A recent article in Journal of the American Medical Association delved into the touchy subject of mandatory alcohol and drug screening programs for physicians. In their piece titled “Identification of Physician Impairment”, the authors Drs. Pham, Provonost, and Skipper concluded healthcare lags behind other high-risk industries in detecting high-risk factors causing injury or accident.
When a critical event occurs in most high-risk industries (such as airlines, nuclear power, or railways), a detailed investigation examines a variety of system and individual factors (such as fatigue and substance abuse) that caused or contributed to the event. Directly involved individuals are commonly tested for alcohol and other drugs. Airplane pilots and truck drivers are tested following crashes and near misses. Some law enforcement officers are tested following fatal shooting incidents.
They noted that mandatory alcohol and drug testing is not conducted for clinicians involved in an unexpected patient death or sentinel event (such as wrong-sided surgery). The authors suggested over their careers, up to 1/3 of physicians will experience a condition that impairs their ability to practice medicine safely. They argued that current systems, such as peer review, are inadequate to detect and treat the underlying problem until a number of patients have been injured.
Their recommended solutions:
- Mandatory physical examination, drug testing, or both prior to providing hospital privileges;
- Random alcohol-drug testing;
- Routine drug-alcohol testing on all doctors involved in sentinel event leading to patient death;
- And so on.
Many hospitals have already initiated drug and alcohol screening for its employees; and presumably physicians who are employed by such hospitals already agree to such testing.
The larger question is whether such proposals would have a favorable cost / benefit ratio. Arguably, the biggest risk factor for physician performance is plain-old fatigue. Not having enough time to sleep or rest. If this is accurate, it might be easier to embrace mini-cognitive tests as a solution, for example, asking clinicians to perform quick calculations on a monitor (or some equivalent), to detect real-time cognitive impairment. This could be as time-consuming as typing in a username and password into an electronic medical record system. In this model, one is merely measuring potential performance before performance is to be rendered.
This metric would be more meaningful than a urine or blood test; tests that might have zero correlation to performance. A positive drug screen for marijuana might be related to a joint that was smoked legally while on vacation in Colorado. And, a doctor might have a valid prescription for low dose narcotics for chronic pain.
The goal of a patient safety program should be to identify performance. There are a million ways performance can be affected. I argue it would be simpler – and more cost effective – to identify ability to perform, real-time, rather than measuring the million causes underlying impaired performance.
It will only fly when only white male physicians are tested.
JH
And, by the way, who needs a 4th Amendment anyway?
If any doctor is stupid enough to believe the idiots that believe “legal marihuana” is compatible with good medical practice they should loose their license to practice anyway.
I am in the twilight of my career and look forward to not having to put up with this bs in the next few years! Pity the poor residents and junior attendings, if I was them I’d slit my wrists then practice in that kind of environment! The mantra of “patient safety” will be the death of all the providers, with little or no benefit to the patient.
We’re mad as hell and not going to do it anymore.
Do they do that in countries with completely socialized medicine? France? Germany? I think not.
I had a friend, German physician who told me that it was not unusual for the residents, serving long days and evenings for many years to split a bottle of wine (among say 4 doctors) at supper together and then do evening rounds.
Some of this is reasonable, especially if there is a perception of an intoxicated MD. What is next? Bad health habits, like smoking (having to take a smoke break is disruptive, right?), or being obese (can’t run fast enough to resuscitate a patient)??
I’ll admit to frequent impairment. 4 Phone calls after midnight will do that to you. Or a whole weekend on call. I’ve even tried to address the issue at staff issues–suppose I’ve had 3 hours sleep in the last 2 nights and feel I am impaired and need the next night off. Good luck.
Another regulation. I’m the only neurosurgeon in an underserved area at a hospital that refuses to buy staple items for the operating room while I make them millions in revenue. Drug test them for the delusional thinking that they know neurosurgery. I refuse to jump through any more hoops. They can kiss my fat, white, male, Marlboro smoking butt. 4th amendment? What’s that?!
Doctors have nothing to hide. we need to be transparent and if we have a drug problem we need help and we need to let our patients know that we are on the road to recovery. We can no longer hide behind our degrees and our license. The time is for all of us to step up and declare we are drug free or if we have problem, and the public is often very understanding if we are forthcoming and honest, we are getting help.
I will gladly submit to drug and alcohol testing, after my drunk, stoned, unemployed ATV crash “victims” who smoke 2PPD and are welfare with 4 kids take one. Why is it that the only segment of society subjected to testing are the people who have worked very hard and have something to loose. It should equal across the board.
I do not think it will help. Often when there is a bad outcome it is not known till much later.
The problem will be that even if there was no error in judgement concerning the patient care, that any body with a positive tox screen must be guilty of something and will be singled out for malpractice or penalty by the state board or hospital, even if it was medically indicated use of a prescribed medication or wine with dinner the night before.
I might be willing to accept this the day authorities apply the identical rules to lawyers.
Michael M. Rosenblatt, DPM
I agree with JD: Revocation of ALL government “benefits” for welfare, Medicaid and Food Stamp recipients sitting around drunk and stoned while watching Springer.
Correct me if I’m wrong, but airline, railway, and nuclear power workers have limitations on the number of hours they can work in a week, so they have mandatory downtime. I’m sure many of these workers enjoy libations during their downtime.
As a supporter of Liberty, I do not support routine drug testing of all physicians. It would certainly be profitable for the labs administering these tests.
Many of us are tortured by MOC: my exam, oral and written, in FPS is in 28 days. If a hospital administrator demanded a urine specimen from me 29 days from now, I would be sure to spill a bit as I lay the specimen on his desk. 🙂
Just say NO!
Who in the United States has the job which, with a single mistake, can wipe out thousands or millions of people? Why, the President. We have a President who has admitted to cocaine and marijuana use. We have an apparent “Presidential malpractice” case in the Benghazi affair…where the president was given urgent information at 5 PM and reportedly was not heard from the rest of the night. So…let’s start with the President, and see how that program works for a year or two. Then we can consider doctors, where one life at a time is at stake.
(BTW, I am in agreement with almost all posters here). Doctors (perhaps pilots, but not really) go through the most vigorous, intense training for years..watched every step of the way by those one, two, or three levels above. So why should they be assaulted with this new requirement later on? It is already bad enough that we are being sued for bad results, even when no malpractice occurred, as stated by experts.
Well, part of the issue rests with many of us who as physicians should speak up when we see that certain health care providers with impaired performance are treating patients. When some dare to speak up hospitals in general look the other way because disciplining those health care providers can affect the bottom line (specially if they are employed) or bring on legal problems. Then, there is also the unspoken Omerta that governs the guilds of health care providers and their legal organizations. So when I need surgery I simply go to my buddies to get the scoop on who is truly good at a very specific procedure>>> Insider Trading. Will that soon be illegal too?
Such proposals as the one for intrusive screening of physicians in the event of a poor patient outcome will quickly lead to physicians rationing care to the sickest patients. If a patient is in need of a relatively elective surgical procedure, but has medical co-morbidities that increase complication risk, it is more likely that they will have a harder time finding a physician to take on the risk to their own career for providing that patient treatment. Physicians have been forced to consider the professional risk-benefit ratio to themselves into the decision-making process for patient care. I keep my pharmacist license active in the event that practicing neurosurgery becomes impossible due to onerous government regulations, ICD-10 implementation, and litigious predatory trial lawyers, all of which keep my solo practice near the death grasp of bankruptcy already.