Impaired Physicians: Speak no evil?

Ethics sometimes takes a back seat to inertia, fear, or empathy for a fellow doctor, but patients may pay the price.

By Ken Terry
Senior Editor

Would you report an impaired colleague to the state medical board or your hospital's chief of staff? Sixty-five percent of the physicians who responded to our 2002 Ethics Survey said Yes, they would report a doctor who was impaired by alcohol or drugs, or had a physical or mental illness that could affect his job performance or judgment.

Internist Catherine Landers of Skokie, IL, is one of those who take this stance. "If we don't police ourselves, someone else is going to do it, and they'll do it more harshly than we might. It's a matter of professional pride, as well. I don't want bad doctors to give all doctors a bad name."

But several ethicists and professionals who work with impaired physicians think our numbers may represent conviction more than action. It's easier to check off a box on a survey than to do the deed. "People tend to talk to friends and close colleagues rather than turn them in," comments Paul Root Wolpe, a bioethicist at the University of Pennsylvania School of Medicine. "They're more likely to report the physician if the person has caused a problem with one of their patients."

Three respondents in 10 say they'd take the course Wolpe outlines, approaching an impaired physician privately to discuss his problem. Of course, physicians would be more likely to talk to someone they knew well than to one they had had only occasional contact with.

"If a doctor had a reputation for alcohol or substance use, and I didn't use him as a consultant, I'd probably not get involved," says FP Craig Wax of Mullica Hill, NJ. However, a staggering 95 percent of respondents say there is an ethical obligation to take some action if they believe a colleague is impaired.

In part, this reflects a cultural shift in attitudes toward addiction. Rather than being regarded as a moral failing that makes an individual unfit to be a physician, drug or alcohol addiction is now seen as a curable illness. As a result, physicians have been increasingly willing to urge addicted colleagues to get treatment, says FP Martha Illige, medical director of the Aurora, CO-based Center for Personalized Education for Physicians. (CPEP does not treat impaired physicians, but helps those whose clinical skills aren't up to par.)

Reporting doctors to the authorities is another matter. Clearly, many physicians would rather not do something that could end a colleague's career or boomerang on them. But Wax and other respondents who hesitate to turn colleagues in say that if they believed someone was harming or endangering patients, they'd report him immediately.

Licensing boards take a new stance

The AMA's Code of Medical Ethics leaves no such room for equivocation, stating that "physicians have an ethical obligation to report impaired, incompetent and unethical colleagues" and lists several guidelines to follow. Before reporting impaired physicians to the state licensing board, it says, doctors should try to get them into treatment programs or contact their hospital's chief of staff.

The reasons for using state licensing boards as a last resort may be disappearing, though. Many licensing boards will now refer impaired doctors who haven't injured patients to treatment programs without imposing sanctions on them, notes geriatrician Steve Miles, a professor of medicine at the University of Minnesota Medical School. The idea, he says, is "to get these docs diverted into treatment, instead of hiding out until they injure somebody."

Since physicians are still reluctant to go to licensing boards, doctors with substance abuse problems may also self-refer to "physician health programs," most of which are run by state medical societies. Twelve states have laws allowing physicians to refer colleagues to physician health programs rather than licensing boards if they haven't hurt patients.

The problem is that it's often hard to spot impaired physicians before they harm patients. In an academic hospital, says Paul Root Wolpe, "it's very difficult to be impaired or incompetent and not have that identified fairly quickly. But a community physician in a small community hospital is much less identifiable. So physicians are very reluctant to make these claims, put people's career at risk, and assume potential legal risk."

That risk may not be as great as some imagine, however. While a falsely accused physician could sue for slander, "in most states, there's immunity for good faith reporting," says Lee J. Johnson, a malpractice attorney in Mount Kisco, NY, and an editorial consultant to this magazine.

In any case, physicians shouldn't let the possibility of legal retaliation deter them from reporting a doctor who may be a threat to patients, says internist Leonard Morse of Worcester, MA, chair of the AMA Council on Ethical and Judicial Affairs. He advises physicians to first consult with other physicians who know that doctor.

Morse himself reported a physician who'd become addicted to pain medication following surgery. He did it after conferring with two other doctors who agreed that reporting the doctor was the right thing to do. They respected the addicted physician and wanted to help him, says Morse. "It was one of the most difficult actions I've ever taken."

Reputations are at stake

Some physicians fear other forms of retaliation if they report an impaired colleague. "They don't want to make an enemy," says Johnson. "They're looking for future referrals, and they also put themselves in the person's shoes, and think, 'What would happen if that was me?'"

Craig Wax can testify to that. When he got out of family practice residency several years ago, he would have been inclined to report any physician he suspected of being impaired. But since then, with both group and solo practice under his belt, he's decided it would be better to approach an impaired physician privately.

"I'd be afraid of ruining the other doctor's reputation. I'd also be concerned about earning a reputation as a whistle-blower," he says. "Other doctors may think I'm overreacting and say to themselves, 'Oh, it's just Charley. He's always done that, and he's always managed it. It's silly to report him.' "

Is it disease or disability?

Before reporting an impaired colleague, says internist Richard Waltman of Tacoma, WA, "I'd want to have a reasonable sense that I was right. I'd want to feel that my concerns were legitimate and that I wasn't misconstruing something."

You have to be especially careful when a colleague seems impaired but isn't a substance abuser. It's more difficult to be sure that a physician is suffering from a mental or physical illness, unless it has made him incompetent. FP Brian Nadolne of Atlanta says that if a colleague's hands were shaking, for instance, he'd probably ignore it. The shaking might not be indicative of Parkinson's disease, he notes—it could be benign familial tremor. "Unless I was his doctor, I don't think I'd address it."

Physicians with mental health problems may not seek treatment, notes Miles, because state licensing boards often equate a diagnosis of mental illness with impairment. He himself has bipolar II disorder. When a psychiatrist diagnosed him, Miles informed his clinical supervisors and the state medical board. The disorder has never interfered with his practice. Nevertheless, he recalls, "the board response was that since you have that diagnosis, you're impaired, and we want to see all your personal psychiatric records, and decide whether we want you to go into a monitoring program." (Eventually, the board complied with a federal ruling that it couldn't infer occupational impairment from a mental health diagnosis and that Miles' medical records were protected under the Americans with Disabilities Act.)

Incompetence is even harder to detect

Physicians are also supposed to report doctors they deem incompetent, but this is trickier than identifying impairment or disability. If you assist someone at surgery or some other highly visible activity, you may be in a position to evaluate his competence. But how do you know whether what someone does in his office meets the standard of care, especially if he's in a different specialty?

Some outcomes information is becoming available in areas like cardiac surgery. But most doctors don't use that data in deciding on a referral; in fact, they rarely even check publicly available information on sanctions by state medical boards.* So their knowledge of whether a consultant is competent comes mainly from patient feedback, hunches, and hearsay.

Contrary to the claims of organized medicine, doctors rarely weed out incompetent and impaired physicians by not referring to them, says ethicist Paul Root Wolpe. "It happens now and then with extraordinarily incompetent people. But for small mistakes, for slight impairment, for people who manage to keep their jobs in the face of addictions or other types of problems, that system works very poorly, especially at a time when managed care has put constraints on referrals. Physicians have to refer within networks that have a limited number of doctors."

We asked about referrals in our survey. Eighteen percent of respondents say they've referred to a physician in their group or managed care network even though they had concerns about that doctor's suitability. Family physicians and GPs are most likely to have done so—probably reflecting the fact that they form the core of many closed HMO networks. Similarly, physicians in large groups are more likely than soloists to refer to unsuitable specialists because those consultants are part of their group.

Wolpe notes that the ethical situation is rarely black and white: Physicians have a range of competencies, and referring doctors must deal with economic realities such as the financial survival of their group or their need to participate in a dominant health plan.

Some physicians, though, simply refuse to deal with HMOs that limit their choice of specialists. Internist Catherine Landers of Illinois is one of them. "I'm not going to be put in the position of choosing care for a patient vs money in my pocket," she says.

*See How good are the specialists you refer to?" June, 18, 2001).

Ken Terry. Impaired Physicians: Speak no evil?.

Medical Economics

2002;19:110.