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A new Joint Commission on Accreditation of Healthcare Organizations accreditation standard for 2001 now requires hospitals to implement a process to identify and treat impaired physicians — a process that is to be separate from the medical staff’s disciplinary functions. The new requirement means that ethics committees will likely play an integral part in identifying those physicians.
"The purpose of the process is assistance and rehabilitation, rather than discipline, to aid a physician in retaining or regaining optimal professional functioning, consistent with protection of patients," reads the revised language of standard MS 2.6 in the Comprehensive Accreditation Manual for Hospitals.
"If at any time during the diagnosis, treatment, or rehabilitation phase of the process it is determined that a physician is unable to safely perform the privileges he or she had been granted, the matter is forwarded to medical staff leadership for appropriate corrective action that includes strict adherence to any state or federally mandated reporting requirements."
The new standard recognizes that impaired physicians — defined as those with mental or emotional problems, alcohol and chemical dependencies, or chronic illnesses that affect their ability to function — are suffering from an illness that requires treatment. They are not clinicians who have willfully engaged in conduct that merits punishment, say experts in provider health issues.
Many state medical boards and professional societies already have separate programs for impaired medical providers that allow providers to receive confidential treatment and counseling and preserve their medical licenses and ability to practice. But hospitals have often lagged behind in recognizing the need to identify these providers and get help.
"Among impaired providers’ peer groups and co-workers, the first reaction to a problem is frequently one of denial," says Judith Anderson, PhD, RN, CNS, a professor and chair of the department of acute and long-term nursing at the Medical College of Ohio in Toledo, who has worked on developing treatment and counseling initiatives for impaired nurses. "They tend to treat it as if it were a problem within the family. They might start making excuses for the person, covering up when they are late for work, or forget to do a task. In other cases, other physicians and nurses simply don’t want to interfere in another person’s personal business. They avoid acknowledging the problem until something forces them to do so."
Impaired providers often are caught in a cycle in which when confronted on the job, they immediately quit to avoid mandatory treatment or disciplinary actions, then seek work elsewhere.
"With addiction problems, over time, the person’s ability to function deteriorates," says Anderson. "They start seeking jobs with less strict supervision, maybe working the night shift or taking a job as the sole RN at a nursing home. We see nurses who have held jobs six months in one place, seven months in another — a series of short-term positions. And because of the nursing shortage, they can almost always get hired somewhere."
Instead of getting treatment that would return them to functioning as productive and able providers, these professionals keep getting passed through the system until their impairment prevents them from being able to perform their duties or an incident involving theft or of patient safety intervenes, she says.
It’s the acknowledgement of this pattern that has led many medical boards to develop alternative programs for dealing with impaired providers. Many states now allow providers who self-report impairment issues or who have been reported by colleagues to undergo a confidential, individualized treatment and counseling program. After successfully completing the program, the provider can retain his or her medical license without a period of suspension or other disciplinary action.
Minnesota was one of the first states to adopt such a program after the state legislature mandated it in 1994, says Kent G. Harbison, JD, an attorney specializing in health law litigation at the law firm Fredriksen & Byron in Minneapolis.
"Prior to that, all of the state licensing boards, when they were faced with a report of a physician or provider impairment, didn’t have any choice but to run it through their standard disciplinary process," he says. "If the allegations were true, the professional faced punishment: suspension, fines, and even revocation of their medical licenses."
Members of the state Board of Medical Practice, which oversees physicians, pushed for the change as they realized the need to treat ill physicians differently than those who "intentionally made an effort to violate some law or standard of practice," Harbison says.
Other professional licensing boards cooperated with the board of medical practice to develop the Health Professionals’ Services Program (HPSP). A provider can either self-report to HPSP, be reported by a colleague or other person, or be referred to the program after a report to their state licensing board.
Once reported, the program works to establish a care plan with that individual, calling for the person to undergo a specified amount of counseling and treatment, submit to regular, random drug and/or alcohol screening, turn over his or her medical records to the program for supervision, and be supervised in the care plan for one to two years, says Harbison.
"In addition to designating a treating physician, the person must also designate a monitoring person — a supervisor or colleague who agrees to provide regular reports to HPSP about the person’s progress," he adds. "In the workplace, that can be potentially awkward. The monitoring person has an obligation not to disclose the person’s treatment information. But, as a practical matter, if it were an MD in a hospital or medical clinic, there would probably be a group of supervisory people who know about the program."
Provided the person completes all of the requirements satisfactorily, they retain all of the practicing privileges and the matter remains confidential.
An added benefit of Minnesota’s plan, Harbison adds, is that medical colleagues, who are often under a mandated duty to report provider impairment, can report impaired professionals directly to HPSP and not the medical board.
Although the medical board might also refer this person for treatment, this way physicians and nurses can be sure their colleague’s confidentiality and medical license is protected, he says.
One of the key fears keeping impaired providers from self-reporting and seeking treatment — and colleagues from reporting problems — is the fear that doing so will cost that person their livelihood, adds Anderson. It is unfortunate that more programs are not like Minnesota’s, she says.
In Ohio, for example, providers are required to report directly to the state licensing boards, even though the state does have a similar provider assistance program.
"Our program used to be similar, but a change in state law requires that all reports be made directly to the board," says Anderson. Some other licensing boards also have different requirements about allowing an impaired provider to continue to practice after acknowledging an impairment, even if they receive treatment, she adds.
Some organizations, notably Public Citizen, have criticized provider assistance programs as too lenient, claiming that since they are sponsored by professional organizations, they focus too much on protecting the confidentiality and working privileges of the professional at the expense of compromising patient safety.
However, Harbison says, most of these treatment programs are difficult to complete and make every attempt to ensure the provider is able to safely practice. "Under HPSP, if the provider has a relapse, tests positive for drug or alcohol use, or commits a violation of the medical practice act while under supervision, they are taken out of the program and face disciplinary action."
Most programs also have fairly stringent eligibility requirements — not taking providers who have committed crimes related to their impairment, such as theft of drugs or prescription fraud, for example.
Providers who successfully complete treatment can become some of the best health care employees because they learn better ways of handling stress and often are more compassionate and able to identify with patients.
"There is often a public perception, and a feeling among nurses themselves, that a professional with a drug or alcohol problem is a morally bad person, or not strong," says Anderson. "However, managers have told me that they [nurses with problems] are often their best nurses. Studies have shown that, of nurses who report impairment issues, most of them were in the top quarter of their graduating class."
Even after treatment, providers who have had issues with chemical dependency or mental illness require support and an understanding work environment, continues Anderson.
She recommends forming support groups of health care providers who have had dependency issues because they can specifically address the pressures and complications that these professionals face — working near controlled substances, for example, or dealing with emotional trauma on the job. It’s also important that the employee is honest about his or her problem. Since many hospitals are reluctant to hire professionals with histories of impairment, many may choose to keep this information confidential.
"I would advise the manager to pay attention to what that person is saying," she says. "If the person says, I had a problem with alcohol or drugs, but that’s all over now,’ or in some other way indicates he or she feels that this issue is in the past, that should be a red flag. They are still in denial, themselves. The process of addiction is ongoing. Someone who says he or she is in recovery or is a recovering alcoholic or addict is someone who has acknowledged the problem."
Hospitals and departments definitely need a plan, not just about how to identify people who might be impaired, but also how to work with people who have had issues in the past and continue to practice, she believes.
Medical and nursing schools and hospitals need to be doing more to head off impairment issues to begin with, adds Anderson.
"We need to begin the process early on, helping medical students and nursing students identify risk factors, such as family history, and educate them about substance abuse issues," she says. "And, we really need to look at how we treat our residents and our students in the workplace."
Medical residents and student nurses often are asked to work incredibly long hours, in very high-stress situations and are then given little opportunity to "debrief" or discuss their reactions to traumatic clinical situations or events.
Nurses and physicians who are treated for a real physical injury may become dependent on painkillers and other medications because they allow them to return to work early instead of taking the time to recover fully and because they feel that the drugs allow them to "cope" with long hours and little rest, she adds.