Impairment in Residents
Impairment is defined as the inability to practice safely, even under supervision. Mental health issues such as depression, anxiety and personality disorders have been described as a causative factor in up to 22- 38% of problem residents and substance misuse in 5-14%. Burnout is a workplace phenomenon, not a mental illness, although it is also a risk factor for performance impairment. A resident with suspected or identified psychiatric illness or substance abuse presents unique challenges for the program director, who is in the difficult role of being a physician and a supervisor. Program directors should first and foremost focus on managing performance, describing performance concerns, providing examples, and holding residents to performance standards. Even in the face of concern that there may be underlying medical issues impacting the resident’s performance, program directors must be cognizant that they are not the resident’s physician, and refrain from attempting to diagnose. While the program director must be aware and respectful of laws such as the Americans with Disabilities Act (ADA), which allow employees (residents included) to keep their medical information private, in some instances it's necessary to make a judgment about whether the resident’s level of functioning presents a risk to patient safety. These are some signs suggestive of impairment. They are not diagnostic, more like non-specific indicators that something is wrong. You may observe yourself or others may report them to you. Many of these signs can occur intermittently in any resident. It is patterns that raise concerns. Physicians have a remarkable capacity to function in spite of stress. When problems surface at work it is often the tip of the iceberg, so please have a low threshold for talking with your residents about what you are seeing. Bolded items warrant immediate attention and intervention.
- Alcohol on breath (at work)
- Looks bad - poor grooming, poor hygiene, overly tired
- Increase in physical complaints
- Decrease in attention span
- Noticeable change in weight
- Pupils dilated or constricted
- Long sleeves in hot weather
- Intoxicated at work/on-call
- Reports of stated suicidal ideations by resident
- Suicide attempt
- Resident asks for help
- Less responsible/unpredictable
- Having conflicts with peers/supervisors/staff
- Unexplained accidents/ER visits
- Frequent intoxication at department functions
- Crying/Mood changes
- Inappropriate comments, jokes, etc.
- Critical incident
- Self-prescribing (controlled substances)
- Asking peers to prescribe controlled substances for them
- Frequent or Unexplained absences
- Decline in dependability (doesn’t answer pages, etc.)
- Decline in quality of work
- Inappropriate orders
- Complaints from supervisors, patients, staff, peers
*Even when faced with a resident or colleague who shows obvious signs of impairment, it is common for those around them to be reluctant to act. There are a number of reasons for this (denial, fear of how the resident will react if confronted, uncertainty about how it will impact the resident’s career, or uncertainty about what to do next.) If any of the bolded items are observed by or reported to you, even after the fact, you have a professional responsibility to act. You do not, however, have to manage this alone. If you have concerns about a resident’s wellness or potential impairment, please contact the Office of Graduate Medical Education.
Residency Program Director Responsibilities/Resources
The OGME created a document to help guide programs in navigating impairment or potential impairment. The guidelines linked here is specific to Springfield programs, however the guidance can be translated to the appropriate staff members at each affiliate location as well.