The American Journal of Bioethics, 14(12): 37–46, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.969544
Open Peer Commentaries
Postincident Alcohol and Drug Testing Julius Cuong Pham, Johns Hopkins University School of Medicine Greg Skipper, Promises Treatment Centers Peter J. Pronovost, Johns Hopkins University School of Medicine Dr. Banja (2014) presents a thoughtful article that addresses the issue of alcohol and drug testing of physicians following adverse events, arguing against testing. The author identifies important logistical and conceptual reasons against postincident physician drug testing. We welcome the thoughtfulness, the open discourse, and the attention to an important issue. We offer some comments in response to the author’s arguments. The author argues that physicians who are under the influence can function adequately and don’t always harm patients. We suggest that the absence of an adverse event (i.e., patient harm) does not free physicians from being accountable for risky behavior. Just because you are drunk and do not hurt someone does not make it appropriate to be drunk. Just culture in health care focuses on risky behaviors rather than outcomes. Our objective in recommending testing is to identify and mitigate those risks, regardless of whether or not they cause harm. The author suggests that testing is humiliating. This needn’t be the case. Many industries have utilized drug testing. While health professionals may find it initially uncomfortable to submit to drug testing, if it becomes common and routine it will be incorporated into peer norms and shouldn’t cause undue concern, especially for those who are not using illicit drugs. In fact, it could be presented as an opportunity, in the face of an untoward outcome, to prove one’s sobriety. Drug testing could be encouraged as a positive benefit rather than as a humiliating accusation. This is how the thousands of current health professionals recovering from substance-use disorders view drug testing. The author argues that a positive drug test does not prove the illicit drug affected job performance. This may well be true, though it is not unique to drug testing; incident investigations identify factors associated with the event; they rarely establish a causal relationship. Because a just culture focuses on behavior, if those involved in an incident were under the influence of an illicit substance, incident investigators should know this. The evaluation team can then decide whether it was relevant to the
incident. Even if it were determined not to be relevant to the harm, it was a reckless behavior that should be addressed. The author suggests that drug testing is an unreasonable search under the Fourth Amendment or that physicians might object to being tested. If a workplace has an established policy that illicit substance abuse is not allowed and employees or staff members have signed an agreement to not use illicit substances and they have in advance agreed to postincident testing as a condition of employment, there is no violation of the Constitution. Moreover, if they have agreed previously to submit to testing if requested and they have been informed that a failure to test is grounds for disciplinary action, the policy would be fair and not violate employees’ rights. The author argues that the workplace is the last place that drug-using professionals have trouble. Even if the workplace is the last place for trouble (which it likely is), some clinicians will be impaired at work, and over time, virtually all impaired clinicians will eventually have trouble at work. If the purpose of physician drug testing is to identify and rehabilitate impaired physicians, workplace testing could have a valuable role, even if trouble occurs more often in a clinician’s home or social life. The author implies that illicit substance abuse could enhance performance. While certain drugs could enhance performance, at least temporarily, few would argue for illicit substance use. This is reminiscent of the surgeon who said upon confrontation that a couple shots of whisky prior to surgery steadies his hand. Until the medical community advocates for the use of performance enhancing drugs, this rationale does not seem relevant. The author suggests that most substance-abusing health professionals are not involved in errors and thus would not be detected by postincident testing. We agree that these physicians are more likely to be detected by random testing, having a physician health program, or having a system that encouraged referral by colleagues. However, this still does not mean that postincident testing couldn’t sometimes detect illicit and dangerous substance abuse.
Address correspondence to Julius Cuong Pham, MD PhD, Johns Hopkins University School of Medicine, 5801 Smith Ave., Baltimore, MD 21209, USA . E-mail: [email protected]
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American Journal of Bioethics
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: [email protected]
38 ajob
December, Volume 14, Number 12, 2014
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Open Peer Commentaries
Postincident Alcohol and Drug Testing Julius Cuong Pham, Johns Hopkins University School of Medicine Greg Skipper, Promises Treatment Centers Peter J. Pronovost, Johns Hopkins University School of Medicine Dr. Banja (2014) presents a thoughtful article that addresses the issue of alcohol and drug testing of physicians following adverse events, arguing against testing. The author identifies important logistical and conceptual reasons against postincident physician drug testing. We welcome the thoughtfulness, the open discourse, and the attention to an important issue. We offer some comments in response to the author’s arguments. The author argues that physicians who are under the influence can function adequately and don’t always harm patients. We suggest that the absence of an adverse event (i.e., patient harm) does not free physicians from being accountable for risky behavior. Just because you are drunk and do not hurt someone does not make it appropriate to be drunk. Just culture in health care focuses on risky behaviors rather than outcomes. Our objective in recommending testing is to identify and mitigate those risks, regardless of whether or not they cause harm. The author suggests that testing is humiliating. This needn’t be the case. Many industries have utilized drug testing. While health professionals may find it initially uncomfortable to submit to drug testing, if it becomes common and routine it will be incorporated into peer norms and shouldn’t cause undue concern, especially for those who are not using illicit drugs. In fact, it could be presented as an opportunity, in the face of an untoward outcome, to prove one’s sobriety. Drug testing could be encouraged as a positive benefit rather than as a humiliating accusation. This is how the thousands of current health professionals recovering from substance-use disorders view drug testing. The author argues that a positive drug test does not prove the illicit drug affected job performance. This may well be true, though it is not unique to drug testing; incident investigations identify factors associated with the event; they rarely establish a causal relationship. Because a just culture focuses on behavior, if those involved in an incident were under the influence of an illicit substance, incident investigators should know this. The evaluation team can then decide whether it was relevant to the
incident. Even if it were determined not to be relevant to the harm, it was a reckless behavior that should be addressed. The author suggests that drug testing is an unreasonable search under the Fourth Amendment or that physicians might object to being tested. If a workplace has an established policy that illicit substance abuse is not allowed and employees or staff members have signed an agreement to not use illicit substances and they have in advance agreed to postincident testing as a condition of employment, there is no violation of the Constitution. Moreover, if they have agreed previously to submit to testing if requested and they have been informed that a failure to test is grounds for disciplinary action, the policy would be fair and not violate employees’ rights. The author argues that the workplace is the last place that drug-using professionals have trouble. Even if the workplace is the last place for trouble (which it likely is), some clinicians will be impaired at work, and over time, virtually all impaired clinicians will eventually have trouble at work. If the purpose of physician drug testing is to identify and rehabilitate impaired physicians, workplace testing could have a valuable role, even if trouble occurs more often in a clinician’s home or social life. The author implies that illicit substance abuse could enhance performance. While certain drugs could enhance performance, at least temporarily, few would argue for illicit substance use. This is reminiscent of the surgeon who said upon confrontation that a couple shots of whisky prior to surgery steadies his hand. Until the medical community advocates for the use of performance enhancing drugs, this rationale does not seem relevant. The author suggests that most substance-abusing health professionals are not involved in errors and thus would not be detected by postincident testing. We agree that these physicians are more likely to be detected by random testing, having a physician health program, or having a system that encouraged referral by colleagues. However, this still does not mean that postincident testing couldn’t sometimes detect illicit and dangerous substance abuse.
Address correspondence to Julius Cuong Pham, MD PhD, Johns Hopkins University School of Medicine, 5801 Smith Ave., Baltimore, MD 21209, USA . E-mail: [email protected]
ajob 37
American Journal of Bioethics
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: [email protected]
38 ajob
December, Volume 14, Number 12, 2014
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
