Philip J. Candilis, MD; Daniel T. Kim, MA, MPH; Lois Snyder Sulmasy, JD; for the ACP Ethics, Professionalism and Human Rights Committee *
Acknowledgment: Philip J. Candilis, MD, received compensation from ACP for consulting on and coauthoring the manuscript. The authors and the ACP Ethics, Professionalism and Human Rights Committee thank peer reviewers Chris Bundy, MD; Humayun J. Chaudhry, DO; Paul H. Earley, MD; John A. Fromson, MD; and P. Bradley Hall, MD, and the many ACP leadership and journal reviewers of the paper for helpful comments on drafts, as well as Kathy Wynkoop of the ACP Center for Ethics and Professionalism.
Financial Support: Financial support for the development of this paper comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3605.
Corresponding Author: Lois Snyder Sulmasy, JD, Director, ACP Center for Ethics and Professionalism, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Dr. Candilis: Interim Director of Medical Affairs, Saint Elizabeths Hospital, 1100 Alabama Avenue SE, Washington, DC 20032.
Mr. Kim: Senior Associate, ACP Center for Ethics and Professionalism, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Ms. Snyder Sulmasy: Director, ACP Center for Ethics and Professionalism, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Author Contributions: Conception and design: D.T. Kim, L. Snyder Sulmasy.
Analysis and interpretation of the data: P.J. Candilis, D.T. Kim, L. Snyder Sulmasy.
Drafting of the article: P.J. Candilis, D.T. Kim, L. Snyder Sulmasy.
Critical revision of the article for important intellectual content: P.J. Candilis, D.T. Kim, L. Snyder Sulmasy.
Final approval of the article: P.J. Candilis, D.T. Kim, L. Snyder Sulmasy.
Provision of study materials or patients: P.J. Candilis.
Administrative, technical, or logistic support: D.T. Kim, L. Snyder Sulmasy.
Collection and assembly of data: P.J. Candilis, D.T. Kim.
Physician impairment, the inability to carry out patient care responsibilities safely and effectively, is a problem of functioning. However, the presence or treatment of a potentially impairing illness or other condition does not necessarily imply impairment. This American College of Physicians position paper examines the professional duties and principles that should guide the response of colleagues and the profession to physician impairment. The physician should be rehabilitated and reintegrated into medical practice whenever possible without compromising patient safety. At the same time, physicians have a duty to seek help when they are unable to provide safe care. When identifying and assisting colleagues who might be impaired, physicians should act on collegial concern as well as ethical and legal guidelines that require reporting of behavior that puts patients at risk. Health care institutions and the profession should support practice environments in which patient safety is prioritized and physician wellness and well-being are addressed. Physician health programs should be committed to best practices that safeguard patient safety and the rights of physician-patients.
AMA urge state medical boards to refrain from asking applicants about past history of mental health or substance use disorder diagnosis or treatment, and only focus on current impairment by mental illness or addiction, and to accept ‘safe haven' non-reporting for physicians seeking licensure or relicensure who are undergoing treatment for mental health or addiction issues, to help ensure confidentiality of such treatment for the individual physician while providing assurance of patient safety (42).
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Nicholas D. Lawson, MD, J. Wesley Boyd, MD, PhD
Georgetown University Law Center, Cambridge Health Alliance/Harvard Medical School
June 11, 2019
Why Do Physician Health Programs Not Want Physicians to Be Aware of Their Employment Rights?
The American College of Physicians (ACP) just released a position paper on state physician health programs (PHPs) (1). The authors claim to have the best interests of physicians at heart. But this is difficult to believe when they fail to inform physicians of their rights under the Americans with Disabilities Act (ADA) to be free from unwarranted medical inquiries and referrals to PHPs for evaluations (2,3). We suspect that the repeated failures of state PHPs (as well as associated medical boards) to notify physicians of their ADA rights relates in part to the fact that the ADA provides physicians with clear rules that would prevent many unwarranted referrals to these programs (3).
The authors also discuss physicians’ duties of “self”-regulation, but given the authors’ praise for and reliance upon state PHPs, we suspect they mean regulation by PHPs (1). Additionally, when the authors refer to physicians’ accountability to “society,” we suspect what they really mean is accountability to PHPs (1). The authors also tout the high success rates of PHPs but fail to note that almost all of the statistics about PHP outcomes are written by individuals who run or work in PHPs and often fail to account for individuals who drop out of treatment with a PHP or who commit suicide while working with a PHP (4).
The authors are asking for a level of influence and intrusion into the lives of physician-employees that we think most would view as problematic (1-4). The authors claim to have an “intervention” for “disruptive behavior” (1), which could easily result in mislabeling of physicians as impaired when they take a stand for better care (2,3). They also frame referees as “in denial,” grant immunity to anyone providing referrals to PHPs, and ask for state PHPs, medical boards, and societies to play a key role in “educating” medical trainees about PHPs and physician impairment (1).
That “education” would almost certainly include misinformation about the appropriate rules that relate to inquiries and referrals to PHPs for evaluations (2-4). It would also likely include PHPs’ descriptions of “impairment” or “reasons to refer” other physicians. In one of our studies, we found that more than 95% of the general population in full-time employment endorses multiple descriptions of “impairment” on a typical PHP list of 25 descriptions, and 10/25 (40%) on average (2). The descriptions are so broad they make almost anyone susceptible to being branded as “impaired” (2).
For these and other reasons, we disagree with much of the ACP position paper about PHPs.
1. Candilis PJ, Kim DT, Sulmasy LS. Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians. Ann Intern Med. 4 June 2019.
2. Lawson ND, Boyd JW. How broad are state physician health program descriptions of physician impairment? Subst Abuse Treat Prev Policy. 2018;13(1):30.
3. Lawson ND, Boyd JW. Do state physician health programs encourage referrals that violate the Americans with Disabilities Act?. Int J Law Psychiatry. 2018;56:65-70.
4. Lawson ND, Boyd JW. Flaws in the methods and reporting of physician health program outcome studies. Gen Hosp Psychiatry. 2018;54:65-6.
Candilis PJ, Kim DT, Sulmasy LS, for the ACP Ethics, Professionalism and Human Rights Committee. Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety: A Position Paper From the American College of Physicians. Ann Intern Med. [Epub ahead of print 4 June 2019]170:871–879. doi: 10.7326/M18-3605
Download citation file:
Published: Ann Intern Med. 2019;170(12):871-879.
Published at www.annals.org on 4 June 2019
Ethics, Tobacco, Alcohol, and Other Substance Abuse.
Results provided by:
Copyright © 2019 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use