Physician health and wellness
Correspondence to: Karine Morin, Council on Ethical and Judicial Affairs, Ethics Group, American Medical Association, 515 North State Street, Chicago, IL 60610, USA. Tel: 312 464 5223; fax: 312 464 4799; e-mail: karine.morin{at}ama-assn.org
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Background Impaired physician health can have a direct impact on patient health care and safety. In the past, problems of alcoholism and substance abuse among physicians have received more attention than other conditions—usually in the form of discipline. While patient safety is paramount, the medical profession may be more successful in achieving the required standards by fostering a culture committed to health and wellness as well as supporting impaired physicians.
Objective To develop ethical guidelines regarding physician health and wellness.
Methods The American Medical Association's (AMA's) Council on Ethical and Judicial Affairs developed recommendations based on the AMA's Code of Medical Ethics, an analysis of relevant Medline-indexed articles, and comments from experts. The report's recommendations were adopted as policy of the Association in December 2003.
Results Individually, physicians can promote their personal health and wellness through healthy living habits, including having a personal physician. The medical profession can foster health and wellness if its members are taught to identify colleagues in need of assistance and initiate appropriate methods of intervention, including referrals to physician health programs.
Conclusions Physicians whose health or wellness is compromised should seek appropriate help and engage in honest self-assessment of their ability to practice. The medical profession should provide an environment that helps to maintain and restore health and wellness. Physicians need to ensure that impaired colleagues promptly modify or cease practice until they can resume professional patient care. In addition, physicians may be required to report impaired colleagues who continue to practice despite reasonable offers of assistance.
Keywords Ethics; health and safety; medical profession; physician; policy; sick doctors
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The World Health Organization defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ [1]. This definition, which has existed since the 1940s, has received valid criticism for being overly inclusive and unattainable [2,3]. Nevertheless, in recent decades, there has been considerable progress in the United States and elsewhere toward a more comprehensive understanding of what constitutes health. This broader commitment to patients' health, ideally, should serve as an impetus for the nation's physicians to focus on their own overall health.
Traditionally, problems of alcoholism, substance abuse and related mental health concerns among physicians have received more sustained attention than other conditions [4]. Unfortunately, these concerns are often expressed in terms of discipline to ensure the safety of patients, rather than in terms of treatments for the affected physicians. These conditions and other health-related conditions that may afflict medical professionals deserve thoughtful and compassionate care of the same standard provided to non-physician patients.
Physicians' overall health may be receiving increased attention [5]. Whether prompted by societal concern for health and wellness in general or by the re-examination of the medical environment that ensues from a culture of patient safety, there is growing awareness, for example, of the detrimental effects of excessive work hours and sleep deprivation that characterize residency training [6–8].
It remains important to develop standards of behavior in the area of physician health and wellness insofar as it affects physicians' professional activities, including patient care and trust in the profession. Indeed, there is increasing evidence that physicians whose health or wellness is compromised risk providing substandard patient care and that physicians with healthy personal practices are more avid preventionists [9,10]. Efforts from organized medicine to promote and maintain health and wellness can be understood as upholding the goals of professionalism: in particular, physicians' dedication to providing competent medical care, to upholding the standards of professionalism and to regarding responsibility to the patient as paramount [11].
The American Medical Association (AMA) has defined impairment as ‘any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities’ [12]. This definition recognizes that a range of conditions may impede physicians from practicing medicine with reasonable skills and safety. Physician welfare can also be compromised by mild conditions that escalate to become impairments. Finally, some environmental stressors may interfere with physician welfare. Although minimal strains, such as an occasional sense of feeling overwhelmed, may constitute a simple inconvenience with an easy solution, they also can create problems by negatively affecting team functioning and patient care.
Disease manifestations may interfere to varying degrees with physicians' ability to practice medicine. For this reason, determining whether a physician whose health is compromised should continue to be involved in patient care—in the present or future—is a complex endeavor.
Acute and chronic diseases have different implications according to severity and treatability, and their impact may also vary according to the nature of a physician's professional activities. For example, a physician suffering from the common cold generally could continue providing quality medical care using certain precautions, but should avoid patients whose immunity is critically compromised. More lethal infectious diseases, such as human immunodeficiency virus, hepatitis C or tuberculosis are far more complicated to address, especially for surgeons performing invasive procedures [13]. Cognitive difficulty and degenerative diseases, such as multiple sclerosis or Parkinson's disease, could also affect the practice of medicine, although some accommodations may enable physicians to prolong or maintain their practice without jeopardizing the safety of patients.
However, when a physician becomes impaired—that is affected by a condition that ‘interferes’ with the ability to engage safely in professional activities—the physician and the physician's colleagues have a responsibility to take action to avoid harm to patients, the physician and the medical profession. Foremost, this requires timely intervention to ensure that the physician ceases practicing—whether temporarily or permanently.
Various factors have been identified as occupational stressors that occur among physicians, regardless of specialty or training [14,15]. One area that has received particular attention is sleep deprivation, which can be more incapacitating than a high blood alcohol level, as recent studies have demonstrated [16]. Recently, new rules limit the number of hours residency programs can require residents to work [17]. However, ‘moonlighting’ (residents' independent practice of medicine during off-work hours) remains a common practice, raising the same concerns of impairment from lack of sleep. Additionally, the new regulations surrounding resident work hours may have the knock on effect of inappropriately extending practicing physicians' work hours. This is concerning, especially considering that sleep deprivation already is a reality for many groups of practicing physicians.
In addition to the challenges of their environmental stressors, physicians often experience psychological factors that lead to feeling overwhelmed or burned out [18]. Some physicians may experience depression or turn to addictive substances for relief.
The implications of all these factors must be taken seriously in light of recent findings that decreased physician wellness is linked to serious consequences for patient care and negatively impacts prescribing habits, test ordering, patient compliance and patient satisfaction with medical care [14,19,20]. Whenever they can, individual physicians should be attentive to their practices and modify their work environment to reduce stressors so as to enhance their wellness. Coping mechanisms such as stress management, family support, recreation, hobbies or participation in support groups are among possible resources that may help physicians prevent fatigue, stress or burn out [15].
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This report and the recommendations that ensue from it are based on AMA policy in general and the ethics policy in its Code of Medical Ethics in particular, as well as on a review of relevant Medline-indexed articles and comments from experts in the field.
The AMA's Code of Medical Ethics already acknowledges that some form of intervention—reporting to appropriate bodies and/or disciplinary sanctions in extreme cases—may be required in the case of a physician who is impaired, incompetent or behaving unethically [21]. The requirement is grounded in physicians' responsibility to self-regulate (professionalism). The code also identifies as unethical the behavior of physicians who practice under the influence of controlled substances, alcohol or any other agents that would be likely to interfere with the safe and effective practice of medicine [22].
With this report, the AMA Council on Ethical and Judicial Affairs wishes to promote overall physician health and wellness, while continuing to recognize that effective skills and patient safety are an absolute requirement in the practice of medicine. Understanding that impaired physicians cannot be allowed to engage in regular patient care, it behooves the profession to support such physicians so that hopefully they can recover and return to productive medical service.
Specifically, this report is intended to emphasize the continued need for forethought and sensitivity in addressing physicians' health and wellness by fostering a culture committed to taking remedial steps at the first sign of deterioration. This requires mechanisms to identify when physicians are in need of assistance, as well as effective and appropriate methods of intervention.
This report concerns itself primarily with practicing physicians. However, it must be acknowledged that medical professionals throughout the entire spectrum of their professional lives, beginning with medical education and training, are affected by health and wellness issues. Appropriate considerations and resources at each stage are important and necessary.
The more general ramifications of a paradigm shift in physician health from a model focused on impairment to a model concerned with promoting wellness still deserve additional consideration elsewhere. In particular, it will be important to gain a better understanding of appropriate physician responsibilities regarding wellness assessment, as well as wellness-related care or activities. This may foster improved quality of care and patient satisfaction—for example by helping a fatigued physician regain energy and alertness.
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Physicians who lack adequate health and wellness
Individual physicians' obligations
When their health or wellness is compromised, individual physicians should engage in honest self-assessment of their ability to continue practicing and seek appropriate help and/or take suitable corrective measures. In many instances, adequate support will enable a physician to continue caring for patients—for example, at times of high stress, the opportunity to discuss the pressure or anxiety with peers may offer a sufficient outlet. Under other circumstances, physicians may need to cease their activities in the short term only—for example, an exhausted physician may require sleep before being able to provide effective and safe care again. In the face of impairment, physicians may need to undergo a lengthier period of rehabilitation, during which their activities are temporarily or permanently interrupted.
While there is nascent research on the issue, more information is needed on what keeps physicians feeling well [23]. Certainly, physicians can benefit from healthy living habits they recommend to their patients, from coping mechanisms and reliable support networks to proactive attempts to modify their work environment, or lessen, if not eliminate, environmental stress [19].
In addition, physicians should be encouraged to select a personal physician who can perform regular check-ups to monitor health as well as serve in the face of illness. Indeed, individual physicians generally lack the objectivity to engage in self-treatment or self-medication [24]. Therefore, establishing a healing relationship with a physician whose objectivity is not compromised by factors such as shared income or referral relationships can be a significant step toward maintaining good health [15].
Some organizational factors that negatively impact physician wellness may not be within physician control, for instance physician working time. Hospitals and other institutions, insofar as they may have some oversight regarding these factors, should be concerned with them, as well as staff health and wellness in general, as a key component of quality.
Obligations of the medical profession
Beyond individual members' responsibility to look after their personal health and wellness, the medical profession has an obligation to ensure that its members are able to provide safe and effective medical care. This obligation translates into different requirements: (i) to promote health and wellness among physicians, (ii) to establish appropriate mechanisms to detect impairment, (iii) to intervene in a supportive fashion and (iv) to refer and/or report impairment if necessary. In the hospital setting, these requirements should be carried out by the organized medical staff.
The effectiveness of the medical profession in identifying and intervening on behalf of its members in need of help has been limited by a reluctance to confront colleagues and refer them to appropriate resources. A possible explanation for this shortcoming is that a colleague, once identified as needing help, will incur licensure actions, shame or stigmatization [25]. Also, physicians may have a reluctance to think of themselves and members of their profession as needing help with health-related matters. Finally, failure to intervene may be due in part to inadequate standards by which to identify signs of need, difficulty in ascertaining with confidence that a colleague is experiencing serious problems and lack of familiarity with available resources that can offer supportive interventions.
However, the medical profession has developed considerable expertise through independent medical examinations in evaluating whether any type of employee (physician or not) has a condition that interferes with the capability to fulfill certain job responsibilities. This occupational health assessment expertise must be expanded so that physicians become better able to evaluate whether a colleague can continue performing professional activities. A resource document recently developed by two councils of the American Psychiatric Association provides an initial model for such guidance. It offers general guidelines and practical considerations for the psychiatric evaluation of a physician's fitness for duty [26].
A physician who notices that a colleague's health or wellness seems to be compromised could approach the colleague to discuss reasons for concern, and the value in seeking assistance, a day of rest, a visit to a personal physician, a medical evaluation or even help from a physician health program. Encouragement of this sort may also help the colleague decide whether it is reasonable to discontinue patient care temporarily. If the affected colleague takes no action while continuing to exhibit signs of physical or mental compromise, concerns should be directed to an appropriate body. In particular, referral to a hospital or state physician health program may be appropriate. A listing of state programs can be accessed at http://www.ama-assn.org/ama/pub/category/6020.html. Many of the programs provide information on their websites regarding consultation, guidance and intervention under instances in which concerns have been raised regarding a health care professional. In addition to these, there may be private programs, either affiliated with hospitals and institutions or independent.
Recognizing the importance of health programs, a recent mandate of the Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires all hospital medical staff to have physician wellness committees or to work with already established physician health programs in the state [27]. More specifically, it insists that ‘medical staffs implement a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function’. The responsibilities of wellness committees include educating medical staff about illness, impairment and referral of impaired physicians to appropriate resources for diagnosis and treatment. According to the JCAHO mandate, physicians who are referred to wellness committees should be evaluated to assess the validity of the cause for referral. Furthermore, wellness committees should monitor affected physicians, as well as their patients' safety, until the intervention is complete, report physicians who are providing unsafe treatment and otherwise maintain the confidentiality of impaired physicians, except as limited by law, ethical obligation or threat to patient safety [27].
Similar to this institutional commitment to address physician wellness, the medical profession has an overall obligation to develop appropriate physician health programs, which provide a supportive environment to maintain and restore health and wellness, as is consistent with the effective and safe practice of medicine. Within these programs, impaired physicians may be required to temporarily suspend activities until they have recovered the ability to resume the practice of medicine. In some instances, physicians may no longer be able to provide patient care.
Physicians who are aware that an impaired colleague continues to practice medicine despite their reasonable efforts to help, including through referral to a physician health program, should report the impaired physician to an appropriate body. This ethical duty, which can be understood as stemming from physicians' obligations to protect patients against harm, may entail reporting to the licensing authority. It is also worth noting that in some jurisdictions, physicians may have a legal obligation to report impaired colleagues.
The physician as patient
Physicians who lack adequate health or wellness and their patients
Physicians ethically are required to ‘deal honestly and openly with patients’ at all times to enable patients ‘to make informed decisions regarding future medical care’ [28]. Physicians have a duty to disclose any information to the patient about their medical condition including information related to physician acts that may have negatively affected the condition.
However, mandatory disclosure by physicians of their own personal medical information to patients may significantly deter physicians from seeking care [29]. Moreover, it has been argued that such disclosure would place patients in the inappropriate role of having to determine whether a physician is safe, when the determination is more appropriately the responsibility of the profession.
As previously noted, an impaired physician should not be involved in patient care until the physician has recovered, so an impaired physician should not be in a situation that would warrant disclosure to a patient. Physicians whose health and wellness are compromised, but in a way that places neither their effectiveness nor the safety of patients at risk need not disclose their condition.
Perhaps most difficult to standardize are obligations of physicians to disclose any illness, disability or circumstance interfering with wellness that ‘could’ affect their practice. In a recent case that reached the Supreme Court of South Carolina, a patient who brought a medical malpractice action following surgery claimed that the hospital should have informed her that her surgeon would be undergoing elective triple coronary bypass surgery 3 days after operating on her [30]. The hospital was found to have no such responsibility for the surgeon's disclosure. At the very least, the claim is among the first to allege a causal link between the harm the patient suffered and health-related events in the clinician's life. Ultimately, under such circumstances, the relevant question seems to be not whether the physician should disclose, but whether the physician should practice. By seeking occupational health advice and engaging in honest self-assessment of their ability to continue practicing, physicians can proceed in a way that does not compromise patient welfare.
Caring for physicians as patients (physician-patients)
Physician-patients, like other patients, are entitled to have their confidences safeguarded, with some limited exceptions that are justified by overriding social considerations [31]. For this reason, physicians caring for colleagues should not report or reveal any aspects of their physician-patients' medical condition except as required by law, ethical and professional obligation or when the safety of other patients is at risk.
In addition, physicians involved in the treatment of their colleagues should be sensitive to some of the unique needs of physicians as patients. Some physician-patients may have difficulty in accepting their diagnosis, especially when their professional life has been devoted to treating similar health problems. Denial or minimization of symptoms may undermine adequate treatment or control, as may self-medication, self-adjustment of dosages or discontinuance of treatment [18].
Ultimately, in caring for themselves and their colleagues, physicians demonstrate a commitment to their professional responsibilities and strengthen public trust in the medical profession.
Recommendations of the council on ethical and judicial affairs
- (i) To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness, construed broadly as preventing or treating acute or chronic diseases, including mental illness, disabilities and occupational stress. When health or wellness is compromised, so may the safety and effectiveness of the medical care provided. When failing physical or mental health reaches the point of interfering with a physician's ability to engage safely in professional activities, the physician is said to be impaired.
- (ii) In addition to maintaining healthy lifestyle habits, every physician should have a personal physician whose objectivity is not compromised. Physicians whose health or wellness is compromised should take measures to mitigate the problem, seek appropriate help as necessary, and engage in an honest self-assessment of their ability to continue practicing.
- (iii) Those physicians caring for colleagues should not disclose without the physician-patient's consent any aspects of their medical care, except as required by law, by ethical and professional obligation or when essential to protect patients from harm. Under such circumstances, only the minimum amount of information required by law or to preserve patient safety should be disclosed.
- (iv) The medical profession has an obligation to ensure that its members are able to provide safe and effective care. This obligation is discharged by
- (a) promoting health and wellness among physicians;
- (b) supporting peers in identifying physicians in need of help;
- (c) intervening promptly when the health or wellness of a colleague appears to have become compromised, including the offer of encouragement, coverage or referral to a physician health program;
- (d) establishing physician health programs that provide a supportive environment to maintain and restore health and wellness;
- (e) establishing mechanisms to assure that impaired physicians promptly cease practice;
- (f) assisting recovered colleagues when they resume patient care and
- (g) reporting impaired physicians who continue to practice, despite reasonable offers of assistance, to appropriate bodies as required by law and/or ethical obligations. This may entail reporting to the licensing authority.
- (b) supporting peers in identifying physicians in need of help;
- (ii) In addition to maintaining healthy lifestyle habits, every physician should have a personal physician whose objectivity is not compromised. Physicians whose health or wellness is compromised should take measures to mitigate the problem, seek appropriate help as necessary, and engage in an honest self-assessment of their ability to continue practicing.
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None declared.
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The council gratefully acknowledges the following individuals for their contributions to the original report: Roger Brown, Physician Health Program, AMA; Martin Doot, Medical Director, Illinois Professionals Health Program; Jenny Firth-Cozens, Special Adviser on Modernization of Postgraduate Education, London Deanery; Mamta Gautam, Founding Director, University of Ottawa faculty Wellness Program, Chair, Expert Advisory Group, Canadian Medical Association, Centre for Physician Health and Well-being; Cassie Kuo, Medical Student, Northwestern University; Susan V. McCall, Medical Director, Oregon Health Professionals Program; Leonard J. Morse, Commissioner, City of Worcester Department of Public Health and Herbert Rakatansky, Clinical Professor of Medicine, Brown University.
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* Members of the Council on Ethical and Judicial Affairs at the time this report was adopted were: Michael S. Goldrich, New Brunswick, NJ (Chair); Priscilla Ray, Houston, TX (Vice-Chair); Regina M. Benjamin, Bayou La Batre, AL; Daniel Higginson, Baltimore, MD (Student Member); Mark A. Levine, Denver, CO; John M. O'Bannon, III, Richmond, VA; Robert M. Sade, Charleston, SC; Monique A. Spillman (Resident Member), Durham, NC; Dudley M. Stewart, Jr, New Orleans, LA. These individuals meet the criteria and requirements for authorship. Staff to the Council on Ethical and Judicial Affairs at the time this report was adopted were: Audiey Kao, Vice President, Ethics Group, American Medical Association; Karine Morin, Council Secretary; Amy M. Bovi, Senior Research Assistant; Sara Taub, Senior Research Assistant; Nathan Gwynne, Council Coordinator.
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