While some physicians forced to leave their positions due to physical impairments are relieved to quit, others are reluctant to leave because of the value and structure their work brings to their lives, said panelist Marilyn Goske, M.D., of Akron Children’s Hospital.

Handling a fellow physician's substance abuse, depression, physical disability or age-impairments can be difficult and even require legal assistance, but all behavior that interferes with patient care must be addressed, said presenters of an interactive session at RSNA 2007.

The session, "When the Doctor Is the Problem: Dealing with the Disruptive or Impaired Physician," was sponsored by the RSNA Professionalism Committee and drew more than 130 attendees.

Alan C. Hartford, M.D., Ph.D., section chief for radiation oncology at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., offered these examples of disruptive behavior: profane, disruptive or demeaning language, inappropriate notes in charts, lack of honesty or ethics and dangerous acts such as throwing things.

Dr. Hartford used clips from the 1954 film The Caine Mutiny to illustrate employees' responsibility to curtail disruptive behavior. The lesson, he said, is that the entire staff is responsible for ensuring patient safety while preserving the dignity of their colleague as best they can.

Inappropriate behavior can take the form of inappropriate radiology reports, including those that criticize other radiologists, said Carol M. Rumack, M.D. Employees working with an impaired physician have responsibilities, she said, and decisions should be made outside the group with administrative and legal assistance.

"Colleagues should address a problem with a physician immediately, beginning with a confrontation in private," said Dr. Rumack, a professor of radiology and associate dean of graduate medical education at the University of Colorado Denver School of Medicine. Problem behavior should be monitored and documented, she added.

"Inappropriate actions must have significant consequences," said Dr. Rumack.

Substance Abuse Rates in Radiology Mirror Those in General Population

John P. Livoni, M.D., M.P.H., a professor of radiology at the University of California, Davis, said rates of substance abuse for radiologists are similar to or slightly higher than those of the general population, with an estimated 3,000 radiologists per year reported as having substance dependencies. The prevalence of substance abuse varies among specialties, said Dr. Livoni, but factors including easy access to drugs and high or "catastrophic" stress tend to contribute to physician problems.

Alcohol abuse is a concern that probably goes underreported, added Dr. Livoni.

All states have procedures to identify and treat dependent physicians, he said, adding that impaired physicians typically won’t seek help on their own. "It's a violation of an unwritten contract that physicians enjoy with colleagues," he said.

Physicians have a duty to avoid patient injury, said Leonard Berlin, M.D., chair of the RSNA Professionalism Committee. If a physician violates that duty and a hospital fails to take sufficient actions against a physician's inappropriate behavior, a jury can find the hospital responsible, said Dr. Berlin, a professor of radiology and chair of the radiology department at Rush North Shore Medical Center in Skokie, Ill.

Physical, Mental Impairment Also Issues

Depression also can contribute to physician impairment, said Stephen D. Brown, M.D., a radiologist at Children's Hospital Boston and assistant professor of radiology at Harvard Medical School. "Depression is its own condition and it can also compound with other conditions," said Dr. Brown. "Colleagues should avoid playing the psychologist and making diagnoses."

Dr. Brown noted that because of the stigma associated with mental illness, physicians are more likely to report substance abuse than psychological impairment.

When the cause of impairment is physical, colleagues are often sympathetic until the impairment affects them, said Marilyn J. Goske, M.D., a radiologist at Akron Children's Hospital. When co-workers are compelled to work longer shifts or otherwise compensate for a physician's inability to work because of chronic illness, she said, the physician often faces a subtle negative attitude in the workplace.

Physicians forced into leaving their positions because an illness impedes work generally respond in one of two ways, Dr. Goske said. "Either they are relieved to quit or they are reluctant to quit because the work gives their lives value and structure," she said.

Dr. Goske cited a case in which a colleague informed a quality assurance committee about discrepancies in performance by a physician impaired by chronic illness. After the committee ignored the complaint, said Dr. Goske, the colleague notified the institution's insurance provider, which threatened to withdraw coverage if the problem was not addressed.


Colleagues must address a problem with a fellow physician immediately, said panelist Carol M. Rumack, M.D. (left), of the University of Colorado Denver School of Medicine. Panelist John P. Livoni, M.D., M.P.H., of the University of California, Davis, said rates of substance abuse for radiologists are similar to or slightly higher than those of the general population.

Age-Related Impairment Cannot Be Ignored

Richard Gunderman, M.D., Ph.D., noted the natural decline in visual acuity and certain cognitive functions such as working memory, multitasking ability and reasoning speed as a person ages. Other abilities such as vocabulary, general knowledge and occupational expertise remain steady—or improve, if education continues—and "crystallized intelligence" continues to increase until age 60 or 70, said Dr. Gunderman, an associate professor of radiology, pediatrics, medical education, philosophy, liberal arts and philanthropy at Indiana University Purdue University Indianapolis (IUPUI).

When an age-related impairment affects physician performance, associates should assess whether it significantly affects patient safety, which must always be the priority, said Donald Bachman, M.D., a radiologist at MetroWest Medical Center in Framingham, Mass.

"Cognitive function can be impaired by a number of factors including depression, stress and substance abuse," said Dr. Bachman. "These impairments are reversible, but dementia is not."

Involved physicians should also consider that the problem may be clouded by personality conflicts, added Dr. Bachman. "The approach may depend on group dynamics and hierarchy," he said. "The group should explore solutions through negotiation. If the colleague is not cooperative, you should bring in a third party. Always document the steps taken."

Dr. Bachman pointed out that simple modifications may be in order in some cases, where disabilities might be accommodated by adjusting workplace conditions such as light levels.

If the impairment has an adverse effect on patient care and cannot be reversed, said Dr. Bachman, the physician should be offered reduced or altered responsibilities or a dignified exit strategy. "The average retirement age for a radiologist is 64 years—2 years older than that of the average U.S. worker," he said. He added that 57 percent of radiologists report wanting to work part-time before retirement.

Quality assurance programs, self-assessment modules and other tools to periodically measure performance are important for all physicians, the session presenters concluded. "Programs like these should be available for all employees," said Dr. Bachman.

Professionalism Courses Expanded for RSNA 2008

In addition to offering “When the Doctor Is the Problem: Dealing with the Disruptive or Impaired Physician” again at RSNA 2008, the RSNA Professionalism Committee is planning another course focusing on ethical relationships among radiologists and radiologists’ relationships with nonradiologic physicians, patients, radiologic manufacturers, research companies and scientific publications. More details about the new course will be published in an upcoming issue of RSNA News.