Impaired Physicians – Health Problems Aren’t Just for Patients

This month’s “Ask the Expert” column addresses a difficult topic, that of physicians dealing with medical and/or psychiatric problems that hinder their ability to practice. With the shrinking of the anesthesiology workforce, and growing demands placed on those who remain, the problems of burnout and poor work/life balance are widespread. Meanwhile, there exists a group of people afflicted with significant medical conditions, rendering them “impaired.” This situation is not rare, and if it has not affected you personally, it is likely you are well acquainted with someone who has been.

Dr. Mike Fitzsimons from Massachusetts General Hospital (MGH) is an expert on the impaired physician problem. He will share his insights in a thoughtful, compassionate manner.

Mike, thank you for joining us. Please describe your current position and responsibilities.

I am the Director of the Division of Cardiac Anesthesia in the Department of Anesthesia, Critical Care, and Pain Medicine at Massachusetts General Hospital. I lead our department’s Substance Use Disorders Prevention Program. I also work with the ASA Substance Use Disorders Advisory Group and Working Group on Physician Mental Health and Suicide.

How did you become interested in the impaired physician?

It did not start with physicians, but with my experience in the military. I served as a General Medical Officer (GMO) at Camp Casey, Korea, and then as Chief of Aviation Medicine at Madigan Army Medical Center at Fort Lewis, Washington. In these roles, I encountered challenges associated with the confluence of health and performance. I managed the health of several pilots with conditions that were considered “disqualifying.” But with appropriate investigation, management, and an understanding of the flight environment and appropriate accommodations, I returned them to career success. In a few circumstances, an aviation career was not safe for them or their crew, and an alternative course was necessary. I then became a resident at MGH. While I was Chief Resident, our chairperson, Dr. Warren Zapol, asked that I help develop a substance use disorders (SUDs) prevention program, including drug testing. Over subsequent years, I saw that impaired performance was rarely due to substances and often due to other factors.

What types of impairments are most common in perioperative physicians?

Substances are only one factor leading to impaired anesthesiologist performance. Studies show that 1%-2% of anesthesiologists are impaired by substances used in the perioperative environment (Anesth Analg 2002;95:1024-30). We do not necessarily have the highest rate of substance use disorders, but the substances we misuse are highly potent. We do make up a far higher percentage of physicians in recovery programs than would be expected based upon our numbers. We make up about 5% of physicians but about 15% of those in organized recovery programs (J Psychoactive Drugs 1991;23:427-31). Alcohol is another risk. Alcohol use disorders impact about 10%-20% of physicians, with females more often impacted than males (Am J Addict 2015;24:30-8). Alcohol is second to opioids among anesthesiologists who develop SUDs after completing training (Anesthesiology 2020;133:342-9).

What treatments are available for substance use disorders, and what are the rates of recidivism?

In my opinion, self-treatment of the diseases that are SUDs is no more successful than attempting to treat cancer without an oncologist. Care guided by a physician formally trained in the diagnosis and long-term management of SUDs is critical for recovery. Inpatient stay is generally recommended, followed by intensive outpatient treatment, which commonly includes participation in 12-step programs, drug testing, and continual therapy (Anesth Analg 2014;119:1007-10). Physician Health Programs (PHPs) function as care coordinators for doctors in recovery. Depending on local regulations, an impaired physician may have the option to seek guidance through a PHP instead of formally reporting to a state medical board. A PHP can establish a recovery contract, containing the stipulations necessary to ensure the highest likelihood of recovery. Stipulations generally include drug testing, meetings, and follow-up with a psychiatrist, among other requirements. Such contracts usually last three to five years. A five-year study of anesthesiologists whose recovery was coordinated through a PHP revealed that approximately 18% relapsed, 2%-3% died, but nearly 80% remained abstinent of drugs (Anesth Analg 2009;109:891-6).

Among residents who develop an SUD but complete residency, over 40% will relapse, while 12% will die with the first relapse (JAMA 2013;310:2289-96). For those who develop a substance use disorder after completion of training, 40% will relapse, while 19% will die of a SUD-related disorder (Anesthesiology 2020;133:342-9). There have been many successful recoveries, and these individuals often become impactful educators and contributors to the effort to reduce SUDs among colleagues.

How common are mental health disorders in American anesthesiologists?

The 2022 Medscape Physician Lifestyle, Happiness, and Burnout survey of anesthesiologists revealed that 28% are clinically depressed, slightly higher than other specialties (asamonitor.pub/4fKCcdX). Among residents and first-year graduates in anesthesia, 32% note distress, and 12% screen positive for depression (Anesthesiology 2019;131:668-77). Burnout may not necessarily be classified as a mental health disorder, but it is one of the most common causes of distress among anesthesiologists (Anesthesiology 2024;140:38-51). Prior to the COVID-19 pandemic, 59.2% of anesthesiologists were classified as “at risk” for burnout, while 13.8% met the criteria for burnout syndrome (Anesthesiology 2024;140:38-51). Post-pandemic, 70% of us are at risk for burnout, while 19% suffer from burnout syndrome (Anesthesiology 2024;140:38-51). Paterson’s 2023 study evaluating the period after the height of the COVID-19 pandemic indicates that mental health conditions may be more prevalent now (Anaesthesia 2023;78:197-206). Alternatively, it may be that we are more cognizant of problems or more willing to discuss them.

An area not necessarily considered a mental health disorder, but which can be a manifestation of an emotional, physical, or SUD, is disruptive behavior (Can J Anaesth 2019;66:795-02). A single-year study showed that almost a quarter of OR physicians experienced abuse, while 39% witnessed colleagues being abused (Can J Anaesth 2019;66:795-02). This study underscores the need to acknowledge that impairment may be a manifestation of other problems.

What avenues are available for treatment?

Treatment starts with recognition and acceptance that there is a problem. Anesthesiologists are encouraged to use online screening material and their primary physicians. Nearly every state has a PHP. These are confidential resources for physicians who have conditions that may impair their performance, including addictions, mental health conditions, physical illness, or behavioral concerns. These programs provide detection, evaluation, treatment, and continual monitoring. Early referral is encouraged. A landmark study showed that anesthesiologists who are cared for through a PHP and who are on a recovery contract have equal rates of program completion, disciplinary action, and return to work as other specialties (Anesth Analg 2009;109:891-6). Anesthesiologists in these programs had a lower rate of failed drug tests. The Federation of State Medical Boards recommends that PHPs serve as safe havens for physicians with mental health and substance-related disorders who voluntarily seek care (asamonitor.pub/48M0Msg). A safe haven may protect a physician from having to report a condition to a state medical board if the physician is monitored and in good standing with a PHP, although this is variable throughout the country (JAMA 2021;325:2017-8). PHP-coordinated care is highly successful, but compliance with the requirements of a contract is often a significant financial burden to the provider, especially those early in their careers (Am J Addict 2023;32:385-92).

One area under investigation is through medication-assisted treatment (MAT) or medications for the treatment of opioid use disorders (MOUD) for anesthesiologists with SUDs. A very small study of anesthesiologists treated with naltrexone revealed a far lower rate of relapse and a much higher rate of return to work compared with those not receiving treatment (J Addict Med 2011;5:279-83). The Federation of State Medical Boards notes that the safety-sensitive nature of the practice of medicine requires that the impairing potential for medication be considered and that decisions regarding practice be made on an individual basis. Physicians on MAT/MOUD should continue to receive counseling and other needed treatment(s) (FSMB Policy on Physician Illness and Impairment 2021) and should not be stigmatized (J Addict Med 2023;17:4-6).

Physician suicide is a high-profile problem. How common is it among physicians in general and anesthesiologists in particular?

Physicians are particularly vulnerable to death by suicide, but the results of studies are conflicting. Medical students and physicians-in-training have lower rates of death by suicide than the general population. However, it is the leading cause of death of male residents and second only to cancer for female physicians (Acad Med 2017;92:976-83). After training, female physicians have a far higher incidence of death by suicide than the general population, while recent data indicate that males may have a slightly lower rate (BMJ 2024;386:e078964). Since the 1980s, the rates for both sexes have decreased. Studies seem to indicate that anesthesiologists have a higher rate of death by suicide than the general population, and, along with psychiatrists, may have the highest rate among physicians. Two studies in the late 1960s and early 1970s revealed that the rate of death by suicide among anesthesiologists was higher than in the general population (Anesthesiology 1968;29:565-9; Anesthesiology 1974;41:71-4). It has been nearly a quarter of a century since Alexander’s study of cause-specific mortality indicated that when anesthesiologists are compared with internists, we have a higher rate of death by suicide and death from other tragic causes, including substance use disorders (Anesthesiology 2000;93:922-30).

We recently established a database of anesthesiologist deaths by suicide as a product of the ASA Working Group on Mental Health and Suicide Prevention, under the Committee on Physician Well-Being. We hope that this ongoing confidential project will shed light on the risk factors and characteristics of anesthesiologists who take their own lives. Such information could allow for early intervention for at-risk individuals. Preliminary data indicate that female anesthesiologists who die by suicide do so on average 10 years earlier than male anesthesiologists. Colleagues can utilize the QR code below to contribute to the database.

“Impairment” calls to mind struggles with mental health and substances. But medical conditions in and of themselves can also be causative, correct?

Physicians are impacted by physical conditions just like other individuals, although we are generally in better health than the general population. Regardless, we must recognize our vulnerability to illness. Years ago, I was suffering from what I thought was crippling anxiety. I went to multiple colleagues, including leaders in my department. I also sought the advice of a psychiatrist friend. Eventually, the anxiety dissipated. But in retrospect, the condition was likely my first bout with atrial fibrillation. Physicians often self-medicate rather than create their own patient-physician relationship (JAMA 1998;280:1253-5; Occup Med 2011;61:490-7). This can lead to inappropriate self-treatment or diagnosis, missing the actual cause of illness or impairment. Self-treatment has unfortunately been historically embedded in the medical culture. Fortunately, recent data in interns reveal lower rates of self-treatment (Arch Intern Med 2021;172:371-2).

Can you relate an educational (and anonymous) anecdote regarding an impaired colleague was treated, successfully or not?

I have performed multiple interventions over the years for colleagues exhibiting impaired professional performance. I am proud of many successes, but one stands out. This trainee’s performance early in his career did not meet our expectations. We worked with him extensively without significant improvement. Substances were not involved at all. He eventually revealed that he suffered from a disability. We worked with him to establish educational accommodations to assist his training. He graduated from our program and is nearly 20 years into a successful career. He has become an advocate for disabled clinicians, and the lessons from his experience have helped numerous others. His story demonstrates that there are other causes of struggles and that good faith mentoring and guidance can make all the difference.

What can ASA members do to support colleagues in need, and to become more involved on an organizational level?

Physicians are often reluctant to intervene when they observe characteristics of impairment in their colleagues (JAMA 2010;304:187-93). We assume that someone else has identified the issue and is acting, we worry about being “wrong” and about false accusations, we do not know where to turn nor whom to contact, and we fear that the same can happen to us. Academic departments and private groups should have formal mechanisms for performing an intervention when there are concerns. We should be willing to extend these concerns outside of occupational problems and should open dialogue when factors arise outside of work that are associated with higher risks of death by suicide, e.g., divorce, illness, and financial and legal issues. The ASA website has numerous resources addressing well-being, including videos and links to self-screening tools like the American Foundation for Suicide Prevention, podcasts, the Physician Support Line, and the Emotional PPE Project (asahq.org/advocating-for-you/well-being). All members can access these resources for personal well-being, support of colleagues, education, and response after a critical event.

Any parting words for readers?

The mental and physical health of the members of the anesthesia care team can no longer be something that “we will sort out later” or react to after performance is impaired, or a tragic event occurs. Well-being must be a part of our design process when new facilities are constructed, when service lines are expanded, when a work structure is altered, or when other disruptive changes occur. Every leader must own the mental health of themselves as well as that of our entire care family.