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.

Student Health Council (SHC)

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 Structure

• Referral

• Establish Contact

• Evaluation

• Contract

• Advocacy and support

SHC ReferralsReferrals by Year

02468

101214

Year

Num

ber

of C

ase

s

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

• Sexual boundaries

• Behavior

• Psychiatric Health

• Physical Health

PHC Scope of Cases

Addictions34%

Sexual Boundaries

16%

Behavior17%

Psychiatric Issues23%

Competency8%

Physical Health

2%

SHC Effectiveness

• Anecdotal evidence of successes

• Advocacy at Deans’ hearings

SHC Structure

• Referral

• Establish Contact

• Evaluation

• Contract

• Advocacy and support

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?

Beyond Brown

Impairment policies in other medical schools

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

Definition of Impairment

Broad Definition

Narrow Definition

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

Disciplinary Protocols

General Protocols

Specific Protocols

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 (Pebble_Kranz@brown.edu)– Ivone Kim (Ivone_Kim@brown.edu)– Ashlynne Harris (Ashlynne@brown.edu)

– RI Medical Society

Rosemary Maher, Program Director (rmaher@rimed.org)

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

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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.

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