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Resource Document for Residency Training Program Directors

This document was developed to assist residency training program directors in the identification, intervention, and monitoring of residents who may be impaired, with input from directors in the state responding to a survey conducted by the PHR Committee in November 2007.

Scope of Problem/Favorable Outcomes With Treatment
Depression is the most common symptom in the residency years. Nearly 30 percent of residents will experience depression, particularly in the PGY-1 year and during rotations with long work hours.  Female residents may be somewhat more susceptible.⁶

The American Medical Association conducted a survey regarding resident physician substance abuse, to which there was a 60 percent response rate. Self reports of drug dependence were very low: 0.2 percent reported being dependent on amphetamines, and 2.3 percent reported dependence on tobacco. In the month preceding the survey, the following percentages of residents used these substances: alcohol (87 percent); cigarettes (10 percent); marijuana (7 percent); benzodiazepines (4 percent); cocaine (1.4 percent); and amphetamines, LSD, other psychedelics, barbiturates, heroin, and other opiates (all less than 1 percent). Use of substances was generally greater for male residents than female residents. The AMA study compared resident physicians with their age peers, which indicated an overall use of fewer drugs by resident physicians, with the exception of higher rates of alcohol use by male and female residents. Male residents used more benzodiazepines and opiates than their age peers but not to a significantly higher degree. Female residents’ use of benzodiazepines was significantly greater than their age peers. Prescription drug use was self-prescribed in the majority of cases for “self treatment.” Eighty percent of residents responding to the survey reported that they began use of most substances before medical school.⁶

Physicians have a significantly higher recovery rate than the general public from substance use disorders (SUD) providing they are properly diagnosed (including any co-occurring conditions), successfully complete a formal treatment program, and enter into a monitored program of follow-up including participation in random drug testing, appropriate group therapy (most often a 12-step type fellowship), and long-term accountability. ^{2, 3, 4, 5, 7}

Residents, on Occasion, Need Help
Residents continuously push their physical and mental capacities beyond their limits. They work in a state of sustained stress. During their medical training, residents are prone to “occupational hazards” of physical and emotional stress, long hours, irregular sleep schedules, and ongoing fatigue. As a result, they often develop alcohol or drug addiction or other conditions that may result in illnesses or impairments in their ability to practice competent and caring medicine.

Continued stress increases their chances of developing impairment that may significantly decrease the number of years they will be able to practice medicine. The Texas Medical Board (TMB) has requirements for reporting that are specific to residency training program directors.

Texas Medical Board Rule for Reporting Resident Physicians
TMB rule §171.6(b)  requires postgraduate training program directors to report to the executive director, in writing within seven days of the program director’s knowledge, the following circumstances for any physician-in-training permit holder completing postgraduate training.

• Did not begin the training program due to failure to graduate from medical school as scheduled or for any other reason(s);
• Has been or will be absent from the program for more than 21 consecutive days (excluding vacation, family, or military leave) and the reason(s) why;
• Has been arrested after the permit holder began training in the program; or
• Poses a continuing threat to the public welfare as defined under Tex. Occ. Code §151.002(a)(2), as amended.

    2.  If the program:

• Has taken final action that adversely affects the physician’s status or privileges in a program for a period longer than 30 days;
• Has suspended the physician from the program; or
• Has requested termination or terminated the physician from the program, requested or accepted withdrawal of the physician from the program, or requested or accepted resignation of the permit holder from the program and the action is final.

Postgraduate training program directors must ensure TMB receives annual reports regarding each permit holder’s progress while in the approved training program.

Failure of the director to comply with the provisions of TMB rule §171.6 or Medical Practice Act §160.002 and §160.003 may be grounds for disciplinary action as an administrative violation.  (A copy of TMB rule §171.6 is attached to this resource document.)

Identification
The following problem behaviors may be early signs of physician impairment.

• Overwork may be an early retreat from overwhelming personal and professional conflicts.
• Working hours become irregular and inefficient.
• Sleeping and eating habits become poor and irregular.
• The physician may withdraw from social and family activities.

In later stages of impairment, the physician may :

• Begin to have difficulties in the diagnosis and management patients;
• Be afraid to refer patients because contact with colleagues may expose perceived or actual deficiencies in patient care;
• Begin making hospital rounds at unusual hours or on a schedule different from colleagues; and
• Be difficult to contact. Nurses may complain of lack of availability.

Several areas of a physician’s life are affected by substance use disorder.

Intervention
An intervention team may consist of, but not be limited to, the following individuals:

• A coordinator;
• A person personally significant to the physician;
• A person professionally significant to the physician;
• A professional who is in successful recovery (if possible);
• A person board certified in addiction psychiatry and/or addiction medicine, if available; and
• A skilled interventionist.

The person reporting the resident physician may be invited to attend the intervention. Other people beneficial to the intervention (spouse, significant others, family members, close friend, but no member of the administration) may be asked to attend.

The intervention is planned without the knowledge of the physician. The intervention team must determine its leverage; decide when, where, and how to intervene; check insurance coverage; determine evaluation/treatment referral sources; plan transportation; anticipate excuses; and observe safety precautions. Final plans for conducting an intervention include defining roles/writing script, developing an agenda outline, reviewing ground rules, and rehearsing.

A successful intervention is best accomplished through a team approach. The goal of the intervention is immediate referral for evaluation.

Upon completion of treatment, the resident will require continuing care and monitoring. Provisions for disciplinary measures can address those impaired residents who either refuse recommended treatment or are unsuccessful in their treatment.

Treatment/Monitoring
A monitoring program includes the following components: (1) random drug screens, (2) written reports from counselors/therapists, (3) a self report provided by the physician in recovery, and (4) written verification of attendance of self-help and support group meetings.  

Some residency training programs have utilized resident assistance programs (RAP) of various designs to address resident impairment. Because of the unique structure of each resident training program, it is important to include necessary components of an RAP that could be integrated into a variety of training settings.

The resident physician who receives a recommendation for treatment must sign a release of information to the RAP. These records are crucial for the RAP to assess progress and treatment compliance. The RAP will be made aware of the treatment progress as reported by the resident physician’s provider.

RAP Design Models
Examples of RAP design models are the employee assistance program (EAP), the teaching hospital’s committee for impaired physicians, and the county medical society PHR committee.  Based on a survey of residency training program directors conducted by the TMA PHR Committee in November 2007, the EAP is the most commonly utilized model.

• EAP model — EAPs have been used to assist employees with personal problems such as substance use disorders, mental/behavioral disorders, and family conflicts.  An EAP may provide limited counseling, or an employee may be referred to another treatment provider for longer, or more extensive, treatment.3 Although many hospitals and teaching institutions offer EAPS for employees, resident physicians may not be covered by the EAP because they are not considered “employees.”
• Hospital committee for impaired physicians — Joint Commission Standard MS.4.80 requires hospital medical staff to implement a process to identify and manage matters of individual health for licensed independent practitioners that is separate from actions taken for disciplinary purposes.
       These committees are composed of medical staff members who educate, assess, and assist their peers regarding impairment. Some hospital-based committees are responsible for assisting resident physicians with hospital privileges. A variety of models exist for hospital committees to deal with impaired medical staff, prompted by the issue of the hospitals’ corporate liability for the actions of their medical staff.²
• County medical society PHR committees — Several county medical societies have a committee designed to assist with education, identification, and assistance for physicians who practice in that geographical area. Those resident physicians with actual or suspected impairment are reported to the TMA PHR Committee area representative.

Essential Features of an RAP

• Written policy statement and goals — An RAP must have a written policy statement and program goals that describe  resident impairment, those who are served by the RAP, the provisions for participant confidentiality, and the advocacy position of those associated with the RAP.
        The statement of policy should address procedures the RAP will be followed when suspected resident impairment is presented to it. Appeals processes, provisions for sick leave for those requiring treatment, confidentiality measures, disciplinary actions, and thorough documentation procedures would best be reviewed and approved by legal counsel.
        Written information describing the RAP should be distributed to each resident and spouse, preferably during orientation. A representative from the RAP could be available at such time to further educate new residents on impairment issues. Periodic educational programs regarding physician health and rehabilitation should be scheduled for all residents throughout their training.
• Supervising faculty — Supervising faculty need to know the purpose of the RAP, how to identify resident impairment, and the means to access the RAP. It is prudent to stress the importance of faculty members’ ethical and legal responsibility to address any suspicion of physician impairment. Although dispersal of written information is necessary, formal training sessions for all supervisors further enhance program effectiveness. All staff who interact with residents (e.g., nurses, clerical staff) should also be made aware of the typical signs of resident impairment and purpose of the RAP.
• Health insurance — Many programs require that payment for treatment be the ultimate responsibility of the resident; therefore, health insurance policies should be reviewed, and adequate coverage for inpatient and outpatient treatment for substance abuse and other psychiatric disorders needs to be ensured.

Documentation and Record Keeping
TMA policies with regard to record keeping and retention are as follows: (1) maintain accurate, written records, (2) know what information to include, (3) keep separate from other records, and (4) store in a secured location, with access only by a limited number of people, but always more than one.

All proceedings and records of medical peer review committees or interveners are confidential, and all communications made to a committee are privileged from disclosure. 

Accurate record keeping is the peer assistance committee’s best defense should a lawsuit occur.  Precise notes of each interview should be kept. The notes should contain documentation of dates and times of specific incidents regarding the physician referred to the committee. These records may include findings of reviews, interviews, or interventions; recommendations for follow-up treatment and/or monitoring activities; reports of follow-up or monitoring activities; committee correspondence; and reports made to TMB. Physicians should be identified in written records by coded number.

Resident assistance committee minutes and individual files of physicians should be retained for a period of at least 10 years from the date of receipt of information pertaining to a physician.  Within this 10-year time frame, the committee should have ample time to investigate a referral, conduct an intervention, and monitor the physician for a period of at least five years after return from treatment (and cover the four-year statute of limitation).

TMB: Self-Reporting and Licensure Issues

The 2005 Texas Legislature added a requirement to TMB’s self-reporting rule that gives physicians an added incentive to self-report drug or alcohol problems and seek TMB’s help.

The legislation prohibits TMB from issuing a confidential rehabilitation order to a self-reporting physician if, before the physician signs the proposed order, the board receives a valid complaint about the physician based on his or her intemperate use of drugs or alcohol in a manner affecting the standard of care (V.T.C.A., Occupations Code §164.202(b) (Vernon Supp. 2006).

For more than 10 years, the Medical Practice Act has provided TMB discretion to issue confidential rehabilitation orders to physicians with alcohol or drug problems (V.T.C.A., Occupations Code §§164.202-164.204 (Vernon 2005 and Supp. 2006). These physicians can come forward voluntarily and receive proper treatment without the fear of being disciplined by TMB. A violation of a rehabilitation order is grounds for temporary suspension of the person’s license.

To be eligible for a rehabilitation order, a physician must self-report to TMB and not previously have been the subject of a TMB substance abuse-related order. A nondisciplinary rehabilitation order is available to any licensed physician (1) for intemperate use of drugs or alcohol directly resulting from habituation or addiction caused by medical care or treatment that another physician provided, (2) or who self-reports intemperate use of drugs or alcohol during the last five years immediately preceding the report that could adversely affect the physician’s ability to practice medicine safely (22 Tex. Admin. Code Part 9 §180.1).

A physician may send a written self-report directly to TMB or on the renewal form where it asks if the licensee has been treated for drug or alcohol abuse. A self-report must contain (1) what substances the physician used, (2) how they were procured, (3) the length and extent of usage, (4) the method of ingestion, and (5) a history of treatment.

Although rehabilitation orders are confidential and not open to the public, the recovery status of a physician could be made known through other means to health care organizations with which he or she is affiliated. These situations exist whether or not a physician elects to self-report to TMB.

A physician involved in an effective monitoring program is able to document his or her continued recovery. This puts the physician in the best possible position to minimize adverse actions.

Summary

Although a percentage of resident physicians will become impaired, their outcomes for returning to the practice of medicine are quite positive when an RAP is well-defined and implemented.  Through early identification and treatment, resident physicians who are impaired can successfully return to the practice of medicine. Physicians have better treatment outcomes than the general population, when long-term monitoring occurs.⁷

Developed by:
Texas Medical Association
Committee on Physician Health and Rehabilitation
May 14, 1993; Review dates: 4/02, 2/08

References

1. Aach RD, Girard DE, et.al.  Alcohol and Other Substance Abuse and Impairment Among Physicians in Residency Training. Ann Intern Med. 116(3):245-54, 1992.
2. Blevins, JW, Bowers, C., et al. Relapse and Recovery: Five to Ten Year Follow-up Study of Chemically Dependent Physicians — The Georgia Experience. MMJ 41(4): 315-319, 1992).
3. Boisaubin, E.V. Identifying and Assisting the Impaired Physician. Am J Med Sci 322(1): 31-36, 2001.
4. Galanter, M., Talbott, G., Gallegos, K., Rubenstone, E. Combined Alcoholics Anonymous and Professional Care for Addicted Physicians. Am J Psych, 147:64-68, 1990).
5. Gallegos, K.V. and Talbott, G.D. 74 Physicians and Other Health Professionals. In J.H. Lowinson, P. Ruiz, R.B. Millman, and Langrod, J.G.  (Eds.), Substance Abuse: A Comprehensive Textbook. Baltimore: Williams & Wilkens, pp. 744-754, 1997.\
6. Nace, E.P.  Achievement and Addiction. Brunner/Mazel, Inc., New York, NY, 1995.
7. Reading, E.G. Nine Years Experience with Chemically Dependent Physicians: The New Jersey Experience. MMJ, 41(4): 325-329, 1992.
8. TMA Constitution and Bylaws, Sec. 11.621, May 2006 Revision.
9. White, RK, Schwartz, RP, et.al. Hospital-based Professional Assistance Committees: Literature review and guidelines. MMJ 41(4):305-309, 1992.

Resources

• Do You Know a Resident Who Needs Our Help?  TMA Committee on Physician Health and Rehabilitation, April 2007 (Order Form).
• Substance Abuse Among Physicians. Early Symptoms and Future Consequences: A Guide for Medical Students, Residents, & Practicing Physicians. TMA Committee on Physician Health and Rehabilitation, April 2007 (Order Form).
• Guidelines for Hospital Medical Staffs regarding Physician Health. TMA Committee on Physician Health and Rehabilitation, 2007.
• Live presentations given by the TMA PHR Committee upon request:
  • Care for the Caregiver (behavioral and emotional problems in physicians)
  • Chemical Dependence in Physicians
  • Coping With the Stress of Malpractice Litigation
  • Disruptive Behavior in Physicians
  • Effective Management of Difficult and Frustrating Patients
  • Effective Strategies for Smoking Cessation
  • Emotional Impact of Retirement on Physicians
  • How to Create Balance in Your Life
  • How to Establish a Peer Assistance Committee
  • Intervention for Physicians Who May Be Impaired
  • JCAHO Standard Regarding Licensed Independent Health
  • Maintaining Professional Boundaries
  • Monitoring Physicians in Recovery
  • Physician Stress/Burnout
  • Recognizing and Coping With Illnesses in the Aging Physician
  • Regulatory and Ethical Aspects of Prescribing Controlled Substances to Pain Patients
  • Spirituality in Medicine
  • The Family in Addiction & Recovery

          These courses also are available as home study courses and on the TMA Web site.

• Medical Staff Chapter: MS.4.80, Licensed Independent Practitioner Health, Comprehensive Accreditation Manual for Hospitals: The Official Handbook, 2007.
• Hughes PH, Conard SE, et.al. Resident Physician Substance Use in the United States. JAMA. 265(16):2069-2073. 1991.
• Smith, CS, Stevens, NG, and Servis, M. A General Framework for Approaching Residents in Difficulty. Fam Med 39(5): 31-336, 2007.

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Last Published: 2/22/2008