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Impairment

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.

Physical    

*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

 

Social/Behavioral  

*Intoxicated at work/on-call

*Reports of stated suicidal ideations by resident

*Suicide attempt

*Resident asks for help

Withdrawn/isolating  

Less responsible/unpredictable

Irritable/Defensive/argumentative

Having conflicts with peers/supervisors/staff

Unexplained accidents/ER visits

Frequent intoxication at department functions

Crying/Mood changes

Inappropriate comments, jokes, etc.

 

Professional 

*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

Responsibility

Resources

   Talk to the resident

   Dr. Broquet, Chief Resident

   Determine if resident is impaired

   Impairment Policy

   Dr. Broquet

   If impaired, take steps to protect patient safety

   (extra supervision, medical leave, suspension, etc.)

   Impairment Policy

   Dr. Broquet

   Hospital CMO

   Whether impaired or not,   help residents access help:  be familiar   with assessment/treatment resources   (physical, substance abuse, mental health)

   Quick Reference for Mental Health Treatment

   Illinois Professionals Health Program

   Dr. Broquet

 

If you suspect that a resident is impaired (unable to practice safely, even under supervision), please consult with ADGME to determine next steps.  Although every situation is unique, there are 3 common paths on the decision tree:

  1. If you have significant concerns about a residents’ ability to function safely, but are unsure about the presence, extent or nature of any impairment, a fitness for duty evaluation is warranted.  By definition, if a resident is sent for a fitness evaluation, it implies a belief that the resident is not fit to work, and needs to be removed from the clinical workplace.  (It is not something that can be put off until after the resident is done with call that night, or until other residents are back from vacation to cover.) The resident should be placed on an administrative leave of absence until the fitness evaluation can be completed and the results returned.   If a resident is exhibiting active symptoms of impairment, a referral for a drug screen should be sought immediately, while the resident is exhibiting the signs and/or symptoms.

If, after consultation with the ADGME, it is determined that a resident is in need of a fitness for duty evaluation, the actual process will be determined by the protocol at the residents employing hospital. The ADGME will contact the CMO or employee/ occupational health nurse at the resident's employing hospital to organize this. 

Typically, an employee health nurse performs an intake assessment by gathering information about the resident's situation through interviews and collected documentation.  At that time, the nurse makes a recommendation as to the next steps in the process. This could include a referral for drug/alcohol testing, assessment by the hospital’s occupational health provider (such as MOHA -Midwest Occupational Health Associates), mental health assessment, physical exam, etc.  Detailed information from the program director can be helpful to the employee health team in making the appropriate referral. Once the appropriate assessments have been obtained, a determination will be made regarding whether the resident is fit for duty and/or if any further assessment is needed or any accommodations need to be made.  The amount of detail from the assessment that is shared with the program director is determined by the protocols of the resident’s employing hospital.

It is important to remember that a fitness evaluation is limited to questions of substance misuse, or physical or psychiatric impairment, not assessments of medical competency, general wellness or professionalism.  Behavioral concerns or interpersonal conflicts may precipitate an evaluation but do not necessarily result from disability or impairment due to a psychiatric illness. Likewise, a resident who is found to be fit to work may still be symptomatic and benefit from mental health treatment.  If a resident is determined to be fit, subsequent decisions regarding return to clinical service or progression in the program must continue to be made on the basis of performance.

  1. If a resident exhibiting signs of impairment is determined to have an identified substance misuse or abuse issue, ( i.e. resident discloses when you talk with them about the concerns) direct referral by the program director to the Illinois Professionals Health Program for assessment and recommendations is recommended.
  2. If a resident exhibiting signs of impairment is determined to have identified mental health issues (again, via disclosure when you talk with them about your concerns), direct referral to a mental health provider or their employing hospital fitness evaluation process may be appropriate.  Obtain consultation from ADGME.

The above discussion specifically centers on residents who are impaired. You may have concerns about a resident’s well-being, even though they are performing safely under supervision.  Please see the section on Wellness Resources.