REVIEW URRENT C OPINION
Service provision to physicians with mental health and addiction problems Marı´a Dolores Braquehais a,b, Andrew Tresidder c, and Robert L. DuPont d
Purpose of review Physicians are reluctant to ask for help when they suffer from substance use disorders and/or other mental illnesses (i.e. when they become ‘sick doctors’). This can result in greater morbidity/mortality and may lead to significant problems in medical practice. This review aims to describe the nature and development of programs that specifically treat sick doctors [Physician Health Programs (PHPs)]. Recent findings PHPs were first developed in the United States in the late 1970s. The purpose was to identify and treat physicians with problems resulting from mental health issues, mainly substance use disorders. Since then, other PHPs have been developed in Canada, Australia, and the United Kingdom, trying to reach sick doctors, offering counseling or other preventive interventions when needed. New models to help sick doctors, such as the Spanish PHP, were also developed. Counseling and support services for sick doctors have been implemented elsewhere in Europe (e.g. Norway and Switzerland). Summary PHPs provide interventions specifically designed for physicians and other medical professionals with substance use and other mental health problems. The balance between guaranteeing safe practice and yet encouraging all physicians to ask for help when in trouble raises questions regarding how these programs should be designed. Keywords mental health services, physician health programs, sick doctors
INTRODUCTION In 1973, the American Medical Association (AMA) published ‘The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence’ [1]. The ‘sick doctor statute’ was defined as ‘the inability of a physician to practice medicine with reasonable skill and safety to his patients, because of one or more enumerated illnesses (...), including mental, emotional disorders, and/or excessive use of alcohol or other drugs’. Physicians are said to have high psychological vulnerabilities and are at risk of suffering from one of the three Ds (drugs, drink, and depression) [2]. An estimate of 10–14% of physicians may become chemically dependent at some point of their careers [3]. Physicians are no more likely than others to suffer from drug and alcohol problems, but their drug of choice may differ from that of the general population [4]. They tend to delay seeking help, complicating their evolution and prognosis [5]. Physicians may use alcohol and, more recently, marijuana (among young doctors), but they specifically have a high risk of using benzodiazepine tranquilizers, minor opiates, www.co-psychiatry.com
and/or stimulants through self-prescription [5–8]. Prescription substances are mainly used for self-treatment, whereas illicit substances and alcohol may be used for recreational purposes [5,6]. Rates of depression or anxiety among physicians are higher than those of the general population [9]. Sick physicians are, however, usually reluctant to ask for help [8,10,11]. This behavior may be the consequence of doctors’ culture of perfectionism, and it reflects their tendency to deny emotional a Integral Care Program for Sick Doctors, Galatea Clinic, Galatea Foundation, Collegi de Metges de Barcelona, bDepartment of Psychiatry and Legal Medicine, Hospital Universitari Vall d’Hebron, CIBERSAM, Universitat Auto`noma de Barcelona, Barcelona, Spain, cGP Patient Safety Lead, NHS Somerset CCG (Clinical Commissioning Group), Somerset, UK and dInstitute for Behavior and Health, Inc., Rockville, Maryland, USA
Correspondence to Marı´a Dolores Braquehais, MD, PhD, Integral Care Program for Sick Doctors, Galatea Clinic, Galatea Foundation, Collegi de Metges de Barcelona Passeig Bonanova, 47, 08017 Barcelona, Spain. Tel: +34 93 567 88 56; fax: +34 93 567 88 54; e-mail: [email protected]/[email protected] Curr Opin Psychiatry 2015, 28:324–329 DOI:10.1097/YCO.0000000000000166 Volume 28 Number 4 July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Service provision to sick physicians Braquehais et al.
KEY POINTS Physicians have difficulties in asking for help when suffering from substance use disorders and other mental illnesses. PHPs specifically try to help sick doctors in order to promote their integral well being and also to support a safe practice. PHPs progressively developed in the United States from the late 1970s and later in other countries such as Canada, Australia, United Kingdom, and Spain. Once sick doctors enter PHPs, their treatment outcomes are better than those of the general population’s. The balance between ensuring safe practice yet still encouraging physicians in trouble to ask for help raises questions regarding PHP design.
needs. In some cases, they may also fear any professional or legal implications. Some medical systems have a hierarchy of power – doctor at the top, patient near the bottom. Fearing loss of status, physicians are reluctant to become a patient. Another barrier is presented by the ‘medical self’, a result of medical training that gives a deeply rooted sense of institutionalized ‘specialness’ [11]. This may lead to the phenomenon of ‘medical invincibility’ and difficulty in releasing the role of a ‘doctor’. Abandoning the medical self can deeply threaten a doctor’s whole meaning structure, and so is subconsciously resisted at an institutionalized level. All these factors, together with specific individual features (e.g. high self-criticism, low self-esteem, poor work-home balance, etc.) and other environmental conditions (e.g. status conscious work environment, high job demands, etc.), may increase physicians’ inability to cope with emotional unbalance or to palliate their problems with alcohol or drugs [8,12,13 ]. The AMA report on the sick doctor phenomenon [1] was the starting point for all Physician Health Programs (PHPs). From the late 1970s, PHPs were developed in nearly every US state, and later in other countries. This study describes the nature and development of the ongoing PHPs. &&
PHYSICIAN HEALTH PROGRAMS: THE PIONEERING EXPERIENCE IN THE UNITED STATES Physician Health Programs PHPs in the United States typically identify and help physicians who have mental health and substance use disorders that could jeopardize their ability to practice medicine
safely. Suspected physicians are referred for evaluation, and when indicated for treatment, they conduct long-term monitoring [14]. All programs manage the care of physicians, but others expand services to help other healthcare professionals (i.e. dentists, veterinarians, etc.). In December 1990, the Federation of State PHP (FSPHP) was created to improve the coordination and communication between the separate state programs. The types of problems US PHPs deal with vary, but substance use disorders are always assessed and receive major attention in all programs (see Table 1) [14,15 ,16]. PHPs themselves do not act as providers of treatment or monitoring. Instead, they manage evaluation, treatment, and monitoring of physicians who have signed contracts for PHP participation [17,18]. The PHPs in the United States are diverse, but all are based on trust, experience, and on their specific arrangements with medical licensing boards. The state PHPs must balance the sometimes conflicting goals of protecting the public while also promoting the recoveries of the physicians they serve. Their existence is dependent on their maintaining the support of their many constituencies, including the physician community and the public. For physicians with performance issues, including substance use disorders, engaging as a patient with a PHP offers support and safe haven from legal– professional consequences, contingent on their compliance with the recommendations of the PHP [7]. With regard to substance use disorders, US PHPs generally begin with an initial intensive evaluation that can lead to a treatment recommendation (either residential or outpatient care) for an average of 3 months, followed by a second phase (for 3–12 months) with less intensive outpatient treatment (generally, two or three times per month). Care management is generally provided for 5 years. This typically includes random drug and alcohol testing, together with compliance monitoring and support, as well as mandatory participation in community recovery support groups such as Caduceus groups, Alcoholics Anonymous, and Narcotics Anonymous. A national study of 16 PHPs found that most doctors with substance use disorders accepted intensive random monitoring, treatment, and other conditions of the PHP care management. Over the course of 5 years of care, 78% never had a single positive drug or alcohol test result and 72% were able to return to practice [7]. These positive outcomes are similar regardless of physicians’ specialty [19–21]. The PHP paradigm in the United States serves as a model for other programs that provide intensive care management for substance use disorders to many different
0951-7367 Copyright Ô 2015 Wolters Kluwer Health, Inc. All rights reserved.
&
www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
325
Provision of services to people with mental illness Table 1. US Physician Health Programs
State(s)
Addictions
Mental disorders
Disruptive problems
Sexual offenders
Malpractice
Stressrelated problems
Physical illnesses
Alabama, Virginia, Washington, California, Georgia, Nebraska, Connecticut, Wisconsin Arizona, Arkansas, Rhode Island, South Dakota, Vermont, Wyoming Colorado, Florida, Maryland, Massachusetts, New Jersey Hawaii, Illinois, Mississippi, Missouri, Texas Idaho, Utah Indiana, Kansas, Kentucky, Louisiana Iowa, Maine Michigan Minnesota Montana Nevada New Hampshire, New Mexico, New York North Carolina Ohio Oklahoma Oregon, Pennsylvania, West Virginia South Carolina Tennessee
populations. These programs fall under what has been labeled the New Paradigm for Recovery [22 ]. One study of physicians with histories of substance use-related involvement with a PHP found that over three quarters (78.4%) reported satisfaction with participation in the PHP, whereas 15.4% reported dissatisfaction. The vast majority (92.5%) reported that they would recommend PHP participation to others, whereas less than 5% reported that the PHP was unhelpful [23]. The impressive long-term outcomes of the PHPs in the United States demonstrate that long-term recovery can be achieved, inspiring the proposal to set a new standard for assessing the effectiveness of addiction treatment of 5-year recovery [24]. The zero tolerance for any substance use is distinctive of US programs, defining this model of care management, and one of the reasons for its great outcomes. &&
THE CANADIAN EXPERIENCE The concern about physicians’ mental health – mainly of doctors with addictions – began in Canada 326
www.co-psychiatry.com
in the 1980s [25]. Early in the 2000, three basic models of programs for physicians had been developed in Canada [26], which are given as follows: (1) Volunteer committees providing peer support (2) Professionally staffed, comprehensive programs that offer a range of services for doctors, trainees, and their families on the basis of available community resources (3) Professionally staffed, comprehensive program based upon an employee assistance program model with a counseling service and other resources In 2001, the Canadian Medical Association (CMA) created the Canadian Physician Health Network [27] to enhance collaboration and communication between all the different programs, and in 2006, the CMA developed a Centre for Physician Health. This was dissolved in 2010 and, following extensive consultation, the CMA entered into a partnership agreement with the Canadian Medical Foundation (CMF) to support physician health Volume 28 Number 4 July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Service provision to sick physicians Braquehais et al.
through the establishment of the Canadian Physician Health Institute (CPHI) [28]. While the CPHI advances a shared national vision for physician health with local application, it is the provincial PHPs [29] that provide direct services to the physicians. For instance, of doctors admitted to the Ontario PHP for substance use disorders, 85% successfully completed the program and, during the monitoring period, 71% had no relapse [30].
PROGRAMS FOR DOCTORS IN AUSTRALIA In Australia, by 2000, most states had the equivalent of a doctor’s health advisory service (DHAS) that had little funding and depended mainly on the goodwill of a panel of volunteer doctors [31]. In November 2000, the Australian Medical Association (Victoria) and the Medical Practitioners Board set up the Victorian Doctors’ Health Program [31]. An independent body, in first 3 years of operation, it had 438 contacts, 220 of which entered the service (92 doctors and students with alcohol or drug problems, 82 with psychiatric problems, and 40 with stress-related or emotional problems). Sixtyfive patients (mostly with addictions) needed an intensive case management, which proved to be satisfactory in 57, and 50 were able to go back to work. Victoria also has the Peer Support Service and the Victorian Medical Benevolent Association as counseling and support services for doctors and their families. In 2004, the DHAS network created a doctor’s health planning and reference group in order to improve efforts and communication between professionals in this area. A variety of other state programs for doctors have followed in the rest of Australia and New Zealand [32 ]. &&
THE UNITED KINGDOM MODEL In the 1970s, the Association of Anaesthetists of Great Britain set up the first dedicated service for doctors [33]. Since then, several programs for physicians have been developed in the United Kingdom. Doctors in the United Kingdom may use the National Health Service (NHS) as patients of a general practitioner (GP), or through the use of NHS Occupational Health Services. Postgraduate Deaneries are responsible for doctors in training and their welfare; their services mainly provide psychological counseling for doctors with difficulties at work. With respect to national services, there are a range of options. The National Counselling Service for Sick Doctors, created in the mid-1980s, remains as
the only independent doctor-to-doctor service, helping them access appropriate healthcare. The British Medical Association also has a ‘doctors for doctors’ service. Other support programs are the British Doctors and Dentists Group, the Sick Doctors’ Trust, the Doctors’ Support Network, the Doctors’ Support Line, as well as some specialty Royal College provision (e.g. the Surgeons). Other programs, such as the Royal Medical Benevolent Fund, provide financial aid to doctors and families in difficulties. In 2008, the NHS Practitioner Health Program was launched in London as a PHP that provides multidisciplinary treatment approach for all doctors and dentists within Greater London. Practitioners with health concerns can contact the service directly for advice of consultation and treatment. The London PHP [12] treated 1078 practitioners during the 2008–2013 period, around 80% for mental health disorders, and 20% for substance misuse (two-thirds alcohol, one-third other substances). Seventy-six per cent of all patients either remained in or returned to work. Over the 5 years of the program, there has been a change of demographics of referrals from mainly older male physicians to mainly women under 35 years of age. The Practitioner Health Program has a memorandum of understanding with the Regulator, giving a degree of autonomy and ability to maintain confidentiality in most cases. The Regulator does not wish to know about cases in which a physician is appropriately engaged in a treatment program. Conversely, the Regulator may mandate a sick physician to engage in such a program as run by the PHP. Patients in the program with Regulator involvement dropped between years 1 (33%) and 5 (7%).
THE SPANISH PAIME In Spain, PHPs (PAIME, in Spanish) have developed since 1998, overseen by the ‘Colegio de Me´dicos’ of each Spanish region [34]. All practicing doctors in Spain need to be registered with ‘Colegios de Me´dicos’, which act both as medical associations and regulatory boards (or medical councils). Every ‘Colegio de Me´dicos’ in Spain offers a PHP outpatient service. The only PHP inpatient unit for Spanish physicians is currently located in Barcelona. Confidentiality procedures in the program include using a different name, with their real identity only disclosed without consent if there is a threat to self or others. The Spanish PHP promotes voluntary treatment, as well as enrollment for preventive interventions. However, doctors with risk or evidence of practice problems are obliged by their ‘Colegio de Me´dicos’ to undergo psychiatric treatment to and monitor
0951-7367 Copyright Ô 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
327
Provision of services to people with mental illness Table 2. European programs for sick doctors Country/program
Interventions
United Kingdom Practitioner Health Program [National Health Service (NHS)]
Integral treatment: mental disorders, addictions, physical illnesses
Doctors for doctors [British Medical Association (DD-BMA)]
Counseling
Doctors’ Support Network (DSN)
Counseling
Sick Doctors Trust
Counseling
Spain PAIME-PAIMM programs
Integral treatment: mental disorders, addictions
Norway Vila-Sana program
Counseling
Switzerland ReMed program
Counseling
ReMed, Rete Medicorum.
their fitness to practice at work a fitness to practice at work; if they suffer from an addictive disorder, treatment measures include proving abstinence once treatment has been completed. If doctors in trouble do not meet the mandatory treatment requirements (‘contrato terape´utico’, in Spanish), their license to practice may be suspended temporarily, or withdrawn. Most doctors with practice problems choose to be treated in PHPs, being highly specialized programs with guaranteed confidentiality. Nevertheless, most doctors treated in Spanish PHPs are self-referred to the programs. In a recent study [35 ], after analyzing data of 1363 patients admitted to the Barcelona PHP (PAIMM in Catalan) during a 13-year period, voluntary referrals grew from 81.3% during the first years (1998–2004) to 91.5% in the last period (2008– 2011). Mean age at admission also decreased from 54.2 to 44.9 over the 13 years. The prevalence of mental disorders among participants other than substance use disorders grew from 71% during the 1998– 2003 period, to 87.4% (2004–2007), and to 83.9% in the latest period. Adjustment disorders have also increased in prevalence, whereas inpatient treatment progressively represents less of total clinical activity. These results altogether could support the hypothesis that sick doctors feel encouraged to seek help in nonpunitive specially designed programs, such as the Barcelona PHP, where treatment becomes mandatory only when there is risk or evidence of malpractice. &&
OTHER PROGRAMS IN EUROPE Other programs developed in other European countries provide mainly counseling to doctors in trouble (see Table 2). However, they do not meet all criteria to be considered as standard PHPs, as they do 328
www.co-psychiatry.com
not include structured treatment strategies and mandatory interventions for cases with practice problems. In Switzerland, a program called ReMed (Rete Medicorum) was founded in 2007. After a 3-year pilot phase in the Swiss cantons of Thurgau and Neuenburg, ReMed was rolled out nationally. The program is sponsored by the Federation Medical Helvetica and the Swiss Medical Association, and offers crisis intervention, mentoring, and coaching. During a 3-year period, 80 patients were treated at the ReMed program mainly for burn-out and depression (43%), followed by practice and everyday life problems (32%), and only 13% for addictions [36]. When a doctor is at risk of practice problems, counseling is offered as part of the treatment plan. In 1998, the Norwegian Medical Association (NMA) established a short-term counseling program for doctors, called Villa Sana. After analyzing the data of 227 doctors who came to the Villa Sana for counseling, 73% needed treatment for anxiety and depression; 82% came for a 1-day counseling session, and 18% took part in the course program. When analyzing access to the program, 45% were self-referred [37]. Other countries such as Portugal and France are developing programs for sick doctors. The European Association for Physicians Health (EAPH) was created in 2009 and gathers professionals from different countries. Expertise and good practice on treatment and prevention strategies to promote doctors’ well being is shared.
CONCLUSION Several PHPs have developed since the first US initiatives. The main aim is providing access to Volume 28 Number 4 July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Service provision to sick physicians Braquehais et al.
mental healthcare for doctors with addictions and/ or mental disorders. Other counseling programs that do not include case management procedures try to reach doctors with emotional and personal difficulties. The balance between ensuring safe practice, yet still encouraging physicians in trouble to seek help, raises questions regarding the program design. The emphasis on confidentiality, on specialized patient-tailored treatment plans, and reserving mandatory treatment solely for cases with risk or evidence of practice problems should be considered in the future. Acknowledgements We would like to thank Gregory E. Skipper, MD, and Martin Vogel, MD, for their thoughtful comments that improved the quality of this work. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. American Medical Association. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. J Am Med Assoc 1973; 223:684–687. 2. Schattner P, Davidson S, Serry N. Doctors’ health and wellbeing: taking up the challenge in Australia. Med J Aust 2004; 181:348–349. 3. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents and physicians. Psychiatr Clin North Am 1993; 16: 189–197. 4. Brewster J. Prevalence of alcohol and other drug problems among physicians. J Am Med Assoc 1986; 255:1913–1920. 5. Braquehais MD, Lusilla P, Bel MJ, et al. Dual diagnosis among physicians: a clinical perspective. J Dual Diag 2014; 10:148–155. 6. Hughes PH, Brandenburg N, Baldwin DC, et al. Prevalence of substance use among US physicians. J Am Med Assoc 1992; 267:2333–2339. 7. McLellan AT, Skipper GS, Campbell M, et al. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. Br Med J 2008; 337:a2038. 8. DuPont RL, McLellan AT, Carr G, et al. How are addicted physicians treated? A national survey of Physician Health Programs. J Subst Abuse Treat 2009; 37:1–7. 9. Cottler LB, Ajinkya S, Merlo LJ, et al. Lifetime psychiatric and substance use disorders among impaired physicians in a physicians health program: comparison to a general treatment population: psychopathology of impaired physicians. J Addict Med 2013; 7:108–112. 10. Stanton J, Randal P. Doctors accessing mental-health services: an exploratory study. Br Med J Open 2011; 1:e000017. 11. Wessely A, Gerada C. When doctors need treatment: an anthropological approach to why doctors make bad patients. Br Med J Careers 2013. doi: 10.113/bmj.f6644 (Available at: http://careers.bmj.com/careers/advice/ view-article.html?id¼20015402.). 12. Firth-Cozens J. Predicting stress in general practitioners: 10 year follow up postal survey. Br Med J 1997; 315:34–35.
13. National Health Service. The first five years of the NHS Practitioner Health Programme (2008–2013). Supporting the health of health professionals. 2014. http://php.nhs.uk/wp-content/upload/sites/26/2014/05/Five-Year-Report.pdf. This report delivered by the UK National Health Service (NHS) gives a wide description of sick doctors who have been treated at the NHS Practitioner Health Program and provides some outcome measures that support its efficacy. 14. Brown RL, Schneidman BS. Physicians’ health programs: what’s happening in the USA? Med J Aust 2004; 181:390–391. 15. Federation of Physician Health Programs [Internet]. United States: Federation of & Physician Health Programs; c2014. http://fsphp.org. [Cited 3 September 2014]. This link provides useful and summarized information about each Physicians Health Program developed in the United States. 16. Federation of State Physician Health Programs, Inc. Physician Health Programs Guidelines. December, 2005 Edition. http://www.fsphp.org/2005FS PHP_Guidelines.pdf. 17. McLellan AT, Skipper GS, Campbell M, et al. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. Br Med J 2008; 337:a2038. 18. DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians Health Programs evaluation review. J Subst Abuse Treat 2009; 36:159–171. 19. Skipper GE, Campbell MD, DuPont RL. Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs. Anesth Analg 2009; 109:891–896. 20. Buhl A, Oreskovich MR, Meredith CW, et al. Prognosis for the recovery of surgeons from chemical dependency: a 5-year outcome study. Arch Surg 2011; 146:1286–1291. 21. Rose JS, Campbell M, Skipper G. Prognosis for emergency physician with substance abuse recovery: 5-year outcome study. West J Emerg Med 2014; 2014:2014; 15:20–25. 22. DuPont RL. The new paradigm for recovery: making recovery – and not && relapse – the expected outcome of addiction treatment. Rockville, MD: Institute for Behavior and Health, Inc.; 2014. http://ibhinc.org/pdfs/NewParadigmforRecoveryReportMarch2014.pdf. This study offers an insight into the New Paradigm for Recovering patients with substance use disorders with a special emphasis on high qualified professionals, including sick doctors. 23. Merlo LJ, Greene WM. Physician views regarding substance use-related participation in a state physician health program. Am J Addict 2010; 19:529–533. 24. DuPont RL. Creating a new standard for addiction treatment outcomes. Rockville, MD: Institute for Behavior and Health, Inc.; 2014. http://ibhinc.org/pdfs/CreatingaNewStandardforAddictionTreatmentOutcomes.pdf. 25. Henderson HW. Addicted doctors: responding to their needs. Can Fam Phys 1983; 29:1691–1699. 26. Myers M, Watkins T, Microys G. CMA guide to physician health and well being. Facts, advice and resources for Canadian doctors. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2003. 27. Canadian Physician Health Network [Internet]. Canada: Canadian Medical Association; c2009. http://www.facturation.net/canadian%20physician%20 health%20network:%20terms%20of%20reference. [Cited 20 October 2009] 28. The Canadian Physician Health Institute [Internet]. Canada: Canadian Medical Association; c2013. http://cphi-icsm.ca/. [Cited 20 December 2013] 29. Provincial Physician Health Programs [Internet]. Canada: Canadian Medical Association; c1995. http://www.cma.ca/En/Pages/provincial-physician-heal th-programs.aspx#saskatchewan. [Cited 23 December 2014] 30. Brewster JM, Kaufman IM, Hutchinson S, et al. Characteristics and outcomes of doctors in a substance dependence monitoring program in Canada: prospective descriptive study. Br Med J 2008; 337:a2098. 31. Warhaft NJ. The Victorian Doctors Health Program: the first three years. Med J Aust 2004; 181:376–379. 32. Australian Medical Association (website). Doctors’ health advisory services. && 2014. http://ama.com.au/node/3592. This link gives summarized information about each Physician Health Program or other support programs for doctors developed in Australia. 33. Oxley JR. Services for sick doctors in the UK. Med J Aust 2004; 181:388–389. 34. Padro´s J. El metge malalt. Com diagnosticar-lo, com tractar-lo i rehabilitar-lo i com intervenir per garantir la bona praxi. L’experie´ncia del Programa d’Atencio´ Integral al Metge Malalt. Universitat Auto`noma de Barcelona, Barcelona, 2012. 35. Braquehais MD, Valero S, Matalı´ JL, et al. Promoting voluntary help-seeking && among doctors with mental disorders. Int J Occup Med Environm Health 2014; 27:435–443. This study summarizes the main purposes of the Spanish Physicians Health Program (PHP), in general, and of the Barcelona PHP, in particular. It also provides data that support the efficacy of the Barcelona PHP in promoting voluntary help seeking among sick doctors. 36. Hegenbarth C. Rescuing doctors in distress. CMAJ 2011; 183:E153–E154. 37. Ro KE, Gude T, Aasland OG. Does a self-referral counselling program reach doctors in need of help? A comparison with the general Norwegian doctors workforce. BMC Public Health 2007; 7:36.
&&
0951-7367 Copyright Ô 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
329
Service provision to physicians with mental health and addiction problems Marı´a Dolores Braquehais a,b, Andrew Tresidder c, and Robert L. DuPont d
Purpose of review Physicians are reluctant to ask for help when they suffer from substance use disorders and/or other mental illnesses (i.e. when they become ‘sick doctors’). This can result in greater morbidity/mortality and may lead to significant problems in medical practice. This review aims to describe the nature and development of programs that specifically treat sick doctors [Physician Health Programs (PHPs)]. Recent findings PHPs were first developed in the United States in the late 1970s. The purpose was to identify and treat physicians with problems resulting from mental health issues, mainly substance use disorders. Since then, other PHPs have been developed in Canada, Australia, and the United Kingdom, trying to reach sick doctors, offering counseling or other preventive interventions when needed. New models to help sick doctors, such as the Spanish PHP, were also developed. Counseling and support services for sick doctors have been implemented elsewhere in Europe (e.g. Norway and Switzerland). Summary PHPs provide interventions specifically designed for physicians and other medical professionals with substance use and other mental health problems. The balance between guaranteeing safe practice and yet encouraging all physicians to ask for help when in trouble raises questions regarding how these programs should be designed. Keywords mental health services, physician health programs, sick doctors
INTRODUCTION In 1973, the American Medical Association (AMA) published ‘The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence’ [1]. The ‘sick doctor statute’ was defined as ‘the inability of a physician to practice medicine with reasonable skill and safety to his patients, because of one or more enumerated illnesses (...), including mental, emotional disorders, and/or excessive use of alcohol or other drugs’. Physicians are said to have high psychological vulnerabilities and are at risk of suffering from one of the three Ds (drugs, drink, and depression) [2]. An estimate of 10–14% of physicians may become chemically dependent at some point of their careers [3]. Physicians are no more likely than others to suffer from drug and alcohol problems, but their drug of choice may differ from that of the general population [4]. They tend to delay seeking help, complicating their evolution and prognosis [5]. Physicians may use alcohol and, more recently, marijuana (among young doctors), but they specifically have a high risk of using benzodiazepine tranquilizers, minor opiates, www.co-psychiatry.com
and/or stimulants through self-prescription [5–8]. Prescription substances are mainly used for self-treatment, whereas illicit substances and alcohol may be used for recreational purposes [5,6]. Rates of depression or anxiety among physicians are higher than those of the general population [9]. Sick physicians are, however, usually reluctant to ask for help [8,10,11]. This behavior may be the consequence of doctors’ culture of perfectionism, and it reflects their tendency to deny emotional a Integral Care Program for Sick Doctors, Galatea Clinic, Galatea Foundation, Collegi de Metges de Barcelona, bDepartment of Psychiatry and Legal Medicine, Hospital Universitari Vall d’Hebron, CIBERSAM, Universitat Auto`noma de Barcelona, Barcelona, Spain, cGP Patient Safety Lead, NHS Somerset CCG (Clinical Commissioning Group), Somerset, UK and dInstitute for Behavior and Health, Inc., Rockville, Maryland, USA
Correspondence to Marı´a Dolores Braquehais, MD, PhD, Integral Care Program for Sick Doctors, Galatea Clinic, Galatea Foundation, Collegi de Metges de Barcelona Passeig Bonanova, 47, 08017 Barcelona, Spain. Tel: +34 93 567 88 56; fax: +34 93 567 88 54; e-mail: [email protected]/[email protected] Curr Opin Psychiatry 2015, 28:324–329 DOI:10.1097/YCO.0000000000000166 Volume 28 Number 4 July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Service provision to sick physicians Braquehais et al.
KEY POINTS Physicians have difficulties in asking for help when suffering from substance use disorders and other mental illnesses. PHPs specifically try to help sick doctors in order to promote their integral well being and also to support a safe practice. PHPs progressively developed in the United States from the late 1970s and later in other countries such as Canada, Australia, United Kingdom, and Spain. Once sick doctors enter PHPs, their treatment outcomes are better than those of the general population’s. The balance between ensuring safe practice yet still encouraging physicians in trouble to ask for help raises questions regarding PHP design.
needs. In some cases, they may also fear any professional or legal implications. Some medical systems have a hierarchy of power – doctor at the top, patient near the bottom. Fearing loss of status, physicians are reluctant to become a patient. Another barrier is presented by the ‘medical self’, a result of medical training that gives a deeply rooted sense of institutionalized ‘specialness’ [11]. This may lead to the phenomenon of ‘medical invincibility’ and difficulty in releasing the role of a ‘doctor’. Abandoning the medical self can deeply threaten a doctor’s whole meaning structure, and so is subconsciously resisted at an institutionalized level. All these factors, together with specific individual features (e.g. high self-criticism, low self-esteem, poor work-home balance, etc.) and other environmental conditions (e.g. status conscious work environment, high job demands, etc.), may increase physicians’ inability to cope with emotional unbalance or to palliate their problems with alcohol or drugs [8,12,13 ]. The AMA report on the sick doctor phenomenon [1] was the starting point for all Physician Health Programs (PHPs). From the late 1970s, PHPs were developed in nearly every US state, and later in other countries. This study describes the nature and development of the ongoing PHPs. &&
PHYSICIAN HEALTH PROGRAMS: THE PIONEERING EXPERIENCE IN THE UNITED STATES Physician Health Programs PHPs in the United States typically identify and help physicians who have mental health and substance use disorders that could jeopardize their ability to practice medicine
safely. Suspected physicians are referred for evaluation, and when indicated for treatment, they conduct long-term monitoring [14]. All programs manage the care of physicians, but others expand services to help other healthcare professionals (i.e. dentists, veterinarians, etc.). In December 1990, the Federation of State PHP (FSPHP) was created to improve the coordination and communication between the separate state programs. The types of problems US PHPs deal with vary, but substance use disorders are always assessed and receive major attention in all programs (see Table 1) [14,15 ,16]. PHPs themselves do not act as providers of treatment or monitoring. Instead, they manage evaluation, treatment, and monitoring of physicians who have signed contracts for PHP participation [17,18]. The PHPs in the United States are diverse, but all are based on trust, experience, and on their specific arrangements with medical licensing boards. The state PHPs must balance the sometimes conflicting goals of protecting the public while also promoting the recoveries of the physicians they serve. Their existence is dependent on their maintaining the support of their many constituencies, including the physician community and the public. For physicians with performance issues, including substance use disorders, engaging as a patient with a PHP offers support and safe haven from legal– professional consequences, contingent on their compliance with the recommendations of the PHP [7]. With regard to substance use disorders, US PHPs generally begin with an initial intensive evaluation that can lead to a treatment recommendation (either residential or outpatient care) for an average of 3 months, followed by a second phase (for 3–12 months) with less intensive outpatient treatment (generally, two or three times per month). Care management is generally provided for 5 years. This typically includes random drug and alcohol testing, together with compliance monitoring and support, as well as mandatory participation in community recovery support groups such as Caduceus groups, Alcoholics Anonymous, and Narcotics Anonymous. A national study of 16 PHPs found that most doctors with substance use disorders accepted intensive random monitoring, treatment, and other conditions of the PHP care management. Over the course of 5 years of care, 78% never had a single positive drug or alcohol test result and 72% were able to return to practice [7]. These positive outcomes are similar regardless of physicians’ specialty [19–21]. The PHP paradigm in the United States serves as a model for other programs that provide intensive care management for substance use disorders to many different
0951-7367 Copyright Ô 2015 Wolters Kluwer Health, Inc. All rights reserved.
&
www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
325
Provision of services to people with mental illness Table 1. US Physician Health Programs
State(s)
Addictions
Mental disorders
Disruptive problems
Sexual offenders
Malpractice
Stressrelated problems
Physical illnesses
Alabama, Virginia, Washington, California, Georgia, Nebraska, Connecticut, Wisconsin Arizona, Arkansas, Rhode Island, South Dakota, Vermont, Wyoming Colorado, Florida, Maryland, Massachusetts, New Jersey Hawaii, Illinois, Mississippi, Missouri, Texas Idaho, Utah Indiana, Kansas, Kentucky, Louisiana Iowa, Maine Michigan Minnesota Montana Nevada New Hampshire, New Mexico, New York North Carolina Ohio Oklahoma Oregon, Pennsylvania, West Virginia South Carolina Tennessee
populations. These programs fall under what has been labeled the New Paradigm for Recovery [22 ]. One study of physicians with histories of substance use-related involvement with a PHP found that over three quarters (78.4%) reported satisfaction with participation in the PHP, whereas 15.4% reported dissatisfaction. The vast majority (92.5%) reported that they would recommend PHP participation to others, whereas less than 5% reported that the PHP was unhelpful [23]. The impressive long-term outcomes of the PHPs in the United States demonstrate that long-term recovery can be achieved, inspiring the proposal to set a new standard for assessing the effectiveness of addiction treatment of 5-year recovery [24]. The zero tolerance for any substance use is distinctive of US programs, defining this model of care management, and one of the reasons for its great outcomes. &&
THE CANADIAN EXPERIENCE The concern about physicians’ mental health – mainly of doctors with addictions – began in Canada 326
www.co-psychiatry.com
in the 1980s [25]. Early in the 2000, three basic models of programs for physicians had been developed in Canada [26], which are given as follows: (1) Volunteer committees providing peer support (2) Professionally staffed, comprehensive programs that offer a range of services for doctors, trainees, and their families on the basis of available community resources (3) Professionally staffed, comprehensive program based upon an employee assistance program model with a counseling service and other resources In 2001, the Canadian Medical Association (CMA) created the Canadian Physician Health Network [27] to enhance collaboration and communication between all the different programs, and in 2006, the CMA developed a Centre for Physician Health. This was dissolved in 2010 and, following extensive consultation, the CMA entered into a partnership agreement with the Canadian Medical Foundation (CMF) to support physician health Volume 28 Number 4 July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Service provision to sick physicians Braquehais et al.
through the establishment of the Canadian Physician Health Institute (CPHI) [28]. While the CPHI advances a shared national vision for physician health with local application, it is the provincial PHPs [29] that provide direct services to the physicians. For instance, of doctors admitted to the Ontario PHP for substance use disorders, 85% successfully completed the program and, during the monitoring period, 71% had no relapse [30].
PROGRAMS FOR DOCTORS IN AUSTRALIA In Australia, by 2000, most states had the equivalent of a doctor’s health advisory service (DHAS) that had little funding and depended mainly on the goodwill of a panel of volunteer doctors [31]. In November 2000, the Australian Medical Association (Victoria) and the Medical Practitioners Board set up the Victorian Doctors’ Health Program [31]. An independent body, in first 3 years of operation, it had 438 contacts, 220 of which entered the service (92 doctors and students with alcohol or drug problems, 82 with psychiatric problems, and 40 with stress-related or emotional problems). Sixtyfive patients (mostly with addictions) needed an intensive case management, which proved to be satisfactory in 57, and 50 were able to go back to work. Victoria also has the Peer Support Service and the Victorian Medical Benevolent Association as counseling and support services for doctors and their families. In 2004, the DHAS network created a doctor’s health planning and reference group in order to improve efforts and communication between professionals in this area. A variety of other state programs for doctors have followed in the rest of Australia and New Zealand [32 ]. &&
THE UNITED KINGDOM MODEL In the 1970s, the Association of Anaesthetists of Great Britain set up the first dedicated service for doctors [33]. Since then, several programs for physicians have been developed in the United Kingdom. Doctors in the United Kingdom may use the National Health Service (NHS) as patients of a general practitioner (GP), or through the use of NHS Occupational Health Services. Postgraduate Deaneries are responsible for doctors in training and their welfare; their services mainly provide psychological counseling for doctors with difficulties at work. With respect to national services, there are a range of options. The National Counselling Service for Sick Doctors, created in the mid-1980s, remains as
the only independent doctor-to-doctor service, helping them access appropriate healthcare. The British Medical Association also has a ‘doctors for doctors’ service. Other support programs are the British Doctors and Dentists Group, the Sick Doctors’ Trust, the Doctors’ Support Network, the Doctors’ Support Line, as well as some specialty Royal College provision (e.g. the Surgeons). Other programs, such as the Royal Medical Benevolent Fund, provide financial aid to doctors and families in difficulties. In 2008, the NHS Practitioner Health Program was launched in London as a PHP that provides multidisciplinary treatment approach for all doctors and dentists within Greater London. Practitioners with health concerns can contact the service directly for advice of consultation and treatment. The London PHP [12] treated 1078 practitioners during the 2008–2013 period, around 80% for mental health disorders, and 20% for substance misuse (two-thirds alcohol, one-third other substances). Seventy-six per cent of all patients either remained in or returned to work. Over the 5 years of the program, there has been a change of demographics of referrals from mainly older male physicians to mainly women under 35 years of age. The Practitioner Health Program has a memorandum of understanding with the Regulator, giving a degree of autonomy and ability to maintain confidentiality in most cases. The Regulator does not wish to know about cases in which a physician is appropriately engaged in a treatment program. Conversely, the Regulator may mandate a sick physician to engage in such a program as run by the PHP. Patients in the program with Regulator involvement dropped between years 1 (33%) and 5 (7%).
THE SPANISH PAIME In Spain, PHPs (PAIME, in Spanish) have developed since 1998, overseen by the ‘Colegio de Me´dicos’ of each Spanish region [34]. All practicing doctors in Spain need to be registered with ‘Colegios de Me´dicos’, which act both as medical associations and regulatory boards (or medical councils). Every ‘Colegio de Me´dicos’ in Spain offers a PHP outpatient service. The only PHP inpatient unit for Spanish physicians is currently located in Barcelona. Confidentiality procedures in the program include using a different name, with their real identity only disclosed without consent if there is a threat to self or others. The Spanish PHP promotes voluntary treatment, as well as enrollment for preventive interventions. However, doctors with risk or evidence of practice problems are obliged by their ‘Colegio de Me´dicos’ to undergo psychiatric treatment to and monitor
0951-7367 Copyright Ô 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
327
Provision of services to people with mental illness Table 2. European programs for sick doctors Country/program
Interventions
United Kingdom Practitioner Health Program [National Health Service (NHS)]
Integral treatment: mental disorders, addictions, physical illnesses
Doctors for doctors [British Medical Association (DD-BMA)]
Counseling
Doctors’ Support Network (DSN)
Counseling
Sick Doctors Trust
Counseling
Spain PAIME-PAIMM programs
Integral treatment: mental disorders, addictions
Norway Vila-Sana program
Counseling
Switzerland ReMed program
Counseling
ReMed, Rete Medicorum.
their fitness to practice at work a fitness to practice at work; if they suffer from an addictive disorder, treatment measures include proving abstinence once treatment has been completed. If doctors in trouble do not meet the mandatory treatment requirements (‘contrato terape´utico’, in Spanish), their license to practice may be suspended temporarily, or withdrawn. Most doctors with practice problems choose to be treated in PHPs, being highly specialized programs with guaranteed confidentiality. Nevertheless, most doctors treated in Spanish PHPs are self-referred to the programs. In a recent study [35 ], after analyzing data of 1363 patients admitted to the Barcelona PHP (PAIMM in Catalan) during a 13-year period, voluntary referrals grew from 81.3% during the first years (1998–2004) to 91.5% in the last period (2008– 2011). Mean age at admission also decreased from 54.2 to 44.9 over the 13 years. The prevalence of mental disorders among participants other than substance use disorders grew from 71% during the 1998– 2003 period, to 87.4% (2004–2007), and to 83.9% in the latest period. Adjustment disorders have also increased in prevalence, whereas inpatient treatment progressively represents less of total clinical activity. These results altogether could support the hypothesis that sick doctors feel encouraged to seek help in nonpunitive specially designed programs, such as the Barcelona PHP, where treatment becomes mandatory only when there is risk or evidence of malpractice. &&
OTHER PROGRAMS IN EUROPE Other programs developed in other European countries provide mainly counseling to doctors in trouble (see Table 2). However, they do not meet all criteria to be considered as standard PHPs, as they do 328
www.co-psychiatry.com
not include structured treatment strategies and mandatory interventions for cases with practice problems. In Switzerland, a program called ReMed (Rete Medicorum) was founded in 2007. After a 3-year pilot phase in the Swiss cantons of Thurgau and Neuenburg, ReMed was rolled out nationally. The program is sponsored by the Federation Medical Helvetica and the Swiss Medical Association, and offers crisis intervention, mentoring, and coaching. During a 3-year period, 80 patients were treated at the ReMed program mainly for burn-out and depression (43%), followed by practice and everyday life problems (32%), and only 13% for addictions [36]. When a doctor is at risk of practice problems, counseling is offered as part of the treatment plan. In 1998, the Norwegian Medical Association (NMA) established a short-term counseling program for doctors, called Villa Sana. After analyzing the data of 227 doctors who came to the Villa Sana for counseling, 73% needed treatment for anxiety and depression; 82% came for a 1-day counseling session, and 18% took part in the course program. When analyzing access to the program, 45% were self-referred [37]. Other countries such as Portugal and France are developing programs for sick doctors. The European Association for Physicians Health (EAPH) was created in 2009 and gathers professionals from different countries. Expertise and good practice on treatment and prevention strategies to promote doctors’ well being is shared.
CONCLUSION Several PHPs have developed since the first US initiatives. The main aim is providing access to Volume 28 Number 4 July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Service provision to sick physicians Braquehais et al.
mental healthcare for doctors with addictions and/ or mental disorders. Other counseling programs that do not include case management procedures try to reach doctors with emotional and personal difficulties. The balance between ensuring safe practice, yet still encouraging physicians in trouble to seek help, raises questions regarding the program design. The emphasis on confidentiality, on specialized patient-tailored treatment plans, and reserving mandatory treatment solely for cases with risk or evidence of practice problems should be considered in the future. Acknowledgements We would like to thank Gregory E. Skipper, MD, and Martin Vogel, MD, for their thoughtful comments that improved the quality of this work. Financial support and sponsorship None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. American Medical Association. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. J Am Med Assoc 1973; 223:684–687. 2. Schattner P, Davidson S, Serry N. Doctors’ health and wellbeing: taking up the challenge in Australia. Med J Aust 2004; 181:348–349. 3. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents and physicians. Psychiatr Clin North Am 1993; 16: 189–197. 4. Brewster J. Prevalence of alcohol and other drug problems among physicians. J Am Med Assoc 1986; 255:1913–1920. 5. Braquehais MD, Lusilla P, Bel MJ, et al. Dual diagnosis among physicians: a clinical perspective. J Dual Diag 2014; 10:148–155. 6. Hughes PH, Brandenburg N, Baldwin DC, et al. Prevalence of substance use among US physicians. J Am Med Assoc 1992; 267:2333–2339. 7. McLellan AT, Skipper GS, Campbell M, et al. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. Br Med J 2008; 337:a2038. 8. DuPont RL, McLellan AT, Carr G, et al. How are addicted physicians treated? A national survey of Physician Health Programs. J Subst Abuse Treat 2009; 37:1–7. 9. Cottler LB, Ajinkya S, Merlo LJ, et al. Lifetime psychiatric and substance use disorders among impaired physicians in a physicians health program: comparison to a general treatment population: psychopathology of impaired physicians. J Addict Med 2013; 7:108–112. 10. Stanton J, Randal P. Doctors accessing mental-health services: an exploratory study. Br Med J Open 2011; 1:e000017. 11. Wessely A, Gerada C. When doctors need treatment: an anthropological approach to why doctors make bad patients. Br Med J Careers 2013. doi: 10.113/bmj.f6644 (Available at: http://careers.bmj.com/careers/advice/ view-article.html?id¼20015402.). 12. Firth-Cozens J. Predicting stress in general practitioners: 10 year follow up postal survey. Br Med J 1997; 315:34–35.
13. National Health Service. The first five years of the NHS Practitioner Health Programme (2008–2013). Supporting the health of health professionals. 2014. http://php.nhs.uk/wp-content/upload/sites/26/2014/05/Five-Year-Report.pdf. This report delivered by the UK National Health Service (NHS) gives a wide description of sick doctors who have been treated at the NHS Practitioner Health Program and provides some outcome measures that support its efficacy. 14. Brown RL, Schneidman BS. Physicians’ health programs: what’s happening in the USA? Med J Aust 2004; 181:390–391. 15. Federation of Physician Health Programs [Internet]. United States: Federation of & Physician Health Programs; c2014. http://fsphp.org. [Cited 3 September 2014]. This link provides useful and summarized information about each Physicians Health Program developed in the United States. 16. Federation of State Physician Health Programs, Inc. Physician Health Programs Guidelines. December, 2005 Edition. http://www.fsphp.org/2005FS PHP_Guidelines.pdf. 17. McLellan AT, Skipper GS, Campbell M, et al. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. Br Med J 2008; 337:a2038. 18. DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians Health Programs evaluation review. J Subst Abuse Treat 2009; 36:159–171. 19. Skipper GE, Campbell MD, DuPont RL. Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs. Anesth Analg 2009; 109:891–896. 20. Buhl A, Oreskovich MR, Meredith CW, et al. Prognosis for the recovery of surgeons from chemical dependency: a 5-year outcome study. Arch Surg 2011; 146:1286–1291. 21. Rose JS, Campbell M, Skipper G. Prognosis for emergency physician with substance abuse recovery: 5-year outcome study. West J Emerg Med 2014; 2014:2014; 15:20–25. 22. DuPont RL. The new paradigm for recovery: making recovery – and not && relapse – the expected outcome of addiction treatment. Rockville, MD: Institute for Behavior and Health, Inc.; 2014. http://ibhinc.org/pdfs/NewParadigmforRecoveryReportMarch2014.pdf. This study offers an insight into the New Paradigm for Recovering patients with substance use disorders with a special emphasis on high qualified professionals, including sick doctors. 23. Merlo LJ, Greene WM. Physician views regarding substance use-related participation in a state physician health program. Am J Addict 2010; 19:529–533. 24. DuPont RL. Creating a new standard for addiction treatment outcomes. Rockville, MD: Institute for Behavior and Health, Inc.; 2014. http://ibhinc.org/pdfs/CreatingaNewStandardforAddictionTreatmentOutcomes.pdf. 25. Henderson HW. Addicted doctors: responding to their needs. Can Fam Phys 1983; 29:1691–1699. 26. Myers M, Watkins T, Microys G. CMA guide to physician health and well being. Facts, advice and resources for Canadian doctors. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2003. 27. Canadian Physician Health Network [Internet]. Canada: Canadian Medical Association; c2009. http://www.facturation.net/canadian%20physician%20 health%20network:%20terms%20of%20reference. [Cited 20 October 2009] 28. The Canadian Physician Health Institute [Internet]. Canada: Canadian Medical Association; c2013. http://cphi-icsm.ca/. [Cited 20 December 2013] 29. Provincial Physician Health Programs [Internet]. Canada: Canadian Medical Association; c1995. http://www.cma.ca/En/Pages/provincial-physician-heal th-programs.aspx#saskatchewan. [Cited 23 December 2014] 30. Brewster JM, Kaufman IM, Hutchinson S, et al. Characteristics and outcomes of doctors in a substance dependence monitoring program in Canada: prospective descriptive study. Br Med J 2008; 337:a2098. 31. Warhaft NJ. The Victorian Doctors Health Program: the first three years. Med J Aust 2004; 181:376–379. 32. Australian Medical Association (website). Doctors’ health advisory services. && 2014. http://ama.com.au/node/3592. This link gives summarized information about each Physician Health Program or other support programs for doctors developed in Australia. 33. Oxley JR. Services for sick doctors in the UK. Med J Aust 2004; 181:388–389. 34. Padro´s J. El metge malalt. Com diagnosticar-lo, com tractar-lo i rehabilitar-lo i com intervenir per garantir la bona praxi. L’experie´ncia del Programa d’Atencio´ Integral al Metge Malalt. Universitat Auto`noma de Barcelona, Barcelona, 2012. 35. Braquehais MD, Valero S, Matalı´ JL, et al. Promoting voluntary help-seeking && among doctors with mental disorders. Int J Occup Med Environm Health 2014; 27:435–443. This study summarizes the main purposes of the Spanish Physicians Health Program (PHP), in general, and of the Barcelona PHP, in particular. It also provides data that support the efficacy of the Barcelona PHP in promoting voluntary help seeking among sick doctors. 36. Hegenbarth C. Rescuing doctors in distress. CMAJ 2011; 183:E153–E154. 37. Ro KE, Gude T, Aasland OG. Does a self-referral counselling program reach doctors in need of help? A comparison with the general Norwegian doctors workforce. BMC Public Health 2007; 7:36.
&&
0951-7367 Copyright Ô 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
329
