Executive Coaching Series

Psychology of Performance: Impaired Physicians and Executives

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Robert A. Mines, Ph.D., Daniel C. Kimlinger, MHA, Sally Hull, Ph.D., Marcia S. Kent, MS, Patrick Hiester, MA, Yvette Moore

Impaired Professionals and Leadership: What are the Costs and Implications?

The prevalence of impaired physicians has been estimated to be at least as high as the population at large, and one study shows they are 30 to 100 times more likely to become addicted to narcotics (Angres & Busch, 1989). McNees & Goodwin (1990) found that 19% of pharmacists and 41 % of pharmacy students had used a controlled substance without a prescription order. In addition, healthcare executives (HE) are just as vulnerable to psychological and addictive impairments as the general population.

Although impairment is most often thought of in terms of drugs and alcohol, the problem is much broader. In its "sick doctor statute," the American Medical Association (AMA) defines impairment as "the inability to practice medicine with reasonable skill and safety due to physical or mental disabilities, including deterioration though the aging process, loss of motor skill or abuse of drugs or alcohol” (American Medical Association Council on Mental Health, 1973). In a similar vein, Lalrotis and Grayson (1985) defined impairment as “the interference in professional functioning due to chemical dependency, mental illness, or personal conflict.” Kutz (1986) indicated that there is a "diminishment from a previously higher functioning" (p. 220). For the purpose of this article, a broad view encompassing the impairment definition is used.

The cost to the healthcare organization is significant when a physician or healthcare executive is impaired. The costs include malpractice claims paid and the cost of employment contract buyouts or payoffs. Other expenses include lost productivity on the part of staff as they compensate for the impaired physician or healthcare executive, lost profitability due to substance-abusing executives making poor business decisions, and increased costs due to sexual harassment or other complaints or litigation driven by a toxic work environment. The list goes on from there.

As Coaches or Bosses what are the Signs and Symptoms?
As a coach or mentoring executive you may not have the clinical expertise to diagnosis your colleague nor would you want the dual role ethical problem. However, it is important to be able to identify the behavior and understand what your options are in terms of resources in your healthcare systems.

Indicators of Declining Job Performance
Work Performance
Lowered productivity
Frequently changing work pace with extreme highs and lows
Limited attention span or impaired ability to concentrate
Disregard of regulatory requirements or constraints
Errors in judgment
Excessive waste
Unreasonable fatigue

Repeated absences, especially following weekends or holidays
Returning late from lunch or breaks
Early departures or unexplained disappearances
Increase in tardiness
Absences without good reason or with increasingly improbable excuses

Increased time needed to complete tasks
Neglect of details and/or required documentation
Missed deadlines
Poor quality of work

Attitudes and Habits
Unreasonable sensitivity to normal criticism from peers or supervisors
Avoidance of fellow workers
Unreasonable intolerance or suspicion
Inconsistent demonstration of clinical objectivity
Sudden shifts in mood
Long lunch hours, long coffee breaks, frequent trips to the water fountain or restroom
Inappropriate communication with patients, peers, or team members

Physical Appearance
Obvious changes in personal grooming, dress, or demeanor
Observable physical changes

Increase in personal injuries due to accidents on and off the job
Carelessness in use of equipment
Lack of concern for safety of others

Case Studies: Composites
The case studies are composites designed to maintain the confidentiality of the individual and the organization.

Case Study A: The Substance Abusing Healthcare Executive
In this case study, a Healthcare Executive who headed up a large division of a hospital system was observed to have increased her use of alcohol at organizational functions; was progressively, over three years, noted to come in late; no longer was accessible to staff without an appointment; started smelling of alcohol during the day; started missing work; and as her job was to oversee the finance function in her division, started missing mission-critical financial deadlines due to procrastinating on financial reviews, ignoring contract negotiations, and similar high-level strategic decisions.

The HE was eventually confronted with her behavior, went into treatment, failed treatment, and was given a large severance package for reasons too complex to detail here. The cost to the organization was significant in terms of lost productivity, lost collections and billing, payouts, legal, and consulting as well as lost intellectual capital and time.

Case Study B: Top Leadership Sexually Harassing Staff and Patients
In this case, the chief physician of a large group practice was alleged to have harassed over 20 staff members by making offensive comments of a sexual nature, inappropriate touching, making inappropriate comments to patients, and exhibiting little or no insight into his behavior. Upon investigation the individual stated he was in recovery from a sexual addiction and sexual abuse. The board was divided as to: (1) sending the person to treatment and retaining; or (2) terminating the person. The decision was to terminate him. The cost to the organization was significant in terms of legal time (litigation was avoided), consultants, and severance. Fortunately, there were no sexual harassment suits as the staff felt that the board had acted in their best interests and in a timely manner. There were other complex legal and licensing matters in the case that are beyond the scope of this paper.

Organizational Impact
The impact of an impaired physician or HE is significant. In a smaller organization, division, or practice the individual may wear many hats and thus negatively impact numerous levels and numbers of staff. The emotional toll on staff is often pervasive with staff either starting to emulate the inappropriate behaviors themselves or becoming depressed, hopeless, feeling victimized, losing productivity, or leaving the organization. The financial costs can vary from the hundreds of millions to the tens of thousands for a small practice.

The recovery time is often two or more years after the situation has been rectified and trust may never be completely reestablished.

What to do when you see the Signs and Symptoms of Impairment
There are some clear steps to take and questions to consider as you proceed.
1. Recognition: What are the signs and symptoms of an employee with a problem?
2. Documentation: Which forms of documentation highlight patterns that are clues? (In situations where illegal or unethical behaviors exist, a formal and well-documented investigation is most often required).
3. Action: Which methods of approaching an employee are most effective? Can this professional be rehabilitated? Do the liabilities of his or her retention make continued action impossible?
4. Referral: How can you maximize the chances that your employee will seek help?
5. Follow-Up: How can you and your Employee Assistance Plan/Consultants work together to get your employee back to acceptable levels of health and work performance?

Be clear about your organizational channels, protocols, human resources, and legal resources. All resources become important as these situations present, evolve, and/or deteriorate.

American Medical Association Council on Mental Health (1973). "The Sick Physician: Impairment by Psychiatric Disorders Including Alcoholism and Drug Dependence," Journal of the American Medical Association, 223, 684-687.
Angres, D.H., & Busch, K.A. (1989). "The Chemically Dependent Physician: Clinical and Legal Considerations," New Directions for Mental Health Services, 41, 21-32.
Kutz, S.L. (1986). Comment: Defining "impaired psychologist." American Psychologist, 40 (1), 84-96.
Laliotis, D.A., & Grayson, J.H. (1985). "Psychologist Heal Thyself: What is Available for the Impaired Psychologist?" American Psychologist, 40 (1), 84-96.
McNees, G.E., & Goodwin, H.N. (1990). "Programs for Pharmacists Impaired by Substance Abuse: A Report," American Pharmacy, NS30(5), 33-37.

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