Physician impairment is a public health issue that affects not just physicians but their families, colleagues, patients and the institutions in which they work. In this context, “impairment” means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.
While physicians are tasked with treating patients, they themselves may be patients and need appropriate care and protections that acknowledge this reality. Physician health is also a concern when considering the goal of maintaining a healthy population of physicians to serve the public through the safe practice of medicine.
Illness and impairment
Of importance, the distinction between functional impairment and potentially impairing illness should guide identification of and assistance for the physician. For the purpose of this document, we can differentiate between illness and impairment, and according to the Federation of State Physician Health Programs:
Some regulatory agencies equate “illness” (i.e. addiction or depression) as synonymous with “impairment”. Physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years. This is a critically important distinction. Illness is the existence of a disease. Impairment is a functional classification and implies the inability of the person affected by disease to perform specific activities
Most physicians who become ill are able to function effectively even during the earlier stages of their illness due to their training and dedication. For most, this is the time of referral to a state PHP. Even if illness progresses to cause impairment, treatment usually results in remission and restoration of function. PHPs are then in a position to monitor clinical stability and continuing progress in recovery…
Medical professionals recognize it is always preferable to identify and treat illness early. There are many potential obstacles to an ill physician seeking care including: denial, aversion to the patient role, practice coverage, stigma, and fear of disciplinary action. Fear of disciplinary action and stigma are powerful disincentives to doctors referring their physician colleagues or themselves. When early referrals are not made, doctors afflicted by illness often remain without treatment until overt impairment is manifest in the workplace.
We have an obligation to ourselves and our colleagues to recognize and assist
in obtaining assistance for illness, before it becomes an impairment.
Impairment however comes with a mandatory duty to report.
Physicians also have to consider the “negative impact” statement – as the term impairment is at times inappropriate and inconsistently applied, and in other instances misses negative effects of physician health-related issues affecting patient safety, which are not caused as a result of an overt disability.
Physicians are trained and experienced in recognizing the signs and symptoms of illness and impairment, and we do our best to provide the best care for our patients, but this does not always apply to our colleagues. Physicians make good care-providers but are often poor patients.
According to a 2014 survey of Canadian medical regulatory authorities conducted by the Federation of Medical Regulatory Authorities of Canada, the top two physician health risks to patient safety are addictions and substance abuse issues, followed by mental health issues including bipolar disorder, depression or personality disorders.
An article published in the Annals of Internal Medicine estimated the incidence rates of physician impairment from mental illness, alcohol dependence and drug abuse, disruptive behavior, physical illness, and declining competencies and concluded that "When all conditions are considered, at least one-third of all physicians will experience, at some time in their career, a period during which they have a condition that impairs their ability to practice medicine safely; for a hospital with a staff of 100 physicians, this translates to an average of 1 to 2 physicians per year."
Seeking assistance from the Physician Health Program
When physicians suspect that they may be at risk of providing compromised care to their patients due to any type of illness or impairment, they are urged to report to the Saskatchewan Medical Association (SMA) Physician Health Program (PHP) to obtain the assistance they need. The PHP is a confidential program and does not share information with the College unless obligated to do so. This program has access to excellent resources, support and the ability to assist with treatment and rehabilitation.
The duty to report
Physicians are expected to take appropriate and timely action when they have reasonable grounds to believe that another physician is impaired, incapacitated or incompetent, including circumstances where a colleague’s pattern of care, health or behavior poses a risk to patient safety. It is also important to remember that unethical conduct (such as a breach of the CPSS Code of Ethics) should be reported. This duty to report also applies to our students and residents, as they are part of our medical community.
The College of Physicians and Surgeons of Saskatchewan regulatory bylaw 7.1, Code of Ethics states under heading Physician and Colleagues, at paragraph 33:
Take responsibility for promoting civility, and confronting incivility, within and beyond the profession. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues or concerns, based upon reasonable grounds, that a colleague is practising medicine at a level below an acceptable medical standard, or that a colleague’s ability to practise medicine competently is affected by a chemical dependency or medical disability.
Often the moral and ethical dilemmas of reporting a colleague can be very distressing, the potential ramifications far-reaching, and the situation is rife with ethical pitfalls. Reporting a colleague is intended not only to protect patients, but also to help ensure that colleagues receive appropriate assistance from a physician health program or other service to be able to practise safely and ethically.
Our duty to promote both beneficence (defined as “doing good”) and nonmaleficence (defined as “preventing harm” and “not inflicting harm on others”) applies to the decision to report a colleague. The duty to prevent reasonably foreseeable harm may also play a role in certain circumstances in creating a positive obligation to take certain steps (which may or may not include reporting to the College) to prevent harm from occurring. Physicians should keep this legal duty in mind.
The decision of whether to report a colleague is not simple; we have heard that the following questions arise for physicians considering such a report:
- Is my colleague really impaired, or just tired, had a bad call-week and just needs rest?
- Are the patterns of behavior changes due to the patient load and burnout?
- Are the mistakes in judgement just oversight, or is something really wrong – physically, mentally, or both?
- What are the risks of reporting, and what if I don’t?
- How will I be perceived by my colleague(s) if I report or not?
- How would reporting a colleague affect my career, my patient load or my practice?
- Will my colleague be punished, and if so, too strictly?
- Maybe I don’t know the whole story, maybe someone else is taking care of it?
- If I report my colleague, will they lose their income or their licence to practice?
- What if the impaired physician happens to be my patient?
- What impact will the stigma associated with illness and impairment have on the professional image of the colleague?
There are no simple answers to these questions, and it is important to know that physicians who report colleagues do not have to navigate the process alone. In Saskatchewan, we are privileged to have the Physician Health Program (PHP) through the Saskatchewan Medical Association. The trained and experienced staff can assist physicians through the process of dealing with a colleague who they are concerned about and have the ability to guide care delivery and provide support to such physicians.
The College of Physicians and Surgeons of Saskatchewan follows a confidential medical model guided approach to physicians who are reported. This approach is not intended to be punitive, but rather to assist physicians to safely return to practice while upholding the mandate of public protection. The approach is to assist physicians in accessing treatment, monitoring the concern with fitness to practice, and overseeing and guiding re-entry into practice. It is exceedingly rare for physicians to lose their licence to practice; this generally only happens if an independent assessment objectively shows that the physician is unfit to continue to practice.
The usual process at the College once a concern is reported is as follows:
- 1. The concern is evaluated by the Registrar or Deputy Registrar.
- 2. A determination is made regarding the concern, on a case-by-case basis, and additional information may be obtained from the physician, colleagues and other physician leaders depending on the situation.
- 3. The outcome depends on the situation and may involve any or all of the following steps:
a. Referral of the physician to the Physician Health
b. Physician withdrawal from active practice (voluntarily if possible,
mandatory in rare occasions),
c. Physician treatment via the PHP,
d. Reporting by the PHP to the College as needed,
e. Monitoring via the PHP,
f. Assessment and supervision if indicated,
g. Assisted re-entry to practice, usually associated with an undertaking
by the physician related to practice within certain parameters,
h. Follow up as indicated.
The College is available for advice and is able to guide and assist physicians through the process of reporting. An example would be – what is my duty to report when the physician happens to be my patient? – this highly nuanced situation is best discussed with a member of the senior management team at the College.
In closing, physician impairment is an underrecognized problem that is inextricably linked with high rates of burnout and suicide. We do not only protect patients during the execution of the “duty to report” expectation – we also honor the profession and assist our colleagues in obtaining the care and support they need. We should foster an environment and culture free of the stigma of the diseases and conditions which cause physician impairment.
CPSS policies, bylaws, standards and guidelines applicable to subject:
Code of Ethics
Code of Conduct
References and additional reading:
CMPA: Reporting another physician
American Medical Association: (Policy H-275.952)
CPSA: Duty to report a colleague
CPSO: Mandatory and Permissive reporting
CMA: Clinician support
AMA: Reporting Incompetent or Unethical Behaviors by Colleagues, and Deciding Whether to Refer a Colleague to a Physician Health Program
CPSBC: Duty to Report
FSMB: Policy on Physician Impairment
Medscape: Would You Report an Impaired Physician? Many Doctors Won't
AAP: Reporting an impaired colleague difficult but necessary
Royal College of Physicians and Surgeons of Canada: Physicians and Substance Abuse
JAMA article: Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues
American Journal of Psychiatry: Impaired Physicians: Obliterating the Stigma
Current Psychiatry: Impaired physicians: How to recognize, when to report, and where to refer
Annals of Internal Medicine: Physician Impairment and Rehabilitation: Reintegration into Medical Practice While Ensuring Patient Safety: A Position Paper from the American College of Physicians
AMA journal of ethics: Identifying an Impaired Physician