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El Programa de Atención Integral al Médico Enfermo de Barcelona: salud mental para una buena praxis
Abstract
The prevalence of mental disorders among physicians is similar and, in some cases, such as suicide, is greater than that of the general population. Those problems may lead to serious consequences, not only for the psycho-physical wellbeing of the doctor and of his/her environment but also for the safety of his/her clinical practice. In Spain, the Integral Care programs for Sick Doctors (ICID) have been developed in order to promote voluntary help seeking, and to enhance prevention, early diagnosis and appropriate treatment of those problems in specialised treatment settings. In this study, we describe how the ICID of Barcelona has worked since it was created in 1998. We also describe the main principles, means of access, inclusion criteria and main service areas of this program. Finally, we present how a specific “therapeutic contract” tries to manage the cases in which there is a risk of malpractice.
... 25 These strategies are oriented towards the care of the mental health of physicians, aiming at the early detection and treatment of mental health problems instead of simply ensuring that conduct does not involve risks to practice. 26 Offering a programme of care as a regulatory body can be perceived as a threat to physicians and it is difficult to balance trust in the institution with the responsibility of the association to self-regulate. It is important to note that developing the care programme must occur in parallel with the regulatory aspects of the professional association, a facet to which the governing boards contribute and not the clinical units. ...
... One of the clauses of said contract includes possible disqualification in case of non-compliance, which allows a rigorous control of the cases that involve a risk to safe clinical practice. 26 However, the main objective continues to be to help the physician achieve a state of health that allows him or her to continue performing professionally in accordance with the established standards. ...
Multiple studies have reported a high prevalence of mental health problems among male and female physicians. Although doctors are reluctant to seek professional help when suffering from a mental disorder, specialised services developed specifically to treat their mental health problems have reported promising results. The purpose of this article is to describe the design and implementation of the Professional Wellbeing Programme (Programa de Bienestar Profesional) of the Uruguayan Medical Council (Colegio Médico del Uruguay). The context, inputs, activities and some of the outputs are described according to a case study design. The main milestones in the implementation of the programme are also outlined, as well as the enabling elements, obstacles and main achievements. Emphasis will be placed on the importance of international collaboration to share experiences and models, how to design the care process to promote doctors' access to psychiatric and psychological care, the need for them to be flexible and dynamic in adapting to new and changing circumstances, such as the COVID-19 pandemic, and to work in parallel with the medical regulatory bodies. It is hoped that the experience described in this work may be of use to other Latin American institutions interested in developing mental health programmes for doctors.
... Si bien en la experiencia de las entidades reguladoras prevalecen las estrategias reactivas bajo la forma de medidas disciplinarias, sucede que, en el caso de los trastornos por abuso de sustancias y de los tratamientos de rehabilitación, así como en otros trastornos mentales graves, en otras ocasiones se ha optado por recurrir a estrategias proactivas y de remediación que facilitan el acceso a los programas de salud por sobre las medidas disciplinarias con el aval de la entidad reguladora 25 . Estas estrategias están orientadas al cuidado de la salud mental de los médicos apuntando a la detección y el tratamiento precoces de los problemas de salud mental, en lugar de simplemente velar por garantizar que el ejercicio no implicara riesgos para la praxis 26 . ...
... En el modelo del PAIME español, en los casos graves o que haya inclumplimiento, falta de adhesión a los tratamientos o riesgo para la praxis, se recurre a la modalidad de contrato terapéutico. Una de las cláusulas de dicho contrato incluye la posible inhabilitación en caso de incumplimiento, lo que perimite un control riguroso de los casos que implican un riesgo para la praxis clínica segura 26 . Sin embargo, el objetivo principal sigue siendo ayudar al médico a lograr un estado de salud que le permita continuar con un desempeño profesional acorde con los estándares establecidos. ...
Resumen
Son múltiples los estudios que informan de una alta prevalencia de problemas de salud mental en médicos y médicas. Aunque los médicos presentan resistencias a la hora de solicitar ayuda profesional cuando están aquejados de trastornos mentales, los servicios especializados desarrollados específicamente para tratar sus problemas de salud mental han reportado resultados prometedores. El propósito de este artículo es describir el diseño y la implementación del Programa de Bienestar Profesional del Colegio Médico del Uruguay. El contexto, los insumos, las actividades y algunos de los productos se describen de acuerdo con el diseño de un estudio de caso. También se señalan los principales hitos en la puesta en marcha del programa, así como los elementos facilitadores, los obstáculos y los principales logros. Se enfatizará la importancia de la colaboración internacional para compartir experiencias y modelos, cómo articular el proceso asistencial para fomentar el acceso de los médicos a la atención psiquiátrica y psicológica, la necesidad de que sean flexibles y dinámicos para adaptarse a circunstancias novedosas y cambiantes como la pandemia por COVID-19 y la necesidad de que vayan en paralelo con las exigencias de los organismos reguladores de la práctica médica. Se espera que la experiencia descrita en este trabajo pueda ser de utilidad a otros colectivos latinoamericanos interesados en desarrollar programas de salud mental para los médicos.
... Therefore, addictions in physicians cause a serious concern due to their potential impact on patients' safety, the lives and careers of the impaired physicians, and the socioeconomic burden of the health-care system as a whole (Talbott and Martin 1986;Boisaubin and Levine 2001;Dupont and Skipper 2012;Braquehais et al. 2012). However, if they come to accept treatment at programs specifically designed for them (such as Physicians' Health Programs, PHP), doctors with SUDs would have better outcomes and recovery rates in comparison to the general population (Herrington and Jacobson 1982;Carinci and Christo 2009;Dupont et al. 2009). ...
Doctors are at high risk for developing addictive behaviors due to their easy access to self-treatment and because they are usually reluctant to ask for help when they feel mentally or emotionally distressed. Alcohol dependence and sedatives and/or minor opioid dependences are the most prevalent substance use disorders (SUDs) among physicians. However, when doctors come to accept treatment in programs specifically designed for them (Physicians’ Health Programs), they show better outcomes than the general population.
The aims of this chapter are (a) to provide a brief comprehensive review of addictions in physicians, (b) to analyze the barriers that prevent doctors with SUDs from seeking help, (c) to give some keys to enhance early detection of affected individuals, (d) to explain the different strategies developed by Physicians’ Health Programs, and (e) to describe the treatment principles that should be considered when treating physicians with addictions.
... Substance use disorders and mental disorders among doctors are causes of serious concern due to the potential impact on patients' safety, the lives and careers of the impaired physicians, and the socioeconomic burden to the health care system as a whole (Talbott & Martin, 1986;Boisaubin & Levine, 2001;DuPont & Skipper, 2012;Braquehais et al., 2012). In the last decades, the term dual diagnosis has been used when a mental disorder and a substance use disorder occur together in the same individual. ...
Co-occurrence of mental disorders and substance use disorders (dual diagnosis) among doctors is a cause of serious concern due to its negative personal, professional, and social consequences. This work provides an overview of the prevalence of dual diagnosis among physicians, suggests a clinical etiological model to explain the development of dual diagnosis in doctors, and recommends some treatment strategies specifically for doctors. The most common presentation of dual diagnosis among doctors is the combination of alcohol use disorders and affective disorders. There are also high rates of self-medication with benzodiazepines, legal opiates, and amphetamines compared to the general population, and cannabis use disorders are increasing, mainly in young doctors. The prevalence of nicotine dependence varies from one country to another depending on the nature of public health policies. Emergency medicine physicians, psychiatrists, and anaesthesiologists are at higher risk for developing a substance use disorder compared with other doctors, perhaps because of their knowledge of and access to certain legal drugs. Two main pathways may lead doctors toward dual diagnosis: (a) the use of substances (often alcohol or self-prescribed drugs) as an unhealthy strategy to cope with their emotional or mental distress and (b) the use of substances for recreational or other purposes. In both cases, doctors tend to delay seeking help once a problem has been established, often for many years. Denial, minimization, and rationalization are common defense mechanisms, maybe because of the social stigma associated with mental or substance use disorders, the risk of losing employment/medical license, and a professional culture of perfectionism and denial of emotional needs or failures. Personal vulnerability interacts with these factors to increase the risk of a dual diagnosis developing in some individuals. When doctors with substance use disorders accept treatment in programs specifically designed for them (Physicians’ Health Programs), they show better outcomes than the general population. However, physicians with dual diagnosis have more psychological distress and worse clinical prognosis than those with substance use disorders only. Future studies should contribute to a better comprehension of the risk and protective factors and the evidence-based treatment strategies for doctors with dual diagnosis.
RESUMEN
El trastorno bipolar es un trastorno mental grave y recurrente de carácter crónico que se caracteriza por oscilaciones del estado de ánimo con fases de manía, hipomanía o mixtas alternadas con episodios depresivos. La prevalencia a lo largo de la vida se estima entre el 1 y 3%, siendo la edad media de debut entre los 18 y 20 años. Los factores estresantes psicosociales influyen en el comienzo y en las posteriores recidivas dentro de un modelo de vulnerabilidad genética. Entre los acontecimientos vitales que pueden influir notablemente en el curso de la enfermedad se sitúan el embarazo y el parto. Son periodos de vulnerabilidad en los que puede acontecer un empeoramiento de los síntomas o incluso una recaída a pesar de existir una buena adherencia terapéutica. El riesgo de recurrencias se incrementa cuando los psicofármacos se retiran bruscamente. De hecho, hasta un 81-85’5% de gestantes con trastorno bipolar tienen el riesgo de recaer si dejan de tomar estabilizantes del ánimo. La exposición al litio durante el primer trimestre se ha relacionado con malformaciones cardíacas en el feto, especialmente la anomalía de Ebstein. El ácido valproico y la carbamazepina aumentan el riesgo de defectos en el tubo neural. En cambio, la lamotrigina en monoterapia ha demostrado menor riesgo de malformaciones que otros anticonvulsivantes. Por todo ello, es fundamental valorar el riesgo-beneficio del uso de psicofármacos, siendo necesario el conocimiento de su uso y elaborar un plan de tratamiento individualizado en cada caso.
ABSTRACT
Bipolar disorder is a recurring and chronic severe mental disorder consisting of mood shifts between manic, hypomanic or mixed phases alternated with depressive episodes. Lifetime prevalence is estimated between 1 and 3%, mean age of debut being between 18 and 20 years of age. Psychosocial stressors influence the onset and subsequent relapses within a model of genetic vulnerability. Among the vital events that can significantly influence the course of the disorder are pregnancy and childbirth. They are periods of vulnerability in which there can be a worsening of symptoms or even a relapse despite having a good therapeutic adherence. The risk of recurrence is increased when psychoactive drugs are withdrawn abruptly; in fact up to 81-85.5% of pregnant women with bipolar disorder have the risk of relapse if they stop taking mood stabilizers. Exposure to lithium during the first trimester has been linked to cardiac malformations in the fetus, especially Ebstein’s anomaly. Valproic acid and carbamazepine increase the risk of neural tube defects. Lamotrigine monotherapy has shown a lower risk of malformations than other anticonvulsants. It is essential to assess the risks and benefits of the use of psychotropic drugs, the knowledge of their use is necessary as is the elaboration of an individualized treatment plan in each case.
An estimated 10–14% of physicians are said to be at risk of becoming chemically dependent at some point in their careers. Defense mechanisms (as denial, minimization or intellectualization), greater stigma associated with mental disorders amongst doctors and easy access to self-treatment with licit drugs, added to specific individual risk factors, may account for this increased vulnerability. Substance use can appear as a an unhealthy strategy to cope with unpleasant emotional states, or it can be for recreational purposes. When it becomes an addiction, it poses risk both on the individual wellbeing and to their clinical practice safety. Among physicians, alcohol, sedatives and opioid misuse are the most prevalent substance use disorders (SUDs). In the last decades, Physician Health Programmes (PHPs) have been developed in several countries to address this problem. Although sharing some similarities, they differ in organizational and clinical aspects. Addicted physicians in treatment prove significantly higher abstinence rates (70–80%) compared to other patients. However, concerns about ethical issues related to the treatment of sick doctors at PHPs, mainly in the USA, have recently arisen in public discussion and need to be carefully considered.
The idiosyncrasy of the medical profession, the characteristic personality traits of the physician and the lack of specific training to properly recognize and treat one’s own vulnerability dispose this group to suffer more mental pathology and probably worse control of other medical diseases. Most of the studies promoted so far focus on the psychiatric and addictive concerns of the physician, from the point of view of the sick doctor as being at risk for malpractice and to guarantee the safety of their patients. The narrative review of scientific literature (MEDLINE, EMBASE and IME 1985-2016) has shown that we do not have in the Spanish-speaking environment updated information about the doctor as a patient, despite being a topic of incipient media repercussion and undoubtedly relevant from the point of view of patient safety, professionalism and medical ethics and as well as the welfare of professionals. The characteristic of a sick doctor are more complex than the rest of patients with a conflict of roles and repercussions on professional ethics and the quality of care.
Objectives:
To explore if the Barcelona Integral Care Program for Doctors with mental disorders (PAIMM, in Catalan) has achieved its goal of enhancing earlier and voluntary help-seeking amongst sick doctors.
Material and methods:
We conducted a retrospective chart review of 1363 medical records of physicians admitted to the inpatient and outpatient units of the PAIMM from February 1st, 1998 until December 31st, 2011. The sample was divided into 3 time periods: 1998-2004, 2005-2007 and 2008-2011 (477, 497, and 389 cases, respectively).
Results:
The mean age at admission decreased (F = 77.57, p < 0.001) from the first period (x = 54.18; SD = 10.28 years) to the last period (x = 44.81; SD = 10.65 years), while voluntary referrals increased from 81.3% to 91.5% (Chi(2) = 17.85, p < 0.001). Mental disorders other than substance use disorders grew from 71% during the 1998-2003 period, to 87.4% (2004-2007), and 83.9% in the last period (Chi2 = 29.01, p < 0.001). Adjustment disorders increased their prevalence, while inpatient treatment progressively represented less of the overall clinical activity.
Conclusions:
Sick doctors may feel encouraged to seek help in non-punitive programs specially designed for them and where treatment becomes mandatory only when there is risk or evidence of malpractice.
To explore doctors' perceptions of the acceptable limits to self-treatment and to identify barriers to doctors seeking appropriate healthcare.
Self-completion, postal survey using three hypothetical case vignettes.
896 Australian doctors randomly selected from the Health Insurance Commission database and stratified by sex, discipline (general practitioner or specialist) and location (urban or rural). Data were collected between May and July 2001.
Doctors' self-reported attitudes on illness behaviour and choice of medical care in response to case vignettes.
358 (40%) doctors returned questionnaires. More participants believed it was acceptable to self-treat acute conditions (315/351; 90%) than to self-treat chronic conditions (88/350; 25%). Nine per cent (30/351) of participants believed it was acceptable to self-prescribe psychotropic medication. A greater proportion of GPs (206/230; 90%) than specialists (101/121; 83%) believed doctors are reluctant to attend another doctor, especially if the problem is psychological. Women and GPs were significantly less likely to report that it was easy to find a satisfactory treating doctor (women, 58/140 [41%]; men, 128/211 [61%]; GPs, 106/231 [46%]; specialists, 80/120 [67%]). Being a specialist was predictive of seeking appropriate healthcare for all three vignettes.
Doctors have varying opinions regarding the acceptability of self-treating chronic conditions, and perceive considerable barriers to seeking appropriate medical care. Strategies are needed to challenge the culture of self-reliance.
Stress in doctors is a product of the interaction between the demanding nature of their work and their often obsessive, conscientious and committed personalities. In the face of extremely demanding work, a subjective lack of control and insufficient rewards are powerful sources of stress in doctors. If demands continue to rise and adjustments are not made, then inevitably a "correction" will occur, which may take the form of "burnout" or physical and/or mental impairment. Doctors need to reclaim control of their work environment and employers need to recognise the need for doctors to participate in decisions affecting their working lives. All doctors should be aware of predictors of risk and signals of impairment, as well as available avenues of assistance. Relevant medical organisations (eg, the Colleges, hospital administrations, and medical defence organisations) need to develop and rehearse effective response pathways for assisting impaired doctors.
This study was designed to describe the alcohol use by female surgeons and the hazards of their drinking habits for them compared with the habits of female doctors from non-surgical specialities, and with those of their male colleagues in surgery, and to identify the variables associated with hazardous drinking.
The data were collected in 2000 from a representative national sample of 1120 Norwegian doctors. Alcohol use was measured using a modified version of the Alcohol Use Disorders Identification Test. A score of 9 or more was used as an indicator of hazardous drinking.
Female surgeons compared with female non-surgeons had tendencies for more frequent moderate alcohol consumption accompanied by more frequent consumption of larger amounts of alcohol, and a significantly higher rate of hazardous drinking (18 vs 7.6%). Being a surgeon (OR = 1.7, 95% CI 1.2-2.4), male (OR = 2.7, 1.7-4.1) and aged 45 years or over (OR = 1.5, 1.1-2.2) were significant predictors of hazardous drinking. With separate gender analyses, being a surgeon was a significant predictor for both females (OR = 2.8, 1.2-6.6) and males (OR = 1.5, 1.0-2.3).
Female surgeons practising in Norway drink more frequently and more hazardously than other female doctors. There are a number of possible explanations for this. Surgical culture may be an important factor.
Background: Despite evidence of dual diagnosis (DD) in impaired physicians, few studies have investigated its prevalence and clinical characteristics.Aims: To assess the prevalence and clinical characteristics of DD in a sample of inpatient physicians and to compare physician patients with DD to other inpatient physicians.Methods: A chart review of clinical and demographic data was conducted on 290 consecutive admissions to the inpatient unit of the Integrated Care Programme for Physicians in Barcelona from January 1999 to August 2005.Results: 60 (20.6%) patients had DD, with the most common form of co-occurring disorders being alcohol dependence with mood disorder (46.4%). DD patients were more likely to be male. DD patients were more similar to patients with substance use disorders with regards to demographic variables and antisocial personality traits, but were more similar to patients with only a psychiatric disorder concerning severity and avoidant traits.Conclusions: DD is a major cause of impairment in physicians and is associated with particular clinical and demographic characteristics. DD in physicians deserves attention to improve early detection, prevention and treatment strategies.
Accountability to the public, through assurance of competent care to patients by physicians and other health professionals, is a paramount responsibility of organized medicine.Occasionally such accountability is jeopardized by physicians whose functioning has been impaired by psychiatric disorders, including alcoholism and drug dependence. An equally important issue is the effective treatment and rehabilitation of the physician-patient so that he can be restored to a useful life.A sampling of boards of medical examiners and other sources reveals a significant problem in this area. Also indicative of the problem, and the difficulty organized medicine has in coping with it, are the numerous requests for guidance received by the American Medical Association.The Council on Mental Health makes the following observations and recommendations:It is a physician's ethical responsibility to take cognizance of a colleague's inability to practice medicine adequately by reason of physical or mental illness, including alcoholism or
Anesthesiologists have a higher rate of substance use disorders than other physicians, and their prognoses and advisability to return to anesthesiology practice after treatment remain controversial. Over the past 25 yr, physician health programs (PHPs), created under authority of state medical regulatory boards, have become primary resources for management and monitoring of physicians with substance abuse and other mental health disorders.
We conducted a 5-yr, longitudinal, cohort study involving 904 physicians consecutively admitted to 1 of 16 state PHPs between 1995 and 2001. This report analyzed a subset of the data involving the 102 anesthesiologists among the subjects and compared them with other physicians. The main outcome measures included relapse (defined as any unauthorized addictive substance use, including alcohol), return to anesthesiology practice, disciplinary actions, physician death, and patient harm.
Anesthesiologists were significantly less likely to enroll in a PHP because of alcohol abuse (odds ratio [OR] 0.4 [confidence interval {CI}: 0.2-0.6], P < 0.001) and much more likely to enroll because of opioid abuse (OR 2.8 [CI: 1.7-4.4], P < 0.001). Anesthesiologists had a higher rate of IV drug use, 41% vs 10% (OR 6.3 [CI: 3.8-10.7], P < 0.001). During similar periods of monitoring, anesthesiologists received more drug tests, 101 vs 82 (mean difference = 19 [CI: 3-35], P = 0.02); however, anesthesiologists were less likely to fail at least one drug test during monitoring, 11% vs 23% (OR 0.4 [CI: 0.2-0.9], P = 0.02). There was no statistical difference among rates of program completion, disciplinary actions, return to practice, or deaths, and there was no report of significant patient harm from relapse in any record.
Anesthesiologists in our sample treated and monitored for substance disorders under supervision of PHPs had excellent outcomes similar to other physicians, with no higher mortality, relapse rate, or disciplinary rate and no evidence in their records of patient harm. It is postulated that differences of study design account for contradictory conclusions from other reports.
Junior doctors can take action to avoid stress and depression associated with their workload. This article explains how, and gives advice on who to seek help from if the need arises
An impaired physician is one unable to fulfill professional or personal responsibilities because of psychiatric illness, alcoholism, or drug dependency. Current estimates are that approximately 15% of physicians will be impaired at some point in their careers. Although physicians may not have higher rates of impairment compared with other professionals, factors in their background, personality, and training may contribute and predispose them to drug abuse and mental illness, particularly depression. Many physicians possess a strong drive for achievement, exceptional conscientiousness, and an ability to deny personal problems. These attributes are advantageous for "success" in medicine; ironically, however, they may also predispose to impairment. Identifying impairment is often difficult because the manifestations are varied and physicians will typically suppress and deny any suggestion of a problem. Identification is essential because patient well-being may be at stake, and untreated impairment may result in loss of license, health problems, and even death. Fortunately, once identified and treated, physicians often do better in recovery than others and typically can return to a productive career and a satisfying personal and family life.
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Salud, estilos de vida y condiciones de salud de los médicos y médicas de Cataluñ
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Stress in health professionals
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Firth-Cozens J, Payne R. Stress in health professionals. Chichester: John Wiley & Sons; 1999.
Kingston: Australia Medical Association
Doctors'health advisory services [página en internet]. Kingston:
Australia Medical Association, Ltd. Inc.; c2012 [consultado 05 Jul 2010; citada 10 abril 2012]. Disponible en:
http://ama.com.au/node/3592.
estilos de vida y condiciones de salud de los médicos y médicas de Cataluña
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C. Salud, estilos de vida y condiciones de salud de los médicos
y médicas de Cataluña. Barcelona: Fundació Galatea Inc; 2007.
Estudio de las necesidades de los profesionales de la Medicina relacionados con la jubilación
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