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Impairment Policy

Description: 
 
 
 

 

I.      PREAMBLE

We are committed to maintaining a safe and drug free clinical learning environment, and to supporting the physical and mental health of residents. The term “resident” is inclusive of all trainees at SIU School of Medicine, whether training in a residency or fellowship program. The goals of this policy are:

  • To prevent or minimize the occurrence of impairment, including substance abuse, among residents at SIU School of Medicine and Affiliated Hospitals.
  • To protect patients from risks associated with care given by an impaired resident.
  • To provide a mechanism for a fair, reasonable and confidential assessment of a resident who is suspected of being impaired, including the development of a plan to address the resident’s professional progress.

For the purposes of this policy Impairment is defined as a physical or mental condition which causes a resident to be unable to practice medicine with care and safety commensurate with their level of training.  Impairment of performance by resident physicians can put patients at risk.

II.      USE OF PSYCHOACTIVE DRUGS BY RESIDENTS

Use of controlled substances must be by prescription of a licensed healthcare provider.  Unprescribed use of controlled substances is illegal.  Unprescribed use of non-controlled psychotropic drugs is inappropriate. Use of alcohol during or immediately preceding work hours is prohibited.

All residents, as employees of SIU affiliated teaching hospitals will be subject to the drug screening guidelines of these institutions.  For the purposes of this policy, any reference to “drug” can be assumed to include alcohol throughout.  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’s behavior or performance suggests intoxication or illicit drug use. 

III     RESPONSIBILITIES

  1. Residents will observe and abide by all policies and protocols pertaining to impairment, substance use or misuse, or drug screening of SIU SOM, their employing hospital, and any clinical site in which they provide clinical care.
  2. Residents and faculty members have a professional responsibility to appear for work appropriately rested and must manage their time before, during and after clinical assignments to prevent excessive fatigue.
  3. 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. All residents and faculty members should be aware of the behavior and conduct of other team members. If a resident or faculty member observes behaviors suggestive of impairment, they should immediately notify their program director or supervising faculty. 
  4. It is the responsibility of program directors and faculty to communicate this policy to their residents and to enforce its provisions.

IV.   EDUCATION AND RESOURCES

1.  Education about prevention and recognition of impairment, including from illness, fatigue or substance abuse, for residents, faculty and program coordinators includes:

  • Session on  impairment prevention and recognition for incoming PGY1s
  • Annual refresher for Graduate Medical Education Committee (GMEC); House Staff Board of Directors (HSBOD) and Program Coordinators Forum
  • Information in Appendix A
  • Resources on the OGME website http://www.siumed.edu/gme/resident-well-being.html
  • Online module on fatigue awareness for incoming residents and faculty
  • Education reinforced by each training program according to its curriculum
  • Specific educational offerings for programs or departments upon request

2.  If a resident is experiencing problems, they are encouraged to voluntarily seek assistance before clinical, educational and professional performance, interpersonal relationships or behavior are adversely affected. Residents who voluntarily seek assistance for physical, mental, emotional and or personal problems, including drug or alcohol misuse, before their performance is adversely affected, will not jeopardize their status as a resident by seeking assistance. Resources available to residents include, but are not limited to:

  • Support/mentorship via resident’s training program
  • Resident’s personal physician or other appropriate provider
  • Employee Assistance Program though resident’s employing hospital
  • Psychiatric evaluation through the SIU OGME Confidential Care Psychiatric Intervention Program 
  • Employee/Occupational Health services though resident’s employing hospital
  • Illinois Professionals Health Program (IPHP)  http://www.illinoisphp.com/

V.   PROCESSES

Assessment

When a concern is raised about a resident who may be impaired, the program director should organize an assessment immediately. As the specific steps and contact individuals for referral for evaluation of confirmed or suspected impairment may vary among employing hospitals, the program director should contact the Office of Graduate Medical Education (OGME) for specific steps.  If the program director or associate program director is unavailable, any responsible faculty member may request an assessment.

If there is concern for active impairment, the resident should be taken off clinical service immediately. OGME should be consulted for next steps.

In most instances, referral to the Illinois Professionals Health Program (IPHP) is the preferred avenue for evaluation and management of impairment. In instances where a resident is exhibiting signs of acute intoxication, or more urgent assessment is warranted to clarify if impairment is present, the resident should be referred to the employee health nurse of their employing hospital. If a resident is demonstrating signs of impairment and/or acute intoxication while at work outside of normal business hours, on a weekend, or on a holiday, the nursing supervisor should be contacted.  

If a resident with suspected or known impairment is referred to IPHP or the Employee/Occupational Health program at their employing hospital for assessment, in order to remain enrolled in the training program, the resident must consent to any evaluations (including drug testing), and must sign a release allowing SIU SOM OGME and their training program director to receive information related to the assessment and monitoring of the resident.

Determination of Impairment

If IPHP (or the appropriate Employee/Occupational Health program) determines that the resident is safe to practice, this should be documented in the resident’s record, and the resident may be allowed to return to work.  If the program director is uncomfortable with the recommendation to return to work, the program may require a fitness to work evaluation.  If there are other performance issues, the program director, in consultation with the Clinical Competence Committee (CCC) should address these in accordance with the Academic Deficiency Policy.

If IPHP (or the appropriate Employee/Occupational Health program) determines that the resident is impaired, the resident will be required to complete treatment prescribed, in addition to any steps or measures required by SIU SOM/Employing Hospital to ensure patient safety. If the resident refuses treatment or required measures, they will not be allowed to return to the training program.

Absent any episodes of egregious misconduct, the Resident will be provided a leave of absence to complete the prescribed treatment and will be informed of the potential for an extension of training due to time away from the program.  The need to report to the Illinois Department of Financial and Professional Regulation (IDFPR) will be evaluated.  It is recommended that the resident self-report in addition to any required institutional reporting.

Return to Work

Residents who have been in treatment for an impairing condition must have a return to work recommendation from IPHP (or the appropriate Employee/Occupational Health program) before consideration will be given to their return to training. The program will make a decision about return to training only if allowed by IDFPR, in consultation with the resident’s employing hospital and after review of the resident’s previous academic performance.

Residents returning to work after treatment for an impairing condition will be required to commit to a full monitoring program as determined by IPHP. The program will allow reasonable accommodations for the resident to meet the requirements of the monitoring program.

Residents returning to work after treatment for an impairing condition will be required to sign a Conditions of Reinstatement letter, which outlines the terms under which the resident is allowed to return to training. The Conditions of Reinstatement letter will be considered a last-chance agreement.  The resident’s employing hospital may require the resident to sign a separate return to work agreement.

Appropriate and complete documentation of the actions taken under Section V shall be performed and maintained.  Such documentation shall be permanently retained securely and separately from the records of the resident in the Program Director’s office.


APPENDIX A: Signs and Symptoms of Impairment

Listed below are some signs suggestive of impairment. You may observe them 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.

  1. Deterioration in personal hygiene and appearance, multiple physical complaints, frequent accidents.
  2. Disturbance in family stability or personal or professional relationship difficulties.
  3. 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 or argumentativeness. 
  4. Professional behavior patterns such as unexplained absences, spending excessive time at the hospital, tardiness, decreasing quality or interest in work, behavioral changes, altered interaction with other staff, inadequate professional performance, or significant change in well-established work habits.
  5. Mood changes, depression, slowness, lapses of attention, chronic exhaustion, risk taking behavior, or excessive cheerfulness.
  6. Decline in dependability (doesn’t answer pages, etc.); decline in quality of work; inappropriate orders; complaints from supervisors, patients, staff, peers.
  7. Self-prescribing controlled substances or asking peers to prescribe controlled substances for them.
  8. Excessive agitation or edginess, dilated or pinpoint pupils, self-medication with psychotropic drugs, stereotypical behavior, alcohol on breath at work, intoxication at work, uncontrolled drinking at social events, blackouts, binge drinking, changes in attire (e.g., wearing of long sleeve garments by parenteral drug users)

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 you have reasonable suspicion that a resident is impaired, or 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.

 

 Last Approval Date:  November 15, 2019  

 Effective Date:  November 15, 2019