How to confront an impaired colleague
Direct, compassionate intervention by peer can help
Suspecting that a colleague might be impaired by drugs or alcohol is difficult; knowing what to do with those suspicions is even harder.
According to some experts, simply broaching the subject with a colleague in a collegial, caring manner is all it takes for the doctor or nurse to acknowledge the problem and seek help. And once that happens, in most cases, recovery is successful.
According to research, nurses and physicians succumb to alcohol addiction at about the same rate as the general population. Their rate of addiction to prescription drugs, however, is estimated to be 50% greater than that of the general public.
By the time co-workers notice that something is wrong, the problem probably has been going on for some time, says one expert.
"Frequently, work is the last place [impairment] is noticed," says Roland W. Gray, MD, medical director for the Tennessee Medical Foundation, one of the nation’s oldest and most successful physician assistance programs. It is the charitable arm of the Tennessee Medical Association. "By the time it’s noticed at work, things can be fairly far along."
Experts in physician and nurse addictions say that’s because nurses and doctors are smart, well educated, and good at what they do.
"Often, it’s our best people," says Laurie Badzek, RN, MS, JD, LLM, director of the Silver Spring, MD-based American Nurses Association Center for Ethics and Human Rights. "They have such good clinical skills that they can be impaired and still be functioning at a good level. But eventually, it catches up [with] them."
Though getting medical professionals well and back to work takes up most of the time in a recovery program, and ideally, the doctor or nurse can continue working while recovering, Gray and Badzek both quickly point out that the safety of patients is critical.
"I won’t allow a physician to practice who is a danger to patients or others," Gray says.
Badzek says, while self-referrals by nurses gets the best results and can keep nurses on the job while they are in recovery, a nurse who is a danger to others can’t be left to work through that problem on the job.
"Obviously, there are a number of things nurses can or must do if a colleague is impaired, depending on the level and type of impairment," she says. "If it’s an emotional crisis at home, or if he or she is crying on breaks but it’s not impacting patient care, that’s one thing.
"But if they’re coming in [to work] impaired, taking drugs from patients and diverting them to their own use — that requires action on the part of the nurse or doctor who is aware of it."
Signs that all is not well
Gray says warning signs — those could signal anything from an emotional problem to substance abuse — generally have to do with a disruption in what is "usual."
"The first thing you might see is behavioral withdrawal," he says. "Maybe you don’t see them around the hospital like you usually do, they come in at odd hours to make rounds, and don’t show up for committee meetings."
Badzek says a nurse who is abusing controlled drugs might come to work when he or she isn’t supposed to be there, might suddenly show an increased desire to distribute medications to patients, spend lots of time in the restroom, and have frequent occasions of drug counts not coming out right. There might be an uptick in the number of patients whose records reflect they received pain medication, but they’re still complaining of pain — a sign that maybe they didn’t receive the medication as reported.
The clinician’s colleagues might notice mood swings, irritability, and a change in appearance. Professionalism that once might have been there evaporates.
"They’ll not answer pages, for example," he says. "Or, in the office setting, they’ll call in and have the office reschedule an entire day’s appointments."
A nurse or doctor who has never received complaints might suddenly become the subject of a flurry of them. "These are all things that make you stop and think," says Badzek. "There could be other reasons for the behavior, but if you see several things happening in the same person, you have to stop and think."
Approaching a colleague, even one with whom a doctor or nurse works with closely, causes most people to take a deep breath.
"It can be difficult to confront a colleague," says Gray, particularly if the signs don’t clearly point to a specific problem, just a general sense that something is wrong.
Doing nothing is not an option
Telling a clinician that he or she has a problem is more daunting than telling a layperson, experts agree.
"A common element among physicians is that we’re smart, we’re intelligent, and that works both for us and against us," says Luis T. Sanchez, MD, director of Physician Health Services, a branch of the Waltham-based Massachusetts Medical Society.
"It works for us once we become self-aware, but it works against us if we’re in denial about a problem," he says. "Physicians tend to forget that we’re no different than anyone else, and that [substance abuse] is far less related to how well trained we are than it is to our genetics, our family, our nurturing, and our upbringing."
The drive to succeed that serves physicians well when they’re working their way through medical school and residency can aid them if they have to battle impairment as well, Gray says.
"When they self-refer and realize there’s a problem, they often think, Look at all I have been able to accomplish; surely I can overcome this,’" he says.
Doing nothing when there are signs a colleague is impaired is not an option for either physicians or nurses, according to ethics rules set out by the American Medical Association, American Nurses Association, and most state professional licensing boards.
"Our code of ethics requires nurses to address impaired practice, and it doesn’t make a difference who their colleague is — a nurse, physician, anesthetist," says Badzek.
The personal, peer-to-peer approach is the most effective, whenever it is possible, Badzek and Gray point out.
"It can be difficult to confront a colleague, but what you should do is talk to the individual, in a collegial manner," Gray suggests. "Sit down with them, and do it as an opportunity to help. Reach out a hand; give him or her the opportunity to talk."
In the best-case scenario, that’s all it takes.
"Sometimes, they welcome the opportunity to talk about the difficulty," he says.
Badzek says, in those cases, the colleague might be relieved to finally have the problem exposed and to have the burden shared rather than borne alone.
"Nurses, and doctors, too, know that to have the fewest restrictions on their licensure [as a result of an impairment caused by alcohol or drugs], in most states, if they self-report and enter into an assistance program, there is less likely to be any action against their license — at least the first time," she points out.
In most states, she says, nurses who don’t self-report and enter into treatment are almost certain to have action taken against their nursing licenses.
Gray says the catalysts that drive physicians to seek help from the Tennessee Medical Foundation vary. "Some of them will just have a moment of clarity."
"I won’t allow a physician to practice who is a danger, but if they work with me, I am not required to report them," he says. "But if they don’t self-report, and I have findings that they are practicing and a danger, I turn them over to the state health-related board."
Good chances for recovery
Substance abusers present a challenge when it comes to getting them to acknowledge the problem, and physicians and nurses may be even more resistant than most people in recognizing their addictions. However, the chances for recovery of their health and careers are very high, according to experts.
One reason is the stigma that medical professionals face if it becomes known that they have a problem with drugs or alcohol has relaxed somewhat in recent years.
"We’re moving in the right direction in that regard," says Sanchez. "There is less of a stigma. That may be a result of all the work being done on patient safety and reducing medical errors. There’s a lot of money being spent on that, and that’s all for the good, and physician health is intertwined in there."
Compared to a decade or two ago, Sanchez says, there is much more an attitude of, "If a doctor is impaired, and gets it taken care of, then they move on and they’re fine."
Gray says the public is more educated and knowledgeable about substance abuse, so it is perhaps not as prone to hold physicians and nurses to a higher standard; however, physicians and nurses report they feel that higher standard, even if patients don’t express it.
The recovery rate Gray sees at the Tennessee Medical Foundation is excellent, he says.
In 2004, the foundation saw 196 new referrals and had 61 in the first quarter of 2005. Most of the referrals work in hospitals or medical groups, and most were self-referrals.
"We found that a little more than 90% of those who go through the complete program never pick up another drink or drug," says Gray, indicating a success rate higher than that in the general population. "Of those 8% to 9% who do relapse, we get all but around 4% into persistent recovery, and we’re very proud of those results."
Badzek says the nursing shortage in the United States adds to the importance of getting nurses healthy and keeping them that way.
"We have fairly big numbers [of impairment] in health care — I have read something like one in 10," she says. "We have to be able to help these colleagues and bring them back, especially in light of the shortages. We need to find mechanisms to help these doctors and nurses; and in larger places, there are support groups on site, where peers can work together to help each other."
Sanchez says the Massachusetts Medical Society’s Physician Health Service does not treat physicians, but evaluates and makes referrals.
"We do provide monitoring agreements to about one-third of the physicians we see, which is a contractual agreement in which workplace monitors — people who work with the physicians — monitor them," he explains. "We require random toxicology screens, and follow that physician for a minimum of two to three years."
There are 20,000 physicians in Massachusetts, and the Physicians Health Service will have 150 on a monitoring program at any one time, with another 150-200 being evaluated or referred on to therapy or counseling at the same time.
"It’s a small percentage [of the physician population] that gets referred, but it’s my belief that all 20,000 of us need to have a good awareness of our own problems and illnesses," Sanchez says. "We also have to improve our capacity to recognize those red flags in our colleagues and be good observers of each other. We’re not good at that; there’s a certain reluctance there."
Suspecting that a colleague might be impaired by drugs or alcohol is difficult; knowing what to do with those suspicions is even harder.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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