Policy of the
Graduate Medical Education Committee Section:
Resident Support/Conditions for Appointment Subject: Physician
Impairment – fatigue or substances Number: 2.300 Date
Developed: 4/97 ACGME Requirement: Institutional II D.4.l.
Last Review/Revision: 2/09,
Replaces: previous policy of same name, dated 2/01
Policy of the Graduate Medical Education Committee
Section: Resident Support/Conditions for Appointment
Subject: Physician Impairment – fatigue or substances
Date Developed: 4/97
ACGME Requirement: Institutional II D.4.l.
To define the procedures and related responsibilities of UAMS Medical Center and residents (includes fellows) in residency (includes fellowship)programs sponsored by the College of Medicine (COM) in regard to drug testing, fatigue, impairment and substance abuse intervention.
The goals of this policy are to:
1. Prevent or minimize the occurrence of impairment, including illness, fatigue and substance abuse, among residents in training programs sponsored by the College of Medicine.
2. Protect patients from risks associated with care given by an impaired resident physician;
3. Confront compassionately problems of impairment including relief from patient care responsibilities if necessary, treatment as indicated, and appropriate rehabilitation.
4. Assert that residents and faculty allow patient need to supersede self-interest by transitioning care to another qualified, rested, or non-impaired provider.
Impairment: For purposes of this policy, impairment is a physical or mental condition which causes a resident to be unable to practice medicine with reasonable care and safety commensurate with his/her level of training or participate in the residency training program as a learner. A decision regarding impairment is not a decision of disability.
Medical Staff Health Committee: a standing committee of the hospital charged to protect patients from exposure to faculty physicians and residents impaired by reason of alcohol, drugs, or serious symptomatic psychiatric disorder and to provide appropriate advocacy for faculty physicians and residents who are successfully participating in an alcohol, drug or mental health treatment program. The term “Medical Staff Health Committee” refers to the UAMS and Arkansas Children’s Hospital (ACH) committees and not the committee of the Arkansas Medical Society.
Employee Assistance Program (EAP): provides counseling, information and referral assistance to all employees who experience a personal or professional problem.
Housestaff Mental Health Service (HMHS): Provides timely access to Department of Psychiatry faculty for a complete mental health program including: diagnostic evaluation, medication management, counseling (individual, family, couples) and preventative services.
The Sponsoring Institution and its programs will be committed to and responsible for promoting patient safety and resident well-being in a supportive educational environment, and ensure a culture of professionalism that supports patient safety and personal responsibility. Residents and faculty must demonstrate an understanding and acceptance of their personal role in: assuring patient safety, assurance of fitness for duty, management of their time before during and after clinical assignments, recognizing impairment including illness and fatigue in themselves and in their peers.
Signs and Symptoms of Impairment
Signs and symptoms of impairment may include, without limitation, the following:
1. Physical signs such as fatigue, deterioration in personal hygiene and appearance, multiple physical complaints, accidents, eating disorders.
2. Disturbance in family stability or evidence of personal or professional relationship difficulties with resulting isolation.
3. Social changes such as withdrawal from outside activities, isolation from peers, embarrassing or inappropriate behavior at parties, adverse interactions with police, driving while intoxicated, being undependable and unpredictable, aggressive behavior, argumentative, or unusual financial problems.
4. Professional behavior patterns such as unexplained absences, spending excessive time at the hospital, tardiness, decreasing quality or interest in work, inappropriate orders, behavioral changes, altered interactions with other staff, inadequate professional performance or significant change in well-established work habits.
5. Behavioral signs such as mood changes, depression, slowness, lapses of attention, chronic exhaustion, risk taking behavior, excessive cheerfulness, flat affect.
6. Signs of drug use or alcohol abuse such as excessive agitation or edginess, dilated or pinpoint pupils, self medication with psychotropic drugs, stereotypical behavior, alcohol on breath at work, uncontrolled drinking at social activities, black outs, binge drinking, changes in attire (e.g., wearing of long sleeve garments by parenteral drug users).
Education and Resources
Each program will have a policy regarding fatigue education, mitigation and the program’s method of ensuring continuity of care when residents are unable to perform his/her patient care duties.
SAFER – online module developed by the American Academy of Sleep medicine. The module is required to be completed once during training time at UAMS.
LIFE Curriculum (Learning to Address Impairment and Fatigue to Enhance Patient Safety) – case-based videos for use individually or in a group setting. Topics among others include: fatigue, stress and depression, substance abuse, and impairments.
Brochure on fatigue – may be distributed regularly to residents, faculty, clinic and hospital staff who work with residents.
Information about physician impairment and the services of the UAMS Employment Assistance Program (EAP) and Housestaff Mental Health Service (HMHS) is provided at Housestaff Orientation/Registration.
Sleep rooms and call rooms. Call rooms are available at each participating institution, additional sleep rooms are available at UAMS MC.
Pre-employment Drug Screen and Other Requirements for Appointment to the Training Program
To be appointed to a residency program of the UAMS-COM, a resident must successfully pass a pre-employment drug screen in accordance with UAMS Drug Testing Policy (Policy 3.1.14) prior to the initial training year.
At the beginning of the program, all residents receive the UAMS Drug-free Awareness Statement and acknowledge receipt by signing the form and returning it to the Director of Housestaff Records. All residents will abide by all conditions in the UAMS Drug Testing policy (Policy 3.1.14) and the UAMS policy for a drug-free workplace (policy 4.405) which states: “The University of Arkansas (UAMS) supports the concept of a drug-free workplace as enacted in the federal Drug-Free Workplace Act of 1988 and the State of Arkansas Executive Order EO-89-2, issued March 30, 1989. It is the policy of the State of Arkansas, and thereby the University of Arkansas for Medical Sciences, that the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance in a UAMS workplace or by an employee while on a University assignment is prohibited. However, nothing in this policy will preclude the medical or research use of alcohol or controlled substances. UAMS will not differentiate between drug users and drug pushers or sellers in the applicability or enforcement of this policy.”
All residents must complete the confidential Practitioner Health Questionnaire and return it to the Associate Dean for GME. This questionnaire will be updated yearly at the time of renewal of the resident’s agreement of appointment. Questionnaires with concerns will be reviewed by the UAMS Medical Staff Health Committee, and may be reviewed by the respective Program Director and Departmental Chairperson. Questionnaires from residents in pediatrics and its subspecialties will be forwarded to the ACH Medical Staff Health Committee and the Program Director for pediatrics.
Repeated evaluations documenting substandard academic performance or other grounds for consideration of academic probation or remedial work, existing in conjunction with one or more signs(s) or symptom(s) of impairment, such as those listed above, may be considered in determining whether or not the resident obtains a medical and/or psychiatric evaluation in accordance with the procedures below. Members of the UAMS and ACH Medical Staff Health committees and staff members of the Employee Assistance Program (EAP), are available to assist in confirming or validating suspected abuse, dependency and/or impairment.
I. Suspected impairment, chemical dependency or abuse
All medical personnel have a duty, as required by ethical standards for the well being of patients and one’s fellow professionals and as mandated by state laws, to report in confidence concerns about possible impairment both in themselves and in others to an appropriate supervisor. Residents should confide their suspicions of possible impairment and/or chemical dependency of another resident to their Program Director, their Departmental Chairperson and/or a member of the Medical Staff Health Committee.
“Suspicions” might include any of the signs or symptoms of impairment listed above as well as smell of alcohol on breath at work; inappropriate behavior at work; reports of DWI’s or stories of “wild behavior”; persistent rumors from potentially credible individuals that the resident is using illegal or legal substances, and writing inappropriate prescriptions for DEA-controlled medications; or declining academic or clinical performance.
When impairment or chemical dependency is suspected of one of his/her residents, the Program
Director or his designee should follow the procedure outlined below:
A. The Program Director should gather all of the pertinent information concerning the individual. This could include but is not limited to Arkansas Department of Health reports of illegal prescription writing; interviewing other residents or faculty about their observations of the individual in question.
B. The Program Director must contact another practitioner who is a member of the Medical Staff Health Committee for assistance and advice.
C. The Program Director and another member of the faculty (this could include a member of the Medical Staff Health Committee) should meet with the individual and discuss the information that has been gathered about the individual.
D. If the data indicate that impairment is likely, the Program Director and another faculty member and/or a member of the Medical Staff Health Committee should discuss the following:
1. The individual should be suspended from clinical privileges until further notice.
2. Treatment options include outpatient evaluation or comprehensive inpatient evaluation.
3. The individual should be provided with and advised about insurance options.
4. At the conclusion of the meeting, the individual should be able to understand the options for the treatment and the conditions applicable for return to active clinical care and educational status following the mandatory suspension of clinical privileges. This understanding should be documented in writing.
E. The individual should have a reasonable but not an extended time to consider his/her options (it is recommended that this time for consideration be no longer than 24 hours). Suicide in such situations can be an issue for impaired individuals when threatened, so suicide precautions may need to be taken in some instances.
F. If the individual agrees to cooperate or the initial evaluation reveals a high probability of impairment or substance abuse, the Program Director should provide a written agreement of a plan for treatment and a plan for returning to the training program. The agreement should be signed by the individual and the Program Director, with copies to the individual and to his/her file.
1. The Medical Staff Health Committee and the University Counsel should be consulted in drafting this agreement.
2. This agreement should address salary, leave status, medical benefits, payment for any required treatment, how long the individual may be absent from the training program, the conditions for returning to the training program as outlined in the Physician’s Health Recovery Contract (see attached), the drug/alcohol screen and monitoring after return to the training program, and who is responsible for paying for these drug screens.
3. The Program Director should obtain a signed “release of information” to enable the Program Director and the Medical Staff Health Committee to verify and monitor the progress of the impaired physician. The Training Program Director must follow the For Cause Drug Testing Protocol of UAMS Administrative Guide Policy 3.1.14.
G. If suspected impairment cannot be confirmed because of lack of substantial data, but strong grounds remain that the individual is involved with chemical dependency, abuse, or other impairment, the Program Director should recommend that the individual obtain an objective and comprehensive diagnostic evaluation.
1. The Medical Staff Health Committee would be available to assist in interventions and recommendations.
2. Options for insurance coverage should be discussed.
H. After the intervention, the Medical Staff Health Committee can serve as an advocate for the impaired individual. The Medical Staff Health Committee will review ongoing evidence on a timely basis.
I. Failure to comply with the initial recommendations is grounds for immediate suspension from the residency program and UAMS, pending a decision to terminate for gross misconduct or while an investigation is being conducted.
1. Contact the Office of the General Counsel of the University of Arkansas, and the Associate Dean for Graduate Medical Education to determine if disciplinary measures or termination will be implemented.
2. Adjust the individual’s clinical privileges at University Hospital accordingly and notify the Office of Housestaff Records at 686-5356.
J. Recurrent inappropriate behavior may be considered grounds for termination from the residency program.
II. Obvious chemical abuse or dependency or impairment
A. The individual must be immediately removed from patient care with suspension of his/her clinical duties. The individual should be sequestered in a safe environment and medical care rendered.
B. The Program Director must follow the For Cause Drug Testing Protocol of UAMS Administrative Guide Policy 3.1.14. The Program Director must contact the Medical Staff Health Committee to obtain its assistance and expertise in dealing with the individual.
C. Once the individual is no longer under the influence, the Program Director and another faculty member and/or a member of the Medical Staff Health Committee should meet with the individual to formulate a plan as in I. D-H above.
D. If the individual agrees to cooperate, proceed as in I D-H above.
E. If the individual refuses to cooperate, proceed as in
III. Self referral for impaired residents
Physicians who choose to refer themselves for treatment, must inform their Program Director and the Medical Staff Health Committee and sign an agreement about their recovery. (See I F above). Program Directors who have information about residents who have self-referred should assure that recommendations in I F above are complied with.
IV. Financial considerations
The costs of initial evaluation for impairment, which are not covered by insurance, will be shared equally between the Medical College Physician Group (MCPG) and the Department housing the residency program.
When a resident has confirmed drug abuse or other impairment, the costs of the diagnostic evaluation, treatment, or after care monitoring, which are not covered by insurance, are the responsibility of the resident. QualChoice health insurance, if accessed appropriately through the primary care physician or through the UAMS Employee Assistance Program, may cover some or most of the cost of the treatment.
V. Preemption of Policy
For residents who have an existing contract with either the Medical Staff Health Committee or the Arkansas Medical Foundation Physician Health Committee, to the extent the terms of the resident’s contract conflict with this policy, the terms of the contract shall prevail.