A Message From the President

Gerald P. Perman, M.D.

President, American Academy of Psychodynamic Psychiatry and Psychoanalysis

Clinical Professor, Department of Psychiatry and Behavioral Sciences, George Washington University Medical Center, Washington, D.C.

The American Academy of Psychodynamic Psychiatry and Psychoanalysis is an organization of physicians and, as such, its members share many of the same stressors and response to those stressors as do other physicians. These stressors can contribute to the syndrome of burnout and to physician impairment. We believe that the Academy can offer helpful information to psychiatrists and psychiatric trainees in view of our collective experience and knowledge. What follows is an overview and summary of the subject of physician impairment including avenues for seeking assistance. Our hope is that this information and the Academy’s Physician Health program will be of help to you, to your patients and to your loved ones.

Reasons to become a physician are numerous. It is an intellectually satisfying and prestigious (although less so in the public’s eye today than in years past) career with many different practice opportunities. The practice of medicine remains for the most part relatively well-compensated and there is an overall shortage of physicians in the United States such that it is unlikely that one will remain substantially unemployed for a long period of time. Whereas being a physician has its risks – with the responsibility for making life and death decisions and being vulnerable to malpractice lawsuits – these aspects of medical practice also add to the excitement of engaging in this profession. In addition, being a physician provides the opportunity for generativity through teaching younger generations of physicians.

What are some of the risk factors that can contribute to impairment over the course of a physician’s career? I’ve already remarked that this is a stressful occupation. Not only does being a physician entail enormous responsibility, but practicing medicine often involves working long hours, accepting the administrative burden that accompanies most medical practices today, and feeling as if one is “on-call” 24/7/365. In 2003, the ACGME limited residents to “only” work 80 hours per week and, in 2011, stipulated that first-year residents could “only” work 16 hours per day. While admirable, these changes have not seemed to significantly improve these physicians’ well-being.

The culture of medicine is a stressful environment in which to work. A physician’s personal identity is intimately tied to what he or she does. In a recent special Time magazine issue (November 2018) devoted to Mental Health, the example is given of two psychiatrists who were accused of unfair Medicaid billing practices and who subsequently suicided by shooting themselves. One factor could have been the assault to their self-image of being caring, competent, and ethical physicians.

Physician practices are constantly being encroached upon by other less well-trained clinicians. Psychologists push for prescribing privileges and physician assistants (PAs) and nurse practitioners assume roles of increasing responsibility. My wife’s internist recently retired and my wife was scheduled to have her annual physical examination performed by a PA who has had two years of training postcollege.

Physicians are under constant pressure to “do more and do it more efficiently” - by managed care companies as well as by our own hypertrophied superegos. We are seen by others (although less so than in the past) as having god-like abilities and authority, and as such we fear being exposed as “only human.” Related to this is our difficulty admitting to ourselves and to others that we too have problems that may require professional attention. We worry that if patients and our fellow physicians were to find out that we are less than perfect, and that we sought help for ourselves, our patients would drop out of treatment and other physicians would stop sending us referrals.

Treating patients who are severely ill and at high risk of dying in the near future, especially if one practices trauma surgery, oncology, geriatrics and other similar specialties, creates an ongoing emotional burden. In this age of managed care, physicians are often under pressure to see an increasing number of patients per hour, offering limited time to make a satisfactory connection with their patients and to develop the necessary doctor-patient rapport. Sleep deprivation has been shown to be the number one contributor to work-related depression, demoralization and career dissatisfaction, and sleep-deprivation is a given during medical school and residency training, and often continues afterwards. It is especially prevalent in obstetrics, emergency medicine and surgical critical-care practices.

These stressors often result in a negative work-life balance with resulting interpersonal problems, the lack of ability for the physician to lead a healthy lifestyle, and damage to the physician’s emotional and physical health itself. Physician impairment can result.

A brief definition of physician impairment is: “The loss of skill and ability to practice medicine safely.” It has been estimated that 10-20% of physicians become impaired over the course of their careers. Alcohol use disorders among physicians – mirroring the general population – occurs at a prevalence between 10-14%, and other substance disorders occur at a prevalence of 1-2%. (1) Additional causes of impairment can be found throughout the DSM-V and include anxiety disorders, depression, dementia in aging physicians, psychotic illnesses, and narcissistic and behavioral problems.

Suicide is a risk factor for the practice of medicine as well. An estimated 400 physicians per year (about the size of one medical school class) suicide with a rate among male physicians 1.5 times greater, and among women, 4 times greater than in the general population. Death by gunshot is the most frequent method used. In a survey of 50,000 medical students, suicidal ideation was shown to be twice that of age-related controls with 15-30% of medical students meeting criteria for clinical depression. Suicide is the second most common cause of death among medical students. (2) Physician impairment often remains hidden until it is too late: suicide may indeed be the presenting symptom.

Akin to physician impairment, burnout (characterized by a state of emotional, mental and physical exhaustion) is increasingly being studied among medical students and physicians. In a presentation given at the 2015 U.S. Psychiatric and Medical Congress by W.C. Jackson and R. Jain, burnout was found in 50% of critical care, emergency room, and family medicine physicians, and in 38% of psychiatrists. At the beginning of the internship year, 3% of interns were found to be depressed (defined by having a depressed mood for two or more weeks) – about the same prevalence as in the general population – but 27% of interns met this criterion after three months.

Manifestations of physician impairment often relate to the particular specialty and the related issue of access. Anesthesiologists have the greatest access to IV drugs and are the most likely to get into trouble (and die) through the illicit injection of Fentanyl and Propofol. Death by overdose was found to have occurred in one out of five residency programs in the U.S. (3) The practice of psychiatry often involves one-on-one, unsupervised, interactions with young, mentally ill patients over long periods of time and a confidential survey revealed that 7% of male psychiatrists and 3% of women psychiatrists admitted to boundary violations of various kinds and degrees. Internists, interventionists and surgeons are at higher risk of self- and family- prescribing than are other specialties. This is problematic because there is no chart on the “patient” and there is usually a lack of objectivity and adequate clinical perspective. Pharmacies have begun to crack down on this practice.

Clues to impairment include writing illegible chart notes and making hospital rounds at 3 AM when there is less oversight and the increased ability to steal medication of abuse. Falling asleep at work and social events, and angry blow-ups in the operating room, are other reasons to suspect impairment.

There is often a conspiracy of silence among fellow-physicians who observe, or are subjected to, abnormal behavior. In one study, 17% of 3,000 physicians admitted knowledge of impaired colleagues, but only 67% (of the 17%) reported the colleague to an administrative body. Reasons given included: “Someone else will do it,” “I’m afraid of retribution if I do report,” and “Nothing will happen if I report.” The study concluded that “Most support a commitment to report but many do not (report).” (4)

In an effort to address physician impairment, every state in the U.S. has a Physician Health Program. Some of these are free-standing, some are connected to state medical boards, and others are run by state medical societies. The Medical Society of the District of Columbia has a long-standing Physician Health Committee (PHC) staffed by a dozen physicians representing several specialties and who meet monthly at the Society on a voluntary basis. The PHC plays an evaluative and monitoring, but not treating, role in which it makes recommendations for and oversees the treatment received by impaired physicians. These physicians are either self-referred (or referred by a departmental chair, etc.) or are mandated to receive an evaluation by the D.C. Board of Medicine.

The PHC evaluation results in a set of recommendations that often include: a physical examination, a psychiatric evaluation, sometimes an inpatient substance abuse evaluation, attendance at 12-step meetings, random urines at a designated frequency, and routine meetings with a physician monitor on the committee or the committee administrator in the context of signing a five-year contract with the committee. In exchange, the committee will “advocate” for the physician with hospitals, residency training programs, etc., that often allows the physician to resume working after demonstrating a “positive paper trail” by meeting contract requirements. Physicians are often highly motivated to maintain their profession in which they have invested so much time and energy over many years, such that their success rate in overcoming their difficulties is considerably higher than in the general population. As many as 75-90% are able to return to work, medical school or residency training, 70% remain drug free (if this was a presenting symptom) since the initial evaluation, 18% relapse once, and 12% relapse more than once before full abstinence.

Burnout and physician impairment are complex topics. This brief overview of some of the gratifications and challenges in being a physician has touched on a few of the issues involved. The opportunity for successful treatment and rehabilitation is high if the troubled physician is able to become engaged in recommended treatment. The process and outcome can be extremely rewarding both for the physician in treatment and for the psychiatrist or committee working with the impaired physician. Successful treatment will have repercussions for the physicians themselves, for their families, for their patients, and for the public health. We hope that the Academy’s Physician Health project takes a step toward accomplishing these goals.

References
1. Pain Physician, May/June 2009
2. Medscape, July 17, 2014
3. JAMA, August 2011
4. Collins, Anesthesiology and Anesthesia, Nov. 2005, Vol. 101, issue 5, p. 1467-1462

Note: Dr. Perman is a voluntary member of the Physician Health Committee of the Medical Society of the District of Columbia. As a result of this involvement, he gives an annual invited lecture on “physician impairment” to the post-baccalaureate class of Georgetown University. This is a class of about 100 students almost all of whom are applying to medical school and who are taking a one-year condensed pre-medical school curriculum to strengthen their applications. Over 90% of these students are accepted into medical school. This paper is a narrative version of Dr. Perman’s PowerPoint presentation to this post-baccalaureate class.

The American Academy of Psychodynamic Psychiatry and Psychoanalysisy
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