WSU College of Veterinary Medicine

February 27, 2009“Veterinary Impairment,

Recovery, and the Role of WPHP”

Mick Oreskovich, MDMedical Director and CEO of WPHPGeneral and Addiction Psychiatrist

Clinical Associate Professor of PsychiatryFellow, American College of Surgeons

First,

The Veterinarian!

How Do They Come To Our Attention?

Someone is concerned that they may have a physical or mental condition that may be potentially impairing!

Impairment:

“INABILITY TO PRACTICE WITH REASONABLE SKILL AND SAFETY”

BEHAVIORIALINDICATORS OF IMPAIRMENT:

• Irritability• Irresponsibility• Inaccessibility• Inability• Isolation• Incidentals

IRRITABILITY

• MOOD SWINGS

• NEGATIVE ATTITUDE

• ARGUMENTATIVE

• INAPPROPRIATE ANGER

• OVERREACTION TO CRITICISM

IRRESPONSIBILITY• SHIFTS WORK LOAD

• MANIPULATES SCHEDULE

• “HURRY UP-CATCH UP”

– HASTY PROCEDURES

– SHORT CUTS

INACCESSIBILITY• FREQUENT TARDINESS• FREQUENT ABSENCE• “MIA”-MISSING IN ACTION

– FREQUENT TRIPS TO BATHROOM– FREQUENT TRIPS TO PARKING LOT– PROLONGED LUNCH BREAKS– UNAVAILABLE WHEN ON-CALL– UNAVAILABLE FOR DISCUSSIONS

INABILITY

• INADEQUATE ORDERS

• INADEQUATE CHARTING– QUALITY– QUANTITY– TIMLINESS– DELAYED BILLING

INABILITY

• DIFFICULTY WITH DIFFICULT CASES

• DEVIATION FROM STND PROTOCOL

• DEVIATION FROM DRUG PROCEDURES– UNWITNESSED WASTING– EXCESSIVE AMOUNTS– INSUFFICIENT ANALGESIA– XS SPILLAGE/BREAKAGE

ISOLATION

• ODD HOURS FOR OFFICE WORK

• EATS ALONE

• “BEHIND CLOSED DOORS”

• AVOIDS– STAFF MEETINGS– CE EVENTS– VETERINARY MEDICAL SOCIETY EVENTS

INCIDENTALS

• EYES

• EARS

• NOSE

• OTHER

TRUE OR FALSE ?

Intoxication in a health professional in

purely social settings should be ignored

since it does not occur during normal

working hours ?

TRUE OR FALSE ?On the job “A O B” (Alcohol On Breath)

is almost always an ominous sign, even

noted on a single occasion ?

TRUE OR FALSE ?Aberrant workplace behavior caused by

chemical dependency should be

addressed rapidly because it usually

indicates progression beyond early-stage

disease ?

TRUE OR FALSE ?Normal behavior following aberrant

behavior usually means that no significant

problem exists ?

TRUE OR FALSE ?While several signs of impairment, or a

cluster of them, usually suggest trouble,

a pattern of aberrant behavior is almost

always indicative of actual or potential

impairment ?

The Washington Physicians Health Program:

Is Defined By:

• It’s Contract With the Department of Health and

• Applicable WACs and Statutes

Department of Health Contract

“WPHP is the qualified provider for potentially impaired physicians, physician assistants, osteopathic physicians, osteopathic physician assistants, podiatric physicians, dentists, and veterinarians and whose objective is to motivate healthcare practitioners to enter treatment and to recovery from their illnesses, and, in so doing, will serve to minimize the losses and other negative impacts that are caused by these illnesses”

WAC 246-160-200

Who must report:• (1) The following persons, entities and

businesses must report conduct and conditions as described in WAC 246-16-210:

• (a) All license holders under the jurisdiction of a disciplining authority listed in RCW 18.130.040

WAC 246-160-200

To report information to the disciplining authority, or an impaired practitioner program, which indicates that the other license holder may not be able to practice his or her profession with reasonable skill and safety to consumers as a result of a mental or physical condition

WAC 246-160-200

• License holders voluntarily participating in the approved programs without being referred by the disciplining authority shall not be subject to disciplinary action under RCW 18.130.160 for their substance abuse, and shall not have their participation made known to the disciplining authority, if they meet the requirements of this section and the program in which they are participating.

Practically speaking:

• HCPs who have a condition that may be effecting their ability to practice safely

• Can get the help they need

• Confidentially

• Endorsement to return to practice

• 90% of WPHP clients are unknown to the disciplinary body

*Washington Physicians Health Program

• MD’s• DO’s• Dentists• Veterinarians

• Podiatrists• Physician Assistants• Residents

*charged under state law to monitor these practitioners andendorse that they are safe to practice

How Do We Do That?

PROBLEM HCPs

• Chemical Dependency

• Mental Illness

• Dual Diagnosis

• Stress Disorder

• Disruptive Behavior

• Psychosexual Disorder

• Incompetence/Dated

• Unethical

Not About Impairment:• Sexually Exploitive

• Incompetent/Dated

• Unethical

PROBLEM HCPs

• Chemical Dependency PHP• Mental Illness PHP• Dual Diagnosis PHP• Stress Disorder PHP• Disruptive Behavior HOSP,PHP,MQAC

• Psychosexual Disorder MQAC• Incompetent/Dated MQAC• Unethical MQAC

MQAC

We work together….we are partners in protecting the public

The Initial Call to 800-552-7236 or www.wphp.org

• 17 % Hospital• 20 % Medical Colleague• 09 % Practice Associate • 08 % Spouse• 01 % Lawyer• 12 % Commission/Board• 05 % Other State PHP • 10 % Self • 18 % Other

Initial Contact• CATEGORIZE

–Chemical Dependency

–Psych

–Disruptive

–Other

THRESHOLD• REASONABLE SUSPICION

• PROBABLE CAUSE

INTERVENTION SITE• 35 % Hospital

• 20 % HCP’s office

• 28 % WPHP office

• 18 % Other– Practice Director’s office– Pastor’s office– Private Doc’s office– Counselor’s office

Purpose of the Intervention:

• For evaluation? 50 %

• Directly to treatment? 50 %

INDEPENDENT EVALUATION

• Medical

• Psychiatric• Psychological• Addiction• Family Dynamics• Peer Interaction

EVALUATION SITE

• Local ? 22 %

• Out of town? 78 %

TRI-DIMENSIONAL TREATMENT

• BODY• MIND• SOUL

TRI-DIMENSIONAL TX• BODY

– DETOXIFICATION– END ORGAN DAMAGE

• MIND– COGNITIVE RESTRUCTURING– EMOTIONAL BALANCING

• SOUL– SPIRITUAL RESTORATION

DURATION: 4 WEEKS-3 MONTHS

TYPE OF TREATMENT

• 5 % Intensive out-patient

• 95 % In-patient

CHEMICALLY DEPENDENT CLIENTS ARE PHP

ELIGIBLE

• SUCCESSFUL COMPLETION OF TX

• D/C WITH STAFF APPROVAL

C D CONTRACT

• Total Abstinence

• Behavioral Monitoring

• Chemical Monitoring

• Worksite Monitoring

• Mutual Help Groups

DURATION: 5 YEARS

TOTAL ABSTINENCE

ALCOHOL

and

any

other

addictive

DRUG

BEHAVIORAL MONITORING

• Phase I-first 2 years– weekly 90’ face-to-face– professionally facilitated– therapeutic monitoring

• Phase II-next 3 years– tapers to monthly face-to-face

MONITORING SITES

• BELLINGHAM VANCOUVER

• EVERETT ELLENSBURG

• SEATTLE TRI-CITIES

• TACOMA PULLMAN

• OLYMPIA SPOKANE

CHEMICAL MONITORING

• Daily call to 1-800 number• “Color of the day” recording• 12 hour window to urinate• Credentialed laboratory• Witnessed micturition• Chain-of-custody handling• Screening test• Confirmatory analysis

WORKSITE MONITORING

• FREQUENT CONTACT

• PREFERABLY SAME FIELD

• NEUTRAL PARTY

• UNDERSTANDS CONFIDENTIALITY

• APPROVED BY:– Physician– Hospital– WPHP

WORKSITE MONITOR REPORT-SIX Is

• Irritability

• Irresponsibility Yes ?

• Inaccessibility

• Inability No ?

• Isolation

• IncidentalsHow often have you had contact ?

Do you want WPHP to call you ?

How well does it work?

Very, very well!

RELAPSED

74/292 = 25 %

Over 11 year follow-up!!

HOW DETECTED 23 % SELF-REPORTED 4 % BEHAVIOR MONITOR 31 % CHEMICAL “ 27 % WORKSITE “ 3 % MEDICAL BOARD 12 % OTHER

How to contact us:

Washington Physicians Health Program

206-583-0127

800-552-7236

moreskovich@wphp.org

www.wphp.org