ethics and professionalism the integrity of medicine impaired physicians
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Ethics and Professionalism The Integrity of Medicine Impaired Physicians. Richard L. Elliott, MD, PhD, FAPA Professor and Director, Medical Ethics Mercer University School of Medicine Adjunct Professor Mercer University School of Law. Goals. Week one Review first year ethics - PowerPoint PPT PresentationTRANSCRIPT
Ethics and ProfessionalismThe Integrity of Medicine
Impaired Physicians
Richard L. Elliott, MD, PhD, FAPAProfessor and Director, Medical Ethics
Mercer University School of MedicineAdjunct Professor
Mercer University School of Law
Goals Week one
– Review first year ethics– Research and ethics
• “The purpose of Community Medicine II is to introduce the concept of evidence-based medicine”
• Tuskegee, IRBs, Pharmaceutical industry– Small group discussions (exam material!)
Week two Medical student abuse Impaired colleagues Exam (10 – 12 multiple choice questions, not all USMLE format) Course evaluation – What can we do differently?
Resources http://medicine.mercer.edu/Academics/
Degree%20Programs/Doctor%20of%20Medicine/medicalethicsprogram– Second year and research subsections– PowerPoint to be loaded on Blackboard
Blackboard Change in readings: Only required
reading is Studdert for malpractice
Ethics and ProfessionalismThe Integrity of Medicine
The Impaired Physician
Richard L. Elliott, MD, PhD, FAPAProfessor and Director, Medical Ethics
Mercer University School of MedicineAdjunct Professor
Mercer University School of Law
Dr. Wells’ case – the missed phone call– System issue
• Forgetting patient• Answering machine• No call from lab
– No “bad apple”
Definitions of Impaired Physician
“unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skill, or excessive use or abuse of drugs including alcohol.” (AMA)
“inability to exercise prudent medical judgment and the ability to practice with reasonable skill and safety without jeopardy to patient care” (AAFP)
Examples of Impairment
Substance abuse Mental Illness Cognitive Personality traits
– Boundary violations Physical condition
– Motor– Visual
Impaired Physician - Epidemiology
Overall – 10-15% lifetime risk of becoming impaired
Substance abuse – 90% of impaired physicians– 8-10% lifetime risk– 2% current
Mental Illness – 8% of impaired physicians No greater than general population except
30-100 times greater risk of narcotic addiction
Impaired Physician - Trainees
Medical students: 11% with excessive alcohol use during at least one 6-month period, 18% with alcohol abuse during first two years
30% residents report depression with suicidal ideation in previous two weeks
14% students reported suicidal thoughts in previous year
Only 22% of depressed students received treatment
Medical Student Impairment
N Engl J Med 353;25 December 22, 2005 2673 235 physicians disciplined by medical boards
matched with 469 physicians who graduated from the same school and year
Students who were described as having unprofessional conduct during medical school were 3 times more likely to be disciplined, with a risk of 26%.
Risk factors during medical school for future disciplinary action included irresponsibility (lack of accountability) and lack of capacity for self-improvement
Impaired Physician – Risk Factors
Problem behaviors, low test scores, drug use in medical school predict problems in residency and later
Sensation seeking and paternal history predict substance abuse in students
Sleep – drugs to sleep or stay awake Access – narcotics Stress – school, family, burnout Specialty – anesthesia, ER – x3 Pharmacological optimism, reliance on
intellect, strong willed, high “T”
Impaired Physician - Recognizing
Personality changes– Patient and staff complaints– Sleep problems– Erratic performance and behavior– Burn out – 50% of physicians– Absences, odd hours– Errors and unusual practices– Irritability, moodiness
Physician Mortality
1261 physicians, graduated 1948-1964, studied through 1998
Overall mortality 56% lower in men, 26% lower in women
Suicide 82% greater in men, 395% greater in women
DM Torre et al. Suicide compared to other causes of mortality in physicians. Suicide and Life-Threatening Behavior. 2005;35:146-53
Aid for the Impaired Medical Student (AIMS)
MUSM Medical Student Handbook – Provide assistance before irreversible harm– Protect rights of students to receive treatment in
confidence– To ensure recovered students can continue
education without stigma or penalty– To protect others affected by impaired students– Prevent future cases of impairment
Aid for the Impaired Medical Student (AIMS) II
Administered by AIMS Council (8 students, 4 professionals)
Referral to AIMS student representative Class representatives and professional
member review circumstances, interview student, recommend action
Professional member monitors follow-up
Impaired Physician - Interventions Key is recognition – colleagues must
overcome denial, reluctance, desire to be “discrete”
Personal vs. formal intervention Thorough assessment – high co-morbidity Physician-focused treatment (e.g., Ridgeway,
Caduceus) Anticipate relapse and determine
consequences Long term monitoring Address specific issues – (e.g., burnout)
Impaired Physician - Reporting
AMA “Physicians have an ethical obligation to report impaired, incompetent, and/or unethical colleagues in accordance with the legal requirements in each state”– August 29, 2005, AMA E-9.031
Reporting not mandatory in Georgia
Attitudes to Reporting Impaired or Incompetent Colleague
JAMA 2010;304(2):187-193 17% MDs had direct knowledge of impaired
or incompetent colleague in preceding year 2/3 reported Most common reason for not reporting:
– Someone else will– Nothing will happen
Less likely to report in high malpractice risk areas
Impaired Physician – Outcomes
Risk of relapse related to family history, opioid use, co-morbid psychiatric disorder
California – 73% drug free more than two years
Missouri Physician Health Program –90% recovery
Anesthesia – 56% success, 40% entered another specialty, 5% mortality within several years
Physician Health Program
Physicians Well-Being ProgramMedical Association of Georgia
339 Tenth Street, NWAtlanta, GA 30318-5681
(404) 875-1061 Fax (404) 875-3084 email [email protected] George D. Miller, MD, Medical Director Types of disease, illness, or conditions monitored:
– Chemical dependency – Mental health – Behavioral health problems – Sexual misconduct and/or boundary violations – Physical illness
Georgia PHP – Chemical Dependency
Length of contract: 5 years Random urine drug screen frequency:
– Year 1: 1 time per week – Year 2: 1 time per month – Year 3: 1 time per month – Year 4: 1 time per month – Year 5: 1 time per month
Support (self help) group requirements:– AA,,NA, Caduceus, Other: IDAA
Support (self help) group frequency:– Year 1: 3 times per week – Year 2: 3 times per week – To completion: 2 times per week
Therapy or treatment requirement: peer group required, other Tx as directed by provider
Work or practice monitor requirement: once weekly contact (minimum) Other provisions: monthly monitoring meeting with program representative
Georgia PHP – Mental Health Length of contract: 5 years Support (self help) group requirements:
professionally facilitated Support (self help) group frequency: as directed by
participant's psychiatrist of record Therapy or treatment requirement: as directed by
participant's psychiatrist of record Work or practice monitor requirement: weekly
contact Other provisions: as needed Other monitoring services provided: as needed,
committee monitor (quarterly), worksite monitor, therapeutic monitoring groups, hair analysis, naltrexone
Slides from this point on were not part of the presentations
USMLE #3
A 95-year-old woman in a nursing home has had advanced vascular dementia, severe dysphagia, and a 9-kg (20-lb) weight loss over the past 2 months. Her four children are divided regarding the decision to provide artificial feeding through a gastrostomy tube. There is no living will. The oldest son approaches the physician after a family meeting and says, “You should simply decide what is best for her and tell the others that’s what we should do.” Assuming the physician proceeds in this manner, which of the following best describes the physician’s action?
Best Interest Standard
Paternalism Preserving fairness in use of
resources Protecting patient autonomy Rationing care Truth-telling
USMLE #4
You are a psychiatrist and Mr. Moore is your patient. Mr. Moore has been talking to you for some time about his neighbor who, he believes, has it in for him. He tells you that he plans to get his revenge. He tells you he plans to kill his neighbor.
Tarasoff – Duty to Protect
Which is the best course of action?– Inform the police of this threat.– Inform the patient’s neighbor– Inform both the police and the patient’s
neighbor– Inform no one but focus on treating the
underlying illness
USMLE #6
You are preparing a clinical trial of different doses of a certain medication. This medication has already been proven to be clinically effective and is already approved by the FDA. You are only studying to see whether a higher dose of the medication will lead to enhanced benefit.
Tuskegee The Tuskegee Study of Untreated Syphilis in the Negro Male
– Do whites and blacks differ in disease course? Treatment planned, cut due to cost Participation of Tuskegee Institute, black nurse eased fears among men Macon County Medical Society, mostly black physicians, agreed to deny
treatment Treatment – arsenic, mercury, ASA, iron, spinal taps – perceived as far superior
medical care than usually received Later, men denied free care for syphilis at PHS clinics Study continued after Nuremberg and Declaration of Helsinki (1964) Expose 1972 ended the study $10 million settlement IRBs established Legacy of mistrust between blacks and whites in research
Where is Tuskegee Today? Vulnerable populations and research AIDS in Africa
– Is use of a placebo ethical? Children
– Proxy consents
Mortality and Vioxx
Data submitted to FDA concluded no significant risk
Intent-to-treat deaths in RCTs for Alzheimer’s– Subjects 34/1069– Placebo 12/1078 – Hazard ratio 2.99
JAMA 2008;299:1813
Policy on the rights of patients in medical education (BMJ)
For educational activities not part of clinical care:– Patients must understand that medical students
are not qualified doctors (and not "young doctors," "my colleagues," or "assistants"). • What about interns? Unlicensed physicians? Non-board
certified physicians? Do all patients understand the distinctions?
– Clinical teachers and students must obtain consent from patients before students take their case histories or physically examine them, making sure they understand the primarily educational purpose of their participation. • What is “primarily educational?” Students are valuable
history takers, examiners, etc.
BMJ Patients’ Rights II
Never perform examinations or present cases that are potentially embarrassing for primarily educational purposes without the patient's consent. When individual students are conducting such examinations a chaperone should usually be present.
Students should never perform examinations on patients under general anesthetia for primarily educational purposes without patients' consent. Patients who are unconscious or incompetent must be involved in primarily educational activity only with the explicit agreement of their responsible clinician and after consent from parents (children) or consultation with relatives (adults).
The Art of Pimping
To pimp: verb. To ask a series of progressively arcane and distantly related questions. The purpose is to establish or confirm power.– Historical, anatomical, physiological, clinical,
eponomical, characterological, hierarchical
Responses: bluffing, feigned erudition Brancati FL. The art of pimping. JAMA. 1989;262(1):89-90. Detsky AS. The art of pimping. JAMA 2009;301:1379-81