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COMMENTARY
Don’t Ask, Don’t Tell: Substance Use by Resident Physicians
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hysician impairment by substance abuse continues to be a significant issue for our healthcare system. It has been identified as a potential source of medical errors and liability and can compromise patient safety.1 It can cause disruption and breakdown of personal and family life for the affected physician. For emergency medicine (EM) residents, residency can be a challenging and stressful period of training, where work hours are long, and sleep patterns are disrupted. Although patterns of physician substance abuse are typically established during teen and earlyadult years, they may become more severe and apparent during residency training. Isolation, long work hours, high job-related stress, and circadian rhythm disruption, along with increased access to prescription medications, may contribute to self-medication and a resident’s increased use of substances during training. However, to the best of our knowledge, there have been no recent studies evaluating EM or other resident substance use. One of the most fundamental problems with timely treatment of impaired residents is delayed recognition and diagnosis. This delay often results in part from denial by the affected individual and reluctance to seek care. However, there are several specific barriers to the diagnosis of chemical dependency in resident physicians. First is the persistent stigma associated with the diagnosis within the medical community. Although progress has been made in educating caregivers and the general public to recognize chemical dependency as a disease rather than a personal weakness or moral failing, these older attitudes persist. Second, the academic hierarchy of graduate medical education may prove a barrier to some who perceive that diagnosis and treatment of chemical dependency during residency may scar or end their academic careers. These beliefs have been cited by residents surveyed and confronted with case scenarios of an impaired fellow resident.2 Some residents, aware of the impairment of a colleague, will choose not to bring the problem to the attention of administrators out of fear of damage to the individual’s career.2 Another barrier to the diagnosis of the chemically impaired resident is related to the culture of residency. Within some groups of residents and residencies, alcohol and even drug use is accepted as a reasonable method of dealing with the stress of residency training (so-called self-treatment). This culture of acceptance is reflected by the popular media, where television shows depict socalled ER residents and staff drinking at bars after a difficult shift, or popular novels like Samuel Shem’s House
ª 2006 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2006.03.564
of God, where alcohol helped residents get through ‘‘.those extra bitter times.when [they are] hurt extra bad..’’ Finally, educators do a poor job of recognizing substance abuse among resident physicians. This is clearly demonstrated by surveys of residency directors, who consistently underestimate rates of substance use problems among their residents.3 This may be the result of multiple factors, including late manifestation of symptoms in the workplace, reluctance of residents to involve the administration, and lack of awareness by educators regarding the prevalence of the problem. Little research on resident substance abuse has been published in the last decade. Most older studies of resident substance use are from single institutions or focused on a specific group of residents. McNamara et al. published the first national study of substance use in EM residents in 1994 and reported a 78% response rate.4 Diagnosis of alcoholism among the 1,580 emergency medicine residents in this anonymous, self-report survey was 4.9% by 2 or more positive responses to CAGE questions during residency. CAGE questioning is a validated screening tool that includes the items: 1) Have you ever felt you should Cut down on your drinking? 2) Have people Annoyed you by criticizing your drinking? 3) Have you ever felt bad or Guilty about your drinking? 4) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener). Prevalence was 16.9% for two or more positive responses at any point in their lives; 12.2% of respondents in that study suspected impairment of a fellow resident. Hughes et al. also surveyed large groups of third-year residents from different specialties anonymously in 1987.5 With a 59.5% response rate, they found daily alcohol consumption to be reported by 5% of the respondents. Although rates of drug use were lower, alcohol consumption rates overall were significantly higher (past month and past year) compared with age- and gender-matched high school graduates. There has been a great deal of past discussion as to which specialty groups may be at highest risk for substance abuse, although the literature in this area is very sparse. Some have hypothesized that EM practitioners, with shift-work schedules of periods of high stress followed by long periods off, could have predilection to substance abuse.6 Hughes et al. also published data that compared substance use patterns among residents across specialties.5 Using the same database, subgroup analysis revealed greater rates of drug use among EM and psychiatry residents, and a higher rate of daily
ISSN 1069-6563 PII ISSN 1069-6563583
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McBeth and Ankel
DON’T ASK, DON’T TELL: SUBSTANCE USE BY RESIDENT PHYSICIANS
alcohol use among pathology residents. The past-year use rate for cocaine among EM residents was 14.0%, although this was not consistent with rates reported in McNamara’s study, and Hughes’ study is limited by subgroup sample size and selection as well as response rate. A recently published report examined acute cognitive performance of emergency physicians who were given modafinil following night shifts, perhaps reflecting a recognition that these newer substances are being used with greater frequency in the emergency department (ED).7 NATIONAL TRENDS IN SUBSTANCE USE—A CHANGING SCENE Although there are few current data on resident physicians, there have been significant changes in prevalence of substance use among young people over the last decade. The Institute for Social Research publishes the annual ‘‘Monitoring the Future’’ Survey, which surveys high school students nationally regarding substance use. Their research suggests increased prevalence of ‘‘active’’ (within the last month) cocaine, marijuana, and opiate use among high school students during the past 15 years.8 The U.S. Department of Health and Human Services also publishes an annual survey of drug use prevalence among U.S. citizens ages 12 years and older, entitled the National Survey on Drug Use and Health. Their research also supports the finding of increasing trends of cocaine, marijuana, and nonmedicinal psychotherapeutic use over the last decade.9 There have also been fundamental changes and reforms in residency education in the last ten years. Institution of the limits of the 80-hour work week is one of the most significant. There has been greater emphasis on faculty supervision and involvement in patient care, and this may also result in a greater amount of faculty–resident interaction. Emergency medicine led the way in this area with support in the 1970s and 1980s for 24-hour faculty presence in the ED. Recently there is also an increasing awareness and attempts to monitor level of stress among residents.10 Many state medical societies have reported favorable prognoses for substance-impaired physicians with early diagnosis and intervention. The success of these treatment programs may be related to investment of substantial financial resources in physician treatment and monitoring, as well as many physicians’ motivation to salvage career and family life. There have been recent data to suggest that certain risk factors, such as family history of substance abuse, and ‘‘major’’ opioid use with dual diagnosis of other psychiatric disease, may predict higher rates of relapse and deserve attention during treatment and monitoring.11 There have been no studies or series reporting specific outcomes from treatment of impaired residents, but there is no reason to believe that physicians in training would have worse outcomes compared with older physicians. A CALL TO ACTION: FUTURE RESEARCH AND DIRECTIONS Substance abuse among residents is a national problem, not limited to any specialty. A three-pronged approach to
the issue is needed. First, greater investment in research is required. The U.S. government recognizes that substance abuse is a complex, ever-changing problem that varies by region, age, and social and familial factors. The government has adopted a proactive approach to understanding the changing dynamics of substance use by investing in ongoing annual studies of representative populations. By understanding the changing prevalence and identification of high-risk groups, resources for diagnosis and treatment can be more effectively targeted. A similar approach is necessary for tackling substance abuse in residents. There is currently a national study underway re-examining current rates of substance use among EM residents; however, an ongoing anonymous annual survey that looks at representative groups of residents across specialties is needed. Emergency medicine as a specialty has the opportunity to lead the way in this area, as it has in other areas of resident education and wellness. As academic leaders of graduate medical education, we must invest in this infrastructure of research and develop innovative ways to dynamically examine and monitor changing trends in this field. The second prong is education. This includes residents and educators alike. The data suggest that educators do a poor job of acknowledging this problem within their programs, and identifying those impaired residents who would benefit from treatment. Educators must be made aware of the risk factors and early warning signs that suggest impairment. Residents as well must be encouraged to refer themselves and their colleagues for treatment when appropriate. A supportive and nonpunitive approach will help facilitate this, and also will help remove the stigma of guilt and fear from treatment of chemical impairment. It is necessary to address these issues early in residency, ideally at orientation sessions, as well as to provide access to resource information on an ongoing basis. Last, clinical treatment must be made available to every resident with chemical impairment at every institution, large or small. Many medical centers have resident crisis hotlines with 24-hour counseling services available. Smaller institutions may not have these resources on site but can contract with larger groups to have them available. Ideally, institutions may have a specialist in addiction medicine or another faculty member with experience with impaired residents who can serve as a liaison to facilitate intervention and treatment. Policies to remove an impaired resident from practice should be clearly written and available, and utilized when appropriate to ensure patient safety. A full medical and psychiatric evaluation with an addiction specialist is appropriate to determine the course of treatment, with an emphasis on rehabilitation and eventual return to training when appropriate. Residency directors and other educators must identify chemically impaired and at-risk residents for earlier intervention and treatment. Certainly a better understanding, identification, and treatment of substance-impaired resident physicians will ensure and improve the quality of graduate medical education in this country. The treatment of physician substance abuse can have direct effects on improvement in patient care through reduction of medical errors, improved communication between patients and care-givers, and improved job satisfaction.
ACAD EMERG MED
August 2006, Vol. 13, No. 8
www.aemj.org
As future leaders of the health care system, residents have the potential to learn and grow into competent, caring physicians who are focused on quality patient care. However, this is not possible when they are impaired by substance abuse. As educators, it is our responsibility to understand the problem and advocate for those physicians in training who are affected. Brian D. McBeth, MD (
[email protected]) Felix K. Ankel, MD Department of Emergency Medicine Regions Hospital St. Paul, MN
References 1. Trunkey DD, Botney R. Assessing competency: A tale of two professions. J Am Col Surg. 2001; 192:385–95. 2. Reuben DB, Noble S. House officer responses to impaired physicians. JAMA. 1990; 263:958–60. 3. McNamara RM, Margulies JL. Chemical dependency in emergency medicine residency programs: perspective of the program directors. Ann Emerg Med. 1994; 23:1072–6. 4. McNamara RM, Sanders AB, Ling L, Witzke DB, Bangs KA. Substance use and alcohol abuse in emergency medicine training programs, by resident report. Acad Emerg Med. 1994; 1:47–53.
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5. Hughes PH, Conard SE, Baldwin DC, Storr CL, Sheehan DV. Resident physician substance use in the United States. JAMA. 1991; 265:2069–73. 6. Hughes PH, Baldwin Jr DC, Sheehan DV, Conard S, Storr CL. Resident physician substance use, by specialty. Am J Psych. 1992; 149:1348–54. 7. Gill M, Haerich P, Westcott K, Godenick KL, Tucker JA. Cognitive performance following modafinil versus placebo in sleep-deprived emergency physicians: a double-blind randomized crossover study. Acad Emerg Med. 2006; 13:158–65. 8. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Results on Adolescent Drug Use. Institute for Social Research, University of Michigan, 2004. Available at: http://www.monitoringthefuture.org/. Accessed Apr 7, 2006. 9. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2004 National Survey on Drug Use and Health: National Findings. Available at: http://www.oas.samhsa.gov. Accessed May 9, 2006. 10. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Int Med. 2005; 165:2595–600. 11. Domino KB, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA. 2005; 293: 1453–60.
