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Recognizing and Addressing Signs of Burnout and Substance Abuse in Physicians

It is estimated that 10 to 12 percent of physicians and nurses develop substance use problems. While there is no direct connection between individuals who work in healthcare and substance abuse, there are job-specific contributing factors. Gaurava Agarwal, MD, assistant professor of Psychiatry and Behavioral Sciences at Northwestern Medicine, specializes in healthcare professional wellness. He discusses resources available to address physician burnout and promote overall wellness as well as signs to look out for in your colleagues.

Related: Combating Physician Burnout: Scholars of Wellness Program
Recognizing and Addressing Signs of Burnout and Substance Abuse in Physicians
Featuring:
Gaurava Agarwal, MD
Dr. Gaurava Agarwal is a board-certified psychiatrist with a special interest in mood disorders, ADHD, schizophrenia, addiction, positive psychiatry, and healthcare professional wellness. Currently, he is an instructor in both the Departments of Medical Education and Psychiatry at Northwestern’s Feinberg School of Medicine. He serves as the Director of Undergraduate Medical Education in Psychiatry for the Department of Psychiatry and Behavioral Sciences. He also serves as an inpatient unit director for Stone Institute of Psychiatry at Northwestern Memorial Hospital. He is the course director for a professionalism and wellness course for medical students called “Personal Transition to the Profession.Dr. Agarwal is a nationally recognized educator who has won the prestigious Association for Academic Psychiatry Junior Faculty Award and is the first psychiatrist to win the George H. Joost Award for outstanding clinical teacher from Northwestern’s Feinberg School of Medicine. He has served as a co-investigator on multiple clinical trials for cutting edge pharmaceuticals studying the treatment of bipolar disorder and schizophrenia. Dr. Agarwal has been published in peer reviewed journals and presented national workshops on issues of physician and medical student burnout, resilience, engagement, and professionalism. 

Learn more about Gaurava Agarwal, MD
Transcription:

Melanie Cole (Host):  Welcome. This is Better Edge, a Northwestern Medicine podcast for physicians. I’m Melanie Cole and it’s estimated that 10 to 12% of physicians and nurses develop substance use problems. While there’s no direct connection between individuals who work in healthcare and substance abuse issues; there are job specific factors that can contribute. Joining me today, is Dr. Gaurava Agarwal. He’s an Assistant Professor of Psychiatry and Behavioral Sciences and Medical Education at Northwestern Medicine. Dr. Agarwal, it’s a pleasure to have you join us and we’ve already mentioned that 10 to 12% of physicians develop substance abuse issues; but the risk can be even higher for physicians in specific specialties. Can you share some of the statistics and why this is the case? Tell us what you’re seeing in the trends with physicians and substance abuse issues and the sometimes resulting unhealthy ways of dealing with their stress?

Gaurava Agarwal, MD (Guest):  Yeah, thank you for having me. The physician substance abuse matches a little bit of what the general population is seeing in terms of the 10 to 12% of rates of alcohol use disorders with an additional about 6 to 8% of physicians with substance use disorders. What we’re seeing is that there seems to be a bit of a specialty difference, although the data is difficult to collect. What we see is that for alcohol; specialties such as dermatology, orthopedic surgery, and emergency medicine physicians seem to have higher rates of alcohol use disorder where specialties like neurology and pediatrics tend to have lower rates of alcohol use disorder. What we also see is that different specialties tend to use different substances and what we think might be responsible for that is different specialties come into contact with different substances more frequently and therefore have great familiarity with those drugs and probably take away a little bit of their scariness if you will. So, for instance, psychiatrists, anesthesiologists, emergency room doctors and family practice solo practitioner doctors tend to have higher rates of substance use than other specialties.

One of the reasons we thing psychiatrists have higher use of benzodiazepine drugs is because they are often big time prescribers of benzodiazepines. Similarly, anesthesiologists have higher rates of using opioids because that’s a big part of their regular daily practice. What we see with emergency room doctors, maybe that they tend to use a little bit more cocaine or marijuana is we think that potentially, emergency room doctors have higher kind of novelty seeking personalities where they are looking for change and new things and that’s one of the reasons that attracted them to emergency medicine. So, we may see some of those differences in types of substances they are using related to different specialties.

Host:  So interesting. What a fascinating topic. What are some of the unique pressures of the healthcare industry and as you’ve mentioned anesthesiologists and behavioral psychologists and different aspects of the healthcare industry. Tell us how that contributes to substance dependency. What are some of those unique pressures?

Dr. Agarwal:  Sure. I think there’s probably two ways to bucket it. One is kind of what do doctors bring to the table and one of the things that people have looked at is this concept of the compulsive triad in terms of what we select for in our physicians and what’s kind of a part of our personality often and that triad is composed of kind of a higher tendency to self-doubt and exaggerated or inflated sense of responsibility and a lot of guilt, frankly. And those three things combined can kind of result in higher perfectionism, kind of pushing through things to take care of our patients even when we maybe hurting our own selfcare. So what we see is we often see physicians with poor sleep, a lot of stress and then they’re self-medicating with these medications. It may have started off as a simple drink at night to help get to sleep or a simple benzodiazepine to help them sleep because they can’t kind of turn it down or they have been on call several nights in a row and before you know it, things kind of get out of control.

So, that’s I think what the individual physician brings and then certainly from the healthcare industry, and organizations what we’re seeing is an increase in physician burnout across the country and this concept of burnout is certainly generating a lot of attention and what we have found is that the contributors to burnout and the interventions that help burnout really start with the organizational structure and organizational factors that physicians deal with in terms of the amount of work, workload and hours they spend at work, how intense those hours are. So, some people might work eight to ten hours but there’s a lot of – it’s not always intense and when you are a physician; those hours are really each patient is somebody that we are very intensely focused in on and that can wear you down after a while is when you are dealing with that 24/7 in that kind of a system.

Host:  That makes so much sense. They way that you laid that out Dr. Agarwal, what are some of the signs and symptoms of addiction to look for among physicians as their coworkers or their assistants, people that work with them or even their loved ones, know the pressure that they are under and as you say, they put themselves under this great amount of pressure. What should people be looking for when they’re working with these physicians?

Dr. Agarwal:  I think a couple of things here. One is really highlighting what you alluded to is that the people in their home lives spouses, children, family and friends may notice different things than people at work. Physicians are notoriously able to hold it together at work while everything at home may be falling apart or has fallen apart for months or even years in advance. And so that’s something that we need to be mindful of and encourage the families of our physicians to have better abilities to help talk to their organizations or the physician’s partners if they have concerns because they are far more likely to see things changing much earlier than people at work.

I think number two, I’d encourage people to have their radars up at specific points. Some of this is anecdotal in terms of the physicians I’ve seen over the years. But what we see is because physicians are kind of always working at high stress; the tipping point can come pretty suddenly. So, what I mean by that is something else – an event in their lives that stresses them out can kind of tip them over where they’ve kind of been able to reach this fragile balance. And so what we see a lot is that if a physician’s child get sick, if they have the death of a parent, if they’ve had a horrible outcome at work or recently been sued, it they have recently changed how they practice i.e. maybe they have sold their practice to a larger organization and now they’ve gone from private practice to working for a big institution; these moments are times where things may have been going along steadily and then things get out of whack. So, in these big change moments in people lives, I think we need to be doubly acutely aware of looking out for things going on. Another big, big moment is divorce or marital strife and after a divorce both the stress of the divorce and potentially getting back out on the dating scene we have seen that can lead to some issues for a lot of our physicians.

And then finally, kind of in terms of signs and symptoms to be looking out for, at work especially is physicians always show up and so if people are not showing up, they’re late, they’re not calling about being late or not calling about showing up; that’s a big red flag that potentially they are hung over or they are under the influence. If you are seeing physicians with big time changes in their weight, big time changes in their sleep and irritability; these can be big warning signs. If you are seeing physicians ask you to order them narcotics. If you are seeing them lingering in the operating rooms potentially wanting to throw away things or help with the trash, things that normally physicians frankly don’t do; those would be warning signs that maybe they are looking for the extra opiates et cetera that they may have been using for their physicians.

If they tend to order more controlled substances than their peers; that can be a warning sign that potentially some of those medications are not being used appropriately. And then finally, thinking about how their behavior is at work functions or even family functions. Are they getting out of control more? Do they have any kind of outbursts or embarrassing moments where they have drank too much at work? That’s pretty unusual and may be a signal of a bigger problem.

Host:  What an amazing list of red flags Dr. Agarwal. Thank you so much for that comprehensive answer. So, tell us a little bit about your clinic that specializes in the treatment of impaired professionals. How do you work with healthcare professionals specifically as they may be reluctant to seek help for fear it will jeopardize their careers? Tell us about some of the treatment programs and resources that you have available.

Dr. Agarwal:  Sure. So, there’s several ways that people come to our attention. As you mentioned, unfortunately, a lot of the times it’s not because the physician says heh you know I think I’ve got a problem. They ways that people come to our program generally are largely through what are called physician health programs. So, most states at this point, have physician health programs and they’re designed to be able to decrease the punitive nature of seeking help. And the idea is that the physicians can call their physician health program for their state and self-report and ask for services or an evaluation and these physician health programs can do their own evaluations but they can also use specialized third party programs that can do comprehensive evaluations that say he you know, is this a substance use problem, is this a mental health problem, is this really a sleep problem? What is causing some of these issues that you might be having? And all of that can be done without reporting to medical licensing boards, especially if treatment is then sought as long as the physician is following the recommendations of the treatment, it doesn’t have to be reported to the licensing boards which is a really, really effective way of trying to make sure that we can get people treatments before something bad happens whether that be something like a DUI, or patient harm.

And so when the physician health program then can refer to our clinic and we would do an evaluation. A lot of times, these evaluations can be multiple days long, involving numerous specialists, people with addiction psychiatry specialty, people with specialty in sexual compulsivity, eating disorders. We do a really comprehensive neuropsychological assessments, psychological assessments, to really try to get down to what is going on, what is driving either the issues at work or if the physician reported themselves or their family member asked them for an evaluation, they can really figure out what’s going on because my philosophy is that you really can’t treat unless you make an appropriate diagnosis.

Host:  How do you help physicians return to their careers after treatment? Can you – you can’t give them any promises, but how do you give them hope and encouragement that yes, they will be able to return?

Dr. Agarwal:  So, some of the things that we do and what I want to highlight for the audience is that about 80% of physicians are successful in their treatment at maintaining sobriety. And that percentage is significantly, significantly higher than the general population. And so, physicians for lots of different reasons have a great success rate. Society is invested in our physicians. Corporations have invested in our physicians and obviously there is a great need for our physicians and so, there are a lot of factors that are working in the physician’s favor to get back to work.

And a couple of things help us I think achieve that really high rate of success. One is physicians obviously have a lot to lose if they can’t maintain sobriety, you are going to be losing your career and it’s not just a career for most physicians, it’s our identity, it’s our calling. And so there’s a lot of motivation to get better. Physicians are able to return to work oftentimes by signing up with the physician health program for generally a five year contract and during those five years, the physicians health program will monitor the physician for the use of any substances whether it be alcohol or controlled substances and that accountability that monitoring provides physicians, is really good in terms of helping maintain long term sobriety. It’s very helpful in organizations trusting the physician is sober. Right? Because there’s documented evidence that the person is maintaining their sobriety which helps take away some of those – the mistrust that may have developed amongst the employers, et cetera.

I think the third thing that is very helpful is generally physicians get treatment or are recommended to get treatment if at all possible, in treatment centers that specialize in healthcare professionals. And what that does is when they are in treatment, there’s a great deal of shame and guilt that physicians go under but by seeing colleagues in that treatment center with them going through the same process they are; that helps decrease that shame and guilt, it helps them see the light at the end of the tunnel as some of their peer graduate and return to work which helps motivate them in those early stages when you are beating yourself up, you are so scared that you may never get to practice again. All of these things help people get through that early phase and see the light at the end of the tunnel.

Host:  What an amazing program. As we wrap up, can you give us some suggestions or examples of how organizations and individuals can create an environment that would support wellness for physicians. It’s such a tough job and share some of the efforts that Northwestern Medicine is using that are underway to help their physicians and staff.

Dr. Agarwal:  Yeah, I think what we’re seeing around the country is a real focus on physician wellbeing and different people have used different organizational structures to do this. Some organizations have created centers of professional wellbeing, Chief Wellness Officers in their organizations et cetera. But how you do it, I think it matters a little bit less. What you are doing, I think is important and one of the ways that we can be very systematic about this is to first of all, make sure that we are measuring physician wellbeing. We always measure how many patients we see, how much income we generate, et cetera. This should be another metric that we are measuring is how are physicians doing from a burnout perspective. And in some ways, for me, more importantly how are we doing around the drivers of burnout? So, figuring out people are burnt out is important, but figuring out why is more important in terms of actually creating interventions.

And so once we measure these things, we then need to be very proactive about addressing these drivers of burnout. Things like excessive workload, things like work getting in the way of people’s personal lives and their family lives, community, isolation. When we talk about substance use in physicians, it’s harder to miss things if we are connected and we have a community of coworkers that can notice those subtle changes that people may be trying to hide or notice the stress that someone is under and check in on you. And so, making sure that we are building a community that cares for each other and knows each other can be useful.

In terms of Northwestern, we’ve created a physician wellbeing program and I direct that program and we really have a framework for how we think about helping our physicians in terms of we are trying to care for individual physicians and their individual needs, we are really trying to make the workplace more efficient and one of the programs that we use for that is called the Scholars of Wellness and what it’s based on is a faculty development program where we train physicians from all around the campus on how wellness works, what are the factors that you need for physician wellness and how do you make change in your local environments to address some of those drivers of burnout? Because what we have realized is that what might cause burnout in someone like me who is a psychiatrist may be very different than what’s causing burnout among surgeons and who better to fix their local environments are the people that live it every day. So, that program has been a great success in creating lots of pilot interventions and dealing with some of those individual drivers that are unique to each of our fields.

Plus we create basically an army of other physicians that are really trained in the vocabulary of dealing with physician wellness who can then do additional – hold additional leadership roles in their departments and in the hospital.

Host:  Wow. What great information and what an excellent, excellent episode. Dr. Agarwal, thank you so much for coming on and sharing your incredible expertise in this very unique position that physicians and healthcare providers find themselves in and thank you again for discussing that with us today. And that wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at www.nm.org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.