Ophthalmologists must take an active role in preventing impaired colleagues from hurting patients, according to Terri Pickering, MD.
"Unfortunately, the hallmark of impairment is denial and rationalization, not just on the part of the impaired individual but also on the part of bystanders," said Dr. Pickering, clinical instructor, California Pacific Medical Center, at the Glaucoma 360 22nd annual glaucoma CME program.
Ten percent of all physicians become impaired at some point during their careers. But 90% of physicians recover and return to a functional life, compared with only half of the general population, she said, citing a study in Can J Anesth (2017;64:219-235).
Physicians fall prey to career burnout, substance abuse, neurologic disease, vision pathologies, common aging decline, emotional and psychological problems, orthopedic issues, and anger and boundary issues.
Burnout predicts medical error more strongly than fatigue, and half of orthopedic surgeons report suffering from it, which is close to the 54% reported for all specialties, Dr. Pickering said, citing a study in CMAJ (2017:E1236-7).
"It's not only the number of patients and hours but the frustrations," she said. That sensation comes with a territory that includes fluctuating reimbursements, fears of malpractice, complex regulations, shifting electronic health records and coding systems, and patients who don't follow advice.
Aging and mid-life diseases take their toll but don't necessarily end the practitioner's career. For example, a doctor with Parkinson's disease may retain the fine-motor control and reaction time necessary for medical procedures despite a tremor. Orthopedic problems can also be overcome.
Only 39% of physicians are familiar with guidelines on when to report an impaired colleague, according to the Can J Anesth study.
It listed the following sings of substance abuse:
- Deteriorating quality of work, sloppy charting, increased surgical complication rate
- Mood swings, irritability, anger, euphoria or depression
- Lateness, forgetting to show up, rescheduling surgeries
- Withdrawal from family, friends and leisure activities
- Weight loss
According to the American Academy of Ophthalmology, physicians should withdraw from any aspect of practice affected by physical, mental or emotional impairment, and when impaired physicians don't withdraw, it is the duty of other ophthalmologists who know of the impairment to take action.
While this includes physical issues, substance abuse, abusive behavior and sexual harassment, it also extends to a colleague's reluctance to learn new techniques in the face of overwhelming evidence.
Dr. Pickering quoted a newspaper report about an ophthalmologist who was credited with helping to invent optical coherence tomography and served as dean of the medical school at the University of Southern California. The administration reappointed this ophthalmologist despite years of complaints of his "hair-trigger temper, public humiliation of colleagues and perceived drinking problem," and did not report his behavior to the California Medical Board, according to a Nov. 14, 2017 article in the Los Angeles Times.
Not only do colleagues have a duty to protect patients, they put their own practices at risk if they don't intervene, since partners can be liable for each other's malpractice, Dr. Pickering said.
She recommended that physicians concerned about a colleague's impairment begin the intervention with a friendly one-on-one conversation, optimistic in tone and including an offer to help. This could include an offer to join the colleague in answering the CAGE questions, which are aimed at revealing alcohol abuse.
If this approach doesn't end the problem, the next step is to document poor performance with specific evidence, not hearsay. A collegial meeting with a few peers can follow after that.
"Unfortunately, the hallmark of impairment is denial and rationalization, not just on the part of the impaired individual but also on the part of bystanders," said Dr. Pickering, quoting a 2014 article on EyeNet.
Next would come a formal confrontation, such as contacting the chief of ophthalmology or a hospital executive.
She pointed out that state medical associations often offer confidential help lines. Most regulatory bodies allow physicians to return to work after treatment for substance abuse, and only 20% of those who enrolled in a monitoring program relapse within 5 years, according to the Can J Anesth study.
"Self-care has to come before caring for others," Dr. Pickering concluded.