He counted the floors of the residents' building. There was no way anyone would survive a jump from that height. Three and a half months before he was to graduate from residency, he was at a crossroads: either leap to certain death or admit defeat to a drug and alcohol addiction that had laid waste to a promising career in emergency medicine.
“I looked up at the building and thought, that doesn't appeal to me one bit,” said John∗ who had recently been confronted by his residency director's insisting he enroll in a drug rehabilitation program. “I thought, ‘well, let's just go to rehab’ so I packed up my things, sort of assuming my career was over. There was no Plan B. It was a very dark, dark time.”
For John, who agreed to coauthor this column but asked to remain anonymous, help arrived in time. He successfully completed rehabilitation, stayed clean, and is about to graduate from an emergency medicine program.
Others have not been so fortunate. Residents have been found dead in hospital bathrooms, needle tracks pockmarking their arms and legs.1 One resident drove off the road, with an intravenous line dangling from his arm.1 These tragedies make headlines, but it is a far more subtle situation that faces most physicians, more often than we would like to admit: a slurred word, a faint odor of alcohol on morning rounds, a drifting down of performance, a page unreturned.
There are aspects of the physician temperament that are conducive to addictive tendencies, John said. “Work hard, play hard” is almost a medical mantra, but it is not so easy to accept the darker implications of that statement.
“The part of my personality that became an alcoholic and a drug addict is the same part of my personality that studied 20 hours a day and scored a 36 on the MCAT. My study habits were pathological, just like my drinking.”
Residents in general are less likely than their same-age peers to abuse drugs,2 but a significant minority starts using prescription drugs during residency. Emergency medicine residents have higher rates of substance use than residents in other specialties and were more likely to report current use of cocaine and marijuana.3 There is also a gulf between the problem and its recognition. In another study, emergency medicine program directors estimated 1% of their residents had substance abuse problems, whereas 13% of emergency medicine residents surveyed 1 month earlier reported CAGE scores4 (Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers) consistent with alcoholism.5 The directors referred only two thirds of suspected residents for evaluation.
The importance of early detection and referral cannot be overstated. Most state medical societies have programs that allow physicians to self-report a substance-abuse problem. The societies and most professional associations, including the American College of Emergency Physicians, view addiction as a treatable medical illness and show physician addicts compassion and support. Those who begin treatment will eventually resume practice, if they abide by treatment protocols, which often include counseling and random urine toxicology screens. This is what John did, and these programs tend to be forgiving, allowing second and even third chances to get and stay clean and sober.
If the physician is not fortunate enough to address his problem this way or repeatedly fails to comply with the treatment regimen, the states' professional conduct committees may come into play. These bodies do not have the same nonjudgmental attitude, and they have punitive power to censure, reprimand, fine, and revoke licenses. And this does not even begin to address the troubles that might face a physician using illicit drugs, prison not being the least of his worries. The physician hiding an addiction is on a razor's edge between the friendlier treatment option and the more punitive possibilities. Specifically, colleagues are required by law to report suspected impairment at work to the professional conduct committee. In most states, it is a crime not to.
The program directors' perspective in identifying impaired residents has been discussed, if not well defined,6, 7 but what to do from a resident's perspective, either the one with a problem or his friends and peers, is less clear. The American College of Emergency Physicians guidelines state:
“Whenever a colleague or consulting physician is believed to be incompetent or impaired by drugs, alcohol, or psychiatric or medical conditions, there is a duty to report the impaired physician to the chief of service, the chief of medical staff, and appropriate committees or regulatory agencies.”8
Unfortunately, emergency medicine joins obstetrics and gynecology as the specialties with the least residency curriculum hours dedicated to recognizing and treating substance abuse.9 So few emergency medicine residents are trained even to identify the problem, much less intervene.
John said identifying troubled residents is difficult because they have become very adept at concealing their addictions, and they live in a constant state of denial. In addition, work performance may not be affected until late in the disease.10
The American Medical Association's Federation of State Physician Health Programs Web site (available online at http://www.ama-assn.org/ama/pub/category/5705.html) provides a state-by-state listing of medical society resources for impaired physicians and their colleagues who desire intervention (Figure and Table).
Figure
ACEP Policy on Impaired Physicians
In recognition of the problem of emergency physician impairment and of the importance of emergency physician well-being, the American College of Emergency Physicians endorses the following principles:
The well-being of the emergency physician is essential to the practice of emergency medicine.
The impaired emergency physician may be unable to practice emergency medicine with the skill necessary for the safety of patients. In any approach to managing problems related to physician impairment, consideration of patient safety must be of primary importance.
The American College of Emergency Physicians is committed to assist the impaired emergency physician and to promote the well-being of all emergency physicians through education, information, and collaborative processes.
Using the disease model of chemical dependence is the best strategy for successful treatment and recovery of the emergency physician who has the disease. The impaired emergency physician should be treated with the respect and dignity due any patient with an illness.
Recovering physicians who successfully complete treatment and are receiving adequate medical follow-up should be allowed to return to the practice of emergency medicine when they are able.
Written policies that foster the well-being of emergency physicians by facilitating early recognition of impairment and intervention in cases of impairment should be developed, and their use should be promoted in the workplace.
Education about factors that promote well-being and those that lead to impairment, focusing on prevention and management, should be included in undergraduate, graduate, and continuing medical curricula.
Research directed at the detection, treatment, and prevention of emergency physician impairment is needed to determine the prevalence of impairment in emergency medicine practice and to provide a basis for developing specific strategies for prevention and management. Research in all areas that may affect emergency physician practice longevity is also needed.
For John, the spiral into addiction began well before the pressures of medical school and residency compounded his need for escapism—in this case, through alcohol and, eventually, cocaine. “For me, they went together like peanut butter and jelly,” said John, who remembers his problem beginning at 13 when he drank his first wine cooler.
“After about 3 or 4 of them, as alcoholics say, ‘it’ happened,” said John. “The change happened. I became funny and outgoing and entertaining.”
Although it escalated in high school, he said the urgency to drink fell by the wayside in college. Then came medical school and the “work hard, play hard” culture, which meshed perfectly with his addictive tendencies.
“Being a student is very conducive to being an alcoholic,” he said. More important than the frequency, John said, medical school is when his attitude toward drinking changed. “It became a vacation to me—a vacation from a very stressful lifestyle.”
By the fourth year of medical school, John started drinking alone and not just on weekends. “I had some externships, and I didn't know anybody in those cities,” John said. “I told myself there was nothing else to do, so I drank.”
It did not go unnoticed.
“I met this girl, and she pointed out that I was drinking alone,” he said. “I remember being angry and indignant, and that's when I realized I should probably start hiding my drinking.”
Even after being confronted, he refused to acknowledge his growing dependency. “I didn't think I was an alcoholic,” he said, “but I became aware though that others might have the mistaken idea that I was one. Clearly they were wrong. I was special, an extremist. I could handle it.”
John acknowledges his addictions may have subconsciously influenced his specialty choice. Especially after residency, emergency medicine facilitates compartmentalization.
“When I'm off, I'm off. EM was it,” he said. “I didn't want a beeper because when I was home, I was going to be partying. At least I thought it was partying. I didn't realize I was just an alcohol addict who was suffering.”
After entering residency, he was carefully planning his drug and alcohol binges around his work schedule so as not to alert his colleagues or bosses. The warning signs were subtle: a few more sick calls than most, a bounced check at the hospital cashier's office. Suspicious, his residency director and mentor pulled him aside, but John assured them there was nothing to worry about. Finally, during his second year, his drinking made him a little too reckless.
“Alcoholics who get really drunk do stupid things—sometimes it's drive; sometimes it's beat someone up; for me it was wandering down into the projects to get cocaine,” he said. “I was attempting to buy drugs, and the police became involved. Trying to talk my way out of it, I mentioned I was a doctor, and the officer knew someone who worked at my hospital. They called my program director, and that was the last straw.”
As a result, John was removed from residency for 6 weeks and enrolled in the impaired-physicians program, but he was not reported to the state's professional conduct committee.
“Apparently, scaring the living crap out of me is only good for a few months of sobriety,” said John who was soon back to using and eventually tested positive for cocaine.
He was about to graduate. He had a job waiting. He was a few steps from the edge of the scrutiny of residency, a few months from a paycheck that might have financed a whole new level of addiction.
“Then I came up positive,” he said, “and it was the best thing that could have happened to me.”
At the time though, John assumed he had reached a dead end. “It had gone on so long that I knew they were not going to let me be a doctor. I thought, they're going to fire me. What am I going to do with my life?”
Fortunately, John received a scholarship allowing him to stay free at a 10-week rehabilitation facility that usually costs physicians $30,000. In addition, his bosses assured him his job would be waiting when he returned.
John embraced religion, feeling as though he had experienced the “white light.”
“I could throw it all away and become a full-time addict or accept God and everyone else's help and recognize I had a disease.”
Religion is a common theme of many rehabilitation programs, and most state medical societies endorse the use of at least some aspects of the “12-step” paradigm developed by Alcoholics Anonymous. It includes acknowledging a “higher power” but is not necessarily religious.
There are programs that exclude any reference to God or a higher power, such as Rational Recovery (available online at http://www.rational.org). Programs vary state to state, so the best resource for what types of treatments are available is your state medical society.
Almost a year later, John is still sober. “I prayed to be released from my obsessions and compulsions with alcohol, and they haven't been there since.” John told his prospective employer about his past problems with addiction. “I figured they'd want nothing to do with me,” John said, “but after speaking to my residency director, they told me to come on down.”
Looking back, John said he wishes he could have found help before it found him. “I would tell any resident that suspects they have a problem, that there is help out there,” John said. “The fact is, if you're going into work with alcohol on your breath, something is wrong. Reaching out doesn't mean the end of your career.”
As for preventive measures that residency directors or colleagues can use, John advises following their instincts.
“If you suspect something is wrong, it probably is.”
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