Physician’s Health Message

Duty to Report: A Loaded Question with No Easy Answer

By Michael Baron, MD, MPH, TMF Medical Director
February 5, 2020

A funny thing happened on the way to work one recent day. I received a call from an old friend, a clinical pharmacist who has worked at an inpatient psychiatric facility for many years. After the catching-up part of the conversation, she asked me about an admitting doctor’s reporting responsibility when discharging a healthcare professional from the inpatient unit. My initial response was, “That’s a loaded question with no easy answer.” 

As it happens, I’m asked this question at least monthly. My usual answer is, it depends. There are many variables that determine the answer. I will attempt to explain, and provide some real-life examples to illustrate those variables.

Generally, management of a colleague’s healthcare is between the physician and the patient, just like with any other case. The treating physician should not disclose any aspect of the medical care without appropriate consent from their patient, with one exception – that being if the colleague is impaired by their physical, mental, or substance use disorder. 

Impairment is very different from illness and it is important to understand those differences. Illness, per se, does not constitute impairment. The short definition of impairment is the inability of a physician to practice medicine with reasonable skill and safety as result of an illness.

The Federation of State Medical Boards’ Policy on Physician Impairment officially defines impairment as a functional classification which exists dynamically on a continuum of severity and can change over time rather than being a static phenomenon.* When functional impairment exists, it is often the result of an illness in need of treatment. With appropriate treatment, the issue of potential impairment may be resolved while the diagnosis of an illness may remain. 

Note that not all impairment ends with treatment. The most glaring example is the physician who has developed dementia. Treatment generally does not reverse the cognitive decline that is causing the impairment. 

The treating physician is well positioned to detect if their colleague patient is impaired by an illness. Although that statement is easily understood it is not easily done. The last thing a physician wants to do is tell a colleague they are impaired and should not practice medicine. No doctor wants to say it, and no doctor wants to hear it. Since most physicians are conflict-avoidant, physician patients are seldom told they must stay out of the office until the illness resolves. 

The ability to detect impairment is much easier for a medical illness than for a behavioral disorder. But the rule for both is generally the same: physicians are permitted to be ill; they are not permitted to work while impaired. 

When a physician gets the flu with symptoms like fever, myalgias, cough, etc., they are expected to stay home because they are infectious and impaired by the febrile illness. When the fever remits, their cognitive ability returns, they are no longer infectious, and the physician can go back to work. Influenza is a clear example. 

Addiction and/or behavioral illness don’t have the same level of clarity. 

Let’s look at a few real-life cases that involve alcohol use and a mood disorder. In each case the patient is a licensed physician. Changes were made in the stories to protect the confidentiality of the physicians involved. In each scenario, pertinent statutes or AMA ethics opinions will be identified.

Case 1: A colleague smells alcohol on Dr. A while making rounds and tells him to get help. For privacy reasons Dr. A goes across state lines for admission to an inpatient detoxification unit. Four days later the attending psychiatrist discharges Dr. A with a return-to-work letter and recommendations that he attend 12-step meetings and contact the state’s Physician’s Health Program (PHP). The discharged physician does neither, but quickly and quietly returns to work and to the use of alcohol. Three months later, a patient smells alcohol on Dr. A and makes a complaint to the hospital. The hospital’s Medical Executive Committee (MEC) issues a precautionary suspension and refers Dr. A to the state PHP. Because the event involved patient care, the hospital reports Dr. A’s precautionary suspension to the National Practitioner Databank (NPDB). The NPDB sends all new entries to the respective licensing board. The PHP refers Dr. A for an appropriate evaluation and treatment. While in treatment, he receives a certified letter from the state medical board stating it has opened an investigation.

Like other addictions, alcohol use disorder is not adequately or even partially treated with an inpatient detoxification stay. Yet, just like Dr. A, many physicians are released to return to work after a three-to-seven-day detoxification stay. During the early phases of the illness – for example, when alcohol is only used on weekends or after work – it is much harder to detect and make a diagnosis. As the disease progresses and alcohol is consumed in increasing amounts, the diagnosis is much easier. But alcohol use disorder can take weeks to even months to appropriately treat, so relapse and impairment can easily occur until the disease is appropriately treated.

The lessons learned from this case are that detoxification from alcohol or any substance does not constitute treatment. With no formal treatment and no follow-up or monitoring, Dr. A had little chance of remaining sober. The treating physician at the detox center should have mandated that Dr. A sign a Release of Information (ROI) and make the referral to the PHP or have proof that he actually contacted the PHP. Another possibility would be for the treating physician to refer Dr. A to a facility that treats healthcare professionals. (Most facilities that treat healthcare professionals won’t accept a physician without a signed ROI for the state’s respective PHP). If all options were refused, the treating physician should not have provided a return-to-work letter. When Dr. A went to work intoxicated by alcohol he was, by definition, impaired. Physicians are safety-sensitive workers and are not permitted to work impaired. 
 
Regarding referral for impairment, AMA Ethics Opinion 9.031 states, “Physicians’ responsibilities to colleagues who are impaired by a condition that interferes with their ability to engage safely in professional activities include timely intervention to ensure that these colleagues cease practicing and receive appropriate assistance from a physician health program.”


Case 2
: Dr. B, a general surgeon, is arrested and charged with Driving Under the Influence (DUI) while she is on call for the hospital. While in jail, her partner covers the remainder of her call. She hires an attorney and refuses to accept her hospital’s referral to the state PHP. The small rural hospital doesn’t have the finances for a legal battle. For that and other reasons, the hospital backs off. Dr. B’s Blood Alcohol Level (BAL) at the time of her arrest was 0.13% (the legal limit is ≥ 0.08%). She is eventually convicted of a DUI first offense. She continues to drink alcohol “except while on call.” Apparently, she would begin drinking alcohol at the office when she saw her last patient, consuming at least three mixed drinks while charting. A few weeks later while leaving her office parking lot, she hits and severely wounds a pedestrian with her car. Her BAL this time is 0.16%.

Dr. B met the definition of impairment when she was arrested for DUI because she was on-call for the hospital. That leverage should have been used to get this physician help before her disease and consequences progressed. This horrible outcome might have been prevented if the hospital called the PHP to help intervene.  PHPs have the skill and experience to get physicians into treatment for substance use and other mental health disorders. Another aspect that offers protection when reporting to a PHP is that hospital peer assistance programs or “wellness committees” that fall under the Quality Improvement Committee (QIC) statutes can talk with the TMF-PHP without a Release of Information. Tennessee Quality Improvement Committee statutes are T.C.A. § 63-1-150 and T.C.A. § 68-11-272. 

Case 3: Dr. C is a depressed internist who sees his primary care provider and is placed on an SRI antidepressant. Within two weeks his mood is greatly improved. However, in week three he is in a florid manic state during which he pays cash for an expensive new car, decides to leave his wife, solicits prostitutes, and develops psychosis. His office partners realize something is amiss and try to intervene on him at the end of a workday. Dr. C responds with persecutory statements that his partners are stealing his money and his patients and leaves the intervention. The partners know he can’t practice in that mental state but are at a loss for how to proceed. One of the partners is married to a psychiatrist who makes a diagnosis of mania by phone and recommends calling Mobile Crisis. Mobile Crisis comes to the office about noon the next day. Some of the patients seen by Dr. C that morning made complaints as they left. He refuses to interact with Mobile Crisis and barricades himself into his office. The police are called, and a SWAT team is brought in because Dr. C collects firearms. He is forcibly removed from his office and committed to a psychiatric facility. He is also charged with resisting arrest, having a concealed weapon, and a few other offenses. Dr. C makes the local newspapers. He is diagnosed with an SRI-induced manic episode and presumptive Bipolar Disorder, Type I. His practice group wants him followed by the PHP. The attending psychiatrist is a recent graduate and is not familiar with the state’s PHP or its mission to assist in these cases. Two weeks later, she discharges Dr. C on mood stabilization medication with no referral for follow-up. The group refuses to allow him to return to work without monitoring and advocacy of the PHP.

Dr. C was clearly impaired by the mania. The legal charges were dropped and no medical board complaint was ever made. Three weeks after discharge he stopped the mood stabilizer. Four weeks after discharge he was involved in a high-speed accident that he eventually admitted was a suicide attempt. Dr. C should have been referred to the PHP. Physicians that have PHP involvement have a much higher recovery rate than the general population. The need for ongoing care and monitoring is evident. The group wanted PHP involvement to make sure the internist was diligent about his follow-up appointments, medications, and therapy – which he was not.

The compelling argument for contacting a PHP is to promote a better outcome for the physician. The physician may not want to be monitored – indeed, who does? – but it is not entirely up to them. As we’ve stated, physicians are safety-sensitive workers who are licensed to practice medicine by the medical board. This is a privilege, not a right. The board’s responsibility is to protect the citizens of the state by ensuring healthy physicians. Medical boards use disciplinary actions to ensure professionalism and patient safety. The PHP has a similar responsibility; it is a diversionary program that uses early identification, intervention, treatment, monitoring, and advocacy to ensure professional health, which protects the citizens of the state.  

Many medical boards do not have a rule about impairment, per se. They use language such as unprofessional, unethical, or dishonorable behavior that are synonyms for impairment. When a physician exhibits such behavior, they are culpable for an action on their medical license. State medical boards, however, do have rules about when a physician’s behavior should be reported. A common rule is that if a physician impairment causes patient harm, a complaint to the medical board should be made. 

The role of the Physician Health Program is to ensure that identified physicians are healthy to provide quality care. The primary reason to refer a physician to the PHP is to ensure that the illness – whether substance-use related, mental, or behavioral – is stable or in remission, and not causing impairment. 

If you are in doubt about how or when to report a colleague, you can make an anonymous and/or confidential call to the TMF-PHP to get an idea about how to proceed. It is always best to intervene early before catastrophe occurs. No physician likes being told they are impaired or that they cannot practice medicine because of an impairment. But nearly every physician who initially resented our help is now grateful for the call that saved their career, or their life. 


Contact the TMF: 615-467-6411 or e-tmf.org.

*Federation of State Medical Boards. Apr 2011. Policy on Physician Impairment. Washington, DC: Author.