What do you do if your relief comes to work intoxicated: An Impaired Provider Scenario

Abstract

Audience

The primary audience for this simulation exercise is emergency medicine (EM) residents, although it could be more broadly applied to all provider groups, including medical students, advanced practice providers, and faculty physicians.

Introduction

Over the course of their professional careers, approximately 10–15% of physicians will misuse or abuse alcohol or drugs.1 Unfortunately, Emergency Physicians (EPs) are not immune to this phenomenon, and although EPs make up only 4.7% of the active physician workforce,2 they are over-represented in samples of physicians referred to physician health programs (PHPs) for substance use disorder.3 Despite this increased prevalence, when EPs were referred to a PHP by themselves, family, or colleagues, 84% of them completed the program and were practicing medicine 5 years later,3 which makes recognition and referral of the impaired physician an important step to provide the treatment needed for recovery and ultimately for return to practice. Given the prevalence of substance use disorder in EPs, it is not surprising that the 2019 Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements in Emergency Medicine stipulate that “residents and faculty members must demonstrate an understanding of their personal role in the recognition of impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team.”4 Furthermore, the common program requirements also outline that each residency program must have “designated individuals responsible for reporting impaired providers in accordance with each institution’s policies as well as being knowledgeable in the resources available to said provider.”4 Despite these requirements, there are no best practices available to outline how residency programs can effectively teach trainees how to recognize and report the impairment. This simulation scenario is intended to provide an opportunity for learners to recognize an impaired colleague in a clinical setting, remove them from the clinical care environment, and notify the appropriate contacts, such as a Program Director, Department Chair, or nursing supervisor. To our knowledge, this is the first described simulation scenario where learners develop competency in recognizing and reporting the impaired provider.

Objectives

By the end of this simulation, learners will be able to: 1) Identify potential impairment in the form of alcohol intoxication in a physician colleague; 2) demonstrate the ability to communicate effectively with the colleague and remove them from the patient care environment; 3) discuss the appropriate next steps in identifying long-term wellness resources for the impaired colleague; and 4) demonstrate understanding of the need to continue to provide care for the patients by moving the case forward.

Educational Methods

This scenario is a simulated encounter taking place in the emergency department (ED) where the patient is a trauma activation who is not critically ill; the learner’s confederate colleague in the scenario arrives for sign-out smelling of alcohol and appearing intoxicated. The learner will need to both provide care for the injured patient while addressing their colleague’s impairment and safely removing them from the patient care area.

Research Methods

The effectiveness of this simulated scenario as a teaching instrument was evaluated utilizing an internally developed evaluation survey that is part of the standard simulation curriculum at West Virginia University (WVU). The survey consisted of questions both regarding the effectiveness of the instructors as well as of the simulation, rated on a Likert scale. Learners were given the opportunity to answer free response questions where they were asked to reflect upon their experience, including the strengths of the experience and any identified opportunities for improvement.

Results

Using a standard Likert scale, learners completing the impaired provider simulation scenario reviewed the effectiveness of the simulation and instructors very positively, with the vast majority of learners scoring all aspects of the scenario either as a 4 or 5. The free response answers were universally positive with many participants considering the experience very useful for training on a topic that is not frequently taught in other portions of the formal didactic curriculum.

Discussion

While it is fortunately rare to encounter a colleague who is acutely intoxicated by alcohol or drugs and to simultaneously be responsible for providing patient care, it is important that learners are provided with formal instruction on how to recognize impairment and navigate the potentially difficult conversation with the impaired provider to ensure patient safety. This simulated scenario provides a realistic curricular instrument that could be implemented in any EM training program.

Topics

Substance abuse; impaired provider; impaired provider reporting policies; professionalism; patient safety; provider safety.

USER GUIDE

List of Resources:
Abstract	1
User Guide	3
Instructor Materials	5
Operator Materials	19
Debriefing and Evaluation Pearls	21
Simulation Assessment	24

Learner Audience:

Medical students, interns, junior residents, senior residents, other APPs and clinical faculty

Time Required for Implementation:

Preparation: Instructors will require roughly 10–15 minutes to review the scenario, including critical actions and debriefing summaries. Instructors should also utilize this time to review relevant institution and state-specific policies on impaired clinicians, which may vary.

Time for case: Roughly 10–15 minutes, depending on case progression.

Time for debriefing: Roughly 15–20 minutes, depending on learner performance and discussion.

Recommended Number of Learners per Instructor:

One to two learners and one instructor per case.

Topics:

Substance abuse; impaired provider; impaired provider reporting policies; professionalism; patient safety; provider safety.

Objectives:

By the end of this simulation session, the learner will be able to:

1. Identify potential impairment in the form of alcohol intoxication in a physician colleague.

2. Demonstrate the ability to communicate effectively with the colleague and remove them from the patient care environment.

3. Discuss the appropriate next steps in identifying long-term wellness resources for the impaired colleague.

4. Demonstrate understanding of the need to continue to provide care for the patients by moving the case forward.

Linked objectives and methods

This format provides learners with a realistic simulation of an encounter with an impaired provider colleague in the patient care environment. The learners are blinded to the true nature of the scenario at the outset, leading them to assume that their main challenge in the simulation will be the care of the trauma patient. As the scenario progresses, the learner is required to recognize an impaired colleague in real time as they are caring for the trauma patient. In order to facilitate this recognition, the confederate playing the role of the impaired physician will have abnormally loud and somewhat irregular behavior as well as have the simulated scent of alcohol through the use of a beer spray and mouthwash (Objective 1). The learner must then navigate a difficult conversation to communicate their concerns effectively to the impaired provider. The effectiveness of the learner’s communication will be demonstrated by the impaired colleague’s acknowledgement of their intoxication/impairment and subsequent willingness to exit the patient care area (Objective 2). The learner must then demonstrate the next steps required in reporting the impaired provider to the appropriate responsible party. Acceptable actions in reporting their colleague could include notification of the program director, a supervising faculty member, department chair, or another designated appropriate institutional official, which may vary depending upon the type of learner or the location. Following the notification step, the learner should ensure that the impaired provider remains safe by not driving themselves home despite the provider’s attempting to insist they have only had a few drinks and are entirely safe to drive themselves (Objective 3). While successfully navigating the first three objectives as outlined above, the learner must then demonstrate understanding of the need to continue to provide patient care by returning to the patient’s bedside and continuing the progression of the case through the trauma scenario once appropriate actions have been taken to ensure the removal and safety of the impaired colleague from the patient care area. (Objective 4). This scenario highlights the need for all providers to be aware of the physical and emotional condition of their colleagues and know when and how to intervene for both provider safety and patient safety. The scenario is meant to place the learner in a situation that is both unexpected and uncomfortable and challenges them to effectively handle an intoxicated colleague on shift, a situation that is very sensitive and potentially anxiety provoking, while in the protection of a safe, simulated environment.

Recommended pre-reading for instructor

Local institutional or state policies regarding reporting of the impaired provider.

Learner responsible content

No pre-session content is recommended for the learner in this scenario. Providing local institutional policies regarding reporting of the impaired provider for review prior to the scenario may give the learner a hint regarding the objectives of the scenario that are intended to be discovered by the learner in real-time. This would decrease realism and be detrimental to the educational value of having to unexpectedly identify and confront an intoxicated colleague in the patient care setting. Perhaps as part of the debriefing session, doing a quick review of the particular institution/programs policy for recognizing and intervening with an impaired colleague situation, along with a reference for where these written policies and suggested reporting structures may be found, would be an additional source of beneficial learner content.

Associated content

No specific additional materials are required.

Results and tips for successful implementation

This simulated scenario has been delivered to EM resident physicians of all post graduate levels in a 3-year program with 30 residents as part of the standard simulation curriculum. It has also been delivered to approximately 30 fourth-year medical students participating in a Preparing for Intern Year course at the WVU School of Medicine during the 2018–2019 and 2019–2020 academic years.

Our simulation center utilizes an electronic Likert scale evaluation system distributed to learners following their completion of the simulation session. Learner reviews and feedback for the simulation session were largely positive. We obtained feedback from the learners on the following categories: usefulness of the simulated scenario, educational content of the scenario, and simulation faculty teaching skills, with the average Likert scale rating for each category being 4.71, 4.86, and 4.86, respectively. The average Likert ratings of all categories rated is 4.81, on a scale of 5. The free responses from the learners were also universally positive, suggesting that the simulated case and safe environment provided made for an effective format that empowered them to find their voice and rise to the occasion in a difficult scenario. Learners specifically commented on the following:

“The impaired physician simulation is great. It is something that is glossed over during medical school and we never get exposure in what to do in those situations.” “The impaired physician simulation was very helpful—interactive and allowed us to work as a team to solve the case—and we learned a lot through the post case discussion.”

This scenario functions optimally when presented as a typical clinical case-based simulation for the learner rather than tipping the learner off that there may be more of a focus on recognition of and intervention for an impaired provider from the outset. When deploying this scenario, our pre-briefing instructions have been limited to a discussion of the trauma notification and associated pre-arrival information for the expected patient. The only additional information provided in the pre-briefing is that it is nearing shift change and their colleague has not yet arrived for their scheduled shift. Prior to arrival of the confederate playing the role of the impaired colleague in the simulation scenario, the scenario should proceed as a standard patient care simulation would in the standard educational structure of the institution at which the scenario is being deployed. We have found one of the barriers to successful implementation is that learners often struggle somewhat with either recognizing that their colleague is impaired or with initiating the difficult conversation to confront them regarding their impairment. In the equipment and props section below, we have outlined our techniques in order to make the impaired colleague smell strongly of alcohol as a non-verbal clue for the learner. If the learner still fails to recognize the intoxication, we have outlined below several other verbal and nonverbal steps for the confederate to follow to assist the learner. As a first step, the confederate playing the colleague should move physically closer to the learner to allow an opportunity for the learner to recognize the smell of alcohol. If the learner does not initiate the conversation following this action, the confederate becomes increasingly loud and obnoxious in their provision of patient care and should intentionally bump into the bed and begin knocking items in the simulation room over, acting out of expected character. It may be necessary for the simulated patient or a confederate playing the role of the nurse to guide the learner with prompts—such as the patient stating, “Is the other doctor okay? He/she is acting a little “off,” or the nurse asking the learner “Do you think that your colleague smells of alcohol?”

INSTRUCTOR MATERIALS

Case Title: What do you do if your relief comes to work intoxicated: An Impaired Provider Scenario

Case Description & Diagnosis (short synopsis): The case begins as a simulated clinical scenario. An emergency medicine provider, at the end of their shift, is presented with a trauma patient. A clearly intoxicated/impaired physician colleague enters the patient care area as the oncoming staff. The goal of the simulation is for the learner to identify an impaired colleague and effectively address the need to remove the impaired provider from the patient care area to ensure the safety of both the impaired provider and patients. The learner will be faced with navigating the challenging and uncomfortable situation of addressing concerns about a colleague’s fitness for duty and reporting and mediating the safe removal of the impaired colleague from the patient care area, while also continuing to provide standard trauma care to the injured patient.

Equipment or Props Needed

A high-fidelity manikin or standardized patient actor could be utilized to play the role of the trauma patient in the scenario. In order to simulate the odor of alcohol on the person of the impaired physician, we have worked with our simulation technicians to place beer into a standard spray bottle and spray it onto the confederate’s scrubs immediately prior to initiation of the case scenario. We also have the confederate swish and spit a small amount of mouthwash just prior to entering the simulation area, in order to further enhance the simulated realism of the intoxicated odor. Given that this case focuses largely on the recognition of an impaired provider and the navigation of the delicate interpersonal communications called for, there are minimal requirements for equipment that would typically be used in standard clinical based scenarios. Given that the case is intended to start out with the learner anticipating the need to care for a trauma patient, having basic simulation equipment available in the room that would be used to initiate the primary survey of trauma patient (ie, intravenous line, oxygen, monitor, etc.) would serve as props for improving the realism of the scenario, but are completely optional. A second room, whether an empty simulated patient room or an adjoining debriefing space, is needed for the sensitive staff-to-staff communication in the scenario to occur because holding the conversation in the active patient room would undermine patient confidence in the medical team and likely lead to defensiveness or denial from the impaired colleague.

Confederates needed

This scenario requires two confederates: one playing the role of a nurse who may prompt additional action if the learner fails to recognize the colleague’s impairment, and an additional confederate to play the role of the impaired colleague. The confederate playing the role of the impaired colleague should wear scrubs or old clothes, if the alcohol spray procedure outlined above is utilized. The confederate should be comfortable with playing this role and acting progressively more belligerent, clumsy, and unprofessional should the learner need further prompting with recognition.

Stimulus Inventory

#1	Complete blood count (CBC)
#2	Basic metabolic panel (BMP)
#3	International Normalized Ratio (INR)
#4	Urinalysis (UA)
#5	Liver function panel
#6	Initial chest radiograph (CXR)
#7	Pelvic radiograph (PXR)
#8	Ankle Radiograph
#9	FAST Exam

Background and brief information: The patient arrives at the emergency department towards the end of the learner’s shift, and the learner initiates the standard evaluation of a trauma patient. While care is ongoing, a clearly intoxicated physician colleague who is taking over at shift change for the primary team (learner) enters the patient care area, accepts a patient handover, but interferes with ongoing patient care by making errors, talking loudly and unprofessionally to the patient, and becoming defensive with staff when questioned. The learner must now continue patient care while subtly engaging the impaired provider to redirect them out of the patient care area.

Initial presentation: Nursing presents the patient’s demographics to the learner to introduce the case. The patient is a 36-year-old male who has been involved in an all-terrain vehicle (ATV) rollover, with stable vital signs, complaining of lower extremity pain. During the learner’s initial assessment, the oncoming impaired physician colleague will rambunctiously enter through the control room doors. He or she will smell of alcohol and be apologetic for being late to the shift. He or she will explain that they were having dinner with friends before his shift, and they lost track of time at the restaurant. The oncoming impaired physician colleague will attempt to begin an examination of the trauma patient and force the learner away from the bedside, telling them to get ready for sign out for other patients and allow for them to finish this simple trauma. As the impaired provider starts examining the patient, he or she will accidentally and aggressively bump into the bed, serving as further non-verbal clues that something is “off” with the impaired provider. The patient will ask the impaired provider if he’s okay, to which the provider will respond with, “Of course I am, I’m the doctor. You’re the one who’s laying there, shouldn’t I be asking you that?”

How the scene unfolds: The learner should quickly identify the oncoming physician colleague as being impaired and unsafe for the workplace. If the learner does not pick up on the verbal and non-verbal clues and fails to recognize the colleague as impaired, the impaired provider will continue to act out by speaking loudly and clumsily navigating the room. They will fail to find the lab sheets (listed in Stimulus section above), yell at the nurse, etc. If not recognized promptly, the impaired provider will talk about needing to use the restroom and will leave the room to find a restroom. At this point, the nurse will prompt the learner by asking if they think that their colleague has been drinking. When the impaired provider returns to the patient care area and continues to behave erratically, the learner should engage with the impaired provider to calmly convince them to leave and escort them out of the patient care area. At first, the impaired colleague will refuse to leave but will be fairly easily convinced if the learner is appropriately firm. After agreeing that it is necessary to arrange other coverage for this shift, the impaired physician will suggest that he drive himself home and that the incident can be discretely handled without involving anyone else. The learner should immediately recognize that this is not an appropriate course of action and suggest contacting the house supervisor (or other similar institution specific administrator role) or program director to arrange a safe ride home for the impaired physician. If the learner does not suggest a ride home for the physician or does not continue to advocate for the physician to leave, nursing will further intervene and prompt the learner to obtain a ride for the impaired physician and continue to push for him to leave the patient care area. If the impaired provider is still not successfully removed from the exam room, the trauma patient will become uncomfortable with the behavior of the impaired physician attempting to care for him and inform the team that the physician “smells like the bottom of one of my beer cans and I’m still sober enough to know that isn’t right. I want a new doctor.” Prior to the impaired physician leaving the ED, the learner should contact the responsible supervising party, as specific to the policies and procedures of that particular institution, express their concerns regarding the impaired physicians behavior, and will be instructed by the supervising party to obtain urine drug screen (UDS) and a blood alcohol level (BAL) from the impaired colleague as part of a fitness for duty evaluation before he or she is permitted to leave the workplace. The impaired physician will be somewhat obstructionist to the fitness for duty evaluation but will ultimately agree to do so. If the learner does not recognize the need to contact an individual of supervisory authority to report the impaired colleague, the nurse can prompt the learner to do so, but this is a critical action and the case cannot end until this action has been completed. If the learner fails to pick up on the nursing prompts to report the impaired physician, the nurse could also become increasingly frustrated, state “this is ridiculous, I’m calling the supervisor myself,” but hopefully the case would not progress to this point.

Critical actions

1. Identify the incoming provider as being impaired and unable to safely perform their duties.

2. Communicate the concerns effectively with the impaired provider and remove them from the patient care area.

3. Discuss the concerns for impairment with the provider and initiate contact with appropriate supervising entity based on local institutional reporting policies and procedures.

4. Recognize the provider is also a danger to themselves and prevent them from driving away from the ED.

5. Initiate specified testing of the impaired provider as instructed by the institutional supervising authority.

6. Continue to care for and treat patient while recognizing the state and assuring the safety of the impaired provider.

Case Title: What do you do if your relief comes to work intoxicated: An Impaired Provider Scenario

Chief Complaint: 36-year-old male involved in an all-terrain vehicle (ATV) rollover accident

Vitals:	Heart Rate (HR) 100	Blood Pressure (BP) 130/80	Respiratory Rate (RR) 18
	Temperature (T) 36.4°C	Oxygen Saturation (O2Sat) 100% on room air

General Appearance: Anxious and mildly uncomfortable due to pain

Primary Survey: Generally unremarkable

• Airway: Talking in a calm clear voice, airway is intact

• Breathing: Normal respiratory rate, clear bilateral breath sounds

• Circulation: Central and peripheral pulses intact, brisk capillary refill

History

• History of present illness: Helmeted ATV driver, lost control and rolled the vehicle over about 30 minutes prior to arrival in the ED. Denies any loss of consciousness and is having some mild right lower extremity pain. Per emergency medical services, patient was hemodynamically stable during transport and there were no pre-hospital interventions required.

• Past medical history: Unremarkable, takes no daily medications.

• Past surgical history: None

• Medications: None

• Allergies: No known drug allergies

• Social history: Had a few beers this evening with friends previous to the accident, works as a coal miner.

• Family history: No significant family history

Secondary Survey/Physical Examination: Complains only of right ankle pain

• General appearance: within normal limits

• HEENT:

  • ○ Head: within normal limits

  • ○ Eyes: within normal limits

  • ○ Ears: within normal limits

  • ○ Throat: within normal limits

• Neck: within normal limits

• Heart: within normal limits

• Lungs: within normal limits

• Abdominal/GI: within normal limits

• Genitourinary: within normal limits

• Rectal: within normal limits

• Extremities: tenderness to palpation over medial and lateral aspects of the right ankle, has pain with passive and active range of motion, no obvious open fracture, and distal pulses are intact and easily palpable. All other extremities are within normal limits.

• Back: within normal limits

• Neuro: within normal limits

• Skin: within normal limits

• Lymph: within normal limits

• Psych: within normal limits

Results

Complete blood count (CBC)
White blood count (WBC)	10.0 ×1000/mm3
Hemoglobin (Hgb)	15.0 g/dL
Hematocrit (HCT)	45.0%
Platelet (Plt)	450 ×1000/mm3

Basic metabolic panel (BMP)
Sodium	138 mEq/L
Chloride	110 mEq/L
Potassium	4.9 mEq/L
Bicarbonate (HCO3)	25 mEq/L
Blood Urea Nitrogen (BUN)	17 mg/dL
Creatine (Cr)	1.0 mg/dL

International Normalized Ratio

INR: 1.0

Urinalysis (UA)
Color	dark yellow
Specific gravity	1.050
pH	7.0
White blood cells (WBC)	0–5 WBCs/high powered field (HPF)
Red blood cells (RBC)	0–5 RBCs/HPF
Ketones	moderate
Nitrites	negative
Leukocyte esterase	negative

Liver function panel
Alanine aminotransferase	50 Unit/L
Aspartate aminotransferase	55 Unit/L
Total bilirubin	1.2 mg/dL
Direct bilirubin	0.7 mg/dL
Alkaline phosphatase	110 Units/L
Lipase	11 Units/L

Chest Radiograph (CXR)

Source: Gaillard F. In: Radiopaedia. rID:8304 https://radiopaedia.org/cases/normal-chest-xray?lang=us. Accessed 2 June 2020. CC BY-NC-SA 3.0.

Pelvic Radiograph (PXR)

Source: Jones J. In: Radiopaedia. rID: 36147. https://radiopaedia.org/cases/normal-pelvis-x-ray-ap?lang=us. Accessed 2 June 2020. CC BY-NC-SA 3.0.

Right Ankle Radiograph

Source: Gaillard F. In: Radiopaedia. rID: 7965 https://radiopaedia.org/articles/weber-classification-of-ankle-fractures?lang=us Accessed 2 Jun 2020. CC BY-NC-SA 3.0.

FAST Exam

Source: Carroll C. Radiopaedia. rID: 64279. https://radiopaedia.org/cases/normal-chest-x-ray?lang=us Accessed 17 August 2020. CC BY-NC-SA 3.0.

Right upper quadrant view

Left upper quadrant view

Suprapubic view

Subxiphoid view

OPERATOR MATERIALS

SIMULATION EVENTS TABLE:

Minute (state)	Participant action/trigger	Patient status (simulator response) & operator prompts	Monitor display (vital signs)
0:00 (Baseline)	Case begins Patient is in stable condition, lying on the gurney in the room.	Learner should begin obtaining the history and physical exam (H&P) and start the initial primary survey assessment of the trauma patient. Can do basic supportive care by asking nurse to start an IV and/or place on the cardiac monitor.	T 36.4C HR 100 BP 130/80 RR 18 O2 sat 100% room air
	Completion of initial H&P and primary survey	Learner recognizes that patient is vitally stable and in no immediate distress. Completion of secondary survey exam and recognizes patient’s primary right ankle injury.
	Primary and secondary surveys are completed	Learner will order some basic trauma labs and basic trauma imaging to include CXR, PXR and right lower extremity XR’s, to include a right ankle film.
03:00	Intoxicated physician colleague arrives about 5 minutes past shift change	Intoxicated provider interrupts learner’s interactions with the patient and attempts to do their own exam, yelling at the nurse, jostling the patient’s bed. May progress to patient asking impaired provider “are you ok?” May progress further to impaired provider leaving the exam room to go to the bathroom and nursing prompting learner to recognize intoxication.	Vital signs unchanged
07:00	Learner discusses concern for impairment with colleague	Impaired provider acknowledges having some drinks with dinner but thinks he is “fine to work”	Vital signs unchanged
	Learner suggests impaired provider leave patient room	Impaired provider resists
	Learner insists that impaired provider	Impaired provider agrees and states they will drive themselves home if they are being released from their shift and asks to keep the situation quiet. If learner allows this, nursing will prompt to rebuke this plan and intervene.
	Learner insists that impaired provider hand over keys	Impaired provider agrees reluctantly. Asks how he/she should get home. If learner is unsure, nursing will suggest speaking to supervisor/administrator for guidance
10:00	Learner contacts institution appropriate authority	Learner is instructed to ask the impaired provider to leave the patient care setting but only after a fitness for duty evaluation, including the obtainment of a UDS and BAL.	Vital signs unchanged
(Case Completion)	Learner informs impaired provider about additional required testing	Impaired provider is somewhat reluctant, but ultimately agrees to recommended testing. At this point nursing or patient prompt learner to continue providing treatment of patient if this has been forgotten.

Diagnosis

Weber A ankle fracture, impaired provider.

Disposition

Patient discharged with short leg cast or ankle boot and orthopedic follow up. Impaired provider referred to institution-specific authority and given a ride home.

DEBRIEFING AND EVALUATION PEARLS

What do you do if your relief comes to work intoxicated: An Impaired Provider Scenario

Physicians, specifically emergency physicians, are at significant risk for substance abuse and related impairment during the course of their careers. Appropriate identification and linkage to care not only ensures patient safety in the immediate patient care setting, but also maximizes the impaired provider’s ability to rehabilitate, recover, and ultimately return to practice. Physicians often have already experienced personal negative consequences of substance abuse before concerns present in the workplace. Thus, it is not advisable to forget this incident, which is a major red flag, as the impaired colleague requests. Although each states’ physician assistance process and program will vary, the debriefing for this case should outline the state specific processes and procedures associated with voluntary reporting and seeking of treatment of physicians in that state. The debriefer should also discuss potential consequences of the reporting. If the physician is voluntarily reporting and submitting to treatment, this is not considered a reportable event and is kept confidential from licensing agencies and the National Practitioner Data Bank. However, if a provider is impaired and resists reporting, treatment or prescribed therapies, more significant and detrimental consequences to license and practice ability may ensue.

Given that physicians are highly functional, have little insight into their own personal and professional challenges, and usually have found a variety of methods to cope with and compensate for their impairment, initial recognition can be difficult because work performance is often the last aspect that will suffer from the impairment. Some warning signs can be a disheveled personal appearance, showing up late for work or being absent altogether, increased patient complaints, decreased quality of care, productivity or efficiency, increased irritability or desire to create conflict, or as in this case, the overt physical clues to impairment (such as smell of alcohol or other substance, notice of track marks, etc).5

Recognizing the above, being placed in the situation where the learner may be confronted with an impaired provider colleague, is uncomfortable and anxiety provoking. The debriefing should allow discussion and exploration of these feelings that the learner may be dealing with, with consolation that these feelings are normal.

The debriefing should also entail the process for addressing and removing an impaired provider from the workplace according to institutional policies and procedures for reporting the concerns for administration and ensuring physician fitness for duty evaluation. Learners will likely have questions about how to appropriately open the initial conversation with an impaired colleague. We recommend initiating with an expression of concern, such as “how are you?” or “is everything going ok?” The hope of the direct style of the conversation is that the learner makes the impaired provider feel comfortable enough to remove themselves from the care setting and initiate the process of seeking help.6 With that said, the physician’s impairment may lead to limited insight, denial, and defiance that will lend them to not being receptive to this discussion.7 Regardless of whether or not the discussion goes well, if the learner suspects impairment, they should proceed to reporting to the appropriate supervisory chain/board to link the provider to care. We recommend that although in a simulated case, it may be hard to have this conversation in a private area, in real life scenarios, this should definitely be done in a private area to support confidentiality and professionalism.

If the learner struggled to interact with the impaired provider appropriately or initiate the difficult conversation with the impaired provider and needed significant prompting, ways to navigate these difficult encounters could be discussed during the debriefing session. Learners should be encouraged that reporting concerns of impairment are absolutely necessary, regardless of the challenge that should present. It is our responsibility to our patients and our colleagues alike to abide by these ethical standards.

The learner should also recognize that when substance abuse and impaired provider concerns arise, there could also be underlying physical and psychiatric etiologies that will need to be explored through testing and further medical assessment. In addition to the specific impairment demonstrated in our scenario, there are many other potential etiologies of “impairment” or inappropriate workplace behavior, inclusive of, but not limited to, the following: medical etiologies such as diabetic ketoacidosis (DKA), hyper/hypothyroidism, hypo/hyperglycemia, depression, psychotic disorders, etc. Faculty implementing this case should ensure that they review the importance of assessing an impaired colleague for these particular medical etiologies of impairment before assuming that it’s related to substance abuse (as in this case).

Alternatively, this simulated scenario is flexible and valuable in that it can easily be altered to fit any other desired impaired provider situation that the educators may want to review with their learners. In full transparency, this case in its original format was modeled after a neonatology fellowship simulation intended to portray an impaired provider suffering from sleep deprivation as part of the Accreditation Council for Graduate Medical Education requirement for sleep training education. Other examples of unprofessional behavior that learners need to be aware of and understand the reporting structure associated with that may be simulated with slight modification of this scenario could include workplace sexual harassment, bullying of colleagues, verbal/physical/emotional abuse of colleague/patient and unprofessional physician/patient relationships of any kind.

Other debriefing points

In the midst of dealing with the impaired provider, if the learner became distracted from patient care, this is a good opportunity to remind them that evaluation and treatment of patients must go on as it normally would. Priority is always given to treating the patient and removing the impaired provider from any situation where they may hinder or harm patient care.

Wrap Up

Refer learner to state and institutional policies and procedures related to the reporting of impaired providers and treatment opportunities and reporting guidelines.

SIMULATION ASSESSMENT

What do you do if your relief comes to work intoxicated: An Impaired Provider Scenario

Learner: _________________________________________

Assessment Timeline

This timeline is to help observers assess their learners. It allows observer to make notes on when learners performed various tasks, which can help guide debriefing discussion.

Critical Actions: Identify the incoming provider as being impaired and unable to safely perform their duties. Communicate the concerns effectively with the impaired provider and remove them from the patient care area. Discuss the concerns for impairment with the provider and initiate contact with appropriate supervising entity based on local institutional reporting policies and procedures. Recognize the provider is also a danger to themselves and prevent them from driving away from the ED. Initiate specified testing of the impaired provider as instructed by the institutional supervising authority. Continue to care for and treat patient amidst the chaos of recognizing the state and assuring the safety of the impaired provider.

0:00

Critical Actions:

• □ Identify the incoming provider as being impaired and unable to safely perform their duties.

• □ Communicate the concerns effectively with the impaired provider and remove them from the patient care area.

• □ Discuss the concerns for impairment with the provider and initiate contact with appropriate supervising entity based on local institutional reporting policies and procedures.

• □ Recognize the provider is also a danger to themselves and prevent them from driving away from the ED.

• □ Initiate specified testing of the impaired provider as instructed by the institutional supervising authority.

• □ Continue to care for and treat patient amidst the chaos of recognizing the state and assuring the safety of the impaired provider.

Summative and formative comments:

Milestones assessment:

	Milestone	Did not achieve level 1	Level 1	Level 2	Level 3
1	Emergency Stabilization (PC1)	□ Did not achieve Level 1	□ Recognizes abnormal vital signs	□ Recognizes an unstable patient, requiring intervention Performs primary assessment Discerns data to formulate a diagnostic impression/plan	□ Manages and prioritizes critical actions in a critically ill patient Reassesses after implementing a stabilizing intervention
2	Performance of focused history and physical (PC2)	□ Did not achieve Level 1	□ Performs a reliable, comprehensive history and physical exam	□ Performs and communicates a focused history and physical exam based on chief complaint and urgent issues	□ Prioritizes essential components of history and physical exam given dynamic circumstances
3	Diagnostic studies (PC3)	□ Did not achieve Level 1	□ Determines the necessity of diagnostic studies	□ Orders appropriate diagnostic studies. Performs appropriate bedside diagnostic studies/procedures	□ Prioritizes essential testing Interprets results of diagnostic studies Reviews risks, benefits, contraindications, and alternatives to a diagnostic study or procedure
4	Diagnosis (PC4)	□ Did not achieve Level 1	□ Considers a list of potential diagnoses	□ Considers an appropriate list of potential diagnosis May or may not make correct diagnosis	□ Makes the appropriate diagnosis Considers other potential diagnoses, avoiding premature closure
5	Pharmacotherapy (PC5)	□ Did not achieve Level 1	□ Asks patient for drug allergies	□ Selects an medication for therapeutic intervention, consider potential adverse effects	□ Selects the most appropriate medication and understands mechanism of action, effect, and potential side effects Considers and recognizes drug-drug interactions
6	Observation and reassessment (PC6)	□ Did not achieve Level 1	□ Reevaluates patient at least one time during case	□ Reevaluates patient after most therapeutic interventions	□ Consistently evaluates the effectiveness of therapies at appropriate intervals
7	Disposition (PC7)	□ Did not achieve Level 1	□ Appropriately selects whether to admit or discharge the patient	□ Appropriately selects whether to admit or discharge Involves the expertise of some of the appropriate specialists	□ Educates the patient appropriately about their disposition Assigns patient to an appropriate level of care (ICU/Tele/Floor) Involves expertise of all appropriate specialists
9	General Approach to Procedures (PC9)	□ Did not achieve Level 1	□ Identifies pertinent anatomy and physiology for a procedure Uses appropriate Universal Precautions	□ Obtains informed consent Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED procedures	□ Determines a back-up strategy if initial attempts are unsuccessful Correctly interprets results of diagnostic procedure
20	Professional Values (PROF1)	□ Did not achieve Level 1	□ Demonstrates caring, honest behavior	□ Exhibits compassion, respect, sensitivity and responsiveness	□ Develops alternative care plans when patients’ personal beliefs and decisions preclude standard care
22	Patient centered communication (ICS1)	□ Did not achieve level 1	□ Establishes rapport and demonstrates empathy to patient (and family) Listens effectively	□ Elicits patient’s reason for seeking health care	□ Manages patient expectations in a manner that minimizes potential for stress, conflict, and misunderstanding. Effectively communicates with vulnerable populations, (at risk patients and families)
23	Team management (ICS2)	□ Did not achieve level 1	□ Recognizes other members of the patient care team during case (nurse, techs)	□ Communicates pertinent information to other healthcare colleagues	□ Communicates a clear, succinct, and appropriate handoff with specialists and other colleagues Communicates effectively with ancillary staff