A definition of IMPAIRMENT for purposes of this policy: A physical or mental condition which causes a resident/fellow to be unable to practice medicine with reasonable care and safety commensurate with his/her level of training.
Impairment of performance by resident/fellow physicians can put patients at risk. Impairment will be managed as a medical/behavioral illness. Implicit in this concept is the existence of criteria permitting diagnosis, opportunity for treatment, and, with successful progress toward recovery, the possibility of returning to work in an appropriate capacity. Impairment may result from depression or other behavioral problems, physical impairment, medical illness, and/or substance abuse and consequent chemical dependency. Untreated or relapsing impairment is not compatible with safe clinical performance. The goals of this policy are:
- To prevent or minimize the occurrence of impairment, including substance abuse, among residents and fellows at SIU School of Medicine and Affiliated Hospitals.
- To protect patients from risks associated with care given by an impaired resident/fellow physician.
- To compassionately confront problems of impairment to effect diagnosis, relief from patient care responsibilities if necessary, treatment as indicated, and appropriate rehabilitation.
In achieving these goals, several principles are involved:
- The safety of the patients and the care for the impaired individual are of prime importance.
- The privacy and dignity of the affected individual should be maintained to the fullest extent possible.
- An Employee Assistance Program will help facilitate education, diagnosis and management.
II. Signs and Symptoms of Impairment
Signs and symptoms of impairment may include, without limitation, the following:
- Physical signs such as fatigue, deterioration in personal hygiene and appearance, multiple physical complaints, accidents, eating disorders.
- Disturbance in family stability or evidence of personal or professional relationship difficulties with resulting isolation.
- Social changes such as withdrawal from outside activities, isolation from peers, embarrassing or inappropriate behavior at parties, adverse interactions with police, driving while intoxicated or under the influence, undependability and unpredictability, aggressive behavior, argumentativeness, or unusual financial problems.
- Professional behavior patterns such as unexplained absences, spending excessive time at the hospital, tardiness, decreasing quality or interest in work, inappropriate orders, behavioral changes, altered interaction with other staff, inadequate professional performance, or significant change in well-established work habits.
- Behavioral signs such as mood changes, depression, slowness, lapses of attention, chronic exhaustion, risk taking behavior, excessive cheerfulness, flat affect.
- Signs of drug use or alcohol abuse such as excessive agitation or edginess, dilated or pinpoint pupils, self-medication with psychotropic drugs, stereotypical behavior, alcohol on breath at work, uncontrolled drinking at social events, blackouts, binge drinking, changes in attire (e.g., wearing of long sleeve garments by parenteral drug users).
Repeated evaluations documenting substandard academic performance or other grounds for consideration by the residency/fellowship program director of academic deficiency, existing in conjunction with one or more sign(s) or symptom(s) of impairment, such as those listed above, may be considered in determining whether or not medical and/or psychiatric evaluation of the resident/fellow in accordance with Section III.D.4. or III.E.2. is warranted.
III. Policy Implementation
A. Education -- In an attempt to minimize the incidence of impairment, residents/ fellows are educated about physician impairment, including problems of substance abuse, its incidence and nature and risks both to the involved individuals and patients. Education includes knowledge concerning signs and symptoms of impairment, emphasizing detection of abnormal behavior associated with use of psychoactive drugs and alcohol abuse.
B. Counseling -- An assistance program will provide individual counseling both to supervisors and to individuals in need. In the latter case, reasonable efforts will be made to maintain confidentiality, subject to any reporting requirements imposed by law.
C. Assessment -- Evaluation of impaired status: For both new residents/fellows with a history of impairment and current residents/fellows who experience impairment and/or for whom evidence of substance abuse exists, assessment of impairment will be performed under the auspices of an Employee Assistance Program of the employing hospital in consultation with the appropriate program director and the Designated Institutional Official to determine appropriate care and monitoring.
- Each program director, after consultation with appropriate resources and the employing hospital, is responsible for certifying the functional status of all residents/fellows and for judging whether functional impairment exists in an individual. When an individual with impairment is identified, the residency/fellowship program director will report this to the Designated Institutional Official.
- Each resident/fellow, as a condition of employment, agrees to accept the decision of the program director and employing hospital. Should the program director and/or the employing hospital conclude, after consultation with the Employee Assistance Program or other appropriate individuals, that a resident/fellow is suffering from impairment, including substance abuse, he/she may immediately take appropriate action, which may include placing the impaired individual on a medical leave of absence with or without suspension from the training program.
- If it is determined that the resident/fellow’s impairment may adversely affect patient care, he/she may be suspended from the training program.
- Appropriate action may also require medical and/or psychiatric evaluation. The sponsoring institution will use its best effort to select a physician and/or psychiatrist acceptable to the resident/fellow.
- A written Return to Work Agreement with the resident/fellow, the School of Medicine and the employing hospital may be required. In this case, return from leave of absence for impairment shall be based upon written recommendations of an approved treatment program and agreement of the employing hospital and Program Director.
E. Reporting Process -- All medical personnel have a duty, in part required by ethical concern for the well-being of patients and one’s fellow professionals and in part as mandated by state law, to report in confidence concerns about possible impairment both in themselves and in others to an appropriate supervisor.
If a resident/fellow is observed to be impaired/disabled while engaged in the performance of his or her duties, the course of action shall be as follows:
- The observer shall report his/her concern immediately to a responsible supervisor, ultimately the residency/fellowship program director.
- When impairment is suspected, the program director shall seek assistance from the Designated Institutional Official. The Designated Institutional Official will ascertain the need for help, and facilitate an intervention leading to further professional evaluation and possible inpatient or outpatient treatment. Under such circumstances further professional evaluation may be required, including a medical and/or psychiatric evaluation.
- The program director will notify the Designated Institutional Official, appropriate officials of the employing hospital and/or other appropriate persons. In consultation, a decision will be made regarding any leave of absence and, 1) information will be made available to the resident/fellow on the effects the leave of absence will have upon training and, 2) an evaluation will be made of the need to report such a leave of absence to the Illinois Department of Financial and Professional Regulation.
- Appropriate and complete documentation of the actions taken under paragraphs E.1. through E.3. shall be performed and maintained. Such documentation shall be permanently retained and filed securely and separately from the records of the resident/fellow.
- Should a resident/fellow about whom concern has been expressed, be determined by the sponsoring institution not to be impaired, the individual will be allowed to return to his/her residency/fellowship program without prejudice, provided that he/she is capable of performing his/her duties with reasonable care and safety commensurate with his/her level of training.
- Should a resident/fellow dispute the findings made or actions taken under this Impairment Policy, he/she shall follow the Due Process and Resident Complaint Policy to resolve the disputed issues.
IV. Policy Regarding the Use of Psychoactive Drugs by Residents/Fellows
A. Use of controlled substances must be by prescription of a physician. Unprescribed use of controlled substances is illegal. Unprescribed use of non-controlled psychotropic drugs is inappropriate. Evidence of such use will result in evaluation for possible treatment and may be grounds for immediate suspension and ultimate termination.
B. For the purpose of this policy, use of alcohol during working hours, and particularly when one is engaged in patient care, is completely inappropriate. When one is “on call”, any use of alcohol that either produces or appears to produce (e.g. odor of alcohol on breath) evidence of behavioral impairment is also regarded as inappropriate.
C. All residents/fellows, as employees of SIU affiliated teaching hospitals will be subject to the drug screening guidelines of these institutions. These guidelines are specifically articulated in the employment policies of each affiliated hospital. In general, the employing hospital reserves the right to perform drug screening if a resident/fellow’s presence, behavior, or performance suggests intoxication or illegal drug use.
Last Approval Date: February 20, 2015
Effective Date: February 20, 2015