Policy of the Graduate Medical Education Committee
Section: Resident Support/Conditions for Appointment
Subject: Physician Impairment, Drug Testing and Drug Abuse Intervention
Number: 2.300
Date Developed: 4/97
Last Review/Revision: 2/06
Replaces: previous policy of same name, dated 2/01
ACGME Requirement: Institutional II.D.4.l.
Purpose
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, impairment
and substance abuse intervention.
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.
Employee Assistance Program (EAP): a program developed to provide counseling, information and consultation for UAMS faculty physicians, residents and staff who experience some form of personal distress.
Background
Untreated or relapsing impairment is not compatible with safe clinical
performance. The goals of this policy are to:
1. Prevent or minimize the occurrence of impairment, including 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 to effect diagnosis, relief
from patient care responsibilities if necessary, treatment as indicated, and
appropriate rehabilitation.
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, undependable and unpredictability,
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).
Repeated evaluations documenting substandard academic performance or other grounds for consideration by the residency training program director of academic probation or remedial work, existing in conjunction with one or more sign(s) or symptom(s) of impairment, such as those listed above, may be considered in determining whether or not medical and/or psychiatric evaluation of the resident in accordance with the procedure below is warranted. 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.
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 that receipt by signing the receipt 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.”
Procedures
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 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 medical part of the resident’s 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 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 submit to 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. I
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 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 I. I. above.
III. Self referral for impaired residents.
Physicians who choose to refer themselves for treatment, without the
intervention of the Program Director or the Medical Staff Health Committee, 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 conflicts with this policy, the
terms of the contract shall prevail.
VI. Protocol for Handling Residents with Suspected Impairment.
1. Program Director (PD) gathers all pertinent information.
2. PD contacts a member of the Medical Staff Health Committee (MSHC).
3. PD follows the For Cause Drug Testing Protocol of UAMS Policy 3.1.14
4. PD and another faculty member (in department or of MSHC) meet with the resident to discuss:
a. Suspension of privileges
b. Treatment options
c. Insurance coverage
5. PD documents the resident’s understanding of the discussion in writing
6. Resident may have 24 hours to review options
7. Resident undergoes initial evaluation
8. Resident and PD discuss plans for treatment and develop letter of agreement
a. Consult University Counsel assists with drafting agreement
b. Letter of agreement addresses:
1) Salary
2) Leave status
3) Medical benefits
4) Payment for treatment
5) Length of absence from program
6) Drug/alcohol screening/monitoring
7) Payment for screening/monitoring
8) PD obtains signed Release of Information
9. Resident completes Physician’s Health Recovery Contract with MSHC member