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Saturday, April 9, 2011

What is an impaired physician?

A hot topic in medicine is the "impaired physician". There was a whole series in the throw-away journal Pain Medicine written by a doctor who spectacularly screwed his life up by getting addicted to opiate pain medications, then overprescribing those same drugs to patients and defrauding Medicare and Medicaid by charging for procedures that he didn't do. He proceeded to run off to various foreign countries where he managed to keep himself fed and housed until finally returning to the US to serve his time and probably not practice medicine. The articles he wrote were luridly exciting, definitely not in the category of "there but for the grace of God go I."

Most of us in medicine have had contact with a colleague who has some kind of a substance abuse problem. I personally have had 3 colleagues with whom I worked closely who had trouble with both drugs and alcohol to the extent that their work was affected and they had to take time off, do a treatment program and be supervised after returning to practice. All three were excellent physicians when they were straight, and jeopardized others when they were not. I think the system probably worked for them, preventing irreversible harm and letting them get rid of their demons and return to practice. The stories these physician addicts tell are often pretty similar. They start self prescribing medications for pain, often headaches, find that when medicated they can work through the pain and maybe the work is just a little more fun. Eventually the dose required to treat their condition increases and it becomes harder to maintain normal work habits. The physician starts missing work and is moodier. Finally there is a mistake that leads to disciplinary action or legal action and the jig is up. The physician gets help.

Substance abuse is the impairment we usually talk about, but by far the least common. Training in medicine is painful. The amount of information to be learned is huge, and the competition to even begin the process is fierce. Once the part of training that involves direct care of patients starts, the patient takes precedence and nothing but incapacitating illness is a good enough excuse for not doing the job. Some medical students or residents have been known to do rounds while hooked up to an IV. Because I was out of town, another doctor in my practice worked with the stomach flu, which she had gotten from a patient in the hospital, pregnant, until she went into premature labor and called me to see if I would come back early to cover the patients. I have worked with influenza until the office canceled all of my patients without my permission, then went home and was unable to move from the couch for 12 hours. It was pretty hard to concentrate on that last patient's questions. At least one of the patients at my office caught the flu one incubation period from when they saw me, and got dangerously ill. My fault.

Another physician impairment that affects patient care is fatigue and burnout. Taking call is a fact of life for most physicians, and can involve sleepless nights. Although rules have been enacted to prevent physicians in training from spending too long at work, this is not the case for physicians in practice. A busy night often means a busy day, since sick patients frequently stay sick and require ongoing care. Doctors who work too hard often begin to get a "God complex" believing that they are so important that life cannot go on without them. They agree to work longer and longer hours and become more irritable and unreasonable. They worry about making more money, since only retirement will ease their suffering. 

I attended the funeral of the nurse practitioner who shared my office this afternoon. She was a wonderful woman with a big laugh, a delightful smile, a quirky sense of humor, big ideas for changing the world and a huge wealth of expertise and experience formed over 25 years of study and practice. Over the last few months she had been missing more work and had seemed more fatigued. I knew that she had chronic pain related to a motor vehicle accident in the past and a couple of chronic medical conditions, autoimmune, that gave her daily trouble. Her gradual decrease in life force seemed like it might be just a bump in the road, an exacerbation of the conditions that she had learned to deal with over many years. I never questioned her about being sick, since she knew that I was there if she needed me, and I didn't want to intrude on her privacy. She worked until one day she couldn't stand up and so she had her husband bring her to the office. She was profoundly anemic and iron deficient, related to slow intestinal bleeding. She knew it was a problem, but not how bad it had gotten. It is not hard to treat iron deficiency. A blood transfusion provides instant relief, though at the risk of overloading a heart that might have weakened by chronic muscle iron deficiency and overwork. Her color was better after getting blood, but she was still feeling bad. A couple of days after going home from the hospital she became more short of breath and died. An autopsy showed that a large blood clot had migrated from her leg to her lung, a completely unexpected event. She had also had small clots in her lungs over the preceding weeks, which must have been a huge strain on a system already weakened by anemia. I will miss her a great deal.

The solution to the problem of "impaired physicians", myself, my stoic partners and colleagues is not in any way simple. With the looming problem of a primary care physician shortage, there will be even more of a conflict between the need to take care of ourselves and the need to care for our very sick patients.  All I can think of to honor my nurse practitioner partner's sacrifice is to consider the many ways in which we can take care of our patients more efficiently, ministering to them in a way that honors what is truly important and backing away from medicine we practice that is defensive or based on reimbursement. Re-working payment strategies and training programs to train adequate numbers of providers is vital. It is also vital to extend the concept of compassion to include the individuals who take care of patients.

1 comment:

keshav said...

Janice, I am personally touched by your experiences and share your view that we as caregivers rarely think to provide care to ourselves. We are trained to desensitize ourselves to our own feelings of pain or sorrow. Without such desensitization we could not focus on the problems we are told. If I thought about how macabre a thing it is to slice open another living human every time I did it, I would not be able to perform such a function. Yet, this desensitization has often caused me to forget who I am and why I am important too. The fact that my salary is under attack doesn't help in validating my self worth. Add to this the continuous fear of being sued that we are trained to expect. Our learning is focused around legally defensible terms such as "standard of care" and "informed consent" and "against medical advice AMA". Our family lives suffer as we focus more and more on shielding ourselves from the multitude of complexities faced in our profession. This is the state of medicine.