Help for the Troubled Health Professional

Gray pinstripe, his suit is immaculate. His bearing, too, at first seems flawless, and as he turns toward the counselor, the resemblance is marked, Marcus Welby, M.D. Avuncular, confident, the man could pass at least for the brother of one of television's most warmly remembered physicians. But the counselor's trained eyes detect tell-tale signs: a slight sweat beading the patrician forehead, an even slighter tremor as the 53 year-old doctor adjusts, with just a hint of nervousness, his fine silk tie.

Then he finally admits: "I just can't stop drinking." His voice catches on "can't" - as though any admission of failure is something he must not countenance. And it's hours later that he concedes, too, a dependency on tranquilizers - prescription synthetic opioids few laypeople know even the names of.

Scott Aldren[1], an attending surgeon at one of his city's better hospitals, has just shown as much courage as he has demonstrated at any point in his life. And it's been a life marked by courageous action: the decision to embark on a medical career despite family misgivings; the long hours in med school spent in arduous training; the daring he's recently displayed in pioneering new surgical methods as he works harder than ever. There has been strain: his 18-year marriage, even he now realizes, is in peril.

Having supported him throughout his schooling, Aldren's wife has witnessed his subsequent professional peaks but also his personal valleys - the days he seems a shadow of his accustomed self, the times his anger has erupted. And, although it's seldom mentioned, there's the D.U.I. charge that hovers; the unresolved case has helped dwindle the family's finances. She's found no evidence of the marital infidelity that often accompanies chemical dependence, but the intimacy the two once cherished is mainly a memory now. Elaine tries to swallow her resentment at the man his patients still regard as omniscient, infallible, but it's hard.

It will be hard, too, Aldren's next passage - through a treatment program that specializes in physicians who suffer from addiction. Elaine, however, is grateful, full of hope that Scott will find help. Scott is eager as well, but anxious - and even now defensive, even now in denial that his chemical dependence is real.

It's known as the "M.D.eity syndrome" - that particular sense of invulnerability that a physician's practice and training can aggravate. And it can make the denial that is part and parcel of addiction especially acute. Aldren exemplifies that arrogance - in the early stages of treatment he'll employ his considerable intelligence to sabotage the recovery process. He'll rationalize, evade, and lash out at the colleagues who've confronted him about his addition and the doctors who work to help him heal. In time, however, he'll turn that intelligence - and the sense of duty and care that marks all good doctors - inward, and from an epiphany of realization, will begin to heal himself.

He is not alone. Not only will he find support from family and friends and the doctors and counselors in the Recovering Professionals Program, but from peers who suffer also from the disease of addiction. Studies over the past 20 years stress that rates of chemical dependence in physicians are roughly equivalent to those of the rest of the population, with estimates ranging from 3 to 15%. Aldren, then, is among the many who've reached the crisis point. Suffering from the fatigue, loneliness, stress and burnout that afflict doctors, dentists and nurses as witheringly as they do members of all high-powered professions, he's acted upon a sadly ironic version of the ancient wisdom - "Physician, heal thyself" - by turning to alcohol and to the drugs to which his profession offers easy access.

"Questions having to do with impairment problems generally represent about 25 percent of our activities," says David L. Morgan, M.D., of the Georgia Composite State Board of Medical Examiners, the board that oversees quality-of-care issues for the state. Andrew W. Watry, the Board's executive director, specifies: "This year, of the 120 disciplinary actions we've taken, 39 had to do with impairment issues. At this point, we have 91 doctors on probation. They are monitored very closely and, for a period of five years, subjected to random drug screening, quarterly reports from their workplaces, and aftercare supervision." While the Board first gathers and corroborates information gathered from family members, colleagues, administrators or patients about physicians suspected of having problems with alcohol or drugs, then interviews those doctors and, when necessary, recommends voluntary treatment, its ultimate power is that of license suspension.

The state regulatory board handles its charges with care - "I think it's important to note that physicians can be reported to us, and undergo successful treatment, without the publicity of media coverage that has surrounded these kinds of cases in the past," Morgan says - and notes that, due to education and to the existence of supportive networks, the detection of impaired professionals is on the rise. "Probably in the last four or five years," he says, "there has been a gradual increase in the incidence of reporting. I doubt that the incidence of impairment is increasing; rather, the mechanism for reporting has improved." And while his Board has real enforcement power, Morgan stresses that its work is redemptive, not punitive: "We like to think of ourselves as being part of the support network, making individuals increasingly aware that there is someone they can report to, and thereby salvage physicians as family members and as professionals."

The doctors and nurses the Board reviews are professionals, like Dr. Aldren, who've had difficulty handling the stresses of their careers and personal lives. Many, like Aldren, have also become addicted to the drugs only physicians find readily available.

Prescription medicines present a special temptation to practitioners with impairment problems. Their training in pharmacology familiarizes them with the drugs' effects; perilous - and sometimes illegal - self-medication can result. Their knowledge produces a false confidence that they can control their consumption and the negative effects of continued use. And, certain studies suggest specific medical specialists may be particularly prone to this form of substance abuse. One study, sponsored by the American Medical Association, showed that psychiatrists and emergency medicine specialists displayed significantly higher rates of substance abuse than did other kinds of doctors. Cocaine and marijuana use was shown to be more frequent among emergency physicians than other health professionals; psychiatry residents reported a much higher rate of marijuana and Valium-type drug abuse. Alcohol dependency among those in the medical field mirrored that of the general population.

The progress of Dr. Aldren's illness, from substance abuse to actual impairment to dependence, was subtle and gradual; it was characterized both by his own denial and that of well-intentioned family members, employees and even peers who unwittingly enabled his disease. They made excuses for his inappropriate behavior at parties, for the mornings he'd arrive at the office late, exhausted. Even as he began helping himself to sedatives to steady his nerves, his staff found little evidence that his surgical practice was jeopardized - with a doctor's discipline and an addict's dissembling, he'd erected a facade of control. But, after literally spinning out of control one night when his blood alcohol level registered 0.17 and his car careened into a telephone pole, he finally reached out for help.

Other impaired health professionals need more than their own harsh wake-up calls. While a "conspiracy of silence" of efforts on the part of others to shield the addict from detection and the wrongly assigned shame that still surrounds what is after all not a moral failure but a disease, persists, these days the medical profession is much better at helping its members seek treatment. Supportive networks, well-educated about the disease, exist. Nurses or doctors may arrive in treatment after an intervention in which concerned family and colleagues deliver the loving ultimatum that they enter treatment. Or the Board of Medical Examiners, alerted, for example, to a physician's dependence problems by discovering that he or she has written illegal prescriptions or diverted drugs, may mandate that they seek treatment. In such cases their motivation may be what's come to be known as "secondary gain" - less of a desire to confront head-on their addiction than to avoid a perceived threat: license suspension, for example, or legal consequences. Initially, these patients may be harder to treat, their denial more stubborn, their willingness to change less apparent.

Recovery begins with evaluation and the development of an individualized treatment plan. In some instances of severe drug dependency, detoxification lasting up to two weeks and requiring inpatient hospitalization may be necessary; in most cases, however, patients enter a physician specialty treatment process. There, many professionals stay for longer periods, up to 90 days or more. All patients enter the a community setting and work together to manage household responsibilities, patients develop a bond of community, a partnership in healing. For many, a "mirror-imaging" phase follows. Working under close scrutiny with other addicted individuals in selected addictive disease programs, recovering professionals learn empathy - in helping others whose struggle reflects their own, they break through the chilling isolation of the addict and recovery too their self-esteem as healers. Some, returning to work, will enter the outpatient program that meets four evenings a week, during which their progress is evaluated weekly. They'll attend 12-step meetings, meetings of a support group for recovering health professionals and undergo random drug screenings.

For all recovering professionals, the continuing care - generally consisting of a 2 to 5 year continuing care contract is often the most crucial phase of treatment. Aftercare may include membership in professional peer groups, advocacy to assist re-entry into their profession and regular monitoring of their progress.

Doctor Scott Aldren will be one of the many who will succeed if they complete an extended program and enter long term monitoring. Says Andrew Watry of the Board of Medical Examiners: "Physicians' rates of recovery are much higher than those of the consuming public. At least seven out of ten physicians succeed. The tremendous desire they have to remain in medicine - a career that is their life's work - is a compelling aid to recovery. Also, their work environments aid their recovery: they're placed in environments where appropriate monitoring can easily occur." As is true of all life-changing passages, the recovery process will be cathartic. Aldren will find the community experience of half-way house living especially challenging. As a surgeon of some renown, the humbling process of sharing his struggle with others will radically change him. But he'll emerge, as do many of his peers, a better physician - more empathic, less given to masking his problems in the overwork that's almost endemic to his profession. According to Watry: "A doctor who has been through recovery, who has acknowledged that he has a problem, is generally a better doctor. He is humble, more accommodating with patients and peers, and more compassionate."

And like many physicians in recovery he'll work to assist change in the way his profession deals with addiction. He's come to believe that education should start early - in medical school, where not only are the specifics of substance abuse seldom examined in sufficient depth, but, more egregiously, where the affective side of the practice of medicine is neglected, often to the point where those stresses build that too easily foster addiction. The work of healing, he realizes, is a matter of heart as well as head, of soul as well as skill. The ancient Green humanists from whom modern medicine ultimately derives understood this, and we must reclaim that wisdom.

As this physician continues to heal himself, he'll treasure finally that sense of community with those who've sustained the same kinds of trial. And to others, even now suffering from the disease of addiction, he will reach out his hand and offer hope.

This article was originally published in Insight Magazine

[1] The name of the physician used in this article is fictitious.