Physicians may be impaired due to substance use disorders, a medical or mental health condition, profound fatigue, or a decline in cognitive or motor skills due to age or disease. Whatever the reason, they usually struggle in silence and delay seeking help, says Lois Snyder Sulmasy, JD, director of the American College of Physicians (ACP)’s Center for Ethics and Professionalism.
“This can be for a variety of reasons, including vulnerability, concerns about privacy and confidentiality, the stigma of addiction, or fear of professional liability,” Snyder says. New ethical guidance from ACP examines the professional duties and principles that should guide the response of colleagues and the profession to physician impairment.1 “This affirms the ethical duties of competence and self-regulation as core principles of professionalism and of the privilege of medical practice,” Snyder explains.
The guidance states that questions about impairment should:
- address a physician’s current status rather than his or her history;
- not distinguish between mental and physical health;
- elicit objective information about functional status.
“Physicians have an individual and collective responsibility to ensure patient safety and to assist an impaired colleague,” Snyder says. An important distinction that ACP’s position paper makes is between functional impairment and potentially impairing illness. The guidance states: “Impairment is a functional classification concerning the physician’s inability to carry out patient care responsibilities safely and effectively. The presence of an illness does not necessarily signify impairment.”
“The central ethical concern should be to appropriately assist an impaired physician, regardless of whether the illness is based in mental or physical health, while maintaining the safety of patients,” Snyder says.
Ethicists working with physicians and others can be helpful by familiarizing themselves with (and helping educate clinicians about) local resources for seeking assistance, Snyder adds. “Physician health programs are an important means of assisting impaired physicians. More evidence-based best practices should be developed and supported.”
A recent example is the Performance Enhancement Review guidelines of the Federation of State Physician Health Programs. Started this year, the program will work with physician health programs to develop best practices and to identify areas for improvement. “ACP has joined with other medical societies to participate in this new program,” Snyder reports.
A primary ethical concern is stigma against physicians who access mental health services. “This stigmatization, present from the time a student enters medical school throughout their career, discourages accessing treatment,” says Tyler S. Gibb, JD, PhD, a clinical ethicist and co-chief in the program in medical ethics, humanities, and law at Western Michigan University Homer Stryker M.D. School of Medicine.
Unless the culture of medicine becomes more tolerant of colleagues needing and accessing mental health services, many will choose not to seek help, Gibb says. Providers are at risk for burnout, substance abuse, and even suicide. Patients are cared for by providers with compassion fatigue who may be more likely to make medical errors. “This is extremely concerning for the entire enterprise of healthcare,” Gibb laments. “This trend should be viewed as a public health crisis.”
- Candilis PJ, Kim DT, Sulmasy LS, ACP Ethics, Professionalism, and Human Rights Committee. Physician impairment and rehabilitation: Reintegration into medical practice while ensuring patient safety: A position paper from the American College of Physicians. Ann Intern Med 2019; Jun 4. doi: 10.7326/M18-3605. [Epub ahead of print].