An impairment policy for medical students: an essential
ingredient for the growth of tomorrow’s physicians
Pebble Kranz, Ivone Kim, Ashlynne Harris
Brown Medical School
Presentation Outline
• Overview of issues in medical student distress and impairment
• Brown’s Student Health Council
• The case for an impairment policy for medical students
• The path to a new policy at Brown
• Questions and Comments
Disclosures
• None of the authors/presenters have any relevant financial arrangements to disclose
• This presentation has been supported by the RI Medical Society, Brown Medical School, and the Charles F. Carpenter Grant
“Disciplinary action by medical
boards was strongly associated
with prior unprofessional
behavior in medical school.”
Papdakis, MA et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005; 353; 2673-82.Teherani A et al. Domains of unprofessional behavior during medical school associated with future discliplinary action by a state medical board. Acad Med. 2005; 80(10 suppl):S12-S20Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279:1889-1893
What does medical student distress look like?
Unproductive coping mechanisms
Leading to…Burnout
Impaired academic performance
Cynicism
Academic dishonesty
Substance abuse
DepressionLack of attention
to balancing
personal needs
Depression
• Reports in 13 to 24% of medical student population
• Overall, studies indicate more depressive symptoms and psychological distress than age-matched peers
• Depression peaks in the 2nd year and tends to coincide with Step 1 board exams
Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002; 77(9):918-921.Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005; 53(5):219-224.Dahlin M et al. Stress and depression among medical students: A cross-sectional study. Med Educ. 2005; 39(6):594-604
Substance Abuse • Problems with self-report mechanisms
• Rates similar to general population: 13-26%
• Increased use of benzodiazepines
• Habits carry over from undergraduate years
• Trends in medical school substance use follow undergraduate patterns
Croen LG et al. A longitudinal study of substance use and abuse in a single class of medical students. Acad Med. 1997; 72(5):376-381.Keller S et al. Binge drinking and health behavior in medical students. Addictive Behaviors. 2006. IN PRESSBoland M et al. Trends in medcial student use of tobacco, alcohol, and drugs in an Irish university, 1973-2002. Drug and Alcohol Dependence. 2006; 85:123-128.Newbury-Birch D et al. Drink and drugs: from medical students to doctors. Drug and Alcohol Dependence. 2001; 64: 265-270.
Program for Liberal Medical Education (PLME)
• High school students accepted into Brown University and Brown Medical School
• 60 students accepted
• PLME students are joined by approximately 40 other students in medical school
Student Health Council (SHC)
• Mission: Promote healthy functioning of Brown PLME and medical students within their social and professional communities
SHC Goals
• Education– Awareness and Discussion– Provide Resources
• Support– Confidential Peer Counseling– Resource connection– Advocacy for students on school issues
• Patient Safety
SHC: Referral Routes
Voluntary Dean
Referral16%
Peer Referral
13%
Self Referral
16%
Mandatory Dean
Referral55%
0 5 10 15 20 25
Depression/Anxiety
Learning Disab/Acad Distress NOS
Family Stress
Other DSM Dx
Substance Abuse
Distress NOS
Eating Disorder
Anger/Boundary Violations
Suicidality/Cutting
Physical Illness
Prior Trauma
Sleep Disorder
No specific issue identified
Issues
Number of Cases Where Issue Has Been Important
PHC Scope of Cases
Addictions34%
Sexual Boundaries
16%
Behavior17%
Psychiatric Issues23%
Competency8%
Physical Health
2%
SHC: Barriers to Utilization
• Stigma
• Lack of defined policies on standards of professional behavior for students
Case Description
Part One: 2003• Junior PLME• Self-referral• No academic issues• Polysubstance abuse• Depression and suicidality • Treatment successes and setbacks
Case Description
Part Two: 2006• 2nd year medical student• Still no academic issues• Continued substance use• Unable to comply with random drug
testing• Beginning to have contact with
patients…
Our Dilemma• 2004
– Do we report him to the deans?
• 2006– Patient safety at stake– Self-referral mechanism does not allow
for reporting– No clear consequences without
academic issues– How do we get this student to comply
with treatment? And protect patients?
Survey Methods
• Non-scientific
• Limited to Northeast schools– Connecticut – Rhode Island– Massachussetts – New Hampshire– Vermont – New York
• Sources: student affairs office, student handbook
Survey Questions
1. Does the school have an impairment policy or equivalent
2. How is impairment defined
3. To whom does the policy apply
4. Protocol
5. Consequences
Schools with Impairment Policies
• Schools contacted 19• Schools responded 18
_________________________________
• Schools with no impairment 2
policies• Schools with official statements 16
on impairment
Scope of Policy
Groups Covered by PolicyNumber of Programs
Medical Students 5
Students in Medical Fields 2
All Members of Medical Community
5
Undergraduate and Graduate Students
3
All Graduate Students 1
Consequences
• Physicians– Medical license
• Medical Student– Probation– Notation on academic record/ Dean’s
Letter– Referral to PHC in state of residency – Expulsion
Our Criteria for Strong Impairment Policies
• Broadly defines impairment• Specific to medical students• Narrowly defined protocols for assisting
impaired students• Clearly delineates consequences for
policy violations
Based on these standards…4 schools’ impairment policies
met criteria
Creating a Policy
Lengthy internal discussion on problem cases
Preliminary research:
How do we define
impairment?
Convene group of faculty
and students
Group Retreat
Team of students and faculty developed a
draft
Meeting with administrative policy makers
Standards of Professional Behavior
Honesty• Cheating on examinations, falsifying
applications or data on medical records and other forms of intellectual dishonesty are wrong not only because such behavior violates intrinsic academic honesty, but also because such behavior may be deleterious to patients.
Standards of Professional Behavior
Health• Specific illnesses that impair performance
include, but are not limited to, active drug and/or alcohol addiction, severe depression and other psychiatric illnesses and, occasionally, physical illnesses. It is not permissable for students to interact with patients while impaired by these conditions.
• It is the policy of the medical school to encourage recognition of illness which leads to impairment in medical students and to support treatment so that those students may continue their education successfully and without stigma.
Standards of Professional Behavior
Boundary violations with patients• It is never appropriate to have a sexual
relationship with a current patient. Knowledge acquired during the doctor-patient relationship should never be used for any purpose other than therapeutic. A romantic relationship based on this information is always inappropriate.
Standards of Professional Behavior
Criminal activities• These include, but are not limited to, selling
or dealing drugs, child abuse, possession of child pornography and sexual activities resulting in legal discrimination as a registered sex offender. Such behavior is incompatible with medical professionalism.
Standards of Professional Behavior
Reporting violations• There is an ethical imperative to report
medical students and physicians in violation of these standards.
• Reports may be made to the Associate Dean for Medical Education
• Reports of health issues may be made to the Student Health Council
• Reports about faculty or other physicians may be made to the medical school or to the RI Physician Health Committee
Communication
• First-year orientation presentation with case discussions
• Online Student Affairs policy handbook• Communication with individual SHC cases• Will make reporting parameters a part of
each new SHC contract
What would have happened?
• If this policy had been in place when our difficult case arose…– Clear from the outset that the behavior was
problematic despite lack of academic difficulties
– Collaboration with the administration– Compliance with random drug testing as a
condition of enrollment– Medical leave of absence for in-patient
treatment when necessary– Arrangements clear about reporting to the
PHC in the student’s state of residency
Hopes for Medical Students at Brown
• Clearer expectations of appropriate behavior
• Increased interventions for problem behavior
• Obligation to report/confront colleagues with problem behaviors
• Improved treatment contract compliance and treatment outcomes
Hopes for the Profession
• Consensus on standards of professionalism for physicians
• Uniform policies at medical schools• Clear communication with students about
consequences of untreated or under-treated impairment
• A culture that values awareness and remediation of impairment and where students and physicians who are successfully engaged in the recovery process are free from stigma
Contact Information
• Brown’s Student Health Council– Pebble Kranz ([email protected])– Ivone Kim ([email protected])– Ashlynne Harris ([email protected])
– RI Medical Society
Rosemary Maher, Program Director ([email protected])
Acknowledgements
• Dr. Herb Rakatansky• Rosemary Maher• Sarah Wakeman• SHC Members• Medical Schools surveyed• RI Medical Society• RI Medical Society Insurance Brokerage
Corporation• Brown Medical School• Charles F. Carpenter Grant
References1. Papdakis, MA et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J
Med. 2005; 353; 2673-82.2. Teherani A, Hodgson CS, Banach M, and Papadakis MA. Domains of unprofessional behavior during
medical school associated with future discliplinary action by a state medical board. Acad Med. 2005; 80(10 suppl):S12-S20
3. Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279:1889-1893.4. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of
Physicians-American Society of Internal Medicine;European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 Feb 5;136(3):243-6.
5. Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002; 77(9):918-921.
6. Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005; 53(5):219-224.
7. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ. 2005; 39(6):594-604.
8. Croen LG, Woesner M, Herman M, Reichgott M. A longitudinal study of substance use and abuse in a single class of medical students. Acad Med. 1997; 72(5):376-381.
9. Keller S, Maddock JE, Laforge RG, Velicer WF, Basler HD. Binge drinking and health behavior in medical students. Addictive Behaviors. 2006. IN PRESS
10. Boland M et al. Trends in medcial student use of tobacco, alcohol, and drugs in an Irish university, 1973-2002. Drug and Alcohol Dependence. 2006; 85:123-128.
11. Newbury-Birch D, Wlashaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug and Alcohol Dependence. 2001; 64: 265-270.
12. DyrbyeLN et al. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81:354-373.
13. Dyrbye et al. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006;81:374-384.
14. Dyrbye et al. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-1622.