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The author argues that postincident testing would occur too late following the incident to pick up the drug or alcohol use. A similar argument is true about participant’s recollection of events and facts after an incident. Like blood levels of alcohol, information decays rapidly after an incident and prompt investigation mitigates this information loss. For example, samples could be collected from everyone involved soon after the accident, and a decision could be made later on whether or not to submit the samples for testing. The author argues that adverse events in health care are complex and often involve multiple factors, systems, and individuals. We wholeheartedly agree with this view. Physician impairment is one of the many factors that may contribute to the adverse event. The objective of incident investigation is not to identify the causal relationship with the one “root cause,” but rather to identify all the contributing factors. Not testing for physician impairment blinds the investigator to a potential contributing factor. The author shares two vignettes of adverse events that likely were due to a series of system failures separated across time and space. While it is unlikely that alcohol or drugs were a significant contributor to either of the events, it would seem important to know if the prescribing physician (in the first case) or reviewing pharmacist (in the second case) was found to have an elevated blood alcohol level or opiate dependence. At the least, this would have identified health care providers in need of assistance. As an alternative to post-incident drug testing, the author advocates for fixing system failures within the healthcare system and encouraging a “speaking up” culture. We wholeheartedly agree with and appreciate the review provided by the author. However, we do not find these issues to be mutually exclusive. The presence of multiple strategies to improve patient safety does not weaken the argument for physician drug testing.
The author also does not consider the patient perspective. How might patients and families feel about being cared for by a physician under the influence of drugs and alcohol, whether or not an error or harm occurred? When we asked our patients and families this, they were incredulous that we would even pose the question. If the medical profession adopted the author’s views, public trust in medicine would likely, and justifiably, erode. In summary, we are enlightened by Dr. Banja’s commentary on the challenges to post-incident physician drug testing. Experience with this in health care is quite limited and the logistics of doing so are not trivial. Dr. Banja identifies many valid challenges to the ethical, conceptual, and logistical reasons for doing so. We find that these challenges, while important, are neither sufficient nor insurmountable. For us, the motivation is that problematic substance use is common among health professionals and drug testing can help identify it (Pham, Pronovost, and Skipper 2013). Because addiction is frequently kept secret, it might otherwise go unidentified. Identifying addiction allows it to be effectively addressed in a supportive manner. Even if addiction among health professionals is only a small fraction of the cause for errors, it is still worth finding, both for patient safety and for the assistance that can be provided to the health professionals. &
REFERENCES Banja, J. 2014. Alcohol and drug testing of health professionals following preventable adverse events: A bad idea. American Journal of Bioethics 14(12): 25–36. Pham, J. C., P. J. Pronovost, and G. E. Skipper. 2013. Identification of physician impairment. Journal of the American Medical Association 309(20): 2101–2102.
Drug Testing of Health Care Professionals to Improve Overall Wellness and Patient Care Lisa J. Merlo, University of Florida There has been a renewed call for comprehensive drug testing of health care professionals, including preemployment screening, random testing, and “postincident” testing following preventable adverse events (e.g., Pham, Pronovost, and Skipper 2013). The goal of such testing
would be to identify “impaired professionals” who are putting patients at risk. In response, Banja (2014) makes the case that postincident alcohol and drug testing of health professionals, in particular, is a bad idea primarily because (1) it represents a humiliating violation of privacy
Address correspondence to Lisa J. Merlo, PhD, MPE, Assistant Professor of Psychiatry, University of Florida, Director of Research, Professionals Resource Network, Inc., 4001 SW 13th St., Suite 713, Gainesville, FL 32608, USA. E-mail:
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that only detects recent substance use, not impairment, (2) it is unlikely to detect many substance abusers, despite the high cost, (3) practical considerations limit the usefulness of test results, and (4) selection of individuals to be tested is likely to result in morale problems and refusal to be tested. Irrespective of the final conclusions and recommendations, this discourse highlights the overarching problems faced by health care professionals with substance use disorders (SUDs); namely, the vilification of individuals who suffer from SUDs, the limited understanding of the disease and its treatment (even within the health care field), and the relative lack of support available for these individuals to obtain the care they need. Research has demonstrated that development of an SUD is an occupational hazard for many health care professionals (e.g., Merlo, Cummings, and Cottler 2012; Merlo and Gold 2008). Various factors, including high levels of work-related stress, occupational access or secondhand exposure to abusable drugs, personality characteristics (e.g., ambition, independence, obsessive-compulsive and narcissistic traits), and behaviors associated with success in medicine (e.g., working long hours, failing to ask for help, neglecting to take sick days or vacation) put these professionals at increased risk. Yet the field is failing when it comes to providing adequate methods of education, prevention, intervention, and treatment for its at-risk workers. By comparison, other areas of high risk for health care professionals are met with comprehensive efforts to minimize the threat. For example, health care professionals are at increased risk of exposure to contagious diseases. As a result, training programs (e.g., medical school) provide significant education about methods of transmission and the importance of contact precautions, and many healthcare professionals are required to complete yearly “bloodborne pathogen trainings” to ensure the information stays fresh. Various safety measures (e.g., gloves, masks, gowns, etc.) are used to decrease risk, and hotlines are available to call in the event of an accident/incident (e.g., needle stick) to assist the professional with immediate intervention and decrease the likelihood of an adverse outcome. If a health care professional’s mistake or negligence results in his being exposed to a dangerous pathogen, the professional is not shamed, threatened, or treated as a criminal. He is given appropriate medical care to protect/recover his health and well-being, and the team is likely to rally around him to provide support. Further, systems issues that may have contributed to the incident are typically reexamined to identify potential areas for improvement. With regard to SUDs, such efforts are almost nonexistent. Despite overwhelming data regarding the high prevalence of SUDs in the general patient population, as well as in the population of health care professionals, most training programs provide very limited education on this topic (Miller et al. 2001; National Center on Addiction and Substance Abuse 2012). With the exception of a few outlier programs, most students do not learn about the occupational risks for SUD in their profession, how to seek help if
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they develop an SUD, or how to appropriately intervene if they are concerned about a colleague. Further, safety measures (e.g., anti-diversion policies/procedures, prescription drug monitoring programs) are relatively new and not yet ubiquitous. Perhaps most importantly, health care professionals with SUDs are often treated more as criminals than patients. In many cases, they are subject to “investigations” and “disciplinary actions,” rather than being referred for a diagnostic assessment and appropriate treatment by an expert medical professional. Some may argue that this discrepancy results from the fact that SUDs could cause “impairment” of the health care professional, putting patients and colleagues at risk. Though substance use can certainly contribute to medical errors, as Banja (2014) described, these errors generally result from multifaceted problems within the overall system, and even health care professionals with SUDs tend to preserve their work performance well into the progression of their disease (Angres, Talbott, and Bettinardi-Angres 1998). Further, other medical conditions can cause “impairment” in the workplace (e.g., dementia, degenerative motor conditions, insomnia, depression, pregnancy). Yet health care professionals dealing with any of these conditions are likely to be met with compassion and offers of assistance, rather than contempt, shame, and attempts to punish. Addiction is now understood to be a chronic disease. The research overwhelmingly supports this notion, documenting a neurophysiological basis, as well as a number of medical consequences related to SUDs (Volkow et al. 2012). Clinical experience and empirical data confirm that treatment of SUDs works, whereas punishment (e.g., workplace sanctions, prison) does not typically result in long-term recovery. Relapse rates for individuals with SUDs are similar to those seen among individuals with other chronic conditions involving a behavioral component (e.g., diabetes, hypertension). In addition, the evidence documenting the effectiveness of SUD treatment is strongest among the population of addicted physicians (DuPont, McLellan, White, Merlo, and Gold 2009). Outcomes for this group are extremely positive, demonstrating the importance of timely identification and appropriate treatment. As a result, significant reforms are needed to reduce the prevalence of SUDs among health care professionals, while also helping to ensure patient safety. First and foremost, more education on the topic of SUDs is needed during the training of health care professionals. Students in medicine, pharmacy, nursing, dentistry, and other health care professions should graduate understanding that addiction is a disease, not a character defect. They should be taught the importance of early intervention and the efficacy of treatment. They should be aware of local resources and evidence-based treatments available for patients and colleagues with SUDs. Second, the health care field must revise its treatment of colleagues for whom SUD is on the differential diagnosis list, as well as those for whom the diagnosis is confirmed. As Banja (2014) described, many view drug testing
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as humiliating, punitive, and an invasion of privacy. Yet substance use is a symptom of SUD, not a sign. It is a necessary but not sufficient indicator for the diagnosis. Therefore, alcohol and drug testing should be viewed the same way as any other screening test (e.g., blood pressure, fasting glucose, cholesterol). Test results should be protected by the Health Insurance Portability and Accountability Act (HIPAA), and a positive test should indicate the need for a more extensive workup, not the need for immediate disciplinary action. Third, random drug testing (i.e., “substance use disorder screening”) with a specialized panel including drugs commonly abused by health care professionals should be included as part of a comprehensive initiative to improve wellness among health care professionals. This should be the standard of care, particularly in specialties of highest risk (e.g., physicians, pharmacists, nurses, and dentists), much as it is in other safety-sensitive professions (e.g., airline industry). Random drug testing may be the most effective method of prevention available. It is documented to prevent/decrease illicit substance use among previous nonusers or infrequent users (i.e., primary prevention); it can identify “casual” substance users, providing an opportunity to intervene early and prevent development of an SUD (i.e., secondary prevention); and it is likely to identify individuals with an SUD who would benefit from treatment, potentially stopping the disease progression earlier than would otherwise have occurred and preventing further negative outcomes (i.e., tertiary prevention). Though some have argued that the cost of widespread drug screening may be prohibitory, it is important to consider the significant cost savings associated with retaining high-value employees, avoiding potential litigation in the future, and preventing catastrophic events within the health care system that random drug screening may afford. Fourth, when a health care professional screens positive on an alcohol or drug screen, s/he should be referred to an expert in the evaluation of health care professionals with SUD, preferably a physician board certified in addition psychiatry or addiction medicine, or a psychologist with significant experience. In most states, this can be accomplished most easily by referral to the state physician health program (PHP). PHPs are organizations that exist to assist with the evaluation and monitoring of physicians (and, in some states, other health care professionals) who have conditions that may directly or indirectly result in workplace impairment (DuPont, McLellan, Carr, Gendel, and Skipper 2009). Professionals with certain medical conditions, psychiatric disorders, behavioral difficulties, or burnout can seek help voluntarily or be referred by concerned colleagues, family, or friends. These programs arrange for a comprehensive evaluation and appropriate treatment of the professional, and continue to monitor progress to ensure patient safety. Past participants in PHPs describe them as lifesaving and career saving, even if the participants were initially referred in an involuntary capacity (Merlo and Greene 2010). More work should be done to ensure that all at-risk health care professionals
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have access to a high-quality PHP-type resource. In states where the PHP is nonexistent or nonfunctional, hospitals and health systems would benefit from arranging for evaluations to be completed by a qualified expert in the state or arranging for the individual to be evaluated at a treatment center that specializes in assessment/treatment of health care professionals with SUD. In short, Banja (2014) is correct in explaining that postincident testing of health care professionals is rife with complication, and the cost–benefit ratio is questionable. On the other hand, mandatory random screening of all health care professionals circumvents many of the perceived concerns. While helping to assure patient safety without waiting for an incident to occur, it prevents the imposition of blame and shame, introduces fairness in the selection of who will be tested and when, precludes the option for personnel to refuse testing, and offers a pathway for professionals struggling with an SUD to obtain careersaving and lifesaving treatment. &
REFERENCES Angres, D. H., G. D. Talbott, and K. Bettinardi-Angres. 1998. Helping the healer: The addicted physician. Madison, CT: Psychosocial Press. Banja, J. 2014. Alcohol and drug testing of health professionals following preventable adverse events: A bad idea. American Journal of Bioethics 14(12): 25–36. DuPont, R. L., A. T. McLellan, G. Carr, M. Gendel, and G. E. Skipper. 2009. How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment 37: 1–7. DuPont R. L., A. T. McLellan, W. L. White, L. Merlo, and M. S. Gold. 2009. Setting the standard for recovery: Physicians health programs evaluation review. Journal for Substance Abuse Treatment 36: 159–171. Merlo, L. J., S. M. Cummings, and L. B. Cottler. 2012. Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction. Journal of the American Pharmacists Association 52: 480–491. Merlo, L. J., and M. S. Gold. 2008. Prescription opioid abuse and dependence among physicians: hypotheses and treatment. Harvard Review of Psychiatry 16: 181–194. Merlo, L. J., and W. M. Greene. 2010. Physician views regarding substance use-related participation in a state physician health program. American Journal on Addiction 19: 529–533. Miller, N. S., L. M. Sheppard, C. C. Colenda, and J. Magen. 2001. Why physicians are unprepared to treat patients who have alcohol and drug-related disorders. Academic Medicine 7: 410–418. National Center on Addiction and Substance Abuse at Columbia University. 2012. Addiction medicine: Closing the gap between science and practice. Available at: http://www.casacolumbia. org/upload/2012/20120626addictionmed.pdf (accessed September 7, 2014).
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Pham, J. G., P. J. Pronovost, and G. E. Skipper. 2013. Identification of physician impairment. Journal of the American Medical Association 309: 2101–2102.
Volkow, N. D., G. J. Wang, J. S. Fowler, and D. Tomasi. 2012. Addiction circuitry in the human brain. Annual Review of Pharmacology and Toxicology 52: 321–336.
Addicted Health Care Professionals: Missing the Wood for the Trees? Alain Braillon, University Hospital, Amiens Banja (2014) is rightly concerned with addicted health care professionals, a security issue too rarely raised as even the magnitude of this problem remains poorly investigated, but his title is unduly provocative and he may have missed the most damaging addiction. First, is testing of school bus drivers a bad idea? Testing is efficient and clearly lays down the rule. Federal law mandates implementing and maintaining a drug and alcohol testing program compliant with the Department of Transportation regulations (49 Code of Federal Regulations [CFR], Part 382 and Part 40). This has not only concerned targeted pilots since 1991 but also includes many jobs, even pipeline controllers. Transportation is the gold standard for security, and the Office of the Secretary of Transportation clearly states that a “drug and alcohol testing program is a critical element of the Department of Transportation’s safety” (http://www.dot.gov/odapc/ why_this_program_is_important). For a long time, identifying best practice through benchmarking has been essential for improvement in quality and security (Braillon et al. 2007). In contrast, focusing on rare and tragic events, such as a Stevens Johnson syndrome or a case settled for $15.5 million (Banja 2014), may not be the best method to improve quality of care (West, Weeks, and Bagian 2008). For too long, health care professional organizations and the Surgeon General have failed to raise the bar. Happily, Levinson and Broadhurst (2014) recently claimed, “Hospitals should be required to perform random drug tests on all health care workers with access to drugs.” Second, an effective policy against addiction, like any other policies, must (a) use methods based upon scientific evidence, (b) be subject to regular evaluation, and (c) stand on several pillars such as prevention, treatment, and public safety. There is no magic bullet and speaking up is only a piece of a comprehensive framework. Moreover, even in the United States, where there is a long history of promoting speaking up and protecting those who do so (the Lloyd–La Follette Act was issued in 1912), retaliation (bullying, gagging, criminal prosecution, etc.) against whistleblowers remains too frequent in health care
organizations (Lowes 2010). It is no accident that Philipsen and Soeken (2011) provided a “ survival guide” for nurses who want to blow the whistle. In Canada, protection for whistleblowers is notoriously poor (http://canadians4accountability.org/accountabilityand-whistleblowing). In Europe, except the United Kingdom, it is even worse, and speaking up is even an offense in France (Braillon 2010). Third, tobacco is the most frequent and damaging drug. It kills one out of two who use it. Approximately 480,000 people die prematurely from smoking or exposure to secondhand smoke each year in the United States, which is far more than the 292,000 U.S. soldiers who died during World War II. Smoking by health care professionals is also damaging to the quality of care. In fact, it is a major barrier to tobacco interventions with patients. When compared with physicians who smoke, nonsmoking physicians are more likely to identify the smoking status of their patients, provide advice on quitting and intensive cessation counseling, and initiate cessation interventions (Huang et al. 2013). Last, the role model cannot be ignored. Nonetheless, among the 800,000 U.S. licensed practical nurses the prevalence of smoking is 21% (Sarna et al. 2014). This is far more than in the general population (16%). Accordingly, pediatric nurses perform poorly in identifying and counseling parents who smoke about the risks of secondhand smoke when their children are treated in hospitals (Braillon and Croghan 2014). Among U.S. physicians, the prevalence is 11%, which remains too high. In Italy, the prevalence of smoking among health care professionals is 44%—more than twice of the general population: 48% for nurses, 34% for doctors (Ficarra et al. 2011). Smoking in health care professionals questions their training and consistency. Are they aware of the outcomes (life expectancy for smokers is at least 10 years shorter than for nonsmokers) and that efficient treatments are available? Personally, I would not rely more on a health care professional who smokes than on a hygienist with grubby fingernails. Impaired professionals can receive the help they need to return to safe practice, as recovering professional
Address correspondence to Alain Braillon, Alcohol Unit Treatment, University Hospital, 80000 Amiens, France. E-mail: braillon.
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