Clinician’s impairment not related to addiction?
EXECUTIVE SUMMARY
Patient safety is at risk if clinicians with undiagnosed conditions causing impairment continue to practice, but colleagues often fail to report the impairment. Bioethicists could play a role by:
- helping their institutions develop a culture of compassionate due process for the impaired clinician;
- encouraging clear standards for reporting;
- advocating the creation of a group to assess cognitive competency.
Process is possibly unethical
Most institutions have protocols in place to address clinicians’ impairment related to addiction, and most states have programs for clinicians to receive addiction treatment and counseling. However, the situation is likely to be much different if a clinician is impaired for other reasons.
"I worry more about the non-addiction related impairment," says M. Sara Rosenthal, PhD, director of the program for bioethics and chair of the Hospital Ethics Committee at University of Kentucky in Lexington. "These situations are murkier, with due process that may be all over the map, depending on the problem and the consequences."
The most typical impairment scenario is due to illness and aging that may elude the clinician until an error is brought to his or her attention. "The oft-cited example of the shaking hands of a surgeon with an early stage neurological disease is not usually the example we see," adds Rosenthal.
Undiagnosed depression can cause clinicians to act in problematic ways with patients or colleagues, for instance. Undiagnosed conditions causing vision changes, such as age-related macular degeneration, cataract, diabetic retinopathy, or glaucoma, can be disastrous for clinicians who have to interpret visual images.
"The tragic scenario is when a serious medical error related to an undiagnosed physical ailment occurs," says Rosenthal. "The clinician is suddenly faced with medico-legal issues in a state of health that is compromising."
In this situation, the clinician is actually in need of medical care, but also becomes embroiled in professional allegations of medical error. "It is a doctor as patient’ problem. But the doctor as patient’ may also lose his or her professional life as a result of an unintentional error," says Rosenthal.
Clinicians in this situation typically experience tremendous moral distress when they realize that they may have harmed a patient, while at the same time learning of a serious illness or medical condition they have to treat. They may find themselves struggling with an often harsh institutional due process regarding the legal implications of their impairment or error, says Rosenthal.
"The loss of their clinical privileges and professional lives may be more devastating to them than the news of their illness or condition," says Rosenthal. "But since they are ill, they are also not in the best condition to handle the medico-legal issues."
Address "whole" clinician
Rosenthal says the institutional due process for impaired physicians is possibly unethical, if there are not clear protocols in place. "When employment law, patient safety, and risk-management approaches prevail, a harsh process may be initiated for the clinician in crisis, who may not be guided towards appropriate resources," she says.
In these situations, a culture of silence is secured to protect the interests of the hospital, with liability and patient safety issues top of mind. "While it’s understandable that the institution just wants the impaired clinician to disappear as quietly as possible, the clinician is still in crisis," says Rosenthal.
At times, clinicians intentionally conceal an illness or condition that they know could cause professional impairment. "Unfortunately, in a patient care setting, this is a frank violation of professional ethical obligations to patient care," says Rosenthal. "There are many clinicians who work while having treatment for serious illnesses without interruption of their professional lives."
Clinicians typically inform their supervisors of their conditions, and ask for necessary accommodations. These may include changing duties such as being on-call or clinical teaching.
Rosenthal says that institutions must deal with impairment in a compassionate manner that addresses the "whole" clinician, not just the consequences of the impairment, which may be serious or even involve litigation.
"The impairment may be easily correctable with treatment, which does not need to end a professional life," says Rosenthal. "On a policy level, clinical ethicists could play a role in helping their institutions develop a culture of compassionate due process for the impaired clinician, who is, after all, also a patient."
Failing to report
"The most common situation we see is failure of peers or trainees to report impairment because of affection, fear, or politics," says Rosenthal. "Failure to report the impairment is a violation of their professional ethical obligations to patient safety."
Eric G. Campbell, PhD, director of research at Mongan Institute for Health Policy and professor of medicine at Harvard Medical School, both in Boston, says that failing to report a cognitively impaired physician is a well-recognized problem. "[Reporting] is the only way that we can get help for the physician and also ensure the safety of their patients," he says. "If a physician is found to be cognitively impaired, I think it is completely unethical to allow them to practice," says Campbell.
Institutions have a further moral and ethical burden to look at the extent to which patients may have suffered negative effects as a result of the clinician’s impairment, argues Campbell, adding that ageism is another ethical concern.
"It is unethical to assume that simply because a doctor is older or even very old, that he or she may be cognitively impaired," says Campbell. "I don’t think this should be framed as an issue of aging, although cognitive impairment is associated with aging." He says that institutions should:
- have clear standards for reporting;
- allow individuals to do so anonymously;
- identify a group of individuals with the ability to assess cognitive competency and advise the institution on further steps.
Campbell says the bioethicist’s primary role is to "continually be the voice to say that the welfare of the patient is paramount."
"At every institution, I would suspect that many people could conjure up a few colleagues who they remember practicing with impairments," says Campbell. "The question is, what does that institution do about it? Do they assign a resident to go after them and clean up after their mistakes, or do they appoint them to be educators and move them into some other function?"
A systematic assessment could help by re-certifying physicians at periodic intervals, suggests Campbell, adding that one of the core responsibilities of medical professionals is self-regulation. "Clearly, in the case of impaired clinicians, the system that exists is completely inadequate to ensure adequate self-regulation," he says. "Hence, with regard to that, the profession is not living up to the implicit contract we’ve created."
While pilots have a mandatory retirement age, notes Campbell, physicians are allowed to decide on their own when it’s time to retire.
"Some physicians have that decision made for them by state licensing boards or hospitals," he says. "One thing we can say with 100% certainty is that the one group we don’t want making that decision on their own are people who are cognitively impaired."
SOURCES
- Eric G. Campbell, PhD, Director of Research, Mongan Institute for Health Policy, Boston. Phone: (617) 726-5213. E-mail: [email protected].
- M. Sara Rosenthal, PhD, Director, Program for Bioethics/Chair, Hospital Ethics Committee, University of Kentucky, Lexington. Phone: (859) 257-9474. E-mail: [email protected].
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