Early Intervention

November 18, 2020 Mike Cox addiction alcoholism Center for Professional Recovery Depression Drug mental health recovery Substance Abuse treatment Uncategorized

Physician health programs (PHPs) provide state disciplinary authorities (medical boards) what wellbeing committees (WCs) provide for hospital disciplinary authorities (medical executive committees). The former regarding licensure and the latter hospital privileges, both necessary for most physicians to practice. In the few states, like California, with no PHP, wellbeing committees take on added responsibilities. In states with well-functioning PHPs, the PHP often partner with hospitals to accomplish Joint Commission standards.

Of all the reasons to have a PHP or WC (i.e. education, referral for evaluation and treatment, overseeing monitoring, advocacy), the most important function, that cannot be accomplished without them, is early intervention. Early intervention should be the primary goal of every PHP or WC. This is one place where there is a clear intersection between patient safety and physician health i.e., it is safer for patients if doctors are healthy. Also, if the doctor has a problem that could cause impairment, it is far safer to obtain help for the physician prior to overt impairment. Having a clinical alternative to discipline, that can assist a physician or other health professional, makes early referral more likely.

Unfortunately, this concept of encouraging early referral has come up against advocates of harsh punishment for doctors who become impaired. Consumer advocacy groups in some states, like California, have capitalized on this issue by making a big fuss about “secret programs to hide bad doctors”. They have conducted audits of existing PHPs and found errors, none of which caused any harm, and claim the program failed. Media loves this type of scandal and have published stories, pointing out that one physician or another who had a known problem is still working at a particular hospital, as if every doctor who has a problem should be expelled from medicine. This negative press discourages early referral. Many studies have shown there is a reluctance to report or refer an impaired (or potentially impaired) physician.[1]

Some factors that increase the likelihood of early referral:

Of course, the degree of impairment correlates to willingness to refer. A physician who is clearly impaired and an obvious risk to patients is more likely to be referred. But the goal is to refer physicians before they are grossly impaired. Often, there are signs of potential impairment long before they become obvious.
Confidentiality increases the likelihood of early referral. In other words, if a referral is going to cause public humiliation, it is less likely to occur.
Referring a physician for evaluation to a supportive program, rather than to a punitive one is more likely. In other words, referring a colleague for help is easier than reporting a colleague to a punitive agency. The former can be seen as trying to help the physician, the latter is seen as “snitching on a colleague”.
Publicizing the existence of the PHP or WC and informing everyone that the program is clinical and not disciplinary, and that it is good for everyone to make a referral before there is a catastrophe, increases the likelihood of early referral.

Some factors that decrease the likelihood of early referral:

Many states have statutes that require reporting. One study found that being required to report decreases the likelihood of referral, whereas having a feeling a societal obligation increased the likelihood of referral. [2]
Not being sure there is actually a problem decreases the likelihood of referral. It is easy to second guess and wonder if one’s intuition may be faulty. This is why it is beneficial to refer a physician for an evaluation when there is a question of impairment to determine if there actually is a problem.
If the physician is highly valued (e.g., a physician who brings in a lot of business for the group or hospital) or is well-known or powerful, it decreases the likelihood of early referral.
Skepticism about whether a referral will be successful, i.e., distrust of the system, decreases the likelihood of referral. This is where the PHP or WC needs to educate and be present so that everyone knows they exist and what they do.

It’s a fact that a significant percentage of physicians will develop problems (i.e., substance abuse, dementia, mental disorders) that could cause impairment, which can put patients at added risk. It makes sense to face this fact and continue to develop approaches that will help detect these issues early and get help for the doctor and protect the patients.

[1] DesRoches, et al. Physicians’ Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues. JAMA. 2010;304(2):187-193

[2] Farber NJ, et al. Physicians’ willingness to report impaired colleagues. SocSciMed 2005 Oct;61(8):1772-5.