Bioethics Discussion Blog: Drug Screening of Physicians: Violations of Personal Privacy vs "Peace of Mind"

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Thursday, May 22, 2014

Drug Screening of Physicians: Violations of Personal Privacy vs "Peace of Mind"





Yesterday, I received the following e-mail from Ed:

"Dr Bernstein, as a retired USAF pilot and current airline pilot who has been subjected to random drug screening for my entire professional career, why aren't medical providers who have easy access to legal drugs as well as the same to access to illegal drugs as the rest of society, subject to random drug screening? The public literally places their lives in our respective hands and it seems both professions have a ethical, moral, and legal obligation to ensure reasonable efforts are made to identify those who abuse drugs. I think this would make a great topic for your blog."

It was.. and here it is.

I wrote Ed back "Good topic for consideration. The question is not the moral, ethical or legal aspects of testing but in the physician population alone, what are the studies and statistics which confirm that such testing would make a significant difference in overall patient safety vs the validity and the economics of a test result?  An airline pilot, in daily work, may have hundreds of lives beyond his/her own at immediate highly significant risk whereas a physician's risk pool is limited to his one patient with less significant risk. ..Maurice. "

We must find the statistics to compare physicians to airline pilots with regard to drug intoxication, frequency of incidence and outcome in terms of risks to lives and health in their daily professions. In reality, the testing of physicians for drug use is already occurring in U.S. hospitals both on staff admission and also randomly. If the statistics show that drug use by physicians is minute and the consequences of such addiction is also minute, then the questions are whether such testing is simply a way to provide society and the patients some "peace of mind" and whether that benefit is sufficient to ethically permit violation of a physician's personal privacy and its professional consequences  for that patient comfort.

If statistics will show that there is a difference between the risks to patients vs passengers, would you agree that there should be a difference between physicians and airline pilots in the way society handles the drug-use issue for safety and "peace of mind"?  ..Maurice.  


Graphic: From Google Images modified by me with ArtRage 3.


21 Comments:

At Thursday, May 22, 2014 7:05:00 PM, Anonymous Anonymous said...

The consequences are not minute if you're that patient who suffers irreparable harm due to the actions of an impaired physician or ancillary staff member. What percentage of U.S. physicians (and staff) are being screened and how is it accomplished. There is a vast distinction between pre-employment testing known in advance vice being subject to truly random screening. How does random screening violate a physician's personal privacy and what are the professional consequences for a negative test? Truly random screening is a legal and effective deterrent simply because it instills the fear of being caught!

Ed

 
At Thursday, May 22, 2014 9:22:00 PM, Blogger Maurice Bernstein, M.D. said...

For those interested in California law. This coming November, California voters will be voting on the
"Troy and Alana Patient Safety Act of 2014" which requires all hospitals to check all physicians attending patients
to random drug and alcohol tests to be financed by the physicians themselves, to immediately test physicians
involved in any "adverse event". Also all physicians and pharmacists must first check the state's electronic history for the patient before first issuing any Schedule II or III drugs.

http://oag.ca.gov/system/files/initiatives/pdfs/13-0016%20%2813-0016%20%28Drug%20and%20Alcohol%20Testing-V%202%29%20%29.pdf

Oh! the Findings and Declarations of the Act paint a horrible picture of physicians as they practice medicine if "one third of all physicians, will at sometime in their careers experience a condition, including alcohol and drug abuse, that impairs their ability to practice safely." Unfortunately as part of this Act's documentation are no statistics of the frequency of death or injury directly associated with intoxicated doctors.

The basis for creating a law which invades, under penalty, the personal privacy of a physician should be supported by facts regarding the actual incidence of drug and alcohol intoxicated physicians performing medical or surgical practice and the incidence of adverse events specifically attributed to the physician's intoxication. Without some attempt to establish the facts, simply creating a law requiring invasion of privacy on assumptions or just to ease the public's worries, to me, seems unethical. Can anyone visiting this thread present references regarding the results of studies aiming to get the necessary facts? ..Maurice.

 
At Thursday, May 22, 2014 9:37:00 PM, Blogger Maurice Bernstein, M.D. said...

Ed, of course, the harmful consequences, if they occur, of any single patient being treated by a drug impaired physician whose actions or inaction created that result is not to be ignored. But, if such an event is exceedingly rare, should laws be passed which deny personal rights allowed to others, simply that this rare event can occur? This is the issue. And without the facts, should laws be passed on the basis of "it just feels that it is the right thing to do"? This is an important point and should be ethically considered in the creation of all laws and regulations. ..Maurice.

 
At Saturday, May 24, 2014 5:33:00 PM, Blogger Maurice Bernstein, M.D. said...

Here in 2 parts, is a review of the topic written today to our blog thread by OSI, but for some reason could not be automatically published. ..Maurice.

PART I/II


I think that there are issues here that need be addressed:



One is that we clearly do not understand r-i-s-k. Consider: e.g., http://www.nytimes.com/2014/05/07/upshot/universal-mammogram-screening-shows-we-dont-understand-risk.html ; or

http://www.john-adams.co.uk/2013/10/17/slides-from-my-lecture-on-the-public-perception-of-risk/ ).



Not a clue. Period.



A second is that people change roles in life, yet seem to think (believe? for that is the holding of a position in the absence of fact) that despite their change of roles, they have a right to the same privileges of privacy as before that change.



Consider: Not being a physician ... then becoming a physician. Not being an attorney ... then becoming an attorney. Not being a pilot ... then becoming a pilot.



The enjoyment of privacy in any of the latter states is not the same as the enjoyment of privacy in any of the former.



In particular:

--one may earn a degree or develop a specialized expertise--whether it be a medical or law degree, or for example training as a pilot; and

--the people, the public (whether through a State medical licensing board, a State Bar association or Court, a State board overseeing nursing or engineering, a pilot-licensing authority or whatever field) act to allow one to employ the knowledge enfolded in that degree/expertise,



then the privilege of privacy changes dramatically.



Some may disagree with that line of thinking, and they may also question whether others have a right to know who is paying a physician's freight where papers and presentations and drugs are involved. No doubt they will continue to disagree and question in the future--and it is their right to do so.



But they well know that--at day's end--they cannot and must not prevail in the real world.



The public, the people, the State has in-vested these professionals and their professions with certain authority(ies).



For example, what greater authority might there be than to:

--push a blade or a drill into the body of another, or

--carry others to 30,000 feet, or

--advance others' rights to life, liberty, property in a court of law or before (or through) a government agency?



As a former federal civil servant, my annual income and liabilities were a matter of public record--as were those of my colleagues--for my 14 years as an attorney at one agency and my prior eight years at another. And in my decade-plus of prior private practice (or even after, for that matter), the State Bar, under the authority of the State Supreme Court, could see my personnel and professional financial records in a blink had there been a question.



The public has a right to know if and when one is not in a physical and mental state to exercise those public-granted powers or in a financial position that is or may be in conflict with one's professional duties.



The drug testing of airline crews, first military and then commercial--cockpit and cabin--arose during the Reagan administration in 1981 and 1986/87, respectively. Executive policy became statutory with the Omnibus Transportation Employees Testing Act of 1991.(See also: DOT and FAA regulations (49 C.F.R. part 40 and 14 C.F.R. part 120).



As for physician testing, the point was raised in an opinion piece in the NYT earlier this year: "Why Aren’t Doctors Drug Tested?" (http://www.nytimes.com/2014/03/13/opinion/why-arent-doctors-drug-tested.html ).

OSI

 
At Saturday, May 24, 2014 5:37:00 PM, Blogger Maurice Bernstein, M.D. said...

Continuing from OSI. ..Maurice.
PART II/II


For professionals such as physicians and attorneys who get their knickers in a twist about drug testing, I think that they need consider their positions in this nation. A 2011:

--census of physicians in the U.S. (based on 2010 data) put the number at something more than 850,000 (https://www.nationalahec.org/pdfs/FSMBPhysicianCensus.pdf);

--census of attorneys in the U.S. (based on 2010 data) put the number at something more than 1,225,000--but with only about three-quarters of that number actually in private practice (http://www.americanbar.org/content/dam/aba/migrated/marketresearch/PublicDocuments/lawyer_demographics_2011.authcheckdam.pdf );

--U.S. Census Bureau analysis put the U.S. population at something near 311,600,000 (http://www.census.gov/popest/data/state/totals/2011/).



Whine and complain as we might about this or that perceived intrusion upon our privacy, those of us who enjoy the status of physician or of attorney comprise, respectively, 0.0027 and 0.0029 percent of the U.S. population.



That is pretty honored ground. (I can hear in my mind's ear a late family member saying that we "ought to get down on our knees and thank God." I have Jewish colleagues, so I appreciate that kneeling may not always be an option. What? Would a genuflect here or a bow there be too much to ask, already?)



And, yes: If one is providing clinical care and/or are doing human-use/human subject research, then not only should one have to pee-in-the-cup, but the rest of the world also has a right to know exactly who is putting money into one's pocket--and exactly how much. (OSI)

End Part II/II

 
At Saturday, May 24, 2014 7:58:00 PM, Blogger Hexanchus said...

What OSI said...

Commercial Pilots, Railroad Engineers, Commercial truck drivers, bus drivers and many others whose jobs, if not performed properly (i,e, not under the influence of drugs or alcohol) may adversely affect safety of others, are subject to drug testing - why should physicians be any different?

Hex

 
At Thursday, June 05, 2014 11:07:00 AM, Anonymous Anonymous said...

A recent article in JAMA, "Identification of Physician Impairment" suggests that undetected physician impairment may be contributing to medical error and that sentinel-event and random alcohol-drug testing could be implemented to address the problem as is being done in the current "Physician Health Program (PHP)" system.

The most consequential and critical issue for physicians, if this comes to fruition, is who will be in organizational and managerial control of the system and what ideological influences will be guiding policy and practice. It is concerning that one of the co-authors of this article, Greg Skipper, is a Fellow of the American Society of Addiction Medicine with strong ties to the 12-step treatment industry and drug testing industry.

One only has to look at the history of the ASAM and FSPHP to see that it is essentially a corporate "front-group" for AA, similar to the National Council on Alcoholism and Drug Dependence (NCADD), an organization that promotes the AA agenda yet claims to have no formal ties to AA. The ASAM and FSPHP are front organizations set up and controlled by AA.

ABAM "board certification" is a sham. It is not recognized by the ABMS but they are fervently lobbying for this and will probably be successful. They have convinced medical societies and medical boards of their "expertise" with a torrent of strategic lobbying efforts on behalf of the 12-step addiction treatment industry towards the AMA (and indirectly thought the FSPHP towards the AMA), APA, FSMB, ABIM, JCAO, CSAT, consumer groups, state medical societies, congress, correction agencies, the media, and others.

Even more concerning is that none of the ASAM generated studies that they use to promote the success of their programs nor the junk science they use (EtG, PEth for alcohol screening) has been the subject of critical review or scrutiny. There is no evidence base for the system or testing methods that they currently use as a successful model to be applied to other populations. No ASAM studies have been reviewed by the Cochrane Collaboration.

 
At Thursday, June 05, 2014 11:16:00 AM, Blogger Michael Langan said...

They are not currently comparable in the current system. The groups you mentioned all have procedural protections and safeguards because the EAP (Employee Assistance Programs) were developed in collaboration with unions or other organizations working on behalf of the employers best interests. In physicians there is no oversight or regulation and the EAP programs have been usurped by unqualified "impaired physicians" who are in "recovery" and "board certified by the ASAM (not recognized by the ABMS).. Federal Drug Testing Guidelines, DOT, or some other system that provides a high level of procedural protection with strict chain-of-custody, custody and control form, MRO review, split specimen with the right to challenge at an independent lab of your choice, an appeal process, etc. Moreover, you are tested for a specific number of substances with FDA approved tests with cutoff levels that have been well thought out. (probably 5-12) And there is no way you are bI doubt you are being tested with long term alcohol biomarkers, hair, nails, etc. So the statement "if I have nothing to hide, then I should be thrilled to (constantly) prove to everybody that I don't do drugs approaches being completely correct but it is not 100% correct. Human error and false positives are a problem even under the best of circumstances. As an MRO for the MBTA I have thrown out several positive tests (mostly for PCP) after careful interview and analysis. The point is you need procedural safeguards as well as accuracy and honesty.

Now let's look at PHPs (Physician Health Programs) populated by the "impaired physicians movement." They tend to think in black and white and don't believe in cutoff levels. ("it's either their or it ain't" I heard one misguided MRO for a PHP tell a doctor once) and as untrue as this statement is there is no arguing with this type of mentality. Secondly they have introduced tests such as long term alcohol biomarkers such as EtG, PEth, EtS that are not FDA approved. They are laboratory developed tests (LDTs) and there specificity is unknown. The only drug testing systems that use these tests are those where the power differential is very high (prisoner, guard type relationship). The PHP -Doctor relationship exceeds that of the prisoner-guard. They are using long term (*biomarkers (weeks to months), alcohol, "health professionals panels," etc. etc. Of course they are making a ton of money off this as doctors are tested 1-3x per week and it is self pay. Any positive, innocent, explained, caused by a valid prescription results in being evaluated at an out of state facility.

So this is comparing apples and oranges.

 
At Thursday, June 05, 2014 11:21:00 AM, Blogger Maurice Bernstein, M.D. said...

In the United States, all physicians are licensed to practice their profession by each individual state and their state medical boards. I would look to each state to set standards, perform and be responsible for the random testing of physicians and not be dependent upon any private organizations. ..Maurice.

 
At Friday, June 06, 2014 8:21:00 AM, Blogger Maurice Bernstein, M.D. said...

I still have a couple questions unanswered. What is the statistical risk of a patient at any one time to be examine and/or treated by a physician who is at that time intoxicated with drugs or alcohol?

And is comparing magnitude of the risks involved between a intoxicated commercial airline pilot and an intoxicated physician, both performing their duties dealing with the number of humans affected in one negative event and the severity of the injury (including death) for those involved in that single event.

These statistics should be an important part of the rationale and decision with regard to universal random testing of all physicians compared to airline pilots. ..Maurice.

 
At Wednesday, June 11, 2014 6:11:00 PM, Anonymous Anonymous said...

Dr Bernstein, since physicians are not randomly tested uniformly or widely, there's no data to address statistical risk. Furthermore, I'm willing to bet the numbers are similar between patients and passengers on a daily basis either receiving care or flying. If correct, I would argue the statistical risk is greater to patients simply because providers aren't subject to the deterrent effect of random screening. Finally, the numbers of providers actually involved in a single patients care (OR for example) is dramatically higher when compared to two pilots flying hundreds of passengers from point A to B. Their professional career and livelihood is on the line and they know it!

For the period 1995 through 2002, the most recent data I could easily find, the FAA reported a prevalence rate of 0.03% for flight crews subject to random screening or post accident/incident alcohol testing.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2041869/

The only accident I could find actually attributed to illicit drug use occurred in 1988.

http://www.nytimes.com/1989/02/02/us/drug-use-ruled-a-cause-in-plane-crash.html

Statistically, those are pretty low numbers. And the procedural protections and safeguards we enjoy to ensure random screening is administered uniformly and objectively can be applied to physicians and ancillary staff as well. Finally, I previously asked how does random screening violate a physician's personal privacy and what are the professional consequences for a negative test; please elaborate.

Ed

 
At Wednesday, June 11, 2014 7:21:00 PM, Blogger Maurice Bernstein, M.D. said...

Ed, there would be virtually no professional consequences to required random testing of physicians if the test result is negative. There would be profound temporary, if not permanent, consequences if the test result was erroneously positive, a result which is certainly possible. And then what?

With regard to violation of personal privacy, personal privacy has Constitutional and general legal support in many areas of society. At times, everyman's privacy must be invaded, but for a valid cause. In the case of physicians having their blood or urine tested the cause should be well established by statistics demonstrating substantial life or health risks to patients and society if physician privacy is not invaded. This entry into anyone's privacy (home,blood or urine or whatever) demands some facts supporting necessity and not.without the facts, simply for the public to attain the comforting "peace of mind". ..Maurice.

 
At Tuesday, July 15, 2014 7:52:00 AM, Blogger M Banterings said...

I have to agree with Maurice.

It may surprise those of you who read my other comments that I am AGAINST drug testing. Things like this have been rammed down our throats "to keep us safe." Just like the modesty debate, the unseen harm is ignored.

Drug testing treats us all as criminals. There is no "innocent until proven guilty," the concept assumes you just haven't been caught yet.

Look what it has done to our schools: they now resemble prisons they assume all students are criminals.

Metal detectors, pat downs, no cell phones, uniforms, lock downs, etc. am I describing a high school, a prison, or both?

The patriot act and the NSA wire taps are too keep us safe. Those who say I am doing nothing wrong so they can look don't see the harm done to civil liberties.

Whether discussing civil liberties or medical safety, consider this:

“Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety” -Ben Franklin

 
At Thursday, August 21, 2014 10:10:00 AM, Blogger OMINTWIZO said...

Dr. Greg Skipper is a convicted felon. He was convicted of theft and possession of controlled substances in November of 1990 in Hamhill County, Oregon. He served three years probation. Prior to that he was in trouble with the Oregon Medical Board for illegal use of controlled substances from at least 1982 to 1986. Google Greg Skipperfelon. OMC

 
At Friday, April 06, 2018 8:20:00 AM, Blogger Maurice Bernstein, M.D. said...

I teach a group of six first year medical students an "introduction into Clinical Medicine" which involves how to interact with the patient, take a history and perform a physical examination. But there are professional issues that need also to be discussed including the topic of this blog thread.

As part of this teaching, I have requested each student to write a one page discussion with references on the issue of drug habituation by physicians and even the same issue with regard to their own population, medical students. They all did a great job and I will reproduce their writings in the postings to follow, identifying them anonymously by "Medical Student" and a number. I hope their writings will contribute to the discussion going on this blog thread in 2014. Your evaluation of the students' writings will be most appreciated. ..Maurice.

 
At Friday, April 06, 2018 8:23:00 AM, Blogger Maurice Bernstein, M.D. said...

MEDICAL STUDENT 1:

Physicians and Substance Use Disorder Report
Substance abuse is the misuse of substances, often in a manner that interferes with relationships and daily life activities (ex. family and friends, work and personal care). If chronic, substance abuse can develop into a substance use disorder, which involves alteration of brain chemistry, amongst meeting other criteria listed in the DSM-5. Substance abuse amongst physicians and medical students is particularly insidious as these individuals are responsible for millions of lives (1).
As medical professionals, physicians have received years of education on the negative effects of substances on the body and mind, down to the molecular mechanisms. Theoretically, the number of physicians that abuse substances should stand at zero, and yet an estimated 10-15% of physicians will develop a substance use disorder during their careers, a number comparable to that of the general population. Stigma plays a central role in physician substance abuse. The role of “physician” is a prestigious position in society, but comes at the cost of “social isolation.” In other words, the community places such high expectations on physicians, that admitting having an addiction can feel particularly stigmatizing. As a result, many physicians are reluctant to acknowledge their addiction or seek help. Additionally, physicians are often enabled by colleagues and even family members, as losing the physician’s source of income can be particularly devastating (2).
Of the specialties, anesthesiologists, emergency medicine physicians, and psychiatrists are the most likely to develop a substance use disorder. These professions are highly stressful and provide easy access to quality prescription drugs, like opioids. Additionally, the persons that chose to pursue such fields might just be more prone to addiction, which studies have indicated has a significant genetic component (2, 3). Interestingly, the type of substance used varies between fields: for example, although alcohol is the “drug of choice” overall, anesthesiologists tend to abuse opioids like fentanyl over alcohol (2).
Studies seem to suggest that medical students are at higher risk of abusing prescription stimulant medications (amphetamines like Adderall) in comparison to other college students. A lot of pressure is placed on medical students to succeed – and placing a group of Type-A perfectionists in such a high stress situation can trigger drive students to seeking “performance enhancing” shortcuts. Stimulant drugs are taken by students in hopes of remaining alert throughout the day and focusing for longer periods of time (4).
Recognizing addiction as a genetic and physical problem rather than a personality defect would definitely help physicians suffering from substance use seek help sooner. Additionally, removing as much competition in medical school to promote a safe learning environment might help lower the rates of stimulant use among students. This can be accomplished by making tests Pass/Fail (rather than the usual A, B, C, and F grading system) and removing class rank. Having regular mental health checkups for both students and physicians with an independent agency can also promote mental well-being. In the future, it is my hope that addiction will be seen as a medical issue, much like a broken foot, so that those who need help do not fear repercussions for seeking it (*). 
1. https://www.samhsa.gov/disorders/substance-use
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704134/
3. http://learn.genetics.utah.edu/content/addiction/genes/
4. https://www.medscape.com/viewarticle/778843#vp_2
(*) These are my own solutions, did not use a source.

 
At Friday, April 06, 2018 8:34:00 AM, Blogger Maurice Bernstein, M.D. said...

MEDICAL STUDENT 2:


It should not come as a surprise that even doctors are susceptible to mental health issues, and particularly addiction and drug use. With the number of stressors in a physician’s workplace – increased work demands and patient load, decreasing financial compensation, increasing number of complicated cases with various comorbidities, the heavy responsibility of caring for the lives of other people, etc. – it is a very human reaction to try and find different ways to cope with all the burden and hardships that come with a demanding profession. Unfortunately, this may lead to unhealthy ways of coping, such as relying on substances. Indeed, there is a high prevalence of substance use disorders among physicians when comparing to the general population – 15.4% in physicians versus 12.6% in the general population (1) – with alcohol abuse and dependence being the most ubiquitous concern. (2).
Knowing this, there are two main issues that comes into mind: how does this affect patient care, and how will this impact the physicians themselves. With regards to care of patients, some may argue that the use of certain substances shouldn’t matter and won’t necessarily impede their decision making and ability to treat patients. However, a study has shown that at least alcohol use was associated with recent medical errors. (2). Understandably, one cannot generalize that alcohol would have the same effect on all people, and that other drugs would cause the same negative consequences as alcohol. Nevertheless, there seems to still be a risk that substance use and abuse can lead to physician impairment. As health care providers, doctors must do their best to minimize the possibilities of causing harm to patients and be fully present and healthy in every aspect of the word. In that note, if we can’t be fully on board with addressing substance use for health care professionals because of possible impairment in patient care, we must at least address the issue due to the consequences it may have on the providers themselves. For instance, anesthesiology residents reportedly had a significantly increased risk of death when they developed a substance use disorder during their training - 14.1% of the case population were deceased compared to just 1.3% of the control population. (3) Those that developed the disorder also had an increased risk of adverse training outcomes such as failure to their complete residency, attaining board-certification and subspecialty certification.
It is clear to me that there are many negative consequences in the use of certain substances in both a physician’s daily life, and also in a physician’s ability to provide the best care that they can to their patients. However, I am also cognizant of the struggles a person would encounter in addressing substance use issues. There is the stigma surrounding substance use and how a person may feel looked down upon because of this. There is the fear of withdrawal symptoms, which may lead to worse performance in the workplace, and the fear of losing their employment in general. We must find a way to both recognize that substance use can have a major impact in health care providers’ ability to care for their patients, while also acknowledging that they are still human and that they may also need help in certain parts of their lives without them feeling ostracized or scared that they no longer have a future in their fields.

1. Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). Results from the 2010 National Survey on Drug Use and Health: Vol. I. Summary of national findings (Center for Behavioral Health Statistics and Quality, NSDUH Series H 41, HHS Publication No. SMA 11 4658). Rockville, MD: SAMHSA.

2. Oreskovich MR, Shanafelt T, Dyrbye LN, et al. The prevalence of substance use disorders in American physicians. Am J Addict 2015; 24:30–38.

3. Warner DO, Berge K, Sun H, et al. Risk and outcomes of substance use disorder among anesthesiology residents: a matched cohort analysis. Anesthesiology 2015; 123:929–936.





 
At Friday, April 06, 2018 8:37:00 AM, Blogger Maurice Bernstein, M.D. said...

MEDICAL STUDENT 3:

Studies indicate that approximately 10% to 12% of physicians will develop and substance use disorder during their careers, which is a similar rate compared to the general population (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704134/). While overall substance abuse is not more common in physicians, addictive disease amongst physicians tends to be more advanced before identification. This difference is largely attributed to how “a physician’s practice is often the last segment of life to be impacted” and that colleagues are less likely to report perceived substance abuse when the physician’s career and reputation will be immediately destroyed (http://www.globaldrugpolicy.org/Issues/Vol%202%20Issue%202/Physicians%20Impaired%20by%20Substance%20Abuse%20Disorders.pdf). The observation I find most interesting from these articles is that physicians maintained their practice and performance despite deterioration of their life outside of work. However, few studies provide specific statistics of how substance abuse affects patient outcomes, which would be invaluable in determining the validity of drug testing.
At this point, it seems to me that drug testing should be called for if there are clear indications that the substance impacts a physician’s ability to perform their duties or if a medical error has been made and substance abuse is a suspected cause. If a physician is abusing a substance that has no impact upon their professional life and performance of duties, then that information stays in their private life. Random and routine drug testing specifically for substances that have demonstrated the capacity to impact perception, decision-making, or any skills related to being a good physician is well within reason, in my opinion. Although these tests impact the privacy of physicians, physicians play a role in caring for the lives of others; anything that might risk the life of another person/stranger/patient no longer falls under the purview of private. I would not want to ride with a pilot whose abilities are impacted by a substance, and I would not want my loved-one to have a surgery with a physician using any substance that has been previously demonstrated to impact performance. However, most of these opinions come with the caveat that the drug test itself must be effective and that those conducting the tests are doing due diligence in regards to false positives. If screening carries a risk of ruining a physician’s life erroneously and cannot detect a substance accurately, the whole thing strikes me as rather pointless. I would not condone this testing purely to “comfort patients,” it must ultimately connect to demonstrably providing better care.

 
At Friday, April 06, 2018 8:56:00 AM, Blogger Maurice Bernstein, M.D. said...

MEDICAL STUDENT 4:

The prevalence and intricacies of substance use disorders among the physician population is not particularly clear given the limited studies. However, a 2015 study by Oreskovich et al. explored the use of substances among a population of 7,288 American physicians and found that the prevalence of substance use disorders was slightly higher among physicians than in the general population (15.4% vs. 12.6%) (1).
Out of all substances, alcohol abuse was the most entrenched in the physician population(2). The study also found that females had a higher prevalence of alcohol abuse, with 12.9% of male physicians and 21.4% of female physicians (3). The use of illicit drugs or prescription drugs was remarkably rare (1.3% of physician abuse of opioids) and co-occurrence of alcohol with illicit/prescription drugs was also infrequent (with cannabis usage being the highest at 2.7%) (4).
In alignment with previous studies, Oreskovich et al. found that a physician’s specialty was strongly associated with alcohol abuse. According to Oreskovich et al., the highest prevalence of alcohol abuse was found among dermatologists. They were followed by orthopedic surgeons (5). Interestingly, a 2002 study by Booth et al. found instead that anesthesiologists led the way in substance use disorders – pointing to the fact that even though anesthesiologists represented 3% of physicians, about 13% of all physicians treated at a substance abuse center in the 1980’s were anesthesiologists. These results may not be as divergent from the Oreskovich study however, as alcohol is only one possible substance that can be abused.
Booth et al. estimated that 10-14% of physicians may become “chemically dependent on some substance at some point in their careers (6). However, when alcohol is removed from the analysis, this statistic nosedives to 1-2%. The same study explored the trend of substance abuse among anesthesiologists and found that 1.0% of faculty members and 1.6% of residents surveyed abused illicit or prescription drugs, with fentanyl being the most abused. Interestingly, Oreskovich found that although there was drug abuse among anesthesiologists, alcohol abuse was far more common (7).
Oreskovich et al. also found that alcohol abuse was associated with burnout, depression, suicidal ideation, lower quality of life, lower career satisfaction and increased medical errors. Given this, it is vital to encourage physicians struggling with substance use to seek treatment.

https://onlinelibrary-wiley-com.libproxy2.usc.edu/doi/full/10.1111/ajad.12173
Ibid.
Ibid.
Ibid.
Ibid.
https://journals.lww.com/anesthesia-analgesia/Fulltext/2002/10000/Substance_Abuse_Among_Physicians__A_Survey_of.43.aspx
https://onlinelibrary-wiley-com.libproxy2.usc.edu/doi/full/10.1111/ajad.12173

 
At Friday, April 06, 2018 8:59:00 AM, Blogger Maurice Bernstein, M.D. said...

MEDICAL STUDENT 5:


Physicians and psychiatrists have always been considered to be a population that is increasingly more vulnerable to substance use disorders and mental illness (this has been well documented in the literature). This is often due to easier access to medications, prescribing power, and a vulnerability that stems from being “embarrassed” to confront mental health issues and addiction with their coworkers, friends and families. Physicians will often hide these flaws in their character because they think that others will judge them for failing to uphold themselves to the standards of their own profession.
Even though substance abuse in medical professionals is not greater than the general populations, some medical specialties such as psychiatry have much higher rates compared to others. Recently, a country wide evaluation of physicians entering state administered physician health programs offered greater insight into the problem of substance abuse among physicians. Interestingly, many of the stigmas that physicians fear about their substance use disorders were in fact substantiated when admitted to these health facilities. They lost their licenses, ability to practice medicine, and where sometimes even outcast from their medical communities rather than receiving social and medical support.
In order for this to change in the future, these societal consequences must be toned down or removed. Physicians should not be held to different standards than the general population, because substance use disorders are not a flaw in character, but rather a mental illness that can affect any individual at any moment in time, regardless of socioeconomic status, race, health, gender, age, or profession. If a physician’s licensure and livelihood was not threatened by their substance use disorders, and if society did not look down upon physicians with this disorder, many more would seek help and treatment. More regulatory measures for prescribing and doling out opioid prescriptions in general would also help both the physician population and general population in reducing the risk of a substance use disorder. Although there is no perfect answer, one step in the right direction would be to help reduce societal stigma against substance use disorders, especially in the medical community.
Huang, B., Dawson, D. A., Stinson, F. S., Hasin, D. S., Ruan, W., Saha, T. D., ... & Grant, B. F. (2006). Prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders in the United States: Results of the National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry.

McLellan, A. T., Skipper, G. S., Campbell, M., & DuPont, R. L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. Bmj, 337, a2038.

Petry, N. M., Stinson, F. S., & Grant, B. F. (2005). Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry.

 
At Friday, April 06, 2018 9:02:00 AM, Blogger Maurice Bernstein, M.D. said...


MEDICAL STUDENT 6:


Substance Use Disorder Among Doctors and Medical Students
I’m reminded of a quote from the 1983 movie Scarface: “Lesson number two: Don’t get high on your own supply.” To me, there is something sadly ironic about a physician (a gatekeeper to prescription supply and preacher of healthy consumption) having a drug problem himself/herself. Like an IRS employee being audited for tax fraud. But, should we be surprised that physicians abuse drugs at rates similar to or higher than the general population?1 Tremendous professional and educational demands, coupled with access to addictive prescription substances, may, in fact, predispose health professionals to substance use disorders. One study shows that female surgeons (a cohort that reports significant burnout) have relatively high rates of alcohol abuse,2 and another study demonstrates that anesthesiologists (with ease of access to opioids) have the highest incidence of substance abuse among physicians.3 Medical students similarly encounter stressful educational and financial demands. This, combined with being recently removed from a widespread party culture in college (one that largely normalizes binge drinking and drug use), may account for relatively high rates of reported alcohol and tranquilizer abuse.4
What can we do to help these health professionals (and thereby, their patient population)? Many states have Physician Health Programs (PHPs), in which physicians can self-report a substance use disorder anonymous and enter a recovery and surveillance program. These programs are often highly comprehensive: with access to numerous recovery resources, support groups and counseling, and rigorous drug testing. As such, physicians demonstrate relatively high rates of recovery.4 A JAMA editorial remarks that this intervention can be “nonpunitive, imperative, and…life-saving—for both patients and the impaired physician.”4 However, PHP referral and treatment is predicated on a physician self-reporting a substance use disorder, or being encouraged to do so by his peers – something that can be problematic in a prideful population. Similarly, medical students can obtain a tailored treatment plan in a confidential manner.1 Ultimately, many of these programs seek to reduce the stigma against seeking medical help for a substance use problem, and provide health professionals with the avenues for recovery. Whether random drug testing should be mandated for medical employees is a whole other can of worms that would require serious ethical and logistical consideration.

Sources
1. Dumitrascu, C. I., Mannes, P. Z., Gamble, L. J., & Selzer, J. A. (2014). Substance use among physicians and medical students. Med Student Res J, 3(Winter), 26-35.
2. Oreskovich, M. R., Kaups, K. L., Balch, C. M., Hanks, J. B., Satele, D., Sloan, J., ... & Shanafelt, T. D. (2012). Prevalence of alcohol use disorders among American surgeons. Archives of surgery, 147(2), 168-174.
3. Booth, J. V., Grossman, D., Moore, J., Lineberger, C., Reynolds, J. D., Reves, J. G., & Sheffield, D. (2002). Substance abuse among physicians: a survey of academic anesthesiology programs. Anesthesia & Analgesia, 95(4), 1024-1030.
4. Gastfriend, D. R. (2005). Physician substance abuse and recovery: What does it mean for physicians—and everyone else?. JAMA, 293(12), 1513-1515.

 

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