# Fellow Resources



# WELLNESS/RESILIENCY RESOURCES DOCUMENT

The University of Nebraska Medical Center has several resources in place to address workplace stress, burnout, depression and suicide. These resources will be useful in proactively identifying any colleagues exhibiting any signs and symptoms of burnout, depression or suicidality, referring them to the appropriate personnel and thereby improving wellbeing.

  
AVAILABLE RESOURCES AND ACCESSIBILITY:

On Campus

<table border="1" id="bkmrk-resource-contact-sus" style="border-collapse: collapse; width: 100%;"><colgroup><col style="width: 50%;"></col><col style="width: 50%;"></col></colgroup><tbody><tr><td>Resource  
</td><td>Contact  
</td></tr><tr><td>Susan Smith, RN, BS, CEAP  
House Officer Assistance Program (HOAP) Manager Available 24/7 by phone- unlimited access, no payment. Susan Smith works exclusively with house officers.</td><td>-402.689.1033 (Mobile) Call or text  
-402.559.5323 (Office)</td></tr><tr><td>Arbor Family Counseling- available 24/7 by phone- At UNMC or offsite- 5 free sessions</td><td>-402.330.0960/1.800.922.7379  
-For Offsite: Web-Ex (HIPAA compliant) via smartphone/tablet or computer  
-www.arborfamilycounseling.com</td></tr><tr><td>UNMC Counseling in Bennet Hall- 6th floor  
David Carver Ph.D, 24/7/Unlimited access/No payment</td><td>-402.559.7276  
-402.203.0592 (after hours)</td></tr><tr><td>Spiritual Care at UNMC A chaplain is available for spiritual counsel, emotional support, prayer, or a nonjudgmental presence while you work through a concern or worry.</td><td>To reach spiritual care Monday through Friday, 8 a.m. to 4:30 p.m., please call the main office at 402.552.3219. After hours, call the on-call Chaplain at 531.557.4559</td></tr><tr><td>Peers in Need of Support (PiNS) Colleagues are matched with one of our behavioral health responders, made up of Nebraska Medicine and UNMC psychologists, psychiatrists, social workers, marriage and family therapists, staff chaplains and other trained staff. This is not a formal evaluation or treatment, but a supportive peer to listen, offer suggestions, share resources and make referrals when needed.</td><td>Complete this confidential form or email pins@nebraskamed.com (Requests for 1:1 support should only be made by colleagues themselves, and not by their peers or supervisors)</td></tr></tbody></table>

Off Campus

<table border="1" id="bkmrk-resource-contact-sui" style="border-collapse: collapse; width: 100%;"><colgroup><col style="width: 50%;"></col><col style="width: 50%;"></col></colgroup><tbody><tr><td>Resource  
</td><td>Contact  
</td></tr><tr><td>Suicide &amp; Crisis Lifeline (call or text)</td><td>988  
</td></tr><tr><td>Metro Omaha Medical Society anonymous online screening</td><td>https://omahamedical.com</td></tr></tbody></table>

  
UTILIZATION OF RESOURCES: Susan Smith works exclusively with the house officers. In addition to Susan Smith, other available resources are listed above. After visiting with Susan Smith or other resources, further referrals can be made to Psychiatry services if required.  
CONFIDENTIALITY: All UNMC internal resources are kept confidential unless required for health reasons (impairment or imminent danger). The house officers program or department leadership will not be aware of these consultations. If further referrals are made to Psychiatry services, they are covered under HIPAA for confidentiality.  
VIGILANCE: We request everyone to be vigilant to identify in self or of any peers demonstrating signs of distress/depression/burnout or suicidal thoughts and refer to the above resources. The attached Powerpoint- “Preventing Physician Depression and Suicide” will help in identifying any individuals at risk.  
CRISIS RESPONSE TEAM: The Crisis Response Team (CRT) is available to prevent further tragedies. The CRT will also be activated to develop a coordinated response in the aftermath of any potential tragic events. Please see contact details of CRT personnel in the Appendix.

ADDITIONAL RESOURCES:

1. ACGME  
    
    - [ACGME Physician Well-being ](http://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being)
    - [ACGME Tools and Resources](http://www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being/Resources)
    - [ACGME After a Suicide](http://www.acgme.org/Portals/0/PDFs/13287_AFSP_After_Suicide_Clinician_Toolkit_Final_2.pdf)
2. AMA (Steps Forward) 
    - [AMA Improving Physician Resiliency Module](https://www.stepsforward.org/modules/improving-physician-resilience)
    - [AMA Physician Wellness: Preventing Resident and Fellow Burnout Module](https://www.stepsforward.org/modules/physician-wellness)
    - [AMA Preventing Physician Distress and Suicide Module](https://www.stepsforward.org/modules/preventing-physician-suicide)
    - [AMA Preventing Physician Burnout Module](https://www.stepsforward.org/modules/physician-burnout)
    - [AMA Creating the Organizational Foundation for Joy in Medicine](https://www.stepsforward.org/modules/joy-in-medicine)
3. [APA Wellness Resources](https://www.psychiatry.org/psychiatrists/practice/well-being-and-burnout/well-being-resources)
4. [Agency for Healthcare Research and Quality](https://www.ahrq.gov/professionals/clinicians-providers/ahrq-works/burnout/index.html)
5. [SAMHSA-HRSA Wellness Strategies](https://www.integration.samhsa.gov/health-wellness/wellness-strategies)
6. Physician Depression and Suicide ppt from UNMC-Psychiatry
7. Resilience Webinars 
    - [Resilience workshop for healthcare workers](https://www.youtube.com/watch?v=ep3n3kFWutU)
    - [Reslilience roadmap for Nebraska Medicine/UNMC colleagues](https://www.nebraskamed.com/sites/default/files/documents/covid-19/pandemic-resilience-roadmap.pdf)
8. Other Recommended 
    1. Mindfulness/Anxiety Mobile Apps 
        - - [Headspace](https://www.headspace.com/)
            - [10 percent happier meditation](https://app.tenpercent.com/redeem/register) (use the gift code HEALTHCARE)
            - [Insight Timer](https://insighttimer.com/) (free with thousands of guided meditations)
            - [PTSD Coach](https://www.ptsd.va.gov/apps/ptsdcoachonline/default.htm) (Not just for PTSD; has numerous relaxation exercised in the Manage Symptoms- Tools section)
            - [Mindfulness Coach](https://mobile.va.gov/app/mindfulness-coach)
            - [CBT-i Coach](https://apps.apple.com/us/app/cbt-i-coach/id655918660) (cognitive behavioral therapy for insomnia)
    2. Mindfulness/Anxiety Websites 
        1. - [The BHECN Serenity Project- Free Yoga](https://www.unmc.edu/bhecn/education/the-bhecn-serenity-project) (UNMC)
            - [Three 2-3 minute lessons on deep breathing](https://www.youtube.com/watch?v=gAkjx25o4eI) (Harvard Vanguard Medical Associates)
            - [3 minute body scan](https://ggia.berkeley.edu/practice/body_scan_meditation) (UC Berkeley Greater Good Science Center)
            - [5 minute body scan](https://www.youtube.com/watch?v=D5OzLizZCrc) (The Sleepy Aardvark)

# DIVERSITY, EQUITY, AND INCLUSION RESOURCE DOCUMENT

DIVERSITY, EQUITY, AND INCLUSION (DEI) LEARNING RESOURCES AND TOOLKITS

  
ACGME Equity Matters: https://www.acgme.org/what-we-do/diversity-equity-and-inclusion/ACGME-Equity-Matters/  
ACGME DEI Officers Forum: Email diversity@acgme.org to join  
American Academy of Family Physicians Health Equity Curricular Toolkit: https://www.aafp.org/family-physician/patient-care/the-everyone-project/health-equity-tools.html  
Association of American Medical Colleges (AAMC) Diversity and Inclusion Video Learning Series: https://www.aamc.org/what-we-do/equity-diversity-inclusion/learning  
AAMC Unconscious Bias Resources for Health Professionals: https://www.aamc.org/about-us/equity-diversity-inclusion/unconscious-bias-training  
AAMC IDEAS Learning Series: https://cloud.email.aamc.org/ideas  
American Hospital Association (AHA) Health Equity Toolkit: https://www.aha.org/toolkitsmethodology/2020-12-14-health-equity-snapshot-toolkit-action  
AHA Inclusion Dashboards: https://ifdhe.aha.org/system/files/media/file/2020/12/ifdhe\_inclusion\_dashboard.pdf  
Association of Family Medicine DEI Milestones: https://meridian.allenpress.com/jgme/article-supplement/480333/pdf/jgmed21007231/  
American Surgical Association DEI E-textbook: https://americansurgical.org/files/2018/Equity.pdf  
American Society for Gastrointestinal Endoscopy LGBTQ+ On-Demand Webinar: https://learn.asge.org/Public/Catalog/Home.aspx?Criteria=26&amp;Option=174&amp;tab=2  
Centers for Disease Control (CDC) Health Equity Video Series: https://www.cdc.gov/healthequity/whatis/videos/index.html  
CDC Resources and Style Guides for Framing Health Equity and Avoiding Stigmatizing Language: https://www.cdc.gov/healthcommunication/Resources.html  
The DEI Shift Podcast Series: https://www.thedeishift.com/  
Harvard University Project Implicit: https://implicit.harvard.edu/implicit/research/  
Institute for Healthcare Improvement (IHI) Triple Aim Curriculum: https://www.ihi.org/education/ihi-open-school/Pages/Curriculum.aspx  
National Institutes of Health (NIH) Advancing Racial Equity: https://www.edi.nih.gov/people/resources/advancing-racial-equity  
NIH Scientific Workforce Diversity Toolkit: https://diversity.nih.gov/toolkit  
Nebraska Medicine Guide to Understanding Gender Pronouns: https://onfirstup.com/nebraskamedicine/nebraskamedicine/contents/35828486  
Ohio State Kirwan Institute Implicit Bias Modules: https://kirwaninstitute.osu.edu/implicit-bias-training  
Stanford Unconscious Bias in Medicine CME Course: https://online.stanford.edu/courses/som-ycme0027-unconscious-bias-medicine-cme

READING COLLECTIONS, PODCASTS, PROCEEDINGS, AND BLOGS  
• AAMC Diversity, Equity, and Inclusion reading collection: https://www.mededportal.org/dei  
• AAMC Anti-Racism reading collection: https://www.mededportal.org/anti-racism  
• AAMC Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine: https://store.aamc.org/proceedings-of-the-diversity-and-inclusion-innovation-forum-unconscious-bias-in-academic-medicine.html  
• CDC Conversations in Equity Blog: https://blogs.cdc.gov/healthequity/  
• National Institutes of Health Equity Diversity and Inclusion Blog: https://www.edi.nih.gov/blog  
• UNMC podcast on unconscious bias by Dr. Jasmine Marcelin: https://podcasts.apple.com/us/podcast/jasmine-marcelin-md-facp-on-unconscious-bias-being/id1414936358?i=1000479025567

UNMC/NEBRASKA MEDICINE PEOPLE AND RESOURCES

  
• Shirley Delair, MD, Associate Dean of Diversity, Equity, and Inclusion, is an active member of the GMEC Committee and provides orientation on DEI topics to new house officers. Her office is devising initiatives to enhance recruitment and retention of a diverse workforce.  
• Sheritta Strong, MD, Assistant Vice Chancellor of Inclusion, leads the Conversations for Inclusive Excellence virtual series for all UNMC faculty, staff, and students, at 2 PM on the second Thursday of every month. She also leads the UNMC Inclusion and Equity Council, which meets at noon on the fourth Thursday of every month.  
• Nada Fadul, MD, Assistant Dean for Diversity, Equity and Inclusion Education Programs, provides faculty development sessions on DEI. She also provides consultative services for graduate medical education programs on addressing DEI in their educational programming.  
• Offices of Inclusion and Equity: The UNMC Office of Inclusion focuses on educational and leadership opportunities in a safe environment, particularly in the areas of awareness/advocacy, developmental opportunities, and DEI initiatives. The UNMC Office of Equity focuses on identifying and addressing inequities in a safe environment, particularly in the areas of awareness/advocacy, collation of efforts, and data-based systems. The UNMC community can provide anonymous feedback on culture or report a bias incident at the Offices of Inclusion and Equity website: https://www.unmc.edu/diversity/  
• The Office of Faculty Development partners with the Offices of Inclusion and Equity to offer trainings and workshops to UNMC faculty.  
• McGoogan Library DEI collections (https://unmc.libguides.com/sb.php?subject\_id=203853) on DEI in Ability, in BIPOC communities, and in LGBTQIA2S+ communities  
• McGoogan Library inclusive spaces: https://www.unmc.edu/library/spaces/inclusive-spaces.html  
• Nebraska Medicine Employee Resource Groups (https://www.nebraskamed.com/diversity-inclusion/employee-resource-groups)  
ARTICLES OF NOTE  
1\. Boatright D, London M, Soriano AJ, Westervelt M, Sanchez S, Gonzalo JD, McDade W, Fancher TL. Strategies and Best Practices to Improve Diversity, Equity, and Inclusion Among US Graduate Medical Education Programs. JAMA Network Open. 2023 Feb 1;6(2):e2255110- https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2801104  
2\. Gonzaga AM, Appiah-Pippim J, Onumah CM, Yialamas MA. A framework for inclusive graduate medical education recruitment strategies: meeting the ACGME standard for a diverse and inclusive workforce. Academic Medicine. 2020 May 1;95(5):710-6. https://journals.lww.com/academicmedicine/Fulltext/2020/05000/A\_Framework\_for\_Inclusive\_Graduate\_Medical.20.aspx  
3\. Usoro A, Hirpa M, Daniel M, Harris V, Ware A, Kernodle A, Elliott T, Piggott DA, Bienstock JL. Promoting diversity, equity, and inclusion: building community for underrepresented in medicine graduate medical education trainees. Journal of Graduate Medical Education. 2021 Feb 1;13(1):33-6. https://meridian.allenpress.com/jgme/article/13/1/33/451599/Promoting-Diversity-Equity-and-Inclusion-Building  
4\. Capers IV Q. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical education. ATS Scholar. 2020 Sep;1(3):211-7. [https://www.atsjournals.org/doi/full/10.34197/ats-scholar.2020-0024PS](https://www.atsjournals.org/doi/full/10.34197/ats-scholar.2020-0024PS)

  
FOR MORE INFORMATION  
An expanded version of this list with additional specialty-specific resources is available in the GMEC Teams folder. If you’re aware of a useful resource, please contact Arianne Marcoux with the UNMC Office of Graduate Medical Education (arianne.marcoux@unmc.edu) to have it added.

# ACGME Competencies and UNMC Scholarly Activities

UNMC Graduate Medical Education: Meeting the ACGME Core Competencies

<table border="1" id="bkmrk-competency-definitio" style="border-collapse: collapse; width: 100%; height: 208.6px;"><colgroup><col style="width: 33.3745%;"></col><col style="width: 33.3745%;"></col><col style="width: 33.3745%;"></col></colgroup><tbody><tr style="height: 29.8px;"><td style="height: 29.8px;">Competency  
</td><td style="height: 29.8px;">Definition  
</td><td style="height: 29.8px;">UNMC GME  
</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Professionalism  
</td><td style="height: 29.8px;">CPR IV.B.1.a) : Residents/Fellows must demonstrate a commitment to professionalism and an adherence to ethical principles.</td><td style="height: 29.8px;">• COPIC  
• Annual Compliance Training (Apollo)  
• Excellence for Building Cultural Differences (annual compliance - Canvas)  
• HIPAA (annual compliance -Canvas)  
• Title IX (Orientation and annual compliance – Canvas)  
• Student Mistreatment (Orientation and annual compliance – Canvas)  
• Residents as Teachers (Orientation)  
• Program-specific initiatives and training</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Patient Care &amp; Procedural Skills

</td><td style="height: 29.8px;">CPR IV.B.1.b) : (1) Residents/Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. (2) Residents/Fellows must be able to perform all medical, diagnostic, and surgical procedures considered essential for the area of practice.</td><td style="height: 29.8px;">• Annual Compliance Training (Apollo)  
• Zero Harm (Orientation)  
• Institutional Quality Goals/Patient Safety (Orientation)  
• Infection Control (Orientation)  
• Program-specific initiatives and training</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Medical Knowledge  
</td><td style="height: 29.8px;">CPR IV.B.1.c) : Residents/Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this knowledge to patient care.</td><td style="height: 29.8px;">Program initiatives and training to include  
• In-training examinations  
• Journal club  
• Specialty-specific curricula</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Practice Based Learning &amp; Improvement  
</td><td style="height: 29.8px;">CPR IV.B.1.d) Residents/Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.</td><td style="height: 29.8px;">Program initiatives and training to include  
• Self evaluations  
• M&amp;M conferences  
• Journal club</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Interpersonal &amp; Communication Skills  
</td><td style="height: 29.8px;">CPR IV.B.1.e) Residents/Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.</td><td style="height: 29.8px;">• COPIC  
• Annual Compliance Training (Apollo)  
• Excellence for Building Cultural Differences (annual compliance - Canvas)  
• Zero Harm (Orientation)  
• Residents as Teachers (Orientation)  
• IHI Module – Teamwork and Communication (onboarding requirement)  
• Program-specific initiatives and training</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Systems Based Practice  
</td><td style="height: 29.8px;">CPR IV.B.1.f) Residents/Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, including the social determinants of health, as well as the ability to call effectively on other resources to provide optimal health care.</td><td style="height: 29.8px;">• COPIC  
• Annual Compliance Training (Apollo)  
• Zero Harm (Orientation)  
• Institutional Quality Goals/Patient Safety (Orientation)  
• ResQ (regular GME meeting)  
• IHI Modules:  
 o Introduction to Patient Safety  
 o Responding to Adverse Events  
 o Root Cause Analyses and Actions  
 o Achieving Total Systems Safety  
 o Teamwork and Communication (onboarding requirement)  
• Program-specific initiatives and training</td></tr></tbody></table>

UNMC Graduate Medical Education: House Officer Scholarly Activity

The GME Office that has created multiple resources to promote scholarly activity for residents and their involved faculty mentors. The GME Office offers the following resources to promote scholarly activity for residents/fellows and their involved faculty members:

  
1\. GME Patient Safety/Quality Improvement/Disparities Research Collaborative: This Research Collaborative promotes research in various aspects related to patient safety, quality improvement and addressing disparities in health care. The Collaborative consists of the Associate Dean, a Ph.D in statistics and two Master’s level statisticians. All of them possess significant experience in clinical research and help residents with: study design, methodology, statistical support, data acquisition, IRB approval, abstract and manuscript preparation. The Collaborative meets every Tuesday to help residents with research.  
2\. GME Educational Research Collaborative: This Research Collaborative promotes research in various aspects related to medical education. The Collaborative consists of the Associate Dean, and MD, Ph.D in education. Both of them possess significant experience in educational research and can help with: study design, methodology, statistical support, data acquisition, IRB approval, abstract and manuscript preparation. The Collaborative meets every Wednesday to help residents with research.  
3\. Annual GME Research Symposium: This campus-wide event provides the opportunity for residents/fellows to present their research abstracts  
4.[ Graduate Medical Education Research Journal](https://digitalcommons.unmc.edu/gmerj/) (GMERJ): This peer-reviewed journal was started on our campus to provide an avenue for the house officers to publish their scholarly activity. Started in 2019 (with DOI), the journal has provided a good platform for residents/fellows to publish their articles.  
Davis Global Center Resource for GME Programs  
The Dr. Edwin G. &amp; Dorothy Balbach Davis Global Center (Davis Global Center) is a highly advanced clinical simulation facility purposefully designed to promote simulation-based training for all health professionals and foster the practice of safe patient care in highly-functioning and effective interprofessional teams. The 192,000 sq.ft. center is spread out over five distinct floors with each floor focusing on a specific domain such as cognitive and psychomotor domains etc. This creates a safe, highly effective and innovative training environment that benefits all health professionals in training and in practice.  
The Davis Global Center is one of the world’s largest simulation center with some of the most advanced simulation technologies in the world that help with house officer training in all the domains ranging from cognitive, psychomotor, affective and team-based training.  
Add additional information about how your program uses the space  
Web site: [Davis Global Center | iEXCEL | University of Nebraska Medical Center (unmc.edu)](https://www.unmc.edu/iexcel/learn/davis-global-center.html)

# Preventing Physician Depression and Suicide

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Department of Psychiatry UNMC</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Top causes of death among residents </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">\#1 Neoplastic </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">\#2 Suicide </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Higher rates of death early in residency (first two years)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Unchanged over the last 15 years</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Yaghmour<span style="mso-spacerun: yes;"> </span>et al. Causes of Death of Residents in ACGME-Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med. 2017 Jul;92(7):976-983</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Suicides cluster at certain times of year</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Higher in the first (July) and third quarters (after winter holidays) of academic year</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt; mso-effects-shadow-color: black; mso-effects-shadow-alpha: 40.0%; mso-effects-shadow-dpiradius: 4.0pt; mso-effects-shadow-dpidistance: 3.0pt; mso-effects-shadow-angledirection: 2700000; mso-effects-shadow-align: topleft; mso-effects-shadow-pctsx: 100.0%; mso-effects-shadow-pctsy: 100.0%; mso-effects-shadow-anglekx: 0; mso-effects-shadow-angleky: 0;">Physician Suicide Is a   
Multi-Faceted Problem </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt; mso-effects-shadow-color: black; mso-effects-shadow-alpha: 40.0%; mso-effects-shadow-dpiradius: 4.0pt; mso-effects-shadow-dpidistance: 3.0pt; mso-effects-shadow-angledirection: 2700000; mso-effects-shadow-align: topleft; mso-effects-shadow-pctsx: 100.0%; mso-effects-shadow-pctsy: 100.0%; mso-effects-shadow-anglekx: 0; mso-effects-shadow-angleky: 0;">Individual factors</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt; mso-effects-shadow-color: black; mso-effects-shadow-alpha: 40.0%; mso-effects-shadow-dpiradius: 4.0pt; mso-effects-shadow-dpidistance: 3.0pt; mso-effects-shadow-angledirection: 2700000; mso-effects-shadow-align: topleft; mso-effects-shadow-pctsx: 100.0%; mso-effects-shadow-pctsy: 100.0%; mso-effects-shadow-anglekx: 0; mso-effects-shadow-angleky: 0;">The training environment </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt; mso-effects-shadow-color: black; mso-effects-shadow-alpha: 40.0%; mso-effects-shadow-dpiradius: 4.0pt; mso-effects-shadow-dpidistance: 3.0pt; mso-effects-shadow-angledirection: 2700000; mso-effects-shadow-align: topleft; mso-effects-shadow-pctsx: 100.0%; mso-effects-shadow-pctsy: 100.0%; mso-effects-shadow-anglekx: 0; mso-effects-shadow-angleky: 0;">Culture of medicine</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt; mso-effects-shadow-color: black; mso-effects-shadow-alpha: 40.0%; mso-effects-shadow-dpiradius: 4.0pt; mso-effects-shadow-dpidistance: 3.0pt; mso-effects-shadow-angledirection: 2700000; mso-effects-shadow-align: topleft; mso-effects-shadow-pctsx: 100.0%; mso-effects-shadow-pctsy: 100.0%; mso-effects-shadow-anglekx: 0; mso-effects-shadow-angleky: 0;"> </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">An estimated 400 physicians die by suicide in the US per year </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds CF 3rd, Silverman M M (2003). Confronting Depression and Suicide in Physicians. JAMA, 289(23), 3161. </span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Risk Factors for Suicide (1/2)</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Mental disorders (particularly depression)</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Alcohol and/or other substance use disorders</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Previous suicide attempt(s)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Family history of suicide</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Impulsive or aggressive tendencies</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Easy access to lethal means (e.g., firearms)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Losses and other events (e.g., the breakup of a relationship or a death, academic failures, legal difficulties, financial difficulties, or bullying)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Isolation, a feeling of being cut off from other people</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Feelings of hopelessness</span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>*

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Risk Factors for Suicide (2/2)</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Trauma or abuse history</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Chronic physical illness, including chronic pain</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Exposure to the suicidal behavior of others</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Unwillingness to seek help because of the stigma attached to mental health and substance use disorders or to suicidal thoughts</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Barriers to accessing mental health treatment</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.</span>*

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Suicide Warning Signs – Talk</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">A person who is considering suicide may talk or write about:</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Killing themselves</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Death or dying</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Feeling hopeless, helpless or worthless</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Having no reason to live</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">No sense of purpose in life</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Being a burden to others</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Feeling trapped</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Unbearable pain</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Suicide Warning Signs – Behavior</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Concerning behaviors, especially if related to a painful event, loss or change:</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Increased alcohol and/or drug misuse</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Searching for a way to end their lives, e.g., searching online for materials or means</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Withdrawing from activities</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Isolating from family, friends and community</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Reckless behavior or more risky activities, seemingly without thinking</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Sleeping too much or too little</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Tying up loose ends</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Visiting or calling people to say “*goodbye*”</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Giving away valued possessions to others</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Aggression</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Fatigue</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Not making plans or looking forward to future events </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Suicide Warning Signs – Mood</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">A person who is considering suicide may display one or more of the following:</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Depression</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Anxiety</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Loss of interest</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Dramatic mood changes</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Irritability</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Humiliation</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Agitation</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Rage</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Sudden improvement in mood after he/she had appeared depressed for a while</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Predictors of Depression in Physicians</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Difficult relationships with senior doctors, staff, and/or patients </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Lack of sleep <span style="mso-tab-count: 1;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Dealing with death <span style="mso-tab-count: 1;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Making mistakes <span style="mso-tab-count: 1;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Loneliness <span style="mso-tab-count: 1;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">24-hour responsibility <span style="mso-tab-count: 1;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Self-criticism <span style="mso-tab-count: 1;"> </span></span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Bright RP, Krahn L. Depression and suicide among physicians. Current Psychiatry. 2011; 10(4):16-30. </span>*

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Protective Factors Against Suicide</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Effective clinical care for mental, physical and substance use disorders </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Easy access to a variety of clinical interventions and support for help seeking</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Connectedness– Strong connections to individuals, family, community and social institutions</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Support from ongoing medical and mental health care relationships</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Skills in problem solving, conflict resolution and nonviolent ways of handling disputes</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Cultural and religious beliefs that discourage suicide and support instincts for self-preservation</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Barriers to Treatment</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Social and professional stigma– </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Fear of recrimination by colleagues, facilities where they work, credentialers, or licensing boards</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Perceived lack of confidentiality– </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Fear that his/her illness will be documented in his/her academic record </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Accessibility– </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Difficulty finding a local provider who he/she trusts, but is not a colleague </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Reluctance to seek treatment</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Time constraints </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Affordability</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">An attempt to diagnose and treat themselves</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Seeking and receiving “*VIP treatment*” from other health care providers</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Belief that treatment does not work </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Bright RP, Krahn L. Depression and suicide among physicians. Current Psychiatry. 2011; 10(4):16-30. </span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Lack of Mental Health Treatment (1/2)</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Fears about the potential for seeking mental health care to negatively impact one’s professional reputation, ability to get or maintain licensure, or malpractice insurance are largely unfounded</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">What is more likely to harm a physician’s reputation, licensure and insurance, are unaddressed and worsening mental health conditions </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span><span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry. 2013; 35(1), 45-49. </span>***<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Lack of Mental Health Treatment (2/2)</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">In cases where **physicians died by suicide**, **depression** is found to be a significant risk factor leading to their death at approximately the same rate as among non-physician suicide deaths</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Physicians who took their lives were less likely to be receiving mental health treatment </span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">compared with non-physicians who took their lives</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Gold K J, Sen A, &amp; Schwenk T L. Details on suicide among US physicians: Data from the National Violent Death Reporting System. General Hospital Psychiatry. 2013; 35(1), 45-49. </span>*

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Burnout</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Emotional exhaustion</span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">– </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Tired, nothing left to give, no pleasure</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Depersonalization</span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">– </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Cynicism, going through the motions, like a robot, automatic pilot</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Decreased sense of accomplishment</span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">– </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Never good enough, not worthwhile</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Stress and Productivity</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Approaching a Depressed Colleague </span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Take the lead and be gently assertive– </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">As a general rule, it is easier and safer for healers to be in the healing role and much harder to be in a position of vulnerabiReach out and do not wait for them to come to you</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Normalize their experience– </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Remind him/her of the difficult realities of medicine </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Your training and your work is inherently stressful and challenging</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Hence, feeling distressed or overwhelmed is natural at times<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">If you are comfortable, self-disclosure or sharing examples of others who have struggled can be powerfully validating</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Be a good observer–</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Do not tell someone how you think they may be feeling, as this could be experienced as either threatening or condescending</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Rather, observe and reflect their behavior, and ask them to ascribe meaning (e.g., “*I notice you have been late to clinic/class a lot lately.<span style="mso-spacerun: yes;"> </span>How are things going for you?*”)</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Be reassuring– </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Even though depression and other emotional problems can impact work performance at times, it does not mean you are a bad physician</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">It means you need to take steps to take better care of yourself</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Be willing to offer flexibility and space for the person to get the help they need– </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">All the compassionate listening and caring for our students, trainees and colleagues will not amount to much if we do not offer opportunities for them to avail themselves of the resources they need in times of emotional distress</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Furthermore, individuals probably need to hear very clearly that there will be no negative repercussions for them seeking and receiving help in times of need</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Speak clearly and directly– </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Once the conversation is opened, do not be afraid to use words like “*depression*” or “*suicide*”<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">If people are struggling with these issues, it can a relief to have an opportunity to discuss them</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Know your resources–<span style="mso-spacerun: yes;"> </span></span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Be ready to offer real help in the form of information about how a person in your environment can get help quickly, if necessary</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Please see “Suicide Prevention” Resource Document provided by the GME office.</span>

# Physician Impairment and Substance Use Disorder

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">UNMC Psychiatry presentation</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Physician Impairment</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">“*The inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness,   
including deterioration through the aging process, the loss of motor skills, or the excessive use or abuse of drugs, including alcohol.”*</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">AMA Code of Medical Ethics.</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">““…physical or mental health conditions that interfere with a physician’s ability to engage safely in professional activities...”</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">AMA Code of Medical Ethics.</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">AMA’s Code of Medical Ethics  
Opinion 8.15</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">“*It is unethical for a physician to practice medicine while under the influence of a controlled substance, alcohol, or other chemical agents which impair the ability to practice medicine.”*</span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">AMA Code of Medical Ethics.</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span><span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">AMA’s Code of Medical Ethics  
Opinion 9.3.1 (b)</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">“Take appropriate action when their health or wellness is compromised, including:</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">(iv) seeking appropriate help as needed, including help in addressing substance misuse or substance use disorders. Physicians should not practice if their ability to do so safely is impaired by use of a controlled substance, alcohol, other chemical agent or a health condition”</span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">AMA Code of Medical Ethics.</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Alcohol Misuse</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Alcohol misuse is a common **response to unmanageable stress** </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Alcohol **increases impulsivity** and the **risk of a suicide attempt** </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.</span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">15-20% </span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">(1,2) of health care professionals will misuse substances at one point in their career</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Alcohol</span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> – Most commonly used</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Opioids &amp; stimulants </span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">– Next most common</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Recreational drugs (cannabis, cocaine) </span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">use is less than the general population </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Men &gt; women likely to misuse substances</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Women have higher prevalence of alcohol use and choose alcohol over other substances</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Female physicians have higher alcohol misuse rates than general population</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, Meredith C, Buhl A, Dyrbye LN, Shanafelt TD. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012 Feb;147(2):168-74. doi: 10.1001/archsurg.2011.1481. PMID: 22351913.</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Female Impaired Physicians</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">More likely to report past (51.8% vs. 29.9%; OR = 2.51) or current (11.4% vs. 4.8%; OR = 2.54) **suicidal ideation**</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">More likely to have made a **suicide attempt** whether under the influence or not</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">More likely to **misuse** **sedative hypnotics** than men (11.4 vs. 6.4; OR = 1.87)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Less likely to have family problems, specifically in the marital realm (OR 0.50; 0.32-0.76) and with their children (OR 0.52; 0.28-0.97)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Less likely to have a mandatory referral as a presenting problem at treatment (OR 0.61; 0.39-0.95) and less likely to have had loss of staff privileges (OR 0.46; 0.26-0.83)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">No gender differences in employment problems (65.3% vs. 67.5%) or legal problems  
</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">By Specialty</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Most studies have reported a consistently higher rate of drug and alcohol use in emergency room physicians, psychiatrists, anesthesiologists and physicians in solo practice</span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">ER physicians </span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">– **Cannabis** (10.5 vs. 4.6%) and **cocaine** </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Psychiatrists</span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> – **Benzodiazepines** (26 vs. 11%)</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Anesthesiologists</span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> – **Major** **opioids** (although more have alcohol use disorders than opioid use disorders)</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Pediatricians, pathologists, radiologists, and obstetricians and gynecologists have the lowest rates of substance use among physicians</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Easy Access Creates Risk </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Physicians have easy access to medications that can be misused:</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">When administering to patients</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">By self-prescription</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Alcohol is available to physicians as it is to anyone in our society</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Identifying Impairment </span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Family and marital problems (often occur first)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Financial issues, legal issues (DUI)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Work performance is typically not impaired until the more advanced stages (Can be 6-7 years from diagnosable SUD to treatment)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Physicians are likely to protect their work performance until the disease has neared the end stage</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">43% of opioid-using doctors had been using opioids for more than 2 years before detection </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">The physician with substance use disorder often retains the ability to protect his/her practice performance at the expense of other dimensions of life</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Social, family, and emotional problems will often occur prior to practice impairment</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">No one sign signifies impairment</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Collectively, however, they may define a pattern and provide warning that a potential problem exists</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Early identification can help remediation and assure patient safety</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Burden and Implications</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Substance use disorder is very disabling among physicians</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Addiction has been directly associated with physician suicide</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Accidental death may occur while intoxicated</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Patient safety</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Substandard care by physicians also affects colleagues</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Legal ramifications</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Loss of job – Difficulty finding other jobs</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Loss of medical license</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Loss of DEA Registration Number</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">The Conspiracy of Silence Related to Stigma</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">The key barrier to intervention is **denial**:</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">By the impaired physician</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">By colleagues<span style="mso-spacerun: yes;"> </span></span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">By family</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">By associates</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Shame</span>**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> –</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Physician as weak, selfish, bad person</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Fear of Reprisal</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Loss of prestige and livelihood</span>

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">The Need for Intervention</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Intervention may be necessary when an individual is either unaware of her/his addiction or, because of shame, fear, or denial, is psychologically unable to recognize the seriousness of the disease or the need to seek treatment.</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Physical or mental illnesses often co-occur with<span style="mso-spacerun: yes;"> </span>substance use disorders and requires intervention in their own right – Have to treat the whole person</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Code of Medical Ethics  
Opinion 9.3.1</span>**

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">When physician health or wellness is compromised, so may the safety and effectiveness of the medical care provided. To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness, broadly construed as preventing or treating acute or chronic diseases, including mental illness, disabilities, and occupational stress.</span>*

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>*

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Collectively, physicians have an obligation to ensure that colleagues are able to provide safe and effective care, which includes promoting health and wellness among physicians.</span>*

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">State laws that require reporting of specified physician conduct to state agencies vary considerably by jurisdiction</span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>**

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">AMA’s Code of Medical Ethics  
Opinion 9.3.2</span>**

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Providing safe, high-quality care is fundamental to physicians’ fiduciary obligation to promote patient welfare. Yet a variety of physical and mental health conditions—including physical disability, medical illness, and substance use—can undermine physicians’ ability to fulfill that obligation. These conditions in turn can put patients at risk, compromise physicians’ relationships with patients, as well as colleagues, and undermine public trust in the profession.</span>*

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>*

*<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">In carrying out their responsibilities to colleagues, patients, and the public, physicians should strive to employ a process that distinguishes conditions that are permanently incompatible with the safe practice of medicine from those that are not and respond accordingly. </span>*

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

**<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Steps for Intervening if Physician Addiction is Suspected  
(*Physicians Helping Physicians*)</span>**

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Contact the state<span style="mso-spacerun: yes;"> </span>physician health program (PHP) Nebraska Does Not Have a PHP – Consider LAP or EAP</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Recruit others to assist you (avoid having a conversation with the physician alone – Should not be a confrontation)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Express positive regard for the physician’s abilities (demonstrate respect for the individual)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Describe specific, observable problem behaviors of concern</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Avoid accusation or blame; be kind and empathetic</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Avoid negotiating, arguing, or bargaining (do not engage the individual in attempts to avoid the intervention)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Present a specific plan of action for assessment and treatment (consider working with the state PHP to develop a plan first)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Indicate clearly the consequences of not following through with the plan</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Insist on immediate action; do not consider requests for “*one more chance*”</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Provide for safe transition and transportation to the next step in the plan (typically, assist the physician in attending a professional assessment )</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Activities of PHP for Physicians with Substance Use Disorders</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Usually Required</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Abstinence from all substances, including alcohol</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Group therapy with other physicians with a professional facilitator</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Individual psychotherapy</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Mutual help meetings (Multiple times per week)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Body fluid screening, random as well as for cause (Multiple times per month)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;"> </span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Possibly Required</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Psychiatry Care</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">PCP (No self prescribing and ask advice on OTC medications)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Family Therapy</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Workplace limitations (No opioids or procedures with opioids)</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Prescribing limitations</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Work hours limited</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Neurocognitive testing</span>

<span style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-font-kerning: 12.0pt;">Return to work evaluation, if disability requires several months’ absence</span>

<span style="font-size: 28.0pt; font-family: 'Corbel',sans-serif; mso-bidi-font-family: Corbel; mso-font-kerning: 12.0pt;"></span>