The Missouri Physician and Health Professional Wellness Program: A Comprehensive Resource for Physician Wellness

Abstract

Burnout is just one of many ways that physicians unintentionally become impaired. This article reviews the relevant literature and issues facing physician wellness and presents information about the Missouri Physician and Health Professional Wellness Program sponsored by the Missouri Association of Osteopathic Physicians (MAOPS) and Capital Region Medical Center in Jefferson City, Missouri. Considerations for when to reach out in addition to information on some of the program’s preventative services are provided.

Introduction

The National Wellness Institute defines “wellness” as “a conscious, self-directed and evolving process of achieving full potential.” Wellness involves attempting to fully integrate and balance approximately eight dimensions including: intellectual, emotional, physical, environmental, financial, occupational, spiritual, and social.¹ Wellness can be compromised when any of these dimensions are suboptimal. In healthcare, multiple occupational factors have made wellness more difficult to achieve.² What were once more resilient and happy medical students (in comparison to equivalent graduate students in other disciplines) are now showing higher rates of burnout and depression during medical school and residency.^3,4,5 Starting a career with elevated competition, an intimidating hierarchy, increased risk of isolation, limited training on how to manage stress or the emotions associated with difficult cases, and significant student loan debt doesn’t help. In cohorts of early career physicians, there is twice as much burnout compared to non-physicians of the same age.⁶ With 50% or more of physicians having experienced burnout, the primary problem is likely not the individual (although personal characteristics common to physicians may contribute).

Physicians are already wired for high achievement, have difficulty setting healthy boundaries and managing work-life balance, and tend to stigmatize mental health with a fear of appearing “weak.” Still, burnout is due to the combined interaction of the individual, the work environment, and the external influences that impact that work environment. Maslach and Leiter have categorized six main organizational drivers of burnout in their research, which include: excessive workload, loss of control, ineffective leadership, insufficient rewards, absence of fairness, breakdown of community, and mission-values mismatch. Our current electronic health record (EHR) system and national billing and documentation standards demand considerable time entering data and performing administrative tasks, limiting the quality face-to-face time with patients that often is a driving motivation for entering the profession. Furthermore, the challenges of ICD-10, HCAHPS, Meaningful Use, and changing reimbursement models make it difficult to avoid, or at least considering, abandoning the current conventional medical system altogether (see The Evolution of Medicine by James Maskell). Higher risks of medical mistakes, lower quality of care, decreased employee and patient satisfaction, increased employee absenteeism and physician turnover, and decreased work production are just some of the consequences of burnout.^7–10 Worse yet, prolonged distress and burnout can lead to broken relationships, depression, anxiety, substance use, and suicide.¹¹

Burnout and Impairment

Burnout is just one of many ways that physicians unintentionally become impaired. Impairment interferes with the ability of a physician to carry out patient care responsibilities safely and effectively and often impacts a physician’s personal life as well. Impairment also may occur as a result of a substance use disorder, mental illness, or a reduction in cognitive or motor ability from age or disease.^12,13 In regards to substance use disorders, the lifetime prevalence of a physician misusing a substance is around 10–15%.¹⁴ Alcohol use disorders are the most common, but prescription drug abuse (i.e. opiates, benzodiazepines, stimulants) is also of concern given that physicians have greater access to these medications. Substances are often used by physicians to try to help manage distress. Female physicians appear to be at higher risk of substance use, in addition to higher risk for depression and suicide.^15,16 A recent meta-analysis of male and female physician suicidality showed that although the suicide rates were similar (~5.4–5.5 per 100,000 population), suicide made up a higher proportion of all-cause mortality in female physicians compared to women in general.¹⁷ According to David J. Skorton, MD, the President and CEO of the Association of American Medical Colleges, “our country will face a significant shortage of physicians in the coming years. The challenge of having enough doctors to serve our communities will get even worse as the nation’s population continues to grow and age.” With this anticipated insufficiency, we cannot afford to have any physician become impaired or worse yet, end their life. So how do we help a physician and health professional workforce that is suffering and unhappy?

Physicians Health Programs in Missouri

One option is with a Physician Health Program (PHP). A PHP is an “early warning system” that watches for potential hazards and helps plot a different course for doctors who fall anywhere on the spectrum from distressed, to burned out, to impaired so they can get treatment and return as quickly as possible to doing what they do best: taking care of their patients. In the state of Missouri, there are two Physician Health Programs. Many readers are likely aware of one of these programs sponsored by the Missouri State Medical Association — the Missouri Physicians Health Program, accessed at https://www.themphp.org. An alternative to this option is the Missouri Physician and Health Professional Wellness Program, sponsored by the Missouri Association of Osteopathic Physicians (MAOPS) and Capital Region Medical Center. Our program was created in 1987 by James Wieberg, LPC, in response to the request of the Osteopathic Association to provide well-being and interventional services to physicians (both DOs and MDs) and their families. In 1990, the mission was expanded to include all allied health professionals licensed by the Board of Healing Arts at the request of the Missouri Board of Healing Arts. Sharing our expertise with other allied health professionals follows our code of ethics. Our program is aimed at addressing the needs of those professionals who find that their personal problems are interfering with their ability to do their jobs. Since 1987, we have averaged between 35–45 medical professionals in our program at any one time.

From Jim Wieberg: “Our mission is to remind medical professionals that when the wheels run off the bus they do not have to suffer alone. We are a resource out there to advocate and care for them.”

The Missouri Physician and Health Professional Wellness Program has developed a set of guidelines that determine protocols for interventions, treatment recommendations, drug screens, and aftercare. Those guidelines are modeled after the guidelines of the Federation of State Physician Health Programs as established by the American Medical Association. Our focus as a program is on prevention, early identification, intervention, treatment, and rehabilitation of health care professionals who may be affected by substance use, mental health issues or disruptive behavior, burnout, or impairments related to aging. Treatment for such issues is accomplished at Board-recognized programs that primarily treat healthcare professionals. Determining who needs treatment is evidence-based and if impairment is suspected, a full evaluation is completed by a program approved by the relevant licensure board. Treatment is more extensive and intensive for physicians than the general population, given that they care for others and therefore carry more risk. Physicians are also monitored more closely. All this leads to a recovery rate higher than that for the general population. When impairment is significant, PHPs want to make sure that recovery is solid and lasting before the physician goes back into full practice. PHPs are a safe place to refer to and typically the sooner we get involved the better the result. We receive self-referrals, family referrals, hospital referrals, and referrals from attorneys.

Physicians who may be working alongside a distressed, burned out, or impaired colleague should consider taking action. A stepwise approach is usually recommended, which may begin with an upfront and direct conversation with the physician if it is unlikely that they are causing patient harm. If there is concern for either previous or imminent patient harm, a report to licensing boards (often anonymously) or a clinical supervisor is instead advised.¹⁸ Physicians often have sophisticated denial with elaborate justification and rationalization, making intervention more difficult.¹⁹ Gender may be an issue, as it appears female physicians with a substance use disorder (SUD) are not referred for treatment as frequently as male physicians.²⁰ Specific potential ramifications of not intervening include: putting the physician’s patients at risk of harm and subjecting the physician to potential professional or legal sanctions, denying the physician an opportunity for treatment, and worsening the long-term effect of the impairment on the physician’s family, career, or personal health.²¹ When PHPs catch potential impairment and begin physician treatment early, success rates are high. In a previous study, 81 percent of physicians who finished their treatment program kept sobriety for five years.²² The best success comes when physicians are supported and monitored over the long term, and that’s a primary feature of the PHP.

Characteristics of the MAOPS PHP

Confidentiality in a PHP is vital because a physician’s reputation, career, and license can be jeopardized, and physicians will seek treatment and will do so earlier from such programs. With confidentiality, PHPs have the ability to address potential problematic behaviors before they begin affecting patients, plus treatment is quicker and more effective.

“Our goal is to heal the physician and protect the public, and with confidentiality, the results are dramatically better. We have seen evidence over and over that when we get involved early and the physician cooperates and is guaranteed confidentiality, four out of five situations can be corrected, voluntarily and confidentially, and don’t have to involve discipline by the licensing boards,” reported Weiberg.

In order to further encourage physicians to reach out for help and support a culture of confidentiality, our program has advocated with the Missouri Board of Healing Arts to remove or revise questions on license applications to avoid discrimination and additional scrutiny by focusing on asking questions that primarily identify active impairment.

Another distinguishing characteristic of our program, in comparison to the MSMA PHP, is the proactive and preventative approach we also take with physician well-being. In this age of COVID-19, we adapted quickly to make additional wellness resources available to help physicians maintain resilience, while assessing the level of stress physicians were experiencing with an American Medical Association-sponsored COVID-19 caring for caregiver’s survey. Our prevention and wellness services have also included various talks and lectures at medical schools, healthcare organizations, and other conferences. At the medical school level, we strive to help foster a curriculum that promotes wellness as a core professional value and attempt to bring awareness of our program while destigmatizing services. In 2018, we started an annual physician wellness retreat (see https://www.maops.org for more details). Other preventative and early intervention services include additional counseling and physician coaching for distressed physicians and/or their families that have not reached the level of impairment but who might benefit from constructive feedback on how to improve their wellness. Goals of physician coaching may include: improving self-awareness, fostering creative problem-solving, challenging self-defeating thoughts and beliefs, aligning individual values with professional responsibilities, maximizing inner knowledge and skills to better navigate challenges, creating an accountability partnership, and/or creating actionable short- and long-term goals consistent with clients’ strengths and values. Randomized controlled studies have shown that physicians who receive professional coaching have a substantial improvement in emotional exhaustion and general symptoms of burnout, as well as an increase in quality of life and resilience.²³

The MAOPS Physician and Health Professional Wellness Program is monitored by a Board of Osteopathic Physicians and Allied Health Professionals who meet quarterly to assess client progress and determine program direction. It is of our opinion that physicians and healthcare professionals in the state of Missouri should not only receive the education that two Physician Health Programs in the state of Missouri exist, but also should have the liberty to choose when it comes to which program they want to represent them. Our program functions on the integrity of our reputation and entirely on donations with a limited budget. It is maintained by a team with extensive knowledge and expertise in wellness, burnout, physician health coaching, addiction, case management, therapy, and mental health. We appreciate and need ongoing financial support not only to allow us to continue providing acute interventions to those who are impaired, but also to continue expanding our outreach to organizations and medical schools around the state providing vital preventative measures to keep our workforce well throughout their training and career.

We hope to have the opportunity to visit and speak with you about our program. Thanks for reading, and best wishes towards the pursuit of wellness. Reach out confidentially to the MAOPS Physician and Health Professional Wellness Program at 573-632-5562.