Talking About Impairment Video Transcript

Interpersonal Communication And Relationship Enhancement (I*CARE)
Talking About Impairment
Date: March, 2012
Time: 1:04:16


Good morning all. Dr. Ralphs, members of the department. Dr. Walsh, welcome to anesthesia rounds. Today we have the first ever I believe presentation for the Practitioner Peer Assistance Committee. I think Dr. Walter Baile is going to start this off, or Dr. Georgia Thomas, one of the two of them. Dr. Georgia Thomas.

Good morning and thank you all for giving us the opportunity to come and talk to you about the subject of practitioner impairment. What you're seeing here is a true group effort by the--by MD Anderson's Practitioner Peer Assistance Committee. We want to hope--we hope to develop a conversation with you around impairment and we're interested in your responses. We're trying to reach each of you as personally as possible. We're going to do this by not only slides but also by asking you to use the audience response system. We have a little role play that we're going to do a case study, and then we're also going to have a panel discussion at the end. So what I'd like to do to begin is to ask the committee members to briefly introduce themselves, so you can put names with faces.

Good morning everyone. I'm Dr. Tayab Andrabi from the Department of Anesthesia.

Pat Lynch from Gastroenterology, Hepatology and Nutrition.

John Hyatt, Director of Employee Assistance and Employee Health and manage the Fitness-for-Duty program.

Elise Cook, Clinical Cancer Prevention.

Warren Holleman, Behavioral Science.

Good morning. I'm Kathy Rickman. I'm a psychotherapist and an addiction specialist with the Department of Psychiatry. I'm chairman of the board of the Advisory Committee to the Board of Nursing and to the Texas Peer Assistance Program for Nurses. MD Anderson has a wonderful reputation in the medical center for being very TPAPN friendly, I'm very proud of that.

Good morning, I'm Todd Pickard. I'm the PA Program Director in the Division of Medical Affairs.

Good morning. I'm Walter Baile and I'm with the Department of Behavioral Science and Faculty Development.

And Walter is going to briefly explain the audience response system.

Okay, so what we've done is to try to make this presentation as interactive as possible. So, as Georgia said, we'll have a panel discussion, we'll have a little skit to start us off and then you all each should have one of these transponders, okay, a clicker, which will allow you to answer some questions which we--Georgia has embedded into the PowerPoint. So that the first thing you need to know is that if you push the little orange button that turns it on. So if everyone could just turn it on, that would be great. And what you'll--what will happen is, is that you'll see a question with the ability to select an answer from A to E, and all you do when we say we're open for responses, just press one of the buttons and you'll see a little click mark on your screen. If it doesn't click, press the--a green one which is the reset button and that should take care of it. If you try to vote twice, you'll get a shock and a loud sound will go off calling attention to you. So the only other piece of business that we have is if you could turn your cellphones and pagers, et cetera, to vibrate. So give people a chance to go. So I think that should take care of it.


And we'll turn it back over to Georgia.

For the first half of our hour long discussion, I'm going to talk to you about the Practitioner Peer Assistance Committee and its charge. We're going to review the definitions of impairment, talk a little bit about the most common impairing conditions in practitioners and what the signs are. And then we're going to proceed with the panel discussion where we'll try to answer any questions that you might have. But we're going to begin with the case. This is a hypothetical case. So we've got Jack who's a 40-year-old internist and he's worked at MD Anderson for almost a decade. His practice includes outpatient care, rotations on the inpatient service, and he also does some procedures. He's normally a very easygoing and very well liked physician but he's had some problematic behavior over the last several months. He's been late for clinic. He's been heard to raise his voice at the nurses, very unusual for him. And he was seen dozing in clinic on Friday between patients. His handwritten consult notes have become short and almost illegible. And he has stopped coming to departmental meetings. So, keep that case in mind and I'm going to now ask our committee members to come up and we're going to do a little role play about what Jack's colleagues are thinking about him.

So we're eavesdropping here on the conversation about what's going on with Jack.

Hell, if I know. All I know is he's screwing up the clinic schedule, he's coming in late everyday and I'm getting sick and tired of it.

Did you see him yesterday? He barely said a word to anyone including his nurse. And I think his speech was slurred. You don't think he's drinking, do you?

I haven't been around Jack much lately but I think if you have a serious concern that he might be impaired, you need to report that either to the EAP or the department chair.

Well, his cat told me he was going through a terrible divorce and who wouldn't be off their game with some stress like that at home?

You guys are more sympathetic than me. I would confront him but it'd be a waste of time, he'll look--he'll just explode and telling the administration around here about stuff like this is a total waste of time.

Thanks guys. When behavior changes, it's sometimes difficult to figure out what to do and although a conversation like this in a break room may not literally occur, that kind of thought process is occurring for many colleagues who watch troubling behavior. So our intent here is to try to give you a sense of what the spectrum of impairment is like and then talk about what the best things are to do when you as a colleague notices something like this.

So why are we here? This is a patient safety issue. MD Anderson's Practitioner Peer Assistance Program is a standing committee of the medical staff. Its charge is to provide peer-to-peer support for licensed practitioners who are struggling with problems that may already be affecting performance or might affect performance in the future. So our twin goals here are patient safety and to maintain health and productivity for our practitioners. The Practitioner Peer Assistance Committee covers every licensed practitioner at MD Anderson with the exception of CRNAs and APNs who are covered under different policies. And I'm going to read you the list of licensed practitioners that come under the structure and function of the policy. That includes physicians, PAs, dentists, medical physicists, speech pathologisst, psychologists, and a few other PhD clinicians in cancer prevention. We're trying to make a difference here by providing education, peer support, and most importantly, we're all available for consultation for any individual who watches problematic behavior and is concerned about impairment. So how do you reach us? The easiest thing is to pick up the phone and call this extension. The telephone number is a dedicated line. It rings into the Employee Assistance Program and is answered by staff there. You could also go online and look under faculty resources, take a look at all the committee members. It's frequently easier to talk to someone that you already know about a problem like this. Okay, now we're going to begin with our first question. The question is, "Impairment refers to any physical, mental, or behavioral issue that interferes with the ability to: A, complete your dictations; B, get to the OR on time; C, bill for your services; D, engage safely on professional activities; and E, give feedback to health staff. Please vote with your systems, A through E, and then we'll take a look at the results and the voting is open now.

[ Inaudible Remarks ]

Has everyone voted that intends to vote? By the way, this is an anonymous system, there's no way that your response can be tracked to your name. Okay, and what a well-educated group we've got here. You can see that the vast majority of people picked the answer that's most correct, that is impairment involves the inability to engage safely on professional activities.

[ Noise ]

Okay, let's talk about what impairment really means. There are 2 good definitions that are in wide use. The first one is the American Medical Association definition that you see up there, "Any physical, mental, or behavioral disorder that interferes with the ability to engage safely in professional activities." And then there's also an excellent definition from the Federation of State Medical Boards that I'm going to read to you. "The inability of a licensee to practice medicine with reasonable skill and safety, by reason of mental illness, physical illness, or habitual or excessive use or abuse of drugs, alcohol, or other substances that impair ability." So there's a difference between mild forms of impairment and being unfit for duty. The mild impairment that occurs after a night without sleep may be minor enough that you're able to see patients the next day with no decrement in your professional performance. The impairment that occurs with alcohol intoxication on the other hand is serious impairment that is going to make you unfit for duty. Serious impairment is what these 2 definitions are revolving around and MD Anderson has a strong Fitness for Duty for policy that requires all of you to report signs of serious impairment. We regard serious impairment as a medical and a safety emergency. So what you're looking at here is a list of types of impairing conditions that were reported to the Texas Medical Association's Physician Health and Rehab Committee by county medical societies in 2010. And you can see we're looking at a spectrum of things, physical disorder, substance abuse, psychiatric illness, a sprinkling of other causes of cognitive impairment, and then finally, disruptive behavior. So we have another audience question here. Of these conditions, which one do you think was the most commonly reported to the TMA? A, physical disorders; B, substance abuse disorders; C, psychiatric illness; D, family problems; and E, cognitive impairments. The voting is open, please select the best answer here.

[ Noise ]

Okay, we've got a sprinkling of responses. The actual answer here is "Substance abuse disorders." Remember, this is a pretty specific sample. It's individuals who have come to the attention of county medical societies and 66 percent of the reports in that year were substance abuse disorders.

[ Noise ]

Now let's talk a bit about common impairing illnesses in practitioners. As I go through the slides, most of my data is on physicians because there's more written on physicians and nurses than any other licensed practitioner. There's some data available on dentists, the data on PAs is really pretty sparse, and below that, we don't have a lot of data. But what we do know about physicians is, no surprise, we look just like the US population. So we have a 10 to 15 percent lifetime incidence of substance use disorders. With alcohol use disorders, slightly more frequent than pure drug abuse disorders. Now, there are also differences between us and the US population in the drugs that we abuse. Physicians are much less likely to abuse, frankly, illegal drugs like marijuana and heroin, and much more likely to abuse narcotics and benzodiazepines. And as you all know, in this audience, ease of access is an important decision maker in a drug of abuse. So the individuals who have access to anesthetic drugs, the most common drug of abuse is fentanyl and its analogues. For dentists, one of the most common drugs of abuse is nitrous oxide. And the most common predisposing condition that leads to substance use disorders in physicians is a genetic predisposition. There was one study of physicians who were--who had gone through treatment and who are already enrolled in monitoring. Thirty-nine percent of this sample had had either substance use disorder prior to entering medical school or a major psychiatric disorder. So we bring our vulnerabilities into our specialties with us. Another common impairing condition is depression. Again, the data on physicians suggest that incidence rates are similar to the general population, but notice how high those rates actually are, higher for female physicians than male physicians. Depression in post-graduate training programs is a big issue. Up to 30 percent of residents meet criteria for major depression at some time in their training program. Although the rate of depression as a diagnosis is similar, suicide rates are higher for physicians compared to the general population and you can see the statistics there, 40 percent higher for male physicians, much higher for female physicians. Some of this may relate to our knowledge base in the fact that we know about the lethality of medications and we're more successful when we make the attempt just like law enforcement personnel are as well.

The intersection between depression and substance abuse can really be a fatal circumstance. Ninety percent of physicians who commit suicide have a diagnosed mental--mood disorder, no surprise there. But up to 50 percent of physician suicides occur in a setting where self-prescribed medication is occurring or where substance abuse is occurring. And I think that what this reflects is the disinhibition that can occur with substances making the difference between thinking about suicide and actually going through with the act. Physical disorders, also common causes of both mild and serious impairment. Cognitive decline is a spectrum. It includes everything from the minor declines that occur with normal aging through mild cognitive impairment and finally into frank dementia. It's been astonishing to me how well-preserved clinical functioning can be in the presence of neurologic illness. About 10 years ago I saw a nurse who was referred over to employee health because she was getting lost going to the cafeteria. And she was performing a very complex postoperative procedure on a lot of patients and her supervisors said, "I don't know what's wrong with her, she's fine when she's seeing patients." When she came over she had a very abnormal mental status exam, indeed was getting lost in other places besides the cafeteria and turned out to have early Alzheimer's, but still continued to function in a fairly narrow scope successfully. Acute and chronic illness, also causes of impairment, as are the medical treatments side effects of some chronic illnesses. Sleep deprivation is an occupational hazard for everyone in this room, I'm sure. Remember that sleep deprivation preferentially affects executive functioning and concentration. The sleep study people say that a night without any sleep at all is equivalent to a blood alcohol concentration of 0.05 to 0.07 percent, so it's a common cause of mild impairment and can be a cause of serious impairment as well.

Do our careers put us at risk? This is Dr. Baile's slide. I don't--you know, I don't know the answer to that, but I am fairly certain that there's a lot in medical careers that conspire to make it difficult for us to ask for help when we need it. So we have the stressors of long work hours, time demands. Working in oncology is a stressor in itself. I think you're all familiar with the syndrome of burnout. There have been some studies of oncologists that show that 50 to 60 percent of clinical oncologists have experienced symptoms of burnout at some point in their professional careers.

Compassion fatigue is also common. That is distinct from burnout and reflects a helper who has experienced tension and emotional distress as a result of the process of the suffering of others. So that individual may experience symptoms of burnout but in addition goes through actual symptoms of secondary psychic trauma as a result of the helping experience.

Is there a medical personality? I don't know but I do know that some of the characteristics of the medical personality that make us fabulous physicians also put us at risk. So, perfectionism and the belief that you have to do everything correctly, that you can't make a mistake. Self reliance, our ability to postpone gratification almost permanently if necessary. We're not good at routine medical care. We're not really very good even at acute medical care for ourselves and even less competent probably at mental healthcare. We have some trouble setting limits both at work and at home and we tend to put off vacations, rest. Again, this is almost allegorical, but I think everyone in the room maybe able to recognize himself or herself in that list of vulnerabilities. Well we have a little bit of information about physicians at MD Anderson.

Between 1990 and 1997, the vice president for medical affairs, a surgeon, decided that he was going to standardize his approach to physician behavior problems that had trickled up to his office. So, these are individuals who had already been dealt with by their department chair or division chief. And as a result of that standardization, he referred every case over to employee health. I didn't always see the individual directly but I reviewed a lot of paperwork and information about the cases. And when this individual left MD Anderson, I went back and looked at the cases thinking that there might be something that we could provide in employee health structurally that would be more effective. And what I saw diagnostically exactly matched the percentages of impairing conditions that the Federation of State Medical Boards was reporting for that time. So, we were mostly seeing disruptive behavior. Right below that was psychiatric illness, then a sprinkling of substance use disorders, and then a few illnesses that have cognitive impairment. So my point in presenting this is that we are not unique, we are absolutely typical of medical institutions across the country. Okay, we have another audience response system here. About what percent of these physicians do you think lost their positions at MD Anderson involuntarily? And by that I mean they were--their contracts were not renewed, their contracts were terminated, or they were forced to resign. And your choices are: A, 80 percent; B, 50 percent; C, between 20 and 40 percent; and D, less than 15 percent. And we're going to open the voting now.

[ Pause ]

Okay, and it looks like most people picked D, less than 15 percent. And you're right. The actual percentage was something like 14.8 percent. That is not to say that these physicians didn't have career consequences as a result of their behavior here at MD Anderson. There's no question that as you go through an impairing condition that our career sometimes stall. But MD Anderson as Dr. Rickman said, has an excellent reputation for hanging in there with people, allowing them to go through treatment and then having them come out and resume their careers. I go to a fair number of promotion as well as retirement parties and several years ago I was at a retirement--a promotion reception, there were 2 physicians there who had been promoted to full professor and both of those individuals had been through substance abuse treatment. So, careers do not end as a result of getting adequate treatment for a problem.

[ Pause ]

Another question here, all of the following are signs and symptoms of impairment except, and you're going to pick the answer that's incorrect. A, frequent tardiness, clinic schedule disruptions, unavailable or late when on call; B, regularly skipping lunch; C, irritability, all of those emotional symptoms; D, a decline in work performance; and E, patient complaints. So, please pick the answer that is least likely to be correct, and we're opening the voting now.

[ Pause ]

And most of you chose that the most incorrect answer which was skipping lunch. We do not advocate skipping lunch. It's a risk factor for fatigue and weight gain. But I'm going to ask you to look again at the symptoms of impairment here because what you're seeing here are the most common things that trigger a concern in a colleague's mind. And I can tell you through almost 30 years of experience with impairment, if you are worried about a colleague, trust your intuition. There's almost always something wrong. What prompts intervention on impairment? A number of things, the most common is that behavior is appropriately observed, is reported, and we're able to get help for that individual. A second event is that patient safety is clearly a risk, either we have a near miss or we have a catastrophic event and then everyone says, oh my gosh, I thought there might have been something wrong but I didn't know what to do or I wasn't sure. And then finally sometimes families intervene. About once a year I pick up the telephone and there's a family member on the other end of the line saying, please help me. Remember that professional functioning is preserved to a really strong extent even when problems like substance abuse are very far advanced, so families have frequently fallen apart. Everything is wrong at home and still people appear to be functioning relatively well at work, which is the reason why sometimes family intervention is so valuable.

Barriers to care. Gosh, this list could be twice as long as it is here. The stigma of mental wellness, the stigma of substance abuse, concerns about discrimination and the effect on your career. As we said, mental health is kind of a low priority for physicians. And some of you may be unaware that you have an affirmative duty to report. MD Anderson policy requires the reporting of severe impairment and if you have a license in the state of Texas by any licensing board, your licensing board has probably required that you report impairment as well. So, we do have to report these things, as well as the moral reason for reporting. One of the true barriers is that not only these signs and symptoms evolve slowly, they don't--they aren't necessarily progressive. They can be intermittent and they also can be cyclical. So you can observe a problem and just as you're ready to say to yourself, I need to say something, things magically improve and everybody breathes a sigh of relief, keeps their fingers crossed and waits until the next time. So that cyclical natures of symptoms, plus the fact that each of you has only a little piece of the puzzle here inhibits reporting. And then, denial about the problem, concerns about what if I'm wrong, what am I going to do to this person, am I going to wreck my professional working relationship with this individual as a result of reporting. And then the culture of medicine that makes it very difficult to admit error. And finally, sometimes we have a low knowledge of the resources that are available. We're going to send out a resource handout that list every place that you can go inside MD Anderson for advice, both anonymously as well as in person. Another audience question. What percent of physicians who successfully complete treatment and monitoring are abstinent 5 years later? A, 20 percent; B, 40 percent; C, 60 percent; D, 80 percent; and E, 100 percent. Please go ahead and vote.

[ Pause ]

Okay, and the correct--the correct response actually is 80 percent, and I'm really pleased to see that everyone has a fairly optimistic outlook about treatment, treatment for physicians, for anyone whose license is at risk can be very, very successful.

[ Pause ]

Now impairment doesn't just occur with physicians. We see impairment in the general employee population. So I'd like you to take a guess at this question. At MD Anderson, in the general employee population, the medical diagnosis that most commonly causes severe impairment is, A, insulin dependent diabetes; B, chronic pain syndromes; C, chronic liver disease; D, complications of cancer; and E, none of the above. Please go ahead and vote.

[ Pause ]

Okay, this is an interesting question and actually the answer is A. It's type 1 diabetes with tight control of glucose and episodes of hypoglycemia at work. We have many people who are in shift work that is very unsupportive for the monitoring of glucose, the need to take frequent breaks. So that is our hands down most common cause of severe impairment. But the other diagnoses that I've listed here also present as impairing conditions.

[ Pause ]

Okay, let's return to Jack, our internist who is yelling at the nurses in clinic, becoming late for clinic and having notes that are illegible, short notes, and in general not being himself. So remember the water cooler conversation. So I'd like you to try to answer honestly for this and there probably are no right or wrong answers. If I were to see someone like Jack in my clinic, I would most likely, A, talk about it at the break room, I don't know how many people even get to the break room these days. Talk about it in private with a colleague. Tell my chair or OPPE officer in my department. D, talk it over with Jack, and E, none of the above. And we're opening the voting now. ^M00:31:15

[ Pause ]

Okay, the majority of you would choose to tell your chair or your OPPE officer, that's an excellent choice. Of all of the choices here, I think the one that's least likely to be useful is to talk about it over the water cooler. Because you run the risk of having other sympathetic people argue you out of what you know to be true. And my experience is that talking about things like this usually doesn't result in anyone doing anything. So I would encourage you to look at other options there. Okay, let's think back about Jack and although we only expect you to report symptoms and signs when you're worried about impairment, I'd like you to take a guess at what Jack's actual diagnosis is. So, his most likely diagnosis is A, sleep deprivation; B, substance abuse; C, physical impairment; D, cognitive impairment; or E, depression, and let's vote now.

[ Noise ]

Okay, so majority of you thought that his problem is substance abuse. Well, Jack's actual diagnosis is an acute inflammatory polyarthropathy. He is on oral steroids --for his joint pain. He is also taking pain medication at work occasionally. He has not told anyone about his diagnosis because he's afraid of the career repercussions. His sed rate is 100. The rheumatologists are having a field day, and he's terrified. So, my reason in presenting this case is to point out to you that not everything that looks like substance abuse actually is, and to point out the complexity of the problems that we sometimes see because it's very possible that Jack's episodes of sleepiness are caused by the taking of pain medications even if he's taking them as prescribed, and his irritability may be related to his steroid use.

[ Noise ]

So as we think about impairment, I'd like everyone to think about what your own personal responsibility is, both to yourself and to your colleagues. Where you can go for help and how you begin. Remember that this is a fatal condition. Patient lives are at risk and so are the lives of healthcare workers. So it's imperative that we act. One of the things you need to remember about impairment is that it's accompanied by a fairly dramatic failure of self insight. So that feedback loop that happens in normal people where you're able to contemplate your own behavior is broken in many forms of impairment. So the only way that someone is going to get help is if other people intervene. And now I'm going to turn it over to Dr. Baile who has a few more questions and then we're going to go to the panel discussion.

So, I think that what we're probably going to do is take questions from the audience now and see if anyone has any comments or questions and at this time maybe I can ask the panel to come on up, members of the PPAC to come up and sort of help us kind of answer any questions, or maybe comment on the presentation with anything that, you know, they'd like to say. Anyone? Yes.

So, is there any effort within professional societies to know that a lot of people that have a diagnosis of psychiatric disorders are required to report it to the Texas Medical Board, and such and then, I think that becomes a barrier to a lot of folks in getting help. And I noticed on one of the slides it said you know that with depression and psychiatric illnesses, there’s a lot of self-prescription, or others that--I mean, do you see that being addressed because, you know, in other careers, is that I think in other professions it has been more accepted but--and now you put that issue--I mean is there any [inaudible] to them?

I'll go ahead and repeat the question. The question is, whether or not professional societies are making any inroads on the problems of needing to self report to boards and the consequences of that, and the implication of course is that you are less likely to get help for your problem if you have to self report. Well, I'm happy to tell everyone that at least in Texas we're making some inroads in that. There is now a Physician Health Program in the State of Texas that handles all complaints to the Texas Medical Board that involve impairment. They exclude from that sexual misconduct and ethical misconduct. But if you call the Board of Medical Examiners and say, "You know, I'm really worried about Dr. Rickman or Dr. Lynch, I'd like to report impairment." They'll say, "Thank you for your phone call, we're going to transfer you over to the Physician Health Program." The advantage of that now is that you're going to be looked at and monitored by people who actually understand impairment. The PHP is actually an arm of the Texas Medical Board, but it's operating fairly independently, and I think the process of monitoring now is a lot more civilized than it used to be. You still are required to report, and at that time of renewal of your license, you're required to report your problem. But as long as you are being monitored by the Physician Health Program, there's going to be a box on the license renewal that says, "Yes, I have a problem, but I am being monitored." You can check that box and that puts you into the arena of the Physician Health Program, rather than the board.

I'd like to add to that as far as nursing is concerned, the statute for mandatory reporting is covered by civil immunity. In nursing, only 5 percent of our cases that we have right now, 650 active cases in Austin, 5 percent are self referral, most are third party referrals, but we have a hotline that anyone can call as an option for your concern is to ask questions anonymously to this 800 number at the Board of Nursing and say, I'm working with a colleague, I have suspicions, I'm not sure what to do, and they will advise nurses about what the next step is.

So can I push that one step further because--so someone calls up to the physician hotline or concern desk and says, "I'm concerned about my colleague doctor so and so because I've seen such and such and such and such." What happens at that point? Do we know that--how--is there an investigation and how does that happen then?

So the question is about the Physician Health Program, Walter?

Yeah, yeah.

Okay, so the question is, you're worried about a colleague, you call the Texas Medical Board and you're transferred over to the Physician Health Program, and you say, "I'm worried about so and so, what happens next?" They're going to take your name and listen to your story, and then get some collateral information as best as they can, and then they're probably going to send someone out to interview you and then to interview the physician in question. So this is a pretty hands-on process. If they can't get any additional collateral information, then they will go ahead and interview the physician in question and say, "We're here from the Physician Health Program, there's been a concern about your behavior, can you talk to us about it?"


On a different subject


I was interested to learn more about the compassion fatigue. I don't know if this is--there's any kind of programs or, you know, classes you can go to, I mean I've been here 10 years and I have found over the last probably 2 years--I have 2 children, 6 and a half and 22 months, and I find taking care of children, because we see them, you know, quite frequently, and you see the same children over and over again. That it--it causes anxiety, you know, and you kind of build this, you know, rapport and relationships with the children and the parents, and how do you—I mean do you see people, you know, come to your clinic or come to your office and say, "How do you deal with this?" You know, not just on a professional level but, you know, on a personal level, I think that's one of the hardest things working here is how do you deal with that?


You want to repeat the question, John, just so everyone--

Sure, yeah. Compassion fatigue, dealing with acute patient situations and the effects of potential burnout or risk for burnout for the clinician, and the Employee Assistance Program is involved in both individual consultations for that. If there is personal stresses that accompany that are concurrent with difficult situations, patient situations, that can make the risk even greater, I think for compassion fatigue and burnout. But one of the things that we're working on is trying to develop informal or formal peer assistance, just making sure that you've got someone that you're comfortable with that you can go to when there's an acute patient episode that you can trust, that you can emotionally debrief with. So, I encourage you to do that informally or to call the Employee Assistance Program where we--we also do classes in that as well, and I know that within the nursing division, John Luquette--there are a number of people that are trying to address these issues. But what you can do yourself above anything else is just being mindful of how that's affecting you, so that you can do more in the way of self care, and support each other.

So, recently, we did some focus screenings with pediatric nurses in the intensive care unit, and they have an informal system where they get together for breakfast, especially after there's been a death of a child that everyone kind of got involved with, and was very—attached to So that happens a little bit informally but you're exactly right, that we need to make people aware of the fact that self care is probably the most important thing that we can do for ourselves that mitigate some of the stresses of the--working in the cancer environment and suffering patient loss. And you know, not only Americans but I think physicians often are the highest professionals in the population in terms of taking the fewest days of vacation that they have coming to them, and I know that recently in the institution when, you know, there's been a sort of financial crunch that sometimes that vacation has been put off so that we could meet quota in numbers. And I think that, you know, hopefully that epic has passed and that folks, and especially people in the leadership should encourage employees to take vacation especially folks who work in high stress areas, so that's a leadership issue also, I think. Yeah.

There's a comment and really 2 follow-up questions. In anesthesia, the incidents of substance abuse or access obviously is a lot higher than the general healthcare population. So, first question is, is I think one of the things that we struggle with all the time is trying to iden--I figure there's what, 150 of us and I'm trying to identify somebody in a preventive aspect as looking out for the signs and symptoms of what are those signs and symptoms to be able to identify the individuals, and then looking for some form of a reporting path. And I know through nursing we have the peer review reporting system which I've accessed a number of times. Now, this type of situation but is there a--I guess a reporting structure not just for nursing but for our entire employee population here in MD Anderson before accessing things like for nursing there is TPAPN and then there's the state hotlines and stuff, so that we can take a proactive approach from an institutional standpoint.

[ Inaudible Remark ]

You want to--

Well, I mean, the--[ simultaneous talking ] yeah--if I understand your question, it's to how to report the numbers of clinicians that might be impacted--

Not the numbers, it's like--so if we, I mean, every single one of us is I'm sure not mature enough in the sense of what are the indicators to say, this individual, it looks like you're falling into that trend.


And then what's the reporting structure?

So where can you go if you have a concern? Where can you go? So what are the resources? You'll be getting actually a handout on that through email, but maybe you can briefly sort of talk about the resources that folks might go to informally to check out whether or not a concern is valid or serious enough, or get some ideas about what to do about it.

Sure. So the question is really who to consult with about concerns, and there are a number of people, certainly the practitioner peer assistance committee would be anyone on the committee you could consult with if there are concerns about potentially serious impairment that may affect patient safety. As Georgia has said, one of the things that you can do is call Dr. Thomas or myself to see if this might reach the level of serious impairment, where we need to invoke some of the procedures with the fitness-for-duty, but we're really trying to--this is an effort to try to proactively make an effort as early as possible. I think supervisor involvement is the crucial, crucial point here, and colleague involvement, just this tough love approach, when you are concerned enough and you care enough about a coworker who is distressed, your conversation with that colleague is the first and most important step. If they don't respond to that initial effort of expressing your caring and concern, then you can bump it up to a higher level. Anybody else want to comment on that?

With regard to your question about signs and symptoms of impairment, particularly in anesthesia that's almost a discussion itself but erratic behavior and if we're talking about someone who's diverting narcotics, any kind of behavior that's out of the norm that would enable that individual to have contact and to able to divert is important to look at. Some patterns that you might see are people who are coming in ultra early, who offer to help waste narcotics, who are very interested in being on call particularly before a weekend or holiday. You can slowly ascertain a pattern. In theory at least, all of the mechanisms we've got in place for the over side of narcotics should help but I can tell you that we're a highly educated, very bright group of people and I think it's always possible to circumvent systems. But also remember that one of the most common symptoms of substance use in an anesthesiologist is death. So particularly for the people in this room, this is a life or death situation.

I wanted to say also there are certain obvious signs that must be reported, patient harm, self harm, and smelling alcohol on someone's breath. Those 3 things have to be--and I'm speaking from the nursing statutes. Other concerns may involve the person being at work but not on the job. Where's Mary? I never see her, the patients are calling. We don't know where she is, she clocked in but--certain other things of tardiness, med errors, documentation errors, those are less clear about what's causing that but certainly cause for a concern.

[ Inaudible Remark ]

Before that happens, it needs to go directly to TPAPN.


Which is supervised by the Board of Nursing.

So here's a--here's a--yeah?

[ Inaudible ] and this again, this is [ inaudible ] for nursing and non-physicians, but are you in alignment with human resources because I think a lot of the issues that come up are from some that you just mentioned, not even knowing about your body [ inaudible ] are and they're not [ inaudible ] these problems at all and in fact work against you. So--

Can we repeat the question?

Sometimes. If impaired nurses are intervened--that's what I'm going to say, intervened by someone other than nursing, can they go to EAP. Yes and no, we love EAP support. They have counseling services for our nurses but it is a nurse to nurse issue, it must be reported to nursing.

And occasionally we find a case where a nurse is working with EAP and the board never knows about it. And then there's an event and that nurse is called on the carpet, maybe there is a peer of review, sometimes there's not. If it's flagrant obvious thing that happens, an incident, then that has to be reported to nursing.

So I think that one of the important aspects of your questions, you know, how do you approach someone that you're concerned about? And I think John's comment about, you know, if you have a relationship with a colleague you're worried about, you got to think about it as something that's caring enough that you express your concern. So something like, you know, would--isn't going to work is something like, you know, you're coming late everyday, I didn't understand what's going on with you better straighten yourself out, okay. That's not going to get you as far as, you know, I'm really worried about you, I've noticed that for the last week or 2 or month or 2 months that you haven't been able to make it to the OR on time, something of that sort. Now, not everybody is comfortable with that. Now I think the second piece of the questions is who you can go to? Well, you've got 8 to 10 people sitting up here today who are willing to take a phone call and curbside around it and maybe direct you to another resource to have you talk it through and think it through. You've got the Employee Assistance Program and for faculty, you have faculty health committee. So you know, as I said, we'll be sending around a more formal list of resources but there are folks you can go to.

Just briefly, I think that you'll be amazed at the power of a peer or a colleague or somebody that you work with just saying how are you doing, I'm worried about you. I can tell you that from personal experiences very powerful thinking and people typically respond to that in some way. Even if it's not the outcome you're looking for, it kind of brings it to their attention that people are noticing.

Pat, did you have something on this?

Well, you know, it's my understanding that the formation of this committee in the first place was really at the behest of the joint commission and I think it was based on fear that death as a presenting symptom of impairment was a little bit late in the process and that some attempt should be made to intervene actually before out and out impairment. And I have to say that I was skeptical and kind of remain skeptical about in many cases the real impact of simple peer-to-peer interaction as ultimately really accomplishing something because what I want to basically say is don't underestimate the denial, particularly with substance abuse but with other things, and I think this is one of the reasons we sometimes don't bother talking to our colleagues is because perhaps based on personal experience, we feel like we're not going to get anywhere doing that. That the person will deny that there's a problem and simply go deeper underground. That commonly happens. And to get back to the point about the board involvement, so many people think of board action as a punitive sort of punishment but in fact it's really the ultimate leverage, the ultimate intervention if you will, even firing somebody from the institution. Well gee, I'll just go somewhere else and, you know, but gosh my license, you know, if they take that away, what am I going to do? Sometimes that's what it takes to get through to people and I know--you know, we've had the experience of people who even that, no, I'll just retire, you know. And so, you know, the issue of reporting, whether it's self reporting which usually does not happen until a person is already in rehab because they've been forced there by somebody else. But reporting to a board by a colleague or boss or something, it may sound paradoxical but is often the biggest favor you can do someone and it's probably the action that is most likely to save their life even though it may seem so paradoxical on the face of it. And the only reason I emphasize that is because up to that point, the typical reaction is just stonewalling, denial where everybody involved in the process is just as frustrated as can be.

I have a question.


[ Inaudible Remark ]

We can review that--

As you know [ inaudible ]. I actually have two questions. The first one is for Dr. Thomas. It refers to the slide that was presented in the years 1990 and 1997 when you had [ inaudible ] physicians that's about, I assume physicians that's about for a year. Since then, our institution is growing a lot. And you have structured the program right now that is much more invisible to--to all the commissions and the [ inaudible ]. Have you seen an increase both in the number and the percentage of [ inaudible ] advice for the [ inaudible ] that we do?

Okay, so the questions is, compared to our informal study of, you know, of 7 years in the 1990s, given that we have more programs available and that our physician population has increased, what are we seeing right now and what are the percentages? It's a really interesting question. The difficulty is that the group we were looking at in--over that 7-year period was so heterogenous. But I'd say we see--what would you think, John? About half a dozen physicians a year who are in the moderately to severely impaired category. So there really isn't much of a change there but I do think we're seeing physicians earlier in the process.

I would say that disruptive behavior is the trigger point for a lot of referrals that we're seeing now. That doesn't mean that there's not impairment of all kinds that we're not seeing. But it's when disruptive behavior is so flagrant, it does end being in the lap of the Fitness-for-Duty Program sometimes as well. We're also seen just mixed serious mental illness sometimes and cognitive deficits, and cognitive problems, and medical problems as Dr. Thomas said as well, mixed in together. So it does make it very, very difficult. So we're seeing more complex cases definitely

Did you have another question?

Yes, I do have a question, which is the things [ inaudible ] the question also and the discussion that when you say peer, does it mean physician to physician or the nurse to the nurse or can there be crossover, you know reporting, you know, physician on the nurse, the nurse to the physician that--and in the same spirit of how to just unveil the problem, I will see that.

Well, I would answer that question by saying, is it somebody that you routinely work with that's a member of your team, and if the answer is yes and you have a close working relationship, then you're their peer as far as working as a team member. Sometimes you do have to go profession--when you're saying peer, we're really talking about profession. So PA to PA, physician to physician, nurse to nurse, but--in close working teams which you all work in close working teams, really anybody from the team, I think it's more meaningful for somebody that you work with closely rather than just bringing some outside person just because they wanted to make sure they're from the same profession. Others might have a difference of opinion but I think it's really based on your working relationship. Okay.

Okay, give me a microphone and I'll have Elise answer. Okay, Elise?

Actually, I would like for someone to elaborate on the differences between contacting PPAC versus contacting employee assistance and the department chair, and what I'm asking for is to elaborate on the benefits of PPAC and why it was formed, instead of using the systems already in place.

[ Pause ]

Well, I'll just--the question is when do you use the EAP versus PPAC, in terms of a resource, and there is overlap there, certainly, but PPAP is an earlier intervention effort before it becomes so serious, where under the Fitness-for-Duty program, people are--the clinician would be taken immediately off the job because of serious concerns. So, if they're taken off the job because of serious concerns under the Fitness-for-Duty, that doesn't mean their job is at stake. It just means that it's serious enough that it becomes mandatory at that point what happens. But the PPAC is again an earlier intervention approach using peers as a resource and committee members as a resource to try to motivate that earlier impaired employee to take action.

So a couple of situations that might--that we have some experience with, so someone calls up one of us and says, you know, I've been having some problems at home, and really they're driving me crazy, I'm not getting enough sleep, and I'm just sort of afraid, I'm at my wits end, what do I do, okay? So, here is an opportunity to consult someone who might be able to steer you to some resources, such as the Employee Assistance Program, the Faculty Assistance Program, in which therapists would be available to kind of address those problems.

The other one is that someone may need to understand whether or not a situation that they see with a colleague rises to the level of a concern. So, in the case of Jack, the doctor, you know, instead of talking about of him around the water cooler, someone might come to the Practitioner Peer Assistance Committee and said, "You know, I'm worried about a colleague of mine, what can I do or do you think this is something serious?" And so, having that conversation may empower the person to go to the next step, and I sort of think that's probably one of the most important things that we do, okay, is empower people to take it some place where they can get some results.

Yes, I did need to answer the question because I guess I wanted something specific for the folks to know, and that is the reporting of PPAC. There--there really isn't reporting as there is with EAP, and that is a significant benefit of this program versus going directly to EAP because you can avoid that reporting.

That's correct. Do remember though that most of the consultations that occur at the level of the Employee Assistance Program are completely confidential. They are not going to get back to your supervisor, they are between you and the specialist in the Employee Assistance Program. The only time that mandatory reporting occurs is if you are unfit for duty. But just to talk about the value that I see for the Practitioner Peer Assistance Committee, for myself, if I was worried about a colleague, I would love to be able to sit down with somebody like Pat over a cup of coffee and say, I don't know what to do here, the idea of talking with this person just terrifies me, what do you think I should do? And Pat would be able to walk me through, sit down with the person, just list the things that you've noticed, and conclude by saying, "I care about you, how can I help?" And just the process of talking to another peer on the committee about the next ways to proceed and knowing that Pat is going to be there when you call him next and say, guess what, well, this person just yelled at me and the behavior is continuing, what do I do next? So I see the value of the committee as, we can walk you through the best ways to proceed, and we can keep it inside this committee structure. It exits the committee structure at a point where an individual appears to be unfit for duty. At that point, there's a patient safety issue and that has to be reported. But anything prior to that, we hope we can help you reason out the best ways to proceed. Did that help, Elise?

It did, thank you.

Okay, well, we’ve sort of run out of time. We thank you all for your attendance and your attention today, and hope we provided you with some information about this important topic and some resources you could use. So--

Walter, I would like to add one little extra piece to this if you don't mind. A couple of years ago, I did a 3-year retrospective chart review of patients that I had seen in the outpatient clinic, and 37.2 percent of those patients had a substance use disorder. For those of you that access patients preoperatively, please ask the questions, rather than calling us when a patient is in full blown DTs in the SICU, that can be avoided. These patients often need to be detoxed. The drug of choice in that 37 percent was just outrageously large alcohol, especially in head and neck clinics, alcohol and tobacco, so--

Thank you.

Ask questions.

Okay, if you would all put your trans--your clicker on the table here and with that thank the panel, thank you.

[ Applause ]