The Victorian Doctors Health Program: the first 3 years

The VDHP joins earlier and continuing contributors to the field of doctors’ health, such as the Doctors’ Health Advisory Service and the Box Hill Hospital re-entry program for impaired anaesthetists, which successfully returned five specialists to practice after treatment for opiate dependency. 1

Here, I describe the principles of the VDHP and its activities and participants in its first 3 years of operation. I do not assess the overall impact or efficacy of the program.

• To draw on the considerable North American experience of Physician Health Programs. 2-7

• To incorporate the 1994 recommendations of the US Federation of State Medical Boards Ad Hoc Committee on Physician Impairment. 8 These include the elements of a model program, such as assessment, relapse management and confidentiality, a two-pathway system of referral (voluntary or mandated), and the principle of a contract for case management).

• To develop a program specifically suited to Australia. For example, the North American culture for managing substance use disorders is largely abstinence-based, and there is much medical and community support for abstinence from all drugs, including alcohol, and for self-help group programs such as Alcoholics Anonymous and Narcotics Anonymous. This is not generally the case in Australia.

The VDHP has a five-person board of management appointed by the Medical Practitioners Board of Victoria and the Australian Medical Association Victoria, but independent of both bodies (ie, no member of the Medical Practitioners Board can be a member of the VDHP board). The management board has appointed three staff members to deliver the program: a medical director with expertise in managing drug and alcohol problems and experience of North American physicians’ health programs (0.8 full-time-equivalent), an office administrator (full-time) and a case worker/psychologist (full-time). The services provided by the VDHP are shown in Box 1.

Primary reasons for the 220 contacts that resulted in program participation are shown in Box 2. Most involved alcohol or other drug problems (92), followed by psychiatric problems (82) and stress-related or emotional problems (40). Of the 92 doctors with an alcohol or other drug problem, 23 had a comorbid mental health disorder. Some of the 17 doctors with a personality difficulty or disorder had been referred by their employers as “disruptive”. Five of the doctors who sought psychiatric assistance had violated sexual boundaries.

All doctors with alcohol or other drug problems were referred to appropriate outpatient or inpatient treatment facilities and, after primary treatment, returned to the VDHP for case management and relapse prevention. All those with psychiatric disorders were referred to an appropriate psychiatrist, with the VDHP monitoring progress by maintaining contact with both the participant and the treating doctor. Many of the 40 cases of stress-related or emotional problems were related to “doctor burnout” and were managed with counselling by a psychologist or psychiatrist.

Six contacts were doctors seeking management for a physical condition. For example, one doctor sought referral to a specialist for management of previously self-managed diabetes and hypertension; another doctor was moving from a rural to an urban area and was looking for a personal general practitioner. Doctors with a physical illness were referred to an appropriate general practitioner or specialist for treatment, with subsequent follow-up by the VDHP.

The VDHP provided care at three levels:

• Standard care: preliminary assessment and referral, and up to two consultations with the VDHP (99 cases);

• Extended care: three or more consultations with the VDHP (56 cases); and

• Intensive involvement: entry into the Case Management, Aftercare and Monitoring Program (CAMP) (65 cases).

In standard and extended care, participants were followed up by the VDHP until it was mutually agreed that the program could be of no further assistance or, in six cases, until repeated attempts at follow-up were unsuccessful. Those receiving standard or extended care included 34 doctors who had early symptoms of alcohol misuse or were in long-term recovery from substance use disorders. The other 58 doctors with substance use disorders entered CAMP, along with seven doctors with mental health disorders requiring intensive after-care and monitoring (eg, psychosis).

Participants in CAMP are required to enter into a written agreement with the VDHP tailored to their individual needs (Box 3). For example, all participants are required to attend a general practitioner, while all with a substance use disorder are required to attend an addiction medicine specialist, and some a psychiatrist.

Of the 58 CAMP participants with a substance use disorder, 50 were men, and 15 were diagnosed with a comorbid mental health disorder. Their drugs of choice were alcohol (21), pethidine (18), heroin (7), codeine (3), benzodiazepines (3), amphetamines (2), cocaine (2), nitrous oxide (1) and ketamine (1). They belonged to a broad range of disciplines: general practitioners (20), anaesthetists (6), hospital medical officers (6), surgeons (4), pathologists (3), radiologists (3), registrars (3), interns (2), physicians (2), researchers/academics (2), overseas graduates (2), and an obstetrician/gynaecologist, an occupational medicine specialist, a paediatrician, a psychiatrist and a medical student.

Group meetings are an important part of the CAMP program for almost all participants. The Caduceus Group (named after similar mutual support groups for health professionals in the United States) meets weekly and is facilitated by professional alcohol and other drug counsellors. Mutual self-help groups, such as Alcoholics Anonymous and Narcotics Anonymous, are considered crucial components of many CAMP agreements. Self-medication is prohibited for all participants, and monitoring for drug use is required.

The optimal outcome for CAMP participants is considered to be stable recovery, abstinence, resumption of work (or the capacity for this) and good quality of life. However, abstinence, even without return to work, or sufficient reduction in drug use to allow return to work, are also seen as satisfactory outcomes. It is also acknowledged that substance use disorders are chronic relapsing diseases. As relapses may occur at any time in the course of life, contact should preferably be maintained indefinitely.

The progress of participants has varied, with most having outcomes considered satisfactory (Box 4). This includes 52 of the 58 with a substance use disorder; 46 are abstinent, 39 of whom are working (see Box 5A and Box 5B). Of the six with unsatisfactory outcomes, three have died. One of these had his CAMP agreement terminated because of non-compliance 3 months before his death. He had not worked as a doctor for over 10 years and was a “street-drug user”, dying of a heroin overdose. Another deceased participant had his CAMP agreement terminated by mutual consent, had been deregistered by the Victorian Medical Board and had moved interstate 6 months before his death, which was drug-related. However, the third participant who died had been active in CAMP and, according to a coroner, died of physical causes, with drugs not implicated. Another of the participants considered to have an unsatisfactory outcome relapsed after more than 2 years’ abstinence and is currently being re-treated.

Of the seven CAMP participants with a mental health disorder but no concurrent substance use disorder, the condition of five has improved, and they are working (see Box 5C). Another also shows improvement but chose to defer his employment for 12 months. The other (with a personality disorder) left the program; although neither his current health nor employment status is known to VDHP, his capacity to practise was never considered impaired, and there was no known or perceived risk to patients under his care.

The VDHP maintains a confidential program independent of the Medical Practitioners Board of Victoria. It is required to notify the Board only of participants who breach the Medical Practice Act 1994 — that is, registered health practitioners with an illness or condition that has seriously impaired, or may seriously impair, their ability to practise and (my italics) may result in the public being put at risk. 9 To date, no Board notifications have been necessary, as impaired participants who enter the program are asked to cease practice until they have achieved stable recovery and can safely return to work; all those considered impaired have either complied with this or had already been suspended from practice.

Of the 65 CAMP participants, 36 are known to the Board. Some participants were referred by the Board to the VDHP, while others were reported to the Board either before they sought VDHP assistance or independently of seeking assistance.

The VDHP provides a structured, confidential way of coordinating and delivering the appropriate management for a range of health problems experienced by an important community resource — medical professionals. The current case profile of the VDHP shows a predominance of substance use and mental health disorders requiring attention, but also a considerable number of doctors seeking help for stress or emotional problems. The VDHP upholds the interests of both the profession and the community. It will maintain its links with the North American Physician Health Programs and will review the recently updated guidelines of the US Programs,10 which provide a new “gold standard” for delivering health services to the medical profession.