Impaired physicians: How to recognize, when to report, and where to refer

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.¹³ In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.¹⁶

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.¹⁷ Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

• skill and knowledge
• psychosocial functioning
• management skills
• performance
• collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.¹⁸

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.¹³

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).¹³

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.¹⁹ Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.²⁰

Shouten²⁰ cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.^20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.²⁰

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.⁵