Who Will Guard the Guardians? Preventing Drug Diversion in Hospitals

• Fairness: All physicians should be subject to regular assessment, and the same standards should be applied to all physicians in the same discipline.
• Objectivity: Performance assessment should be based on objective data.
• Responsiveness: Physicians with performance issues should be identified and given feedback promptly, and provided with opportunities for remediation and assistance when underlying conditions are affecting their performance.

Some progress has been made toward this goal, especially in identifying underlying factors that predispose to performance problems.⁵ There is also greater awareness of underlying factors that may predispose to more subtle performance deterioration. The recent focus on burnout and well-being among physicians is long overdue, and the recent Charter on Physician Well-Being⁶ articulates important principles for healthcare organizations to address this epidemic. Substance-use disorder is a recognized risk factor for performance impairment. Physicians have a higher rate of prescription drug abuse and a similar overall rate of substance-use disorders compared to the general population. While there is limited research around the risk factors for drug diversion by physicians, qualitative studies⁷ of physicians undergoing treatment for substance-use disorders found that most began diverting drugs to manage physical pain, emotional or psychiatric distress, or acutely stressful situations. It is plausible that many burned out or depressed clinicians are turning to illicit substances to self-medicate increasing the risk of diversion.

However, 13 years after Leape and Fromson’s commentary was published, it is difficult to conclude that their vision has been achieved. Objectivity in physician performance assessment is still lacking, and most practicing physicians do not receive any form of regular assessment. This places the onus on members of the healthcare team to identify poorly performing colleagues before patients are harmed. Although nearly all states mandate that physicians report impaired colleagues to either the state medical board or a physician rehabilitation program, healthcare professionals are often reluctant⁸ to report colleagues with performance issues, and clinicians are also unlikely⁹ to self-report mental health or substance-use issues due to stigma and fear that their ability to practice may be at risk.

Even when colleagues do raise alarms—as was the case with Dr. Duntsch, who required treatment for a substance-use disorder during residency—existing regulatory mechanisms either lack evidence of effectiveness or are not applied consistently. State licensing boards play a crucial role in identifying problems with clinicians and have the power to authorize remediation or disciplinary measures. However, individual states vary widely¹⁰ in their likelihood of disciplining physicians for similar offenses. The board certification process is intended to ensure that only fully competent physicians can practice medicine independently. However, there is little evidence that the certification process ensures that clinicians maintain their skills, and significant controversy has accompanied efforts to revise the maintenance of certification process. The medical malpractice system aims to improve patient safety by ensuring compensation when patients are injured and by deterring substandard clinicians from practicing. Unfortunately, the system often fails to meet this goal, as malpractice claims are rarely filed even when patients are harmed due to negligent care.¹¹

Given the widespread availability of controlled substances in hospitals, comprehensive solutions must incorporate the systems-based solutions proffered by Fan and colleagues and address individual clinicians (and staff) who divert drugs. These clinicians are likely to share some of the same risk factors as clinicians who cannot perform their professional responsibilities for other reasons. Major system changes are necessary to minimize the risk of short-term conditions that could affect physician performance (such as burnout) and develop robust methods to identify clinicians with longer-term issues affecting their performance (such as substance-use disorders).

Although individual clinician performance problems likely account for a small proportion of adverse events, these issues strike at the heart of the physician-patient relationship and have a profound impact on patients’ trust in the healthcare system. Healthcare organizations must maintain transparent and effective processes for addressing performance failures such as drug diversion by clinicians, even if these processes are rarely deployed.