Helping Others

"We as a profession, have been the wellspring of compassion and caring for our patients. We are always there when they need us. We must also be there for our colleagues in distress when they need us." —Dr. Dana Hanson, CMA President 2002–2003

• Recognizing patterns of impairment
• Mood disorders
• Disruptive behaviour
• Suicide
• Healthy workplace strategies
• Support groups/mentoring programs
• Faculty wellness

Recognizing patterns of impairment

Physicians may be particularly vulnerable to impairment such as burnout, depression and chemical dependency due to the rigors of practice, including long hours, the urge for perfectionism, the threat of litigation and the need to solve complex problems. Though many cope well, others don't. Doctors at particular risk may include those with a genetic predisposition for psychiatric illness or chemical dependency, or a personal history that makes them vulnerable.

Estimates of the prevalence of impairment among practising physicians in Canada range from 7% to 10% (Treatment of the mentally ill physician). Of these, 75% are believed to be dependent on alcohol or other drugs; an unknown number suffer from a dual diagnosis, such as chemical dependency plus major depression, bipolar illness, panic disorder, or obsessive-compulsive disorder (JAMA 1990;264:2511-18).

If you suspect a colleague is having problems, contact your provincial or territorial physician health program.

With respect to substance abuse and addiction, a survey of 9000 physicians found that nearly 8% suffered from substance abuse or dependence problems during their life (JAMA 1992;267:2333-9). Data from the Ontario Medical Association (OMA) Physician Health Program indicated that 47% of doctors monitored by the program use alcohol as their drug of choice, 35% are dependent on opioids; 7% use cocaine, 5% use sedatives and hypnotic drugs and the remaining 6% use a variety of other drugs including cannabis, solvents and anesthetic agents (Ontario Medical Review October 2002, pp 43-7).

Dr. Michael Kaufmann of the OMA's Physician Health Program has identified possible signs of substance abuse and addiction in physicians (Ontario Medical Review, May 1999, pp 46-7 and October 2002, pp 43-7) including the following.

• personality change
• loss of efficiency and reliability
• increased sick time and time off
• patient and staff complaints abut physician's changing attitude/behaviour
• indecision
• increasing personal and professional isolation
• physical changes
• unpredictable work habits and patterns
• anxiety, depression, suicidal thoughts or gestures
• memory loss
• uncharacteristic deterioration of handwriting and charting
• unexpected presence in hospital when off-duty
• wide mood swings; moodiness, withdrawal, and more irritability
• angry or inappropriate outbursts
• excessive use of alcohol at social and CME events
• heavy prescription writing, unusually high doses or wastage noted in drug logs and insistence on personal administration of parenteral narcotics to patients
• unkempt appearance, alcohol on the breath, drowsiness

Overt intoxication is rarely seen, but the above signs must be heeded. "Delay can result in needless suffering, patient harm, or even the affected physician's demise by accident or suicide," writes Kaufmann.

Remember that physicians who have a personal physician are less likely to self-medicate (Myers MF. The well being of physician relationships. West J Med 2001;174:30-3).

Contact your provincial or territorial physician health program for advice. See also Chemically dependent health professionals (McCall SV.West J Med 2001;124:50-4.)

Mood disorders

Chemical dependency often co-exists or camouflages a mood disorder. The actual incidence of depression among physicians is not know, but we do know that between a quarter and a third of residents become clinically depressed during training (Am J Psychiatry 1987;144:1561-6 and Arch Intern Med 1985;145:286-8) and that depression is more common among women. About 75% of the calls to the Quebec Physician Support Program concern mental health issues such as depression, burnout, stress and anxiety, reports director Dr. André Lapierre (CMA Guide to Physician health and well-being [PDF], p. 6).

The Canadian Psychiatric Association (CPA) states in the Treatment of the mentally ill physician position paper that "Any illness that affects the central nervous system and results in cognitive, mood, memory or behavioural changes will impair a physician's judgement. These include alcohol or other drugs, metabolic impairment and dementias associated with Alzheimer's disease, vascular disorders, Parkinson's disease, head trauma and HIV infection.

Unfortunately, many physicians delay or avoid seeking help because of the stigma attached to depression and other mood disorders (see Stressors unique to medicine: Stigma under Helping Yourself). When they finally do reach out, they are in an extreme state and, according to the CPA's position paper, must be seen very quickly, usually the same day.

Contact your provincial or territorial physician health program for more information.

Disruptive behaviour

According to the CMA Guide to physician health and well-being, disruptive behaviour can include the following

• swearing or foul language
• use of racial, religious, gender epithets
• jokes or witticism that make fun of self or others
• sexual talk
• insults and verbal put-downs
• staring or glaring
• stalking
• unnecessary physical contact
• menacing gestures
• demeaning tone
• yelling, throwing objects

Compounding the problem is the fact that an estimated 80% of physicians who demonstrate new-onset disruptive behaviour are also struggling with some kind of chemical dependency (CMA Guide to Physician health and well-being 2003, pp 18-19 [PDF]).

How prevalent is disruptive behaviour? Between 1995 and 2001, about 4% of the cases referred to the Ontario Medical Association's Physician Health Program were related to disruptive behaviour (Recognition and management of the behaviourally disruptive physician).

Identifying and confronting a colleague about disruptive behaviour can be daunting because the individual is often a high achiever who is friendly and outgoing. However, disruptive behaviour must be addressed. The CMA Code of Ethics (1996, section 37) advises interveners to: "Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues. "Healthy workplace strategies can aid compassionate collegial intervention.

TheHandbook of Physician Health (Chapter 9) from the American Medical Association contains helpful information on administrative management and clinical valuation.

Contact your provincial or territorial physician health program for more information.

Suicide

It's well known that physicians are especially vulnerable to suicide. A BC study put the incidence of physician suicide at 21.9 per 100 000 population (Kaufman M. Physician suicide: risk factors and prevention). The suicide rate in the general population over the same period (1991 to 1998) was 13.8 per 100 000 per year.

According to Dr. Michael Kaufmann of the Ontario Medical Association, "Often physicians who have committed suicide have experienced significant losses: failure of important relationships, the death of loved ones, financial setback, revocation or suspension of professional licence, reputation damage by any real or perceived insult, an inability to work or enjoy work for any reason."

"Any physician who suffers actively from a disorder prone to suicide, who has experienced significant strain or loss, who expresses or demonstrates suicidal thought or intents, must be viewed at high risk for suicide," writes Dr. Kaufmann.

Contact your provincial or territorial physician health program for more information.

Healthy workplace strategies

There is ample evidence that the workplace is a key determinant of health, and that healthy workplaces promote healthy workers and healthy workers produce more and therefore lead to successful organizations. The bottom-line: it's in everyone's best interest to have healthy workplace strategies.

In the US, health organizations must have physician health programs, separate from the medical staff disciplinary function, as a prerequisite for accreditation (see http://www.jcaho.org/) These standards, adopted in January 2001, also require health organizations to educate medical staff to recognize illness and impairment in colleagues; to make provision for both referral and self-referral; to ensure confidentiality; to evaluate the credibility of complaints, allegations or concerns; to monitor the affected physician; and to report to medical staff any situation where a physician is providing unsafe treatment.

Successful programs should be non-persecutory, non-punitive (unless absolutely essential) and preventive, and should promote voluntary access and rehabilitation. Here are a few tips for developing a program (CMA Guide to physician health and well-being, 2003, p 23-4).

• establish a dedicated committee of 8-20 people
• establish a formal structure
• establish relationships with treatment providers
• report cases when necessary
• support intervention
• know the legal issues in your province
• maintain confidentiality and records
• be visible
• undertake special projects such as retreats or education programs
• build on the work of others (e.g., the Vanderbilt Physician Wellness web site

The American Medical Association's Physicians' Guide to Medical Staff Organizational Bylaws (for AMA members only), provides information on writing and designing bylaws. For Canadian resources see the Canadian Healthy Workplace Criteria (1998) and Framework for Development of a Healthy Workplace, both available from the National Quality Institute.

Support groups/mentoring programs

Physicians and other health professionals in recovery may find it helpful to meet in professional facilitated, peer support groups. Not only are participants grappling with similar problems, they also share an understanding of the culture and demands of medicine. Many physicians find such groups invaluable in ridding them of the shame and stigma of illness or in relieving them of perceived isolation and lack of understanding from the medical community.

The Ontario Medical Association Physician Health Program has found that many physicians who are recovering from addiction heal better within groups. "In therapy groups, personal and vitally important issues are revealed and reconciled," states Dr. Michael Kaufmann, head of the OMA program (Seeking help through group therapy)

Mutual help groups, such as Alcoholics Anonymous, already operate in most communities (see your Yellow Pages). Since these groups cater to people with similar problems, participants gain a sense of belonging as well as practical tools to speed their recovery. Where possible physician-only AA support groups are advised.

Traditionally, physician support programs have offered services for doctors suffering from drug and alcohol problems and other conditions that impair judgement and the ability to practice medicine. Many have now expanded their focus to include programs on health promotion and illness prevention. Almost every provincial program offers lectures, workshops and seminars on these topics for medical students, residents and physicians. And some healthcare organizations are offering retreats or educational programs on personal development topics such as coping with medical malpractice, aging, recognizing stressers, coping skills and care of self. Informal discussion groups, meeting every 2 weeks or so, offer a comfortable place for physicians to share ideas, feelings and values — or have a laugh.

Contact your provincial or territorial physician health program for more information.

Faculty wellness

The University of Ottawa set up an effective Faculty Wellness Program after a 1999 survey revealed the need for such a service. It found that university physicians were working about 59 hours a week and that 48% reported low job satisfaction. In the 3 months preceding the survey, 25% were under high stress, 12% had thoughts of suicide and 7% (about 10 physicians) had planned a suicide attempt (CMA Guide to physician health and well-being, 2003, p. 20).

Dr. Mamta Gautam, an Ottawa psychiatrist who specializes in physician health, founded the Faculty Wellness Program, which promotes maximum wellness by addressing issues of education, prevention, research, resources and intervention for stress and burnout, anxiety, conflict, bereavement, relationship, finances and time management.

Dr. Gautam offers the following tips for starting a successful university-based wellness program:

• document the need
• get buy-in from the dean (or it won't happen)
• obtain senate approval and a place on the organization chart
• get a budget, terms of reference and a mandate
• ask the dean to invite prospective committee members
• recruit committee members from all specialties (include junior faculty)
• recruit a respected committee leaders (not a psychiatrist) to destigmatize illness