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.
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Explore This IssueOctober 2018
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?
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.
Once it is clear and certain that a colleague is legitimately impaired, several ethical questions must be considered. You must be sure you are being objective and have no ulterior motive in making the decision to report:
- Is this a person with whom you’ve had previous negative personal interactions?
- Would you stand to gain something if this colleague were found to be impaired, such as a desired panel of patients or an improvement in status or salary by a promotion into their former position?
- Would your own workload increase if this person were forced to take a leave of absence?
- Would there be a taint on the reputation of the hospital or practice if they were found to be impaired?
- What is the chance of retaliation from the impaired colleague or ostracization from other physicians who also know or work with the one who is impaired?
Some experts have suggested a tiered system of responses. Of course, discretion must be used depending on the severity of the impairment and the possibility of risk to patient safety. A level 1 response is a collegial expression of concern, just between yourself and the colleague in question. It’s important to keep this conversation supportive and directed toward concrete plans of action, rather than turning it into a confrontation or any kind of attack on their character. It may be wise to have a neutral party, such as a practice’s lawyer, accountant or a mutual friend, present in some circumstances.
If there is no change in behavior or the other physician doesn’t seek help after that interaction, a level 2 response would involve confidentially approaching the individual’s manager or supervising clinician and asking them to approach the individual with you.
The last and final intervention, which is usually not necessary, would involve reporting the impaired colleague to a physician’s health program, hospital board of directors or applicable state medical board.4,5
In the case above, a reasonable course of action would include seeking out the impaired colleague as soon as possible after the incident and approaching him with your concerns. Because he is putting patients in danger, his supervisor needs to be involved. A kind and compassionate option would be to offer to go with him to present the incident to his supervisor; if he resists your offer, it would be necessary to approach his supervisor alone.
The legal obligation to report an impaired physician varies by state, but as physicians, we have an ethical obligation to report. This helps protect the public from careless and negligent behavior, and protects the physician from further consequences of their behavior. Doing so may save a life—your colleague’s or one of their patients.
Practical considerations, ethical questions and emotional conflicts due to personal relationships with the impaired person make these confrontations difficult, but we must make the right choice to protect our patients’ well-being first and foremost and to help impaired colleagues receive the care they need.6
Jill Johnson, MD, is in private practice in Philadelphia and Bucks County, Pa.
What Would You Do?
Have you been in a similar situation? Tell us about it. What were the circumstances? How did you handle the situation? Do you know what the ultimate outcome was? What would you do differently (if anything) now? Send an email to email@example.com.
- Johnson BA. Dealing with the impaired physician. Am Fam Physician. 2009 Nov 1;80(9):1007–1008.
- Competency and retirement: Evaluating the senior physician. AMA Wire. 2015 Jun 23.
- AMA code of medical ethics.
- O’Neil MG. You suspect that your coworker is impaired—What should you do? Medscape. 2012 Aug 23.
- Adler EL. How should your medical practice handle an impaired physician? Physicians Practice. 2012 Jan 18.
- Mossman D. Current Psychiatry. 2011 Sep;10(9):67–71.
Editor’s note: Do you have an ethical dilemma you’d like to see discussed in this forum? Contact us via email at firstname.lastname@example.org.