Fromson - Substance Misuse Among Professionals - Show · 2014-03-07 · reference to commercial products or services. • I do not intend to discuss an unapproved/ investigative use

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1st Annual Professionals Conference:

Health Wellbeing and Awareness

Substance Misuse Among

ProfessionalsFriday, April 5, 2013Friday, April 5, 2013Friday, April 5, 2013Friday, April 5, 2013John A. Fromson, M.D.Director, Professional DevelopmentDepartment of PsychiatryMassachusetts General Hospital

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Disclosure• Neither I nor any member of my immediate

family has a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CME activity.

• My content will not include discussion/reference to commercial products or services.

• I do not intend to discuss an unapproved/investigative use of commercial products/devices.

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References

• Brook D, Lieteau T, McHugh KB, Reddy S, Fromson JA; Substance abuse within the health care community. In: Friedman L, Fleming NF, Roberts DH, Hyman SE, eds. Source book of substance abuse and addiction. Baltimore: Williams & Wilkins, 1996.

• Fromson JA, Kim A, Levy BS; On becoming a physician: the successful transition to medical school. In: Lens P, van der Wal G, eds. Problem doctors a conspiracy of silence. Amsterdam: IOS Press, 1997.

• Fromson JA. Growth hormone therapy in adults and children [Letter to the Editor]. N Engl J Med. 2000; 342:359.

• Knight J, Sherrit L, Sanchez L, Bresnahan L, Thoren J, Fromson JA. Monitoring Physician Drug Problems: Attitudes of Participants. Journal of Addictive Diseases. 2002; 21(4): 27-36.

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References

• Fromson JA; Addressing clinician performance problems as a systems issue. In: Youngberg B, Hatlie MJ, eds. The patient safety handbook. Boston: Jones and Bartlett, 2004.

• Anfang SA, Faulkner LR, Fromson JA, Gendel MH. The American Psychiatric Association's resource document on guidelines for psychiatric fitness-for-duty evaluations of physicians. J Am Acad Psychiatry Law. 2005; 33(1): 85-8.

• Leape LL, Fromson JA. Problem Doctors: Is There a System-Level Solution? Ann Intern Med. 2006; 144: 107-155.

• Knight JR, Sanchez, LT, Sherritt L, Bresnahan LR, Fromson JA. Outcomes of a Monitoring Program for Physicians with Mental and Behavioral Health Problems. J Psychiatric Practice. 2007; 13(1): 25-32.

• Nace EP, Birkmayer F, Sullivan MA, Galanter M, Fromson JA, Frances RJ, Levin FR, Lewis C, Suchinsky RT, Tamerin JS, Westermeyer J. Socially Sanctioned Coercion Mechanisms for Addiction Treatment. Am J Addictions. 2007;16: 15-23

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References

• Scope of problem in nurses:

http://informahealthcare.com/doi/abs/10.3109/10884609709022239

• Storr CL, Trinkoff AM, Hughes P, Substance-Using Health

Professionals: Similarities of Substance Use between Medical and Nursing Specialties; Substance Use & Misuse 2000 35:10, 1443-

1469

• MA Board of Nursing Substance Abuse Rehabilitation Program

(SARP) 617-973-0800

• http://www.mass.gov/Eeohhs2/docs/dph/quality/boards/nursing_sarp_handbook.pdf

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Learning Objectives• Review the stressors leading to substance misuse.• Explain burnout and preventive strategies.• Identify confidential sources of support.• Recognize the ethical dilemma of reporting a colleague to the relevant authority and having the “difficult conversation”.

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• Less than forty-eight years of age• Female• One hundred percent solo practice• Greater number of work hours• Greater number of hours in direct patient care• Takes fewer vacation days•http://www.beckershospitalreview.com/hospital-physician-relationships/study-physicians-in-their-40s-have-highest-stress-levels.htmlProfile of Most Stressed

Physician

(Lewis, J.M., et al, Texas Medicine, 1993)(Lewis, J.M., et al, Texas Medicine, 1993)(Lewis, J.M., et al, Texas Medicine, 1993)(Lewis, J.M., et al, Texas Medicine, 1993)

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Five most stressful times in a nurses

career

1. First day in nursing school.

2. The licensure exam.

3. The first day of employment as a graduate nurse.

4. The first time you make a patient care mistake.

5. The first time a patient dies while in your care.

(LL Anderson 2011)

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Professional Burnout Syndrome• Loss of enthusiasm for work (emotional exhaustion) • Feelings of cynicism (depersonalization)• Low sense of personal accomplishment

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Physician and Nurse BurnoutPossible Causes• Excessive workloads• Loss of professional autonomy• Higher patient load to make up for declining reimbursement rates• Lack of time to build relationship with the patient• Too much paperwork

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Physician Burnout and Satisfaction• National survey of 7,300 doctors as experimental group• Control group of 3,400 employed non-doctors• Evaluated:– Work-life balance– Burnout– Emotional exhaustion– DepersonalizationShanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to

the General US Population. Arch Intern Med. Published online August 20, 2012.

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Physician Burnout• More common in physicians than other professions– 38% doctors– 28% of employed non-doctors • Most common in physicians at “frontline of care”– Emergency and family medicine– Dermatologists and preventive care specialists less affected• 4 in 10 physicians feel emotionally exhausted, cynical or depersonalized towards their patientsShanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to

the General US Population. Arch Intern Med. Published online August 20, 2012.

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From: Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US

Population Arch Intern Med. 2012;():1-9. doi:10.1001/archinternmed.2012.3199Burnout by specialty.

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From: Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US

Population Arch Intern Med. 2012;():1-9. doi:10.1001/archinternmed.2012.3199Satisfaction with work-life balance by specialty.

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Physician BurnoutConsequences• Burned-out doctors more likely to:– Think about suicide– Make medical errors• Patient care is compromised• Relationships with other healthcare professionals and patient families affectedShanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US

Physicians Relative to the General US Population. Arch Intern Med. Published online August 20,

2012.

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Physician Burnout PreventionPersonal• Identify and adhere to core values• Self-care• Supportive partner • Family and friend connections• Spiritual outlook

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Physician Burnout PreventionProfessional• Identify and adhere to core values• Adhere to meaningful schedule• Peer support• Mentorship • Administrative support

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Professional Effects of Burnout• Erode professionalism • Influence quality of care • Increase the risk for medical errors• Promote early retirement- Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J

Med. 2003;114(6):513-519

- Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among

American surgeons. Arch Surg. 2012;147(2):168-174

- Shanafelt TD, Balch CM, Dyrbye LN, et al. Special report: suicidal ideation among American

surgeons. Arch Surg. 2011;146(1):54-62

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Personal Effects of Burnout• Contributes to broken relationships• Problematic alcohol use• Depression • Suicidal ideation - Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J

Med. 2003;114(6):513-519

- Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-174

- Shanafelt TD, Balch CM, Dyrbye LN, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62

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Physician Burnout• 38% doctors had high emotional exhaustion scores– Related to losing enthusiasm for their job• 30% doctors had high depersonalization scores– Related to viewing patients as objects rather than human beings• 46% doctors had high emotional exhaustion and/or high depersonalization scoresShanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US

Physicians Relative to the General US Population. Arch Intern Med. Published online August 20,

2012.

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Burnout Among Nursing Staff• Strain - growing number of demented patients in long-term institutions; different leadership styles by the directors of nursing (Brodaty et al. 2002); staff did not have enough time to complete their tasks and woried that their jobs would be affected by organizational changes ( Brodaty et al. 2002).• Overload – quantitative( more work than a caregiver can do in a given time) and qualitative( the job requires skills and knowledge exceeding those of the staff) (Åstrom et al.1990); Pines et al (1981) found that 50% of the stress mentioned was a result of overload.• Problems in coping with expectations from the patients and relatives ( Åstrom et al. 1990).

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Burnout Among Nursing Staff• Education – high levels of empathy can be obtained through education if there is a need for this among the nursing staff ( Fine & Therrien 1977, La Monica 1981)• Patient-staff ratio• Stress – an increase in nurses’ stress is significantly related to higher levels of patient aggression, especially if the behavior is perceived as threatening (Rodney 2000)

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Scope of Physician Substance Use Problem•Prevalence• Prescription substances used primarily for self-treatment (minor opiates and benzodiazepines)• Illicit substance abuse primarily forrecreation• As likely as non-physician age andgender peers to have experimentedwith illicit substances in lifetime(Hughes et al. 1992)(Hughes et al. 1992)(Hughes et al. 1992)(Hughes et al. 1992)

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Scope of Physician Substance Use Problem• Far less likely to be current users of illicit substances• More likely to have used alcohol; maybe related to socioeconomic class rather than profession

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Nursing Scope of Substance Use

Problem

• Chemically dependent nurses– Work in hospital settings

– Medical surgical units

– Primarily day shift• Nurses were referred to the substance abuse program most

often by their employers. • Subjects reported

– History of medical problems

– Experienced past attempts at treatment for their addiction – Alcohol and drug use began at an early age

– Dependence was reported on a variety of drugs, mainly Percocet (acetaminophen and oxycodone)

• Early age of first drug use suggests the need to recognize abuse early and to intervene before the disease progresses.

(Kowalski, Rancourt; Journal of Addictions Nursing, 1997)

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Leading Contributors to Substance Use Disorders• Stress• Isolation• Accessibility• Genetic predisposition• Chronic medical illness

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Medications Abused• Opiates – hydrocodone, oxycodone, meperidine, morphine• Benzodiazepines• Barbiturates – butalbital (Fiorcet)• Anesthetics– fentanyl, sufentanyl, propofol, midazolam• Others – (VI) tramadol (Ultram), Nubain (IV) Stadol

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Mental Health Problems• Mood disorders• Anxiety disorders• Posttraumatic stress disorder• Adjustment disorders• Personality disorders• Cognitive impairments• Psychotic disorders

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Behavioral• Boundary violations• Disruptive behaviors• Dishonesty

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Barriers to Getting Help•Denial and minimalization of symptoms• Fear of disclosure & its consequences�Treatment�Reporting�Reputation• Self-medication• Shame and humiliation

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Barriers to Getting Colleagues Help• Failure to recognize signs and symptoms• Denial• Over-identification• Embarrassment• Not knowing what to say• Not aware of resources

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JC Licensed Independent Practitioner (LIP) Health

RequirementLIP Health MS.4.80• The medical staff implements a process to identify and manage matters of individual health for licensed independent practitioners.

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JC LIP Health RequirementsDevelop a process:• Educate the LIPs• Self referral and referral by others• Confidentiality• Evaluate credibility of complaint/concern • Referral for diagnosis & treatment • Reporting if LIP unsafe

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Is There a Problem?How to resolve uncertainty and doubts:• Talk with colleague• Confer with colleagues• Discuss with designated hospital committee• Maintain confidentiality• Hospital Physician or Nurses Health Committee• Maine Medical Professionals Health Program

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Intervention• Don’t delay, the earlier the better• Avoid risk of patient harm• Offer structure and support• Use as education opportunity

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Maine PUBLIC Law, Chapter 190• Sec. 5. 24 MRSA 24 MRSA 24 MRSA 24 MRSA §§§§2502, sub2502, sub2502, sub2502, sub----§§§§4444----A, A, A, A, as amended by PL 2009• "Professional review committee" means a committee of health care practitioners formed by a professional society for the purpose of identifying and working with health professionals who are disabled or impaired by virtue of physical or mental infirmity or by the misuse of alcohol or drugs, as long as the committee operates pursuant to protocols approved by the various licensing boards that license the health professionals the committee serves.

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• A program of the Maine Medical Association (1987)• Operates under protocols developed with Maine: Board of Licensure in MedicineBoard of Osteopathic Licensure Board of Dental ExaminersBoard of PharmacyState Board of Nursing Board of Veterinary Medicine• Advocacy to licensing board, employers, & credentialing agenciesMaine Medical Professionals Health Program

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•Initial interview and screening; •Referral for evaluation and treatment; •Recovery monitoring and documentation; •Advocacy to those seeking re-licensure, credentialing, etc.; •Networking opportunities with colleagues in recovery.Maine Medical Professionals Health Program

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Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent

colleagues.

Catherine M. Desroches, DrPH

Sowmya R. Rao, PhD

John A. Fromson, MD

Robert J. Birnbaum, MD, PhD

Lisa Iezzoni, MD, MSc

Christine Vogeli, PhD

Eric G. Campbell, PhD

JAMA. 2010 Jul 14; 304(2):187-93.

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Problem• Physician’s judgment and actions can cause medical errors• Factors that impair judgment:– Mental health conditions– Alcoholism– Drug use– Failure to maintain technical competence• Reporting statutes • “Ethical obligation to report”• Rate of reporting low

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Methods• Survey– Revised from 2004 professionalism questionnaire (Campbell, Regan et al. 2007; Campbell, Gruen et al. 2007)– Revisions based on 4 focus groups, expert advisory committee– Final version: 7 pages, 110 individual survey items• Sample– Identified all US physicians in primary care (family practice, internal medicine, pediatrics), anesthesiology, cardiology, general surgery, psychiatry– Randomly selected 500 physicians per specialty (total: 3,500)

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Methods• Survey Administration– Mailed survey packet (cover letter, fact sheet, questionnaire with ID number, postage paid return envelope, $20 incentive)– Telephone calls and additional mailings to nonrespondents

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Dependent Variables of Survey• Beliefs about commitment to self-regulation through reporting significantly impaired or incompetent colleagues• Preparedness to report• Personal experiences with these difficult situations• Actions taken when confronted with impaired/incompetent colleagues

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• Beliefs about commitment to self-regulation through reporting significantly impaired or incompetent colleaguesQ: Q: Q: Q: “Please rate the extent to which you agree with the following statement…Physicians should report all instances of significantly impaired or incompetent colleagues to their professional society, hospital, clinic, and/or other relevant authorities”A:A:A:A: Completely AgreeSomewhat AgreeSomewhat DisagreeCompletely Disagree Dichotomous variables for analysesDependent Variables of Survey

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• Preparedness to reportQ: Q: Q: Q: 1. [Rate the extent to which] you feel prepared to deal with colleagues who practice medicine while they are impaired.2. [Rate the extent to which] you feel prepared to deal with colleagues who are incompetent in their medical practice.A:A:A:A: Very preparedSomewhat preparedSomewhat unpreparedVery unprepared Dichotomous variables for analysesDependent Variables of Survey

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• Personal experiences with these difficult situations• Actions taken when confronted with impaired/incompetent colleaguesQ: Q: Q: Q: 1. In the past three years, have you had direct, personal knowledge of a physician who was impaired or incompetent to practice medicine in your hospital, group, or practice?2. In the most recent case, did you report that physician to a hospital clinic, professional society, or other relevant authority?A:A:A:A: YesNoDependent Variables of Survey

47 47• If they had direct, personal knowledge of an impaired/incompetent colleague…Q: Q: Q: Q: [Report whether there had been a time in the past 3 years when they did not report because of any of the following reasons or beliefs]- Someone else was taking care of the problem- Nothing would happen as a result of the report- The physician would be excessively punished- It could easily happen to you- It was not your responsibilityA:A:A:A: YesNo Per item

Dependent Variables of Survey

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Independent Variables of SurveyPhysician:•Sex•Race/ethnicity•Specialty•Graduate of US medical school•Number of years in practice•Practice organizationsSystem:•Total malpractice claims paid per physician per state

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Analyses• Significant differences between groups:– Continuous variables – 2-sided t test– Categorical variables – X2 test• Association of outcomes with independent variables– Multivariable logistic regression models• SAS version 9.2

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Results1,891 of 2,938 eligible physicians completed survey (64.4% response rate)• Response rates % by specialty• Pediatrics 72.7• Family Practice 67.5• Surgery 65.1• Anesthesiology 64.6• Psychiatry 64• Internal Medicine 60.8• Cardiology 50.6

51 51ResultsBeliefs and Preparedness•Percentages of physicians who completely agreed with:

“Physicians should report all instances of significantly impaired or incompetent colleagues to their professional society, hospital, clinic and/or other relevant authority.”• 64 completely agreed• Women physicians, more than men were significantly more likely to completely agree• US med school grads compared to non-US grads were significantly more likely to completely agree• Physicians practicing in hospitals or clinics more likely to agree• Physicians in solo, 2 person , or group practice least likely to completely support reporting• Physicians practicing in areas with low numbers of malpractice claims were significantly more likely to completely agree vs those in areas with medium to high malpractice claims

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52 52ResultsPreparedness to deal with impaired colleagues• 69 % very or somewhat prepared• Anesthesiologists and psychiatrists most likely• Pediatricians least likely• Physicians in medical school and university settings more likely to be prepared• No difference in men and womenPreparedness to deal with incompetent colleagues• 64 % prepared• Women significantly less likely than men to report being prepared

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ResultsExperiences with Impaired/Incompetent Colleagues• 17 % (n=309) reported having direct personal knowledge of an impaired or incompetent colleague• Anesthesiologists most likely and pediatricians least likely to report• 67% with knowledge of an impaired or incompetent colleague actually reported to hospital, clinic, professional society or other relevant authority• Underrepresented minority physicians and non-US med school grads were significantly less likely to report• 76% in hospitals and 77% in universities or med schools having direct personal knowledge of an impaired or incompetent colleague reported• 44% in solo or 2 person practices reported

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ResultsReasons They Did Not Report Colleague

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Comment• More than 1/3 physicians did not completely agree that physicians should report colleagues– 40% physicians in solo and dual practices; fewer than half reported their colleagues• Underrepresented minority physicians endorse commitment to report and feel prepared, but more than half do not report– Same with physicians educated outside US– “Outsider” status—more vulnerable?

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Limitations• Reliance on voluntary disclosure of failure to report—lower-bound estimate• Response bias• Accuracy of physicians’ beliefs that their colleagues were impaired or incompetent

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CommentFindings:Findings:Findings:Findings:•Reliance on self-regulation is not sufficient•Underreporting due to physicians’ fears of retaliation•Underreporting due to physicians’ belief that nothing will happenImplications for improving Implications for improving Implications for improving Implications for improving system:system:system:system:• Stronger external regulation (professional societies, hospitals, licensing groups, patient groups)•Ensure confidentiality of reporting physicians•Provide reporters with confidential feedback about actions taken

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Conclusions

• All health care professionals must understand the urgency of preventing impaired or incompetent colleagues from:

– injuring patients

– the need to help these physicians confront and resolve their problems

• The system of reporting must facilitate, rather than impede, this process.

• Reliance on the current process results in patients being exposed to unacceptable levels of risk and in impaired and incompetent colleagues possibly not receiving the help they need.

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Conclusion• All susceptible• Education and awareness• Prevention and early intervention• The earlier the better• There is help and it works• Protected and confidential

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[email protected]