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Do physicians have diminished capacity as a result of substance abuse, burnout, behavioral or psychological issues, or physical illness? Regardless of the reason for impairment, physicians have an ethical obligation to protect their patients from harm.
“One key ethical principle that should be highlighted when discussing impaired physicians who self-report is that of nonmaleficence,” says Sigal Klipstein, MD, chair of the American College of Obstetricians and Gynecologists Committee on Ethics. Above all else, physicians have a responsibility to protect their patients from harm.
“When physicians suspect that they may be at risk of providing compromised care to their patients due to any type of impairment, they should take all possible actions to prevent harm to patients,” says Klipstein, a clinical instructor of obstetrics and gynecology at University of Chicago. The first step in this prevention is for physicians to remove themselves from situations which may compromise patient care. “This may involve completely relinquishing all clinical responsibilities, or modifying their practice so that they do not place patients at risk,” says Klipstein.
Practices that may need to be modified or eliminated include providing consultation, writing prescriptions, and performing surgery. “Any actual or potential deficit in decision-making capacity or physical limitations that can affect patient care should lead physicians to remove themselves from situations of responsibility,” says Klipstein. She offers these recommendations:
• Physicians should regularly self-assess their ability to provide the highest standard of care to their patients. “Any doubt that they have should immediately prompt them to further investigate whether such doubt is founded in fact,” she adds.
• Bioethicists should provide counseling to physicians and institutions regarding the appropriate approach to situations in which it is not initially clear whether an impairment exists.
“Bioethicists are also crucial in providing consultation when there is not clear agreement among stakeholders regarding whether or not an impairment is present,” says Klipstein.
Failure of impaired physicians to self-report puts patients and the integrity of the medical profession at risk, warns Helen M. Farrell, MD, an instructor at Harvard Medical School and a staff psychiatrist at Beth Israel Deaconess Medical Center in Boston. Several obstacles make self-reporting a challenge; physicians may experience emotional conflicts such as denial and fear of stigmatization. “They might also worry about the status of their position and license stability if one reveals a mental condition or substance abuse problem,” says Farrell.
Nonetheless, just as physicians are obligated to report colleagues who present with signs and symptoms of substance abuse, so, too, are they obligated to report themselves. “Physicians should be encouraged by the highest levels of institutional governance that self-reporting of impairment and removal of oneself from situations that are potentially harmful to patients is a strategy to improve patient care,” says Klipstein.
Bioethicists can be instrumental in assisting institutions in writing policies that encourage physicians to self-report when they suspect that they are impaired. “They can provide guidance to institutions and physicians in order to safeguard confidentiality while not impacting patient care,” says Klipstein.
Physicians should not be penalized for self-reporting, but rather, should be commended for their focus on patient safety.
“Rehabilitative programs should be put into place that support and assist physicians, with the aim of returning them to health and imbuing them with the ability to resume their professional roles,” says Klipstein.
Modifications to practice could include referrals of patients to practice partners or, if needed, to physicians in other practices that can meet their needs. “Physicians need not specify the reason for their leave of absence,” says Klipstein. “They do, however, have a responsibility to not abandon patients and to provide alternative options for care.”
Institutions should make state rules for reporting physician impairment readily available to employees, advises Farrell. “Laws and regulations are similar in spirit across jurisdictions,” she adds.
Many states have “sick doctor” statutes allowing license protection and preservation for doctors who report impairment from a mental illness or substance-related condition. “Institutions can proactively help colleagues seek treatment, which is often very successful, under physicians’ health committees and treatment programs,” says Farrell.