analyses consider the role of 'enablers', who, from misguided motives, protect the doctor with a problem rather than reporting them to someone who could help.

Because of doctors' status, the people who ultimately confront a doctor need to be important enough to require them to listen. This could be the hospital chief executive, the director of a programme or the director of a medical society. The message must be in the form of an ultimatum - get treatment or lose your privileges or licence. Yet knowing that the accusation itself could have an impact on the livelihood of the doctor, a guarantee of confidentiality must be upheld.

In the US there are two competing approaches for dealing with doctor impairment - voluntary and mandatory. In some states, both approaches co-exist and doctors can choose. The main issue has to do with the legal liability of a hospital or group of doctors for permitting a doctor with an impairment to continue to practise, as well as from malpractice insurance companies seeking to limit their potential losses. The mandatory programmes are generally run by state medical licensing boards, which have the power to suspend or revoke licences to practise if a doctor does not undergo treatment or if the treatment is not successful. The boards are notified more often by insurance companies, managed care companies and patients about doctor problems than by other doctors.

The voluntary programmes tend to be run by medical societies and are seen as more protective of the rights of the doctor and better able to keep matters quiet. When doctors report problems with drug-abusing colleagues they generally contact the medical society-run programme. Where the two programmes co-exist there is sometimes unhelpful competition between the two. A complicating element is the existence of the National Practitioner Data Bank, which was established so that consumers could learn more about the histories of their doctors, particularly with regard to loss of licence, sanctions and malpractice. Before the NPDB was formed, a doctor with an abuse problem could leave the jurisdiction of one state and seek refuge and licence in another.

If a doctor is reported to the NPDB as a substance abuser, it will be more difficult for them to get a licence in another state without the abuse becoming known. This may make it more difficult for mandatory programmes to get referrals.3

While every state has a programme, they are not of equal quality and do not reveal an equal commitment to the problem of rehabilitation. For example, a recent survey indicates that only 19 of the 50 state medical society programmes has a medical director (full or part-time). The programme budgets range from over $500,000 a year to just the costs of printing a brochure. Some receive state financing either through increases in medical licensing fees or direct appropriations. There is little publicity for these programmes since almost everyone wants to keep the issue quiet.4

The most effective strategies for dealing with impairment are comprehensive and long-term. Because of fears of a relapse, most programmes favour an unusually aggressive first-time intervention. Two to four weeks of intensive psychotherapy in hospital seems to be effective in half of cases, while the other half require additional residential treatment to avoid a relapse.

Most programmes require the doctor to become active in a self-help group such as Alcoholics Anonymous, Narcotics Anonymous, International Doctors in Alcoholics Anonymous, special hospital-sponsored groups, or Cadeuceus clubs (with 12-step programmes modelled on AA but designed for doctors). In addition, some programmes favour the use of pharmacological treatments such as Antabuse or Naltrexone. Almost all programmes require random urine testing.

After the initial treatment, most programmes allow the doctor to re-enter medical practice so long as an agreement is signed stipulating the conditions of return. These may include continued attendance at support group meetings, continued psychiatric help, and further urine tests. The contract and its monitoring make the treatment most effective in preventing doctors from returning to abuse, as doctors fear losing their job and livelihood. The overall time in a programme ranges from two to seven years.

Some studies have found recovery rates for doctors in the 75-80 per cent range - substantially above the success rates of drug treatment in the overall population. But the literature on doctor impairment programmes is thin, with few high-quality studies. Perhaps the most important thing is the growing awareness over the past decade of the scale of the problem and the increasing attention it is receiving from medical groups and the public. Clearly much more needs to be done.