from Psychiatric Times, April 2003
For some of us, treating fellow physicians is an ambivalent endeavor. Although it can be gratifying, we tend to perceive our colleagues as arrogant, obstinate, and non-compliant in the patient role (Fayne 1999, Schneck 1999).
HOW WE AS PATIENTS DIFFER FROM LAY PATIENTS
As patients, physicians’ psychosocial and psychiatric issues differ from those of the general public (Bell 1999, Weinberg 2000). Our profession is intense, challenging, and dynamic. Consequently, some physicians will suffer from depression and have unmet expectations, despite many years of training, large debts, and other sacrifices (Bohigian 2002, Edwards 2002, Mansky 1999, Miller 2000). Other ways that we differ from lay patients include frequent self-medicating, higher rates of job impairment, and greater reluctance to seek outside assistance.
SELF-MEDICATING
Self-medicating is common among physicians (Bennett 2001). It is most prevalent among emergency medicine physicians, psychiatrists, anesthesiologists (ibid., Christie 1998, Wachtel 1995). The most commonly used substances are alcohol and prescription opiates (McGovern 2000, Nelson 1996, Yarborough 1999). Reasons for physicians self-medicating include management of insomnia, anxiety, depression, and pain, all of which may create functional impairment. Other reasons include our knowledge of pharmacotherapy, access to medication samples, and reluctance to seek outside assistance.
HIGHER RATES OF JOB IMPAIRMENT
Compared to the general public, physicians have higher rates of job impairment (Bohigian 2002, Wijesinghe 1999, Winter 2002, Yarborough 1999). Chemical dependency is the most common cause of physician impairment (Blondell 1993, Walzer 1990, Winter 2002, Wijesinghe 1999). Regarding the rate of alcohol dependence, men and women physicians are similar (Skipper 1997). Alcohol is a gateway drug to other types of substance abuse (Coombs 1997). Moreover, substance abuse has a high mortality rate among physicians (Yarborough 1999).
Reasons for these high morbidity and mortality rates include the nature of our profession and delayed recognition and intervention for impaired professionals (Blondell 1993, Bohigian 2002, Wijesinghe 1999). In particular, impaired physicians are most commonly identified only after patient care is compromised (Blondell 1993, Coombs 1997, Yarborough 1999).
RELUCTANCE TO SEEK OUTSIDE ASSISTANCE
Impaired physicians, especially those with substance abuse, do not commonly seek treatment until their licensing board is notified (Wijesinghe 1999). In addition to denial, physicians have other reasons for refusing outside assistance. One reason is a fear of exposure. As professionals entrusted with patients’ lives, we are subject to public scrutiny and discipline from several entities, including the courts, professional organizations, and licensing boards.
According to Maria T. Lymberis, MD, clinical professor of psychiatry at UCLA and senior faculty at the Los Angeles Psychoanalytic Institute: "Currently, the public is pushing for a FULL disclosure to the National Data Bank of all information about any and all malpractice suits as well as any and all disciplinary actions that affect any practitioner."
Furthermore, the Internet makes clinicians’ licensure information and even personal data readily available to the public. Fearful of public scrutiny and professional discipline, impaired professionals may be unwilling to become vulnerable and seek treatment without outside pressure.
In particular, patients and colleagues stigmatize impaired physicians (Parran 2000). One psychiatrist, who requested anonymity, explained this predicament. "When patients find out that my medical license is on probation and that I’m receiving psychiatric treatment, almost all of them leave me. It’s ironic, because patients usually complain that their psychiatrists lack compassion and empathy. But being a patient is the ultimate experience in empathy. And once my colleagues find out that I’m on probation, they stop referring to me and don’t return my calls. It’s as if psychiatrists are not allowed to have problems themselves."
Yet another reason contributes to physicians’ ambivalence over accepting the role of patient. Being authorities in control are familiar and comfortable roles for us. In contrast, being a patient is an awkward, vulnerable position that we would rather avoid.
FACTORS AFFECTING PHYSICIAN-PATIENTS’ EXPECTATIONS OF PSYCHIATRISTS
Several trends tend to skew physicians’ perceptions of psychiatric services. Managed care, advances in biological psychiatry, and the pharmaceutical industry’s direct-to-consumer (DTC) advertising may lead physician-patients to equate psychiatry with psychopharmacology. Moreover, antidepressant advertisements may lead readers to focus on antidepressants as a treatment for depression to the exclusion of psychosocial treatments of the disease (Kleinman 1991, Nikelly 1995). Physicians are not immune to these perceptions, particularly when such advertisements are present in The American Journal of Psychiatry (Kleinman 1991). Anecdotally, physicians frequently request psychiatric services only for medication management and are disinterested in psychotherapy. Consciously or unconsciously, they seem to expect the "magic pill" that gives them immediate and complete symptom relief. Therefore, they tend to idealize psychiatrists initially, only to devalue them, perhaps in part from these unmet and unrealistic expectations.
TRANSFERENCE
Because transference is ubiquitous, all clinicians should be aware of it, regardless of their theoretical orientation. In psychiatrist-patient relationships, transference commonly manifests itself as victim-victimizer and dominance-submission roles (Twemlow 1997). Denial and suppression are common defense mechanisms for physician -patients. Moreover, physicians’ tendency toward perfectionism may defend us against feelings of inadequacy (Reynolds 2002, Schneck 1998).
Other issues involve physicians who try to exploit the clinician-patient relationship. Patients with borderline personality disorder are at a high risk for such exploitation with entitled or demanding behaviors (Gutheil 1989). These behaviors may escalate to boundary violations. In general, patient-initiated boundary violations are common, particularly by male patients toward female clinicians (Farber 2000). Predictors of impending boundary violations include the patient’s ruminating outside session or dreaming about the clinician (Twemlow 1997).
COUNTERTRANSFERENCE
Like transference, countertransference is ubiquitous (Ellis 2001). Clinicians in the "doctors’ doctor" role may find their work narcissistically gratifying. Because this role is considered an honor and privilege, colleagues may idealize such clinicians for their "humanity and competence" (Schneck 1998). At the same time, dual relationships may occur and can lead to boundary violations (Hines 1998).
Reminiscent of the saying, "help is the sunny side of control," control issues tend to be more intense when physicians are patients. In particular, the rescuer-victim dynamic may play itself out (Brock 1999, Twemlow 1997). The treating clinician’s urge to "help" and control situations may be a defense against anxiety, inadequacy, and other unresolved issues (Reynolds 2002, Schimmer 1998, Twemlow 1997).
Another defense against powerlessness is idealizing physician-patients. For instance, idealizing the patients’ knowledge of psychiatry may lead the clinician to omit informed consent for medications or inappropriately delegate responsibilities to patients. Other countertransference manifestations include failing to refer patients appropriately, discharging patients prematurely, practicing outside of scope of one’s abilities, and failing to report impaired colleagues to the authorities (Twemlow 1997, Wijesinghe 1999).
When patients do not respond adequately to treatment, clinicians’ defenses are challenged and may result in boundary violations, such as rage, discrimination, deception, and exploitation (Dehlendorf 1998, Enbom 1997, Freeman 1999, Morrison 2001, Twemlow 1997, Unutzer 1999). Risk factors for boundary violations include clinicians’ failing to evaluate patients adequately, missing up-to-date knowledge, not setting appropriate limits with patients, and lacking an adequate treatment plan (Simon 1996). One of the most serious boundary violations is patient exploitation. Risk factors for patient exploitation include personal or family illness, anger, and large caseloads of patients with borderline, antisocial, and narcissistic personality disorders (Garfinkel 1997, Twemlow 1997).
MANAGEMENT OF COUNTERTRANSFERENCE
Fortunately, because countertransference is in part learned, clinical experience helps mitigate it (Ellis 2001, McIntyre 1998). To keep knowledge current, participate in continuing education and seek peer consultations or supervision from more senior clinicians. Ways to reduce the risk of exploiting patients include establishing reasonable office policies and enforcing them consistently, stress management, and frequent self-evaluations to detect countertransference problems early (Twemlow 1997).
During the initial psychiatric evaluation, addressing the patient's expectations aligns treatment goals and reduces patient dissatisfaction. Document all interactions with patients and third parties (Schneck 1998).
Formulate a diagnosis and treatment plan for every patient. When indicated, combine psychotherapy and medication management. Refer complex cases for a second opinion. Also refer patients for whom you cannot provide care consistent with that of community standards (Twemlow 1997).
Regarding reimbursement, the only benefit for psychiatrists should be a cash payment (ibid.). This limit reduces clinicians’ entitlement and perception of patient indebtedness, and helps clinicians more easily resist bartering and "gifts."
The most important approach is to focus on the patient's welfare as primary goal of all interactions and interventions. Doing so requires self-honesty and justification of any boundary violations (ibid.). One way to assess the appropriateness of intended actions involves imagining how you would explain your actions to a judge or licensing board about your actions. Alternatively, if you would not undertake the same action for other patients, it is unlikely that undertaking the action at issue is appropriate.
OTHER INTERVENTIONS, TREATMENT, AND PROGNOSIS
Despite the seemingly grim statistics provided above, impaired physicians who receive treatment have favorable prognoses (Bohigian 2002, Boisaubin 2001). Winter (2002) offered an algorithm for identifying and treating physicians impaired by cognitive difficulties or mental illness (1993). The algorithm involves recognizing signs of impairment, planning and conducting an intervention, and offering treatment and aftercare. Regarding recognition of the signs of impairment, family and social problems appear before work impairment. These problems include withdrawal from activities, hostile or abusive behavior, and mood swings. Impairment progress to public intoxication, including arrests for driving under the influence. Next, impaired personal appearance and health consequences become apparent. Finally, workplace impairment occurs, such as erratic work behavior and inappropriate medical care.
An intervention involves at least two people who have established assessment and/or treatment goals and provide concrete examples of problem behaviors. Presenting the intervention in a disease model framework that is non-judgmental, confrontational, and concerned works best. Denial and anger are common responses from the impaired physician.
Diversion programs, inpatient treatment, and Alcoholics Anonymous (AA) contribute to the success rates of impaired physicians (Galanter 1990, Ikeda 1990, Morse 1984, Nelson 1996, Winter 2002). Aftercare is a necessary component of the treatment plan due to the risk of relapse and is individualized, based upon the particular physician’s needs and state law (Wijensighe 1999, Winter 2002).
CASE STUDY
Dr. J is a 64 year-old family physician with lupus, obesity, elevated liver functions, and breast cancer in remission. She requested antidepressant medication management from me. Her expectation of my services comprised my providing a one session evaluation with specific treatment recommendations (denial of severity of illness, idealization of the clinician, and unrealistic expectation of a panacea). This expectation consciously arose from her own patients' reported experiences at their HMO. After I had explained to Dr. J that her expectation was not feasible, she spent most of the next visit discussing her anger and disappointment over my work with her (narcissistic injury and devaluation of me). Dr. J complained, "I feel totally in your power. I realize that I'm overreacting, but I feel trapped" (victim-victimizer and dominance-submission transferences). Psychodynamic psychotherapy, psychoeducation, limit-setting, and a consultation with a more senior psychiatrist were necessary components of her treatment plan.
Dr. Menaster has a private practice of psychiatry in San Francisco.
REFERENCES
Bennett J, O’Donovan D (2001), Substance misuse by doctors, nurses and other healthcare workers, Curr Opin Psych. May;14(3):195-199
Blondell RD (1993), Impaired physicians, Prim Care, 20(1):209-18
Bohigian GM; Croughan JL; Bondurant R (2002), Substance abuse and dependence in physicians: the missouri physicians health program--an update (1995-2001). Mo Med, Apr;99(4):161-5
Boisaubin EV, Levine RE (2001) Identifying and assisting the impaired physician. Am J Med Sci, Jul;322(1):31-6
Brock CD, Johnson AH (1999), Balint group observations: the white knight and other heroic physician roles. Fam Med Jun 31(6):404-408
Christie JD, Rosen IM, Belline LM, et al (1998), Prescription drug use and self-prescription among resident physicians, JAMA 280(14):1253-1255
Coombs RH (1997), Drug-impaired professionals, Cambridge, Massachusetts: Harvard University Press
Dehlendorf CE, Wolfe SM (1998), Physicians disciplined for sex-related offenses. JAMA Jun 17 279(23):1883-1888
Edwards N (2002), Unhappy doctors: What are the causes and what can be done? BMJ Apr 6(324):835-838
Ellis A (2001), Rational and irrational aspects of countertransference. J Clin Psychol, Aug 57(8):999-1004
Enbom JA, Thomas CD (1997), Evaluation of sexual misconduct complaints: the oregon board of medical examiners, 1991 to 1995. Am J Obstet Gynecol Jun 176(6):1340-1348
Farber NJ, Novack DH, Silverstein J, Davis EB, Weiner J, Boyer EG (2000), Physicians’ experiences with patients who transgress boundaries, J Gen Intern Med Nov;15(11):770-5
Fayne M, Silvan M (1999), Treatment issues in the group psychotherapy of addicted physicians. Psychiatr Q Summer 70(2) 123-135
Freeman VG, Rathore SS, Weinfurt KP, et al (1999), Lying for patients: physician deception of third-party payers. Arch Intern Med, Oct 25:159(19):2263-227
Galanter M, Talbott D, Gallegos K, Rubenstone E (1990), Combined Alcoholics
Anonymous and Professional Care for Addicted Physicians, Am J Psychiatry, 147(1):64-8
Garfinkel PE, Bagby RM, Waring EM, Dorian B (1997), Boundary violations and personality traits among psychiatrists. Can J Psychiatry Sep 42(7):758-763
Gutheil TG (1989), Borderline personality disorder, boundary violations, and patient-therapists sex: medico-legal pitfalls. Am J Psychiatry 146:597-602
Hines AH, Ader DN, Chang AS, Rndell JR (1998), Dual agency, dual relationships, boundary crossings, and associated boundary violations: a survey of military and civilian psychiatrists. Mil Med. Dec;163(12):826-33
Ikeda R, Pelton C (1990), Diversion programs for impaired physicians, West J Med, 152:617-21
Kleinman DL, Cohen LJ (1991), The decontextualization of mental illness: the portrayal of work in psychiatric drug advertisements, Soc Sci Med, 32(8):867-74
Mansky PA (1999), Issues in the recovery of physicians from addictive illnesses, Psychiatr Q, Summer;70(2):107-22
McGovern MP, Angres DH, Leon S (2000), Characteristics of physicians presenting for assessment at a behavioral health center, J Addict Dis, 19(2):59-73
McIntyre SM, Schwartz RC (1998), Therapists' differential countertransference reactions toward clients with major depression or borderline personality disorder. J Clin Psychol Nov 54(7):923-931
Miller NM, McGowen RK (2000), The painful truth: physicians are not invincible, South Med J, Oct;93(10):966-73
Morrison J, Morrison T (2001), Psychiatrists disciplined by a state medical board. Am J Psychiatry Mar 158(3):474-478
Morse RM, Martin MA, Swenson WM, Niven RG (1984), Prognosis of physicians treated for alcoholism and substance abuse, JAMA, 251:743-6
Nelson HD, Matthews AM, Girard DE, Bloom JD (1996), Substance-impaired physicians: probationary and voluntary treatment programs compared, West J Med, 165:31-6
Nikelly AG (1995), Drug advertisements and the medicalization of unipolar depression in women, Health Care Women Int, May-Jun;16(3):229-42
Parran TV, Grey SF (2000), The role of disabled physicians in the diversion of controlled drugs, J Addict Dis, 19(3):35-41
Reynolds P (2002), The role of role avoidance, BMJ Apr 6(324):857
Schimmer P (1998), Medicine and the manic defence. Aust N Z J Psychiatry, Jun 32(3):392-397
Schneck SA (1998), "Doctoring" doctors and their families. JAMA Dec 16 280(23):2039-2042
Simon RI (1996), Psychological injury caused by boundary violation precursors to therapist-patient sex. Psychiatric Annals 21:614-619
Skipper G (1997), Treating the chemically dependent health professional, J Addict Dis, 16(3):67-73
Trinkoff AM, Storr CL (1998), Work schedule characteristics and substance use in nurses, Am J Ind Med Sep;34(3):266-71
Twemlow SW (1997), Exploitation of patients: themes in the psychopathology of their therapists. Am J Psychother Summer 51 3:357-375
Unutzer J, Katon W, Russo J, et al (1999), Patterns of care for depressed older adults in a large-staff model hmo. Am J Geriatr Psychiatry Summer 7(3):235-243
Wachtel TJ, Wilcox VL, Moulton AW, et al (1995), Physicians’ utilization of health care, J Gen Int Med 10(5):261-265
Walzer RS (1990), Impaired physicians-an overview and update of the legal issues, J Leg Med, 11:313-98
Weinberg A, Creed F (2000), Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet Feb 12;355(9203):533-7
Wijensighe CP, Dunne F (1999) Impaired practitioners notified to medical practitioners board of victoria from 1983 to 1997. Med J Aust Oct 18:171(8):414-417
Winter RO, Birnberg B (2002), Working with impaired residents: trials, tribulations, and successes, Fam Med, Mar;34(3):190-6
Yarborough WH (1999), Substance use disorders in physician training programs, J Okla State Med Assoc, Oct;92(10):504-7
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