fornia’s Confidentiality of Medical Information Act (CMIA), Federation of State Medical Boards (FSMB), Federation of State Physician Health Programs (FSPHP), Medical Board of California (MBC), The Joint Commission (TJC).
LEVELS OF PROFESSIONAL EVALUATION
Preliminary or “screening evaluation” and “comprehensive evaluation” are two levels of evaluations that can be conducted by professional evaluators. As noted below, there are some cases in which a preliminary or screening evaluation may be acceptable. Always, the professional evaluator should be mindful of the possibility of more serious underlying problems which may result in a recommendation for a comprehensive evaluation. The risk in conducting a Screening Evaluation is that it may miss important underlying conditions. It is in the nature of impairment that psychological dynamics of shame and denial can result in the physician obscuring problems in order to avoid consequences. Lack of accurate self-assessment and insight can be a part of physician impairment. The impaired physician genuinely may not recognize the nature and extent of the impairment and plead for return to practice. Allowing a physician who manifests impairment to return to work does not benefit that physician. It risks poor patient care, the shame and guilt associated with preventable adverse outcomes, lawsuits, discipline, and even permanent loss of licensure. The Comprehensive Evaluation is intended to be comprehensive and in-depth; it is the equivalent of psychological surgery. Because addressing psychological issues can be challenging, considerable time is spent extensively covering history, and the physician under evaluation is encouraged to freely present his/her viewpoints. When evaluating impaired physicians, the evaluator can be confronted with the physician’s deeply embedded defenses of minimization and denial. Too easily, inexperienced evaluators ally with the physician’s defenses, often well articulated. The impaired physician may invite a cursory evaluation by trying to impress the evaluator with his/her prestige and status. Brief evaluations often miss the mark resulting in protracted impairment. It is important to do the evaluation right the first time for the benefit of the physician, significant others in the physician’s life, and patients. A comprehensive evaluation can be life saving to the physician’s professional career and personal life.
Screening Evaluation: • MD has positive attitude toward PWBC and acceptance of referral for evaluation • Cooperates in providing information and background records • Open to feedback and recommendations • Presents with “minor problems:” ȧȧ Stress or burnout without diagnosable mental illness ȧȧ Recent or occasional occurrence of problems; not part of a long-standing pattern ȧȧ No actual impairment in work performance • Agrees to subsequent, periodic evaluation before final evaluation and determination regarding FFD • Agrees to a preventive approach, especially in cases of “potentially impairing illness” (ASAM) • Presents with a low risk of litigation • No need for an extensive written report • The preliminary or Screening Evaluation may result in a recommendation for a Comprehensive Evaluation. Comprehensive Evaluation: • Problem is part of a longstanding recurrent pattern.
• MD is contentious, oppositional, and resistant to intervention and assistance. • Complex diagnostic case involving potentially many cooccurring conditions, e.g., substance abuse, mental illness, personality problems, physical conditions, and/or external stressors. • Impaired work performance or disruption of coworkers. • Failure to respond to prior discussions, redirection, or discipline. • Unreasonably blames others and circumstances for problems. • Wants retribution. • Little or no prior treatment or inadequate treatment. • Significant denial, lack of self-awareness, and lack of insight. • Litigious. • Placed on administrative leave because of seriousness of problems. • Need to ensure protection of the public while pursuing a goal to alleviate the symptoms, return to work, manage problems, and prevent recurrences. • Need for an extensive written report with data and analysis to support recommendations; report serves as case management plan for treatment and monitoring. Failure of the physician to accept or comply with remediation could result in a recommendation to pursue disciplinary action through the MEC, especially if there is risk of danger to the public.
ELEMENTS OF COMPREHENSIVE EVALUATION
Modified from Reynolds NT, A model comprehensive fitness-forduty evaluation. Occupational Medicine: State of the Art Reviews, 2002.
Review of Records: • Incident reports prompting the referral for evaluation • Job description • Job performance evaluations • Police reports • Department of Motor Vehicle records • Prior psychological evaluations (e.g., pre-employment) • Medical and mental health treatment records • Pharmacy records of medications obtained by the individual being evaluated • National Practitioner Data Bank entries Face-to-Face Interviews for Comprehensive History: • Basic identifying data • History and perspective of the physician • Habits: nicotine, caffeine, alcohol, and substances • Background history: medical, financial, legal, education, employment, family, and social Mental Status Examination: • General appearance • Alertness and orientation • Symptoms (physical, psychological, psychosomatic) • Mood and affect • Cognitive screening • Personality dynamics and relationship skills (pathological, defenses, positive coping skills) • Reality testing Laboratory: • Alcohol and drug urine screening via chain-of-custody • Hair sample analysis for drugs Continued on page 30 SEPTEMBER / OCTOBER 2015 | THE BULLETIN | 29