This article was originally published in the SCPS Newsletter, May 2017. It is reprinted here with permission and slight editing.
Physicians suffer from mental health conditions such as depression, anxiety, psychosis and bipolar disorder at the same rates as the general public. However, Physicians are much less likely to get the care that they need. Unfortunately, more often than not, healthcare providers end up relying on self-treatment. The reasons are varied and include lack of time, lack of ability to take off of work, inability to find someone to cover a shift and so on. The most common reasons physicians and other healthcare providers do not seek treatment is fear.
There is fear that seeking help will lead to medical board and licensing issues, loss of malpractice coverage, loss of one’s livelihood and so on. Due to these fears, mental health problems and addiction are two of the least likely medical problems a physician will seek help for. Somewhat counter-intuitively, those with more severe symptoms are less likely than those with mild symptoms to seek help.
Physicians and other healthcare providers who rely on self-treatment have worse outcomes than those who are under the care of a mental health or addiction professional. Some of negative consequences of relying on self-treatment include worsening of the primary condition (worsening depression, worsening anxiety etc), increased risk of substance abuse (self-prescribing addictive substances is never a good idea) and increased risk of suicide (see my article from last month). Additionally, self-treatment puts the public at unnecessary risk, as there are evidenced based treatments that physicians and other healthcare providers can receive to safely continue to practice medicine.
To me, the saddest part of these statistics is that there is solid data from decades of research that treatment of healthcare professionals is successful, highly successful. In fact, physicians have far superior outcomes than the general population. The standard of care for healthcare professionals is threefold:
1) A Thorough Evaluation: The evaluation should be conducted by a neutral and experienced clinician who has experience working with healthcare providers with suspected impairment and co-occurring mental health conditions. It should NOT be completed by a colleague, co-worker or someone who otherwise knows the individual personally or professionally. This evaluation should ideally be provided outside the healthcare system of the healthcare provider being evaluated to increase the opportunity for self-disclosure. Additionally, an evaluation provided by a colleague, friend, or someone otherwise connected to the individual, increases the risk of bias. Most notable, is the potential risk for under-recommending treatment, which directly undermines the care that will be provided and available to the healthcare provider. For example. if a physician needs hospitalization for their depression or psychosis, they should get it. There must be no erring on the side of caution because the evaluator has “worked with them for 10 years and is sure they will be fine”.
2) Treatment: The standard of care for healthcare providers with moderate to severe substance use disorders is 60 to 90 days of treatment. This is usually in a residential setting, with other healthcare provider peers. While this may be surprising, it is because healthcare providers serve the public in safety sensitive roles. While the general public can start with the lowest level of care and then increase the intensity if they fail/relapse, those in safety sensitive roles cannot take that risk. Doing so both puts the healthcare providers lives and career in unnecessary jeopardy and also puts the public at unacceptable risk. Getting healthcare providers into intensive and high quality treatment as soon as possible is the best way to insure they can return to work safely. After residential treatment, the healthcare providers should then step-down to outpatient treatment and monitoring (see below).
3) Monitoring: After completing treatment, healthcare providers continue to be monitored by outpatient providers (i.e. psychiatrists, addiction specialists, therapists, workplace monitors etc.) and also undergo random drug testing to insure they are doing well and in good recovery. The standard is five years of monitoring. This often takes place through State Physician Health Programs, which are separate from but are under the authority of the state licensing boards and also state laws. These programs insure that healthcare providers receive appropriate treatment and continued monitoring, while insuring the safety of the public.
Outcomes
By following the above standards of care, numerous studies have shown that over the five years of monitoring, after receiving treatment, only about 20-25% of physicians have a relapse. That is significantly less than the general population where as many as 50-90% of individuals receiving detox or outpatient treatment will relapse in the first few months. Overall, the data suggests that 80-95% of physicians are able to return to work and are able to do so safely.
Unconscionably, tragically and almost unimaginably, California is one of only three states that does not have a Physician Health Program. This has left individual hospitals to provide access to evaluation and referrals to treatment for their healthcare workforce. An organization, the California Public Protection and Physician Health (CPPPH), has been created to support a healthy physician workforce in the state of California.CPPPH is dedicated to enhancing patient safety by developing programs that assist health professionals who identify, refer, treat, and monitor physicians with potentially impairing conditions.
Without organizations like CPPPH, many healthcare providers who work outside of hospital settings would be truly on their own. A physician, or other healthcare provider, with depression, addiction or other condition, in the state of California, is basically left to fend for themselves. That is a tall order for someone who is in the midst of a mental health condition or addiction. There is already enough stigma, shame, fear and barriers for healthcare providers to get help. Why we have made it even more difficult makes absolutely no sense.
The good news is last year Governor Jerry Brown signed legislation that authorizes the California Medical Board to form a Physician Health Program. My hope is that it will be one that serves to promote evidence based treatment of physicians in our state. There is ample evidence that early intervention, thorough evaluation, high quality treatment and ongoing monitoring works extremely effectively. An important aspect of successful Physician Health Programs in other States is the ability for Physicians to self-refer, when they need help. Therefore, the program must be confidential, insuring that physicians getting the help they need can do so without additional stigma, public ridicule or punishment. This is the most effective way to insure patient safety.
Therefore, the most significant way to quickly improve patient care and patient safety in our state would be to get a quality Physician Health Program up and running, now. Delaying the development of a program, or creating a program that serves to penalize physicians with mental health or addiction conditions, only promotes the continued sweeping of these conditions under the rug and further stigmatizes healthcare providers in need of treatment.
In the meantime, those who specialize in the evaluation and treatment of healthcare providers with suspected impairment, mental health conditions, or addiction must pick up the slack. Getting treatment is always better than not getting treatment. Suicide, burnout, addiction and worsening symptoms are all known adverse outcomes when healthcare providers avoid seeking care and rely on self-treatment. Getting connected to a specialist can also provide access to employment/licensure attorneys, monitoring groups and drug testing and other resources known to promote solid recovery and the ability to return to work safely. The goal must be providing access to high quality care, focusing on the current condition of the healthcare provider and not their historical diagnosis and promoting sustained recovery for those who seek help.
If you or a colleague needs assistance, reach out to your hospital wellbeing committee, a local attorney experienced in healthcare/licensure law or CPPPH for a referral to an experience evaluator and/or treatment provider for Healthcare professionals.
Matthew Goldenberg D.O. is double boarded in General and Addiction Psychiatry and maintains a private practice in Santa Monica, CA. Dr. Goldenberg has presented data related to Physician Suicide, Physician Substance Abuse Physician Burnout and other Physician Health related topics, at local and national conferences. For more information about education related to Physician Health visit: www.ProfessionalsHealthSolutions.com