In the mailbag comes this letter, asking for advice about whether / how to report physician impairment. I’ve modified it so neither the sender nor the subject can be identified.
Put this down as a ?nobody asked me, but??
I stumbled onto your Blog, and enjoy it. Its content leads me to believe you would be in a position to comment on a dilemma I recently faced in an emergency room recently. My HMO requires that I use an ER when I need medical help, even for conditions of a non-urgent nature. Hit with the excruciating pain and discomfort …, I went to the local ER around midnight on a Friday night and sat there waiting for close to five hours, mixed in with the usual assortment of drunks, druggies, and drifters that seem to inhabit ER waiting rooms these days.
I finally got to see the MD, who diagnosed and treated the condition. What struck me, and what lead to this missive was the fact that when he came into my examination room, the unmistakable aroma of scotch preceded him. My diagnosis of his breath odor was confirmed as he worked on me.
I am not a prude, and have probably (certainly) imbibed more than my allotment of scotch in my years, but I do believe there is a time and place for everything, and on the breath of an ER MD on duty at 5:00 AM is not one of them. My experience has taught me that booze, even in minute quantities, tends to dull one?s mental acuity, something that can lead to mistakes. I did not challenge the man at the time, but I have been seized with doubts since.
What is the protocol in such circumstance? Challenge the MD on the spot? Report him to the hospital administrators? Or do as I did, nothing?
Your thoughts would be appreciated.
Challenging the doctor on the spot, though the most direct option, is probably not the best way to handle the problem. I think the best way to approach this would be to ask, politely, to speak with the hospital administrator, and barring that, to speak with the charge nurse of the ED. Make your concerns known, then, when your doctor in question is still there. They would then be a) aware and b) on alert that a patient had made this complaint.
Proximity to the event (doing it while you and the doctor are both there) would have been best, as the medical staff could have taken steps to confirm or refute your concerns. (There are limits to Medical Staff powers here: they cannot force a doc to have a blood draw, piddle in a cup, etc, but can suspend a doctor for ‘conduct’ that requires no such proof) (but does require a medical staff that’s well-covered against suits from the doc).
Uniquely, ER docs are the easiest for a hospital to get rid of (the vast majority of us can have our medical staff privileges revoked without appeal as part of our contracts), so that would certainly embolden the medical staff to act where the might be more reluctant to suspend their only brain surgeon, for instance.
At this point the only thing to do is write a nice, polite "I thought you’d want to know…" letter to the hospital president. Unfortunately, you’re then in a he said / I said loop, and the doc might be able to sue you (please consult an attorney before writing this letter: I’m not an attorney, and the only advice I’m giving to you at this point is "talk to a lawyer"). However, this is behavior that need to be reported, and you’re right, there’s no room for drinking on the job (even if it does make you ‘fit in’ with most of your evening patients).
Now, what would you like to tell the letter writer?
Boy, tough one. I think maybe not doing anything at the time was the best bet. Not much is going to happen at 5 AM in any hospital I’ve ever worked at. If the doc was obviously impaired that’s a different story, you should ask the nurse who you could talk to about it right then.
But since there’s a delay, I would recommend calling the hospital’s administration office, say you have a concern about a physician, and ask to either speak or write directly to either the departmental chairman or chief of staff, with a copy or call to the one you’re not writing directly to. You may be told to write a complaint letter which depending on the hospital may work wonderfully or be totally useless, so I think writing to a couple of docs with some responsibility would be a better bet. If the one doc knows you wrote to the other they will be much more likely to check it out.
I have no idea as to legal liability but I would think notifying a hospital of a possible impaired physician would be a fairly safe thing to do.
If going through the chain of command at the hospital is a dead end, what about filing a complaint directly with the state medical board? Actually, I think I would consider doing both – writing the hospital administration as well as the medical board and include the “cc” to the medical board on the bottom of the letter to the administration. That way they may feel more compelled to pursue the allegation and evaluate the physician for EtOHism and get him the appropriate tx if he does have a substance abuse issue.
As an obsessive and excessive user of soap-free alcohol hand wash, I have been (jokingly) accused of sipping vodka on the job. This patient probably smelled Scotch on the doctor’s breath, but the possibility of a false positive must be considered.
A doctor practicing while impaired with
alcohol or drugs is a bad outcome
waiting to happen.
Along with contacting the hospital, I
would file a complaint with the state
medical board or agency that regulates
MDs in your state. A doctor who shows
up drunk or with alcohol on his breath
would be guilty of unprofessional
conduct. He would likely have to
have an evaluation to determine if he
had an alcohol problem. And he would be
subject to disciplinary action. As a
result, he would probably be placed on
probation (if this was his first
offense) and have to participate in
some form of monitored aftercare program.
Not only does this doctor need help,
but he also represents an imminent
danger to public health and safety.
If the doc’s drinking on the job, he needs to be out of there… period.
I’ve known several impaired physicians… none of which I EVER suspected at the time. In retrospect, some of their erratic behavior fits the pattern, but at the time I just felt they were eccentric.
It’s hard enough working when you’re not at the top of your game, whether from circadian dysrhythmia, or illness (I’ve worked a few shifts with an IV in my arm). In those cases, you do what you have to do to endure those things that aren’t within your control… but there is no excuse for cheating your patients of your best by engaging in substance abuse on the job.
This doc needs to go get some help, and he may require an “intervention” by the hospital to push him in that direction. Either way, it serves neither the patient, nor the physician to keep silent about the matter.
I used to work at a hospital where the nursing supervisor on evenings was constantly drunk; one night she was so drunk she fell over and fractured her humerus…got 3 months of workman’s comp. Everyone employee in the hospital knows she drinks on the job, she has been suspended in the past. I complained about her several times, for her drinking and her incompetence….I was labeled a “complainer”….Bottom line is, she still works there, I don’t.
It’s hard to judge whether it would have done any good to talk to the ER charge nurse that morning. Don’t you think she knew what was going on?
I might have asked to speak to the nursing supervisor or the administrator on call. In our hospital, there is a roaming nurse who is “in charge” at night and there is an administrator on call who could have come in to make their own observations.
A letter now is better than nothing. If it is the only thing that ever shows up in this guy’s file, then nothing will happen. But what if 20 people that month smelled it, and all 20 wrote in?
The proper route in most cases for suspected MD impairment is through the state impaired physicians program, (or the hospital’s, if they have one). Most states have such bodies to my knowledge. The report is confidential and anonymous, and they can see if any other similar reports are on file. Medical disciplinary boards are an unenlightened lot–and if this is a mistaken assessment (ie, the doc is not impaired), you just created a nightmare for an innocent doc whose career and reputation will be ruined.
The one exception I would make to this is immediate patient endangerment, eg, a surgeon shows up obviously drunk to the OR.
I agree that there are no easy answers to this, unfortunately not so infrequent, problem. But the following story, which I heard a few years ago at a credentialing seminar, is worth thinking about.
The speaker was a physician involved with his state’s physician impairment program. He related that while in his residency he was called in late one night to care for a patient because the attending doctor showed up drunk.
Concerned for the attending physician, he approached a senior member of the medical staff the next day and asked what could be done to help him.
“Don’t worry about him” came the reply. “As soon as we get one more documented instance we’re getting rid of him.”
Of course, that documentation soon followed and the physician was dismissed. Several months later he died from an alcohol overdose.
The speaker said that experience led him to a life-long commitment to finding ways to help physicians in trouble, particularly those dealing with substance abuse issues.
Physicians have a higher-than-average rate of addiction. About 15% of them suffer from some form of it at some time in their lives. They also have a phenomenal rate of success with treatment. Statistics indicate that between 80 and 90 percent recover and learn to live sober.
So report the matter? Absolutely. I agree that it should be reported both to hospital administration and to the state medical board. A practitioner who drinks on the job is not safe and should not be permitted to care for patients.
However, in the process let’s not forget that we’re dealing with a valuable human being who needs help and may well be willing to accept it and get better.
Rita Schwab, CPCS, CPMSM
MSSPNexus Blog
http://msspnexus.blogs.com/mspblog/