New American College of Physicians guidance on impaired physicians features five prescriptions for struggling clinicians, their colleagues, and their employers.
When physicians are impaired, the clinicians, their colleagues, and their healthcare organizations are obligated to address the problem, according to new American College of Physicians (ACP) guidelines.
An impaired physician is incapable of providing patient care safely and effectively. There are several causes of impairment, including substance abuse, mental illness, profound fatigue, or deterioration of cognitive or motor skills linked to aging or illness.
The ACP Ethics, Professionalism, and Human Rights Committee has adopted five positions on physician impairment. The ACP Board of Regents approved the guidelines, which were published today in Annals of Internal Medicine, in November.
Position 1: "The professional duties of competence and self-regulation require physicians to recognize and address physician illness and impairment."
Self-regulation is essential in professions. In medicine, the profession is expected to uphold standards of competence that ensure safe, ethical, and effective patient care. At the personal level, impaired clinicians should try to see they are unable to offer safe and effective care, then seek treatment.
Peers have an obligation to assist or report impaired clinicians. If there is no threat of patient harm, a collegial conversation can raise concerns and provide an opportunity to urge physicians to seek help. If the threat of patient harm is high, colleagues should report concerns to licensing boards or clinical supervisors. When the threat of patient harm is unclear, concerns should be raised to designated organizational officials or other senior leaders such as a department chair.
Position 2: "The distinction between functional impairment and potentially impairing illness should guide identiﬁcation of and assistance for the impaired physician."
An impaired physician is incapable of functioning safely and effectively. But the presence of illness does not always result in impairment.
Impairment may be linked to substance abuse, mental or medical conditions, effects of aging, or fatigue. The presence of these risk factors or treatment of them is not conclusive proof of impairment. Help should target the underlying illness or condition.
Best practices for helping a clinician with an impairing condition should be guided by the status of the condition and potential for patient harm. Whenever possible, rehabilitation should be the primary goal for physicians who face impairing conditions. Evaluation and treatment should be consistent with standards of care.
Position 3: "Best practices for physician health programs (PHPs) should be developed systematically, informed by available evidence and further research."
Most PHPs are affiliated with state medical boards or medical societies. The organizations do not treat physicians directly, working instead to monitor and oversee treatment, contract with impaired physicians on treatment plans, and maintain compliance records.
There are PHPs in 46 states and the District of Columbia. Research is needed to determine which PHPs are most effective and their keys to success.
Position 4: "PHPs should meet the goals of physician rehabilitation and reintegration in the context of established standards of ethics and with safeguards for both patient safety and physician rights."
In the rehabilitation of impaired physicians, PHPs face several ethical considerations. For example, constituencies including hospitals, insurers, and medical societies can support PHPs, but they should not sway operations or case management. PHPs should also avoid competing interests such as entanglements with treatment programs or monitoring labs.
Patient safety is always a paramount concern, but PHPs should try to guarantee procedural fairness for impaired physicians. For example, monitoring is subject to administrative and legal oversight ranging from internal processes to civil procedures.
Position 5: "Maintenance of physician wellness with the goal of well-being must be a professional priority of the healthcare community promoted among colleagues and learners."
Healthcare organizations should establish an environment and culture that supports wellness and wellbeing, including assistance for clinicians with impairing conditions.
More broadly, fostering physician well-being involves outreach, education, and leadership throughout the field of medicine such as state medical boards, professional societies, and PHPs.
As part of the profession's commitment to society, physician well-being should be a quality marker at healthcare organizations. The more well-being is elevated, the greater the expectations of benefit in terms of physician recruitment and retention.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
There are multiple causes of physician impairment, including substance abuse and mental illness.
Professional duty obligates impaired physicians and their colleagues to address the problem.
Whenever possible, rehabilitation should be the primary goal for physicians who face impairing conditions.