Phase II Home Page
The
Language of Bioethics (Glossary)
Objectives
Goals
Required
Reading
Outline of
Issues
Clinical
Vignettes
Suggested
Readings/References
References
& Resources
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The Impaired
Colleague
Objectives
To explore the effects of substance
abuse upon the physician, patients and colleagues; professional, ethical and
legal responsibilities to all affected, and a practical approach to the problem.
Goals
Each student will understand and
apply the following in discussion of cases:
- The definition of impairment and its major
forms.
- How impairment might be manifested in medical
students, housestaff, and practitioners.
- One's ethical obligations to colleague,
patients and the profession.
- Practical approaches to an impaired colleague
and resources available
- The primary ethical, legal and professional
guidelines for these topics.
Required Reading
- Code of Medical Ethics, American
Medical Association "Reporting Impaired, Incompetent, or Unethical
Colleagues," 9.031
Note: Many of these AMA statements are in Doctor's
Dilemma
- Ethics
Manual, Fourth Edition, American College of Physicians
"Impaired Physician"
- Collins
GB. New hope for impaired physicians: Helping the physician while
protecting patients. Cleveland Clinic Journal of Medicine. Vol.
65(2); February 1998: 101-106.
Note: This article can be found through Ovid and will require an ID and
password.
Outline
of Issues
I. The problem physician
A. Impairment due to substance abuse
B. Other reportable problems: incompetence and unethical conduct
II. General obligations of
physicians to report
A. Owed to the profession
B. To the community
C. To one's patients
D. To the colleague
III. Effects of a physician's
impairment
A. On the integrity of the
profession
B. On the health and welfare of the community
C. On safety of your patients
D. On the impaired colleague
IV. Effects of your choice to report
a colleague
V. Guidelines for the appropriate
course of action
A. When to act
1. Common signs of physician
impairment
2. How serious must the abuse be
B. Confronting your
colleague–The process
C. Due process for the reported
physician
1. To whom reports should be
made
2. Assuring a fair hearing for your colleague
D. Impaired physician programs
1. The objective--Rehabilitating
a valued colleague
2. Guidelines for impaired physicians
3. The recovery contract
Clinical
Vignettes
Arthur Jones
When Arthur Jones became a medical
student, he was 35 years old and married with two children. He had been a civil
engineer with a small land surveying company and, by all accounts, was a hard
worker and devoted father. At first, he had some difficulty adjusting to the
role of a medical student, particularly to the small amount of time his studies
left for his family. He was advised at one point that he was in jeopardy of
failing Anatomy. By the middle of the year, however, he had managed to pull his
grades up and was expected to a pass all of his courses. When Phase I was
completed, Arthur had completed the requirements for promotion, but just barely.
Throughout his trials at school, he seemed to maintain a very positive and
confident attitude about his future. He made friends easily with his class
mates, particularly his study partners. After their intense study sessions, they
would often relax together at a local bar frequented by medical students.
Arthur and his family moved back to
Atlanta for the summer and he worked at his old trade to try to replenish his
dwindling bank account. He did not return to Augusta until the first day of
classes. He left his family in Atlanta.
From the first day, it was apparent
that Arthur had somehow changed. He no longer met with his old study group. In
fact, he was seldom seen outside of class. After the first two weeks, he began
missing most classes, even the ones that had a reputation for being particularly
helpful or entertaining. When he did attend, he seemed inattentive or frequently
dozed off. One morning he asks you, a friend and member of his old group, for a
ride to Atlanta. He explains that his car is in the shop there, and he needs to
check on his family. You detect the distinct odor of Scotch as he speaks. During
the trip, he confides that his driver's license had been revoked. and that he is
thinking of dropping out of school.
Discussion Questions
- How does a medical student deal with a
colleague who is impaired by the abuse of alcohol or other drugs?
- What are the consequences of taking or not
taking action in the case?
- What responsibility does the student have
for the interests of the impaired colleague and his/her patients?
- What guiding principles determine the
appropriate response and how is it to be executed?
Dr. Fred Williams
Dr. Fred Williams is a 2nd year
Resident on-service in the Ambulatory Pediatric Clinic in July. He has a
reputation of being very outgoing, and even for being "a party
animal," his antics winning him praise and laughs at the Intern's
year-end party last month. He takes night call every 4th night in the
Pediatric ICU (PICU) and, generally, loves the scope of practice opportunity
each week holds between clinic patients by day and hospital patients at night.
However, this past weekend things became difficult when his maternal
grandmother, who raised him, had a stroke in her home five hours away. On
Sunday she was reportedly doing better, and being moved out of the ICU to an
inpatient ward in her local hospital. Dr. Williams knows she had an underlying
arrhythmia and may yet have circulatory or coagulation problems.
Monday morning Dr. Williams' car
gives him fits and he barely makes it on time to Morning Report, where he
delivers a poor case presentation and is cornered by his attending, Dr. Yoo,
who gently suggests he be better prepared next time. After a particularly
frustrating day in the clinic, Dr. Williams' car overheats on the way home. He
calls for a lift from Dr. Jim Hines, one of his Interns, who picks him up and
offers to buy him a beer on the way home. They stop at a local club and an
hour turns into four. Jim finally gets Fred, who is now drunk, to get into the
car and drives him home promising to be back by at 6:30 am to pick him up in
the morning.
Tuesday morning Fred oversleeps.
He and Jim are both an hour late to work. Dr. Yoo arranged cross-coverage for
the first hour of clinic and makes a note to speak with Drs. Williams and
Hines. But very quickly after clinic is over they leave to pickup Fred's car.
Fred asks Jim if he wants to join him at the club for a few drinks. Jim says
no and they go their separate ways. Dr. Williams goes out for a round and gets
home about 11:45 p.m.
Wednesday sees Dr. Williams late
again, this time for Morbidity & Mortality Conference at 7:30am. Dr. Hines
overhears Dr. Williams explain to an attending (the Residency Program
Director) that he is simply stressed because of his grandmother's condition.
The Program Director tells Dr. Williams to take care of personal matters that
day, but reminds him that he is on PICU call that night, "Be here at 4:30
for sign-out rounds, Fred."
Dr. Williams returns at 4:30 PM. A
Nurse asks him if he got any sleep lately. One of his Resident colleagues
tells him he smells like a beer and urges him to clean up before rounds begin,
and even then to speak as little as possible. That night Dr. Williams attends
to problem ventilators, low potassium levels and a vomiting child. He has no
new admissions. His clinic goes well Thursday morning and he has lunch with
Dr. Jim Hines, asks him over for dinner, and then goes home.
At home, Fred crashes for a few
hours sleep. Then he gets up and grabs a beer. The phone rings, his
grandmother is back in the ICU. As he gets off the phone, and grabs a second
beer, the doorbell rings. Jim Hines is there with some favorite take-out
Chinese food. "Hey, I think I have some Chinese beer in here!" says
Fred. "Don't bother," says Jim, "Besides, after what I heard
about your appearance at sign-out rounds yesterday, you'd better watch
it." Somehow the dinner was cut short and Jim left within the hour.
Dr. Williams' next call night
doesn't go so smoothly. He admits 3 patients to the PICU. A Respiratory
Therapist has to call Dr. Williams' attending, Dr. Yoo, to get what he
believes are appropriate ventilator settings for a patient in status
asthmaticus who has developed a pneumothorax after Dr. Williams placed him on
inappropriately high pressures. A Nurse files an Incident Report for an IV
Potassium bolus Dr. Williams ordered, which she refused to give, because it
was a tenfold dosing error; and the Pharmacy failed to catch a dosing error in
dexamethasone that Dr. Williams ordered, thus allowing a neurosurgical patient
with cerebral swelling to develop marked hypertension. Luckily, the
Neurosurgery Resident reacted quickly and brought the patient's BP under
control, much to the surprise of a seemingly confused Dr. Williams.
Discussion Questions
- What response do you have to Dr.
Williams' actions?
- Does he have a problem?
- Is he impaired?
- What responsibilities exist for each of the
following persons, and why?
Dr. Fred Williams, PL2
Dr. Jim Hines, Intern (PL1)
Dr. Yoo (the Attending)
You, as a medical student
on-service or on-call with Dr. Williams and knowing of his drinking
patterns?
- What risks are taken by impaired physicians?
- What potential harms must be considered in
dealing with physician impairment?
Suggested
Readings/References
- Code of Medical Ethics, American
Medical Association
"Principles of Medical Ethics," p xiv-xxxviii
"Fundamental Elements of the Patient-Physician Relationship,"
p xxxix-xliii
"Discipline and Medicine," 9.04
"Due Process," 9.05
"Substance Abuse," 8.15
"Reporting Impaired, Incompetent, or Unethical Colleagues," 9.031
- Ethics
Manual, Fourth Edition, American College of Physicians
"The Physician and the Patient"
"Physician and Society"
"Impaired Physician"
- The Doctor's Dilemma
"Dr. Paul Williams Case"
Index under "Problem Physicians"
Impaired Physician Programs
Guidelines for Problem Physicians
Physician Well-being Program Contract, Med. Assoc. of Georgia
Common Signs of Physician Impairment
The Process for Confronting an Impaired Colleague
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