Physician Substance Abuse
By Autumn Dawn Galbreath, MD, MBA | November 17, 2016
by Autumn Dawn Galbreath, MD, MBA
According to a 2009 article in Mayo Clinic Proceedings, “Approximately 10% to 12% of physicians will develop a substance use disorder during their careers, a rate similar to or exceeding that of the general population.” But while our addiction rate may be similar to the rest of the country, the characteristics and consequences of our addictions are not.
Physician substance abuse, though oft-discussed in current events, is an age-old issue. William Halsted (1852-1922), father of modern surgical techniques, was widely known to be addicted to cocaine and morphine—and he was but one well-documented example. However, despite the long history of physician addiction, the first major academic exploration of the topic did not occur until 1973 in a Journal of American Medicine article entitled “The Sick Physician.” This landmark article attempted to define the magnitude of the physician addiction problem in the U.S. and make the case for treatment. Since that first article, numerous authors have examined physician addiction, but little progress has been made in reducing the overall burden physician addiction presents to the profession and to society at large.
Physicians have several unique risk factors for substance abuse. While the general population typically begins illicit drug use recreationally, physicians usually begin as a means of stress relief. Medical training and medical practice create levels of stress rarely experienced by others. From sheer number of hours in the hospital to an often-abusive culture in which colleagues treat one another very un-collegially to the life-and-death decisions physicians make on a daily basis, the psychological life of a physician is rife with opportunity to be overwhelmed by stress—and being overwhelmed by one’s stress is a prime temptation to indulge in inappropriate means of stress relief. For the physician overwhelmed by stress, access to drugs only enhances that temptation. Physicians have among the easiest access to prescription drugs of any profession, and our knowledge of the drugs and of the healthcare system gives us the ability to “cover our tracks” well, at least at the beginning.
Compounding the personal risk factors is the fact that physicians are less likely to be reported for signs of substance abuse. The power differential in healthcare settings often discourages other healthcare personnel from reporting, and physicians generally don’t report colleagues. A 2010 JAMA study showed that, while almost 1 out of 5 physicians have had direct personal knowledge of an impaired colleague, 1/3 of them did not report. Reasons ranged from thinking someone else would do it to fearing the colleague would be excessively punished. In addition, safeguards “to detect and prevent drug abuse in other high-risk industries rarely are employed in health care. No state has universal drug testing requirements [and]…. facilities almost never do so on their own.” Personally, I believe the culture of medicine, in which physicians honor an unspoken pact to protect one another to the outside world, even if we abuse one another within our inner circle, is also a significant factor in under-reporting. Whatever the reason, failing “to report an impaired colleague, or one who's suspected of being impaired, is neither an act of mercy nor a professional courtesy….”
When colleagues fail to report, the addicted physician continues to practice medicine, opening the door to a host of terrible outcomes. The addicted physician is “left to practice until something happens that ruins their career -- a patient is injured, there’s a criminal incident, there’s an arrest for DUI -- or worse.” In addition, drug abuse has been directly associated with physician suicide.
For the addicted physician, self-preservation and protection of the medical license is paramount. Physicians’ “addictive disease (when compared with the general public) is typically advanced before identification and intervention. This delay in diagnosis relates to physicians’ tendency to protect their workplace performance and image well beyond the time when their life outside of work has deteriorated and become chaotic.” In addition, numerous physicians engage in self-treatment for their addictions, or they secretly engage a colleague to help them “unofficially.” Sadly, as with so many things in life, things done in secret generally grow and metastasize rather than healing—which is why we have a legal and ethical obligation to report physicians we suspect are abusing substances.
Once the addiction is exposed, the healing can begin. Though the immediate consequences are often devastating to the physician personally and professionally, the long-term outcome of sanctions and treatment are extremely positive. Physicians respond to treatment much better than the general population. According to this article from Medscape, “Physicians who undergo treatment and participate in ongoing monitoring…have a far lower rate of relapse, with only 22% testing positive at any point during the 5-year monitoring period and 71% still licensed and employed after 5 years.” This is due, in part, to a unique treatment option available to physicians: the Physician Health Program (PHP). Present in 48 states, PHPs provide a different treatment paradigm, utilizing residential treatment following by long-term outpatient treatment and monitoring. There is ongoing investigation into the value of extrapolating the PHP model to drug treatment for the general public, given its effectiveness for physicians.
Ultimately, as with almost every struggle we face in this world, addiction has spiritual ramifications. When I read this quote from an impaired physician, I felt I could have said it about any number of struggles in my own life: “As a physician, I had such a hard time relinquishing control of my own care. I’d always been able to do things on my own. I studied hard, I worked hard, and I succeeded. But I finally had to learn that I couldn’t will myself into recovery.”
As physicians, we struggle to relinquish control. Be it addiction or relationships or professional commitments, most of the time we are able to control our lives and force the world around us to bend to our self-sufficient wills…until we can’t. And isn’t that the moment when grace comes in? When God shows us who He is in a fresh, new way? Why do we need Him when we are doing fine on our own? It’s only when we reach the end of ourselves, unable to will ourselves to success in our chosen endeavors, that we fall into His sufficiency. Maybe addiction is only a more obvious example of the struggles we all face. As Christian physicians, we are uniquely equipped to show compassion to impaired colleagues, even as we hold them accountable for their recovery. But we are also uniquely equipped to see our own weaknesses, to allow God to touch us in our self-sufficiency and to lay the control of our lives at His feet.
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