Managing impairment: Advocacy or betrayal?

Physician leaders struggle with managing potential impairment in their colleagues—some may see it helping the physician, and others consider it a betrayal. Not so long ago, physicians turned a blind eye toward their colleagues who had a suspected impairment, but today, we are reconsidering whether this is in patients’ or even our colleagues’ best interests.

Impairment is defined as the inability of a physician to safely exercise privileges due to any reason. Types of impairment include, but are not limited, to:

• Physical (e.g., weakness due to aging)
• Cognitive (e.g., dementia)
• Psychological (e.g., depression, substance abuse)
• Neurological (e.g., multiple sclerosis, Parkinson’s disease)
• Metabolic (e.g., diabetes)

Any number of factors may cause impairment, and a physician can be suffering from more than one type of impairment at any given time. For example, a physician who has been diagnosed with Parkinson’s disease may experience a period of depression as he or she adjusts to a new way of life.

The level of impairment among the physician population parallels the incidence in the general population and increases with age. For example, by age 65, approximately 11% of individuals manifest the early signs of dementia, 25% of individuals will have clinical manifestations of depression, and 14% will have clinical manifestations of alcoholism.

When identifying a potential impairment, leaders have two options—wait for it to directly affect patient care or address it empathetically before it does. Either way, the purpose of managing impairment should be assistance and rehabilitation, not discipline, according to the rationale for Joint Commission medical staff standard MS.11.01.01. The emphasis should be on supporting your colleague through confidential vocational assessment and ongoing support.

Many medical staffs have a physician health committee or advocacy committee to manage potential impairments in a sensitive, multidisciplinary manner and make a recommendation whether to proceed with a formal evaluation.

At the core of an impairment assessment is a “fitness-for-work” evaluation. The evaluation is performed by a practitioner who is skilled in assessing impairment and who has a working knowledge of the clinical privileges that the problem physician holds. The evaluator determines what physical, cognitive, and metabolic issues are involved; suggests a treatment and rehabilitation plan; and ascertains whether the physician should continue to exercise his or her privileges and brings that recommendation to the MEC.

Professional organizations that do these exams include:

• Physician Assessment and Clinical Education at the University of California San Diego
• Colorado Physician Health Program in Denver
• Texas Medical Association in Austin
• Professionals at Risk Treatment Services in Elmhurst, IL

In addition, most state medical associations keep a listing of local organizations that offer fitness-for-work evaluations and assessments.

Once a physician’s health or advocacy committee receives the results of the fitness for work evaluation, it can recommend action to the credentials committee or MEC. In the best case scenario, the fitness for work evaluation lays any concerns to rest. If the physician is deemed capable of practicing, but the medical staff still isn’t 100% sure, the medical staff may wish to monitor the potential issue over time. If the fitness to work evaluation reveals serious issues, the medical staff may ask the physician to voluntarily modify his or her privileges pending ongoing assistance and treatment.

Dealing with potential impairments is at best uncomfortable. However, medical staff leaders should not sweep problems under the rug. Not proactively managing impairment may make matters worse and possibly lead to patient harm. When I counsel hospitals on this issue, I think back to my first consulting engagement during which I worked with a surgeon with untreated depression. This physician inadvertently allowed two of his postoperative patients to die from normal postoperative complications because he refused to come in at night. The nurse on duty, in order to protect him, did not go up her chain of command. After successfully being treated for his depression, the physician turned to the chief of staff and asked why the medical staff did not help him while he suffered from depression, which is a treatable illness. The chief of staff looked him directly in the eye and stated calmly, “I thought we were helping you by looking the other way.”

Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.