Ethics Forum: When & How to Intervene with the Impaired Colleague

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You are seeing a hospital consult late in the afternoon on a Saturday. The patient has suspected, new-onset lupus with inflammatory arthritis, renal failure with nephrotic range proteinuria and a malar rash. You plan to start the patient on high-dose IV steroids, and you decide to speak to the nephrologist on call first.

When he answers the phone, you hear loud music in the background and you surmise he is at a party. When he starts speaking, his speech is slurred, he laughs inappropriately, and he has difficulty recalling the patient in question, even though a chart note from earlier that day has his name on it. You have discussed mutual patients with him before, and you don’t recall any odd or inappropriate behavior during those interactions.

What should you do?

Discussion

A physician may be impaired due to any of a number of possible reasons. Substance use is just one of these possible reasons.¹ The way one’s brain changes with age, with or without dementia, is also an impairment of sorts.² Perhaps someone reading this article has faced a situation similar to the one described above.

What is the right way to respond to an impaired colleague? What ethical principles can help guide our decisions?

The American Medical Association (AMA) has stated in its Code of Medical Ethics that physicians have a moral obligation to fellow physicians and to their patients to “intervene in a timely manner to ensure impaired colleagues cease practicing and receive appropriate assistance” when they have reason to believe that a physician is impaired in a way that affects their ability to provide safe and effective care.³

This statement is based on the basic ethical principles of benevolence (acting for the good of another) and nonmaleficence (acting to prevent harm to another). These principles are the foundation of medical ethics and are implied in the Hippocratic Oath and Maimonides Physician’s Prayer, which include important guiding principles for the personal interactions inherent to the practice of medicine.

Physicians may also have legal obligations to report an impaired physician, and we all need be familiar with the applicable laws.

When it comes to dealing with a situation involving an impaired colleague, practical and logistical issues can complicate matters. Example: Hospital systems and large practices often have a formal system in place, but small practices may struggle with even knowing where to begin. If the impaired physician has a position of seniority or management of personnel and finances within a practice, making a decision to approach or even report them is even more fraught with difficulty. And how can you know for sure a problem truly exists without having directly witnessed a colleague using an intoxicating substance during duty hours? Some odd or unprofessional behaviors could be attributed to severe mental stress due to personal difficulties at home, professional pressures, illness or sleep deprivation.