Case Conference: Alcohol Use Disorder in One of Our Own- Challenges of Treatment Engagement in a Resident Physician-Alcohol Use Disorder in One of Our Own- Challenges of Treatment Engagement in a Resident Physician

Alcohol Use Disorder in One of Our Own- Challenges of Treatment Engagement in a Resident Physician
Video Transcription
My name is Carol Weiss. I'm one of the co-chairs of the Case Conference Committee. I'm standing in for Dr. Caridad Ponce-Martinez, who did the bulk of the work for this project  but lost her voice. I'm excited to introduce our case conference for this year, Alcohol Use Disorder in One of Our Own, Challenges of Treatment Engagement in a Resident Physician.  The case will be presented by one of our trainees, Dr. Arun Prasad. The structure for this morning is that our presenter and our three discussants will each  speak for under 10 minutes, and the remaining time, hopefully 35 minutes, will be for audience discussion.  Dr. Prasad is a current PGY-5 Addiction Fellow at Mount Sinai West, New York, Addiction Psychiatry Fellow, I should specify.  We're proud also that he's an awardee of the AAAP John Renner Travel Award for 2023. Congratulations. And we look forward to his continued active involvement in AAAP.  Our three exquisitely curated discussants are Drs. Mark Gallanter, Karen Miyato, and Alana Igluwitz.  We're most honored to have with us Dr. Mark Gallanter, Professor of Psychiatry at New York University, where he founded their Division of Alcoholism and Drug Abuse and their Robust  Fellowship. He is a luminary and an icon in our field. He's a founder of AAAP and International Society of Addiction Medicine, past president of AAAP,  ASAM, and ISAM, as well as countless other leadership positions, awards, and publications. It would take our whole morning to review his innovations and contributions to our field,  so I will stop here. Dr. Miyato is a Professor of Clinical Psychiatry in the Department of Psychiatry at UCLA and  the immediate past president of the California Society of Addiction Medicine. She also serves as the Chair of the UCLA Physician Health Committee and Director of Physician  and Faculty Wellness at UCLA. And finally, Dr. Alana Igluwitz, Clinical Professor of Psychiatry at University of California, San Diego.  She's Director of the Wellness Initiatives at the UCSD School of Medicine. And prior to this role, she served as an Associate Residency Training Director in the UCSD Department  of Psychiatry, where she oversaw wellness initiatives. Now let's welcome our trainee, Dr. Prasad.  Hi, good morning, everybody. My name is Dr. Prasad. I'm one of the fellows at Mount Sinai West, New York.  So we have a very interesting case today, and I think it's worth a lot of discussion. And I'm happy to have an experienced panel to help us navigate all the issues that we've  faced in this case. And yeah, let's start off. So first of all, disclosures, none of the faculty listed have any relevant financial  relationships with ineligible companies to disclose. So I think an important thing is to navigate the objectives.  We want people to describe the importance of adequate treatment of any kind of physician from any field in the fraternity with substance use disorders, including the monitoring by  physician health program and services, which are, I think, pretty much varied and different across the country.  We also want to describe the role of AA, 12-step facilitations, NA, and other programs in the treatment of physicians with substance use disorders.  We also want to discuss ways in which prevention of burnout and promotion of wellness can reduce  substance use disorders in physicians, which I think is one of the major reasons as health care has become more competitive.  Even though there are restriction of hours, a lot of times physicians do end up working more than they were legally allowed to.  And as a result, it does precipitate a lot of use among young physicians. So coming to the case presentation, chief complaint of the patient was, when can I return to work?  It's a 27-year-old single woman, physician resident, who was referred for addiction treatment by the state physician health program for the treatment of alcohol use disorder.  She had been previously found intoxicated in a call room and removed from all work duty. And after completion of inpatient treatment, including detox, she was required to engage  in further outpatient treatment. That's when we pretty much got to see her, and that's how the case progressed.  So when we initially saw her in the outpatient program, her mood was pretty depressed, anxious,  and she wanted to be involved in the program for treatment of alcohol use disorder, as it was mandated by her state monitoring program, so that she could retain her residency spot.  When we met her, she was already in trouble with her residency spot, and she was being given some academic leave and being involved in research to maintain a position while she  was treated. She complained mainly of symptoms of insomnia, anhedonia, low energy and concentration, which  I assume, I think, on different points of visiting was mainly due to alcohol withdrawal and also substance-induced mood disorder.  She denied any perceptual disturbances, no suicidal or homicidal ideation. Just coming to a little bit about her substance use history, the main substance of concern  was only alcohol. She didn't use any other substances. Her usage started at the age of 18, mainly on weekends, in which she would drink three  to four drinks per day, usually hard liquor, I think it was whiskey, rum, and vodka. Her use progressively increased to daily use, so one to two drinks of hard liquor pretty  much after her day at the hospital, after a tough day she would indulge, and mostly going out to have these drinks.  These drinks were mainly at 22, when she was drinking every day, and it was related to academic stress while in medical school.  Also pressure from her parents was another main reason to perform academically and to, as they said, to make it in life. Her ex-boyfriend was another major trigger.  He was a regular alcohol user, and this use continued for another two years, till age of 24, after which it progressively decreased for some reason.  Use again went up significantly at 26 years of age during the match process. As you all know, matching to residency is extremely stressful, and that triggered a  lot of binge drinking in her again. One of the significant events that happened during this process was she was physically  attacked by a homeless person in New York City while she was intoxicated and outside, and she reports that she started drinking more and more to numb the memories of that assault.  She denied all other substances. Coming to her treatment history, so following clinical suspension when she was placed on  leave, she had to attend an inpatient program for detox, and then she completed a full rehab session of like 28 days and was started on Naltrexone 50 PO daily.  As she was put on Naltrexone, she denied the Vivitrol shot, stating that she didn't do well with shots, so she was only placed on oral Naltrexone.  Coming to her past psychiatric history, she has no past psych history, including no suicide  attempts or self-injurious behavior, no inpatient, outpatient treatment prior to current episode.  While in rehab, she was started on Lexapro, and she didn't really tolerate from 10 to 20, so we went out of 15 milligram daily. Past medical history, none.  Social history, which is pretty important in this case, is that her upbringing, originally from Asia, immigrated to the U.S. at the age of nine.  Parents are both physicians, and she has one younger sister. She has a very strict and rigid upbringing in which success is measured pretty much by  academic performance and how well, what position you reach in life. Strict relationship with parents, who viewed her as a failure and weak because of her alcohol use and issues.  Recently, at that point, she had ended engagement with her parents because of the constant conflicts regarding her substance use while in training.  Family history, no such formal psychiatric diagnoses, but she does report that her sister  has suffered from depression since adolescence, but not formally diagnosed, and no known history of substance use.  So coming to a mental status examination, appearance and behavior were pretty much anxious and mildly tremulous. Well-groomed, cooperative, good hygiene. No issue with speech.  Her mood is pretty much depressed and anxious, and affect was pretty much congruent with the mood as well. Thought process was goal-directed. Thought content was normal.  No suicidal or homicidal ideation, intent, or plan. No perceptual disturbances. Intuition was A0 into 4. Memory was as good.  And incentive judgment, well, at that point, was good because she was recognized she had a problem and was trying to be engaged in treatment.  Rheo system was negative for everything except for mild tremors on bilateral upper limbs and appeared anxious. This is a brief timeline of how her case came across us.  She was assaulted on the streets of December 2021. In April of 2022, was found intoxicated during her call.  Inpatient treatment in July 2022, and then intensive outpatient treatment August 2022. Broke up with her fiance in December 2022, and then was referred by Physician Health  Services to us. The diagnosis was alcohol use disorder, substance-induced mood, and anxiety disorder.  Assessment was pretty much 28-year-old single resident physician referred to addiction treatment by state physician health program for the treatment of alcohol use disorder.  So currently, the medication that she was placed on was Naltrexone 50. We went up to the max dosage of Lexapro 20 milligram daily, continued intensive outpatient  groups and individual therapy, and continuing monitoring. During the course, she was admitted to IOP.  In IOP, she repeatedly came in intoxicated, pretty much missing some groups, not very adherent with groups, ambivalent about being treated initially, superficially engaged with  poor insight. Her treatment consisted of coming in to group five times a week, and she was monitored by  weekly urine tox screens and, as needed, breathalyzers, which she many times tested positive. And ongoing communication with PHS about treatment progress and medical license at  that point remained active. She relapsed into drinking in April 2023, increased frequency of IOP in July 2023, and she was subsequently dismissed from residency in August of 2023.  And then in September, she got a restraining order against her ex-boyfriend, where there  was a history of assault. We're not sure who, but both of them were physical towards each other.  So discussion pretty much was, how does the PHS offer a monitored treatment for psychiatric or substance use disorders for physicians in a way that is not punitive, yet protects  the public from potential harm? And are there differences in the approach PHS takes with practicing psychiatrists and  any kind of trainee, be it resident or fellow or even medical students? And the AA 12-step facilitation, what role can they play in the treatment of physicians  with substance use issues, and can they be used to provide culturally informed care? And about wellness and burnout, how should programs and institutes address burnout in  physicians, including trainees, especially, at a way to reduce substance use disorder? And how do we promote wellness of trainees and physicians to avoid development of a substance  use disorder or help prevent relapse? Thank you.  Thank you.  Dr. Gallagher, would you like to start?  Hi. So, I was asked to talk about 12-step programs, AA in particular, since it focuses primarily on alcohol, at least historically.  And I wanted to put this into some context because I think that the degree to which we can make use of AA depends a lot on a variety of circumstances, which I hope we'll be able  to talk about.  But the...  Trying to time myself here. Here we go.  But one thing is that, and this was so amply illustrated in the previous session, that  we've become very much oriented towards a biomedical view of addiction treatment. And it tends to turn us less toward the degree of social support and the kind of social issues  that have been studied quite actively but are not part of our armamentarium as much as they should be.  And so, the interesting thing to know, but I don't want to take the time for the moment and I'll spare you that, how many of you are acquainted with 12-step?  But generally, our trainees know something about it but coming into the fellowship have very little exposure with it and it often gets subsumed under a lot of biomedical issues,  pharmacologic issues, and the like.  But AA has 2 million members worldwide. Half of them are in the United States.  And a person with a substance use disorder can very easily get contact almost immediately with AA group and get support in trying to achieve abstinence.  And now, and it's a little bit like telemedicine with the advent of such easy access to clinicians,  somebody can actually go to a Zoom meeting online and they keep repeating every hour and around the clock and that will fit in with their schedule.  We have people tuning in from around the world actually and create some more intensive experience of belonging to something with mutuality and support from others.  So, actually, AA is a resource that we can all draw on.  But as you saw from the presentation, the role of the psychiatrist is becoming somewhat  removed from being in charge of treatment and managing treatment.  And there are various rehabs involved, IOPs and the like.  But we're the doctors and traditionally, and I think if we're going to be effective in getting people better, we have to be in charge of treatment and providing treatment.  So actually seeing a psychiatrist at the end of the presentation definitely represents a chance to do this and to develop a relationship that could have permanence with the patient.  We in fact looked at people who were in the New York State Committee on Physicians' Health.  It was some years ago when AA was pretty much universally required for attendance for people coming into the CPH program.  As you know, the states all have programs for physicians' health operating independent of the state licensing authority so that if somebody goes into the program and continues  to participate as planned, and that includes being involved in some kind of therapeutic experience, often AA, then after a period of years, they can go back into the practice  that they may have subsumed under that time and not worry about their licensure.  But if they don't get involved with some continuity, then they can be referred to the state licensing authorities and suffer considerably. So, AA can be a big part of that.  And now, even though it's not used as intensively as it was, it's still recommended through most physician's health programs. So we, in fact, followed up 104 cases in the state.  And of them, after an average of four years of following up and monitoring, 91% succeeded and could graduate from the program successfully, but 9% did not and ended  up having to be referred to the state. But AA was very much a part of these programs. There were a lot of programs besides straight-out AA meetings that are a part  of this whole network. For example, there's an international society of doctors in AA that has 9,900 members and meets every year. And these are people who are abstinent and, again,  are mutually supportive and very important in that regard. There are problems in getting people to be involved in AA so that you can't just say, well, go to AA meetings.  And I think that's really a problem because most of us do not have the experience, and we should, in working with a patient and trying to get them  to accommodate themselves to AA, and we'll talk about how 12-step facilitation can be a part of that. But patients first are reluctant to go to an entity  where abstinence is considered essential. Most patients will still come in believing that sooner or later they can go back to drinking.  So it has to be made clear that it's just one day at a time in AA, and you don't have to worry about the remote future. And just make use of it as you can.  And, in fact, a lot of patients will go for a period of time to AA and then phase out but still continue to be abstinent. So AA is not necessarily an issue of lifetime attendance.  And I think we often have a rigid view in terms of what we expect of patients or what patients expect of us as they come in as to what the AA encounter can be.  Because, like I found it very useful to have patients of mine go to AA for a period of time, and then they're involved in treatment, and they may stabilize and then occasionally go  to AA just to sustain their involvement.  I have two minutes? I'm talking too much. Well, let me just say that the 12-step facilitation, which you can look up on the internet, is a very good vehicle  for developing the kind of relationship that you can work with with the patient. And it's been found quite effective, comparable to CBT and motivational enhancement.  I just want to put in one more thought that's in some ways related to AA, which is that we developed an approach for working with patients shortly after they come  into treatment with them and their families and with people close to them, which we call a network. And you work with the patient in order to work out who that group would be.  And then that network can come to sessions at intervals that are thought out and planned and support the patient's abstinence.  Apparently, the father may be involved in the treatment now, but having a group of people coherent in a way, as AA does, can be a very effective vehicle for getting people to hold  on to their recovery. Okay. Thanks a lot. Well, thank you for the opportunity to be here to talk about something so near and dear to my heart, which is helping colleagues.  And I think it's an excellent case that brings out so many points. And one of them, the weight is so heavy, and that's the, it's not just shame of addiction.  It's not shame having addiction as a healthcare provider. It's, as our colleague Garrett O'Connor would say, it's malignant shame.  It's shame that is so deep and so heavy, it impairs us from taking an action and sinks us further into the disease. And so, to follow you, what do 12-step programs do?  What does IDAA do? International Doctors of Alcoholics Anonymous, a recovery community that can say, I'm a physician too, and I'm working at overcoming the weight of my self-shame,  my family's shame, my community's shame. So, very powerful. And in California, or in the western regions, there's a separate IDAA, not a separate, it's,  in February, we have our meeting. It's called Western Doctors in Recovery. It's just an excellent three-day meeting, and the fellowship is the fellowship.  So, let me get to the question of PHP and this woman. Tell me how many are familiar with the state physician health program model? Okay. It looks like maybe a few of you are not.  So, let me just review. For a state physician health program, really is the intersection. It's patient safety and physician rehabilitation. Just in between that is our physician.  And the goal of the state physician health program, you could call it leverage treatment, right? You're in treatment, but you're motivated.  Part of the motivation is there's consequences of not proceeding. And what is the real strength in that positive data that you talked about is because doctors are monitored.  So, once they're through with the acute treatment program, they're surrounded by a group of people who really understand the practice of medicine,  but they have an app to check in every day to determine whether they need a random drug test or a breathalyzer. And so, that leverage is an everyday reminder. Oh, my goodness.  I have to test today and very powerful. And so, the question about what would be different for a trainee, ideally in the state physician health program that has the resources,  and I just talked to Laura Moss at the Washington program. A, they have a fund to help residents because this is costly, costly monitoring,  as well as ideally we can send a physician, a physician in training to treatment with other physicians. Why? Why is that important? And, you know, I've talked to so many people  that say they go to a program where there are no other healthcare professionals, and if word gets out they're a physician, pretty soon people are asking them  to prescribe Prozac for them. You know, it's not a group of people who A, maybe really understand how cunning and baffling this disease is in our population.  So, ideally if they can go to a program with other healthcare professionals, and so we heard about her multiple times trying, and so usually the PHP would come second.  Once there was an agreement to go back to work, then this intensive monitoring would occur along with groups, with other physicians, really help negotiating all the things,  the long work hours, the burnout, the insensitive supervisors, whatever the circumstances, the ability to be excused if that was the day she had to go test.  So, PHPs, many of them are able to work, A, with financial assistance or able to work with the training program so that they can advocate for the physician in training.  And so those are really, and how do we engage, how does a PHP engage someone and be sensitive to their disease? I think really all the motivational skills that you use all the time,  but the PHP is a group of people very familiar with working with physicians and the unique kind of ambivalence or denial of getting into treatment that physicians have.  How many here do evaluations on physicians? Oh, a good number of you. And I think that's so important to share our collective experience and wisdom.  The fact that I'm up here is not lost on me that our state, the state of California, doesn't have a state physician health program. So it's just very serious to lose that program.  And so I see colleagues here who are on physician well-being committees at their hospital or their medical societies. How many serve that role?  Yes, definitely a few of you are trying to do the work without a state physician health program. And so I think having a voice in your state physician health program,  it does have regulatory oversight. So the partnership between your state medical society and the health program I think are so important. And it's not that physician health programs  don't have their controversy, but I think the voice of the psychiatrist, the voice of all of us coming together, we do have say into helping to shape those programs  and also helping to shape the regulatory agencies. Lorna Breen died, but her family came forward and used their foundation and their power of the collective to say,  no more questions on licensure applications, which were there. The license said, have you ever been diagnosed with a substance use disorder? Triggered a board investigation.  So, so important that we are beginning to address those kinds of things so physicians can receive their confidential treatment for psychiatric disorders and still practice medicine  because somebody asked me once, would you hire a physician in recovery? And I said, oh my goodness, physicians in recovery, are an excellent hire. Yes, 100% I would.  All right, I thank you for your attention and turn it over to our next speaker. Well, such an honor to be here with all of you and to be on this esteemed panel.  I want to always put out my disclaimers, which are the nontraditional disclaimers. I am not an addiction psychiatrist. So my being here is very special for me.  I'm excited to learn from all of you. I was really asked to be here for my roles in wellness and burnout. And when I was first invited, of course my answer was yes.  And then I saw these questions I was posed. I said, what did I just get myself into? I'm being asked to spend five minutes each on topics  that there are entire conferences dedicated to. One on burnout, one on wellness, and then of course it's intersectionality with all of your expertise on addiction.  So what I did is I took a couple of notes to keep me a little bit in line, and I'll share some of my thoughts with you. The short answer to the question of how  should physicians and institutions address burnout in physicians, including trainees, is a way to reduce substance use disorders. My short answer is thoughtfully, holistically,  broadly, and with care. There's a much longer answer, and I'll dive into that. I think to really do this, we must both zone in  on what is the connection between substance use disorders and burnout, and then broaden way out of what do we even mean by burnout,  and what is the larger context in which that swims. So first, the zone in. The quick answer is yes, there is a connection between burnout and substance use disorders  amongst physicians and physicians in training. But when we dive deeper, there's so much we don't know. And the more you scratch the surface of any  of these topics, the more we know there's layers, just like there are tremendous layers to that beautiful case that you presented to all of us to have as a bouncing board  to dive into these matters. The layers there are the chicken and the egg phenomenon. What came first? Was it the substance use and the tendencies towards that? Was it the burnout?  Or is it something altogether that underlies both? Maybe discomfort with tolerating distress.  Maybe a punitive superego. And so I think even the simple one is not so simple when you dive into it. The other one is, if we broaden out now, is this notion of burnout.  I think burnout swims in this broader context of what it means to be a physician. And as physicians, we tend to the suffering of humanity.  We tend to what ails people, what hurts people at deep psychic levels. And yet, to do that in our own training and in our own careers, we must reduce, minimize,  and sometimes actually disavow our own humanity. Think of our sleep deprivation. Think of how we must learn to suppress our own feelings to tend to someone else's.  And when we do that repeatedly, and we don't have systems in place to help support us, and this is well beyond psychiatrists here, people can forget to come back  and tend to their own humanity, their own emotional needs. The other is to step out. What do we even mean by burnout? We all know, we could probably all recite  Maslach's definition of burnout, and it's a very helpful start. But my concern with endeavors on burnout is that maybe we've simplified things too much.  This textbook definition misses the marks at times. How many people in this room feel a little burned out on burnout? I do, and this is my arena, yeah.  So I think we've sort of gotten this wrong, and I'm gonna do a thought experiment to bring us all together. Whatever all of you do right now in this moment,  do not think of a pink elephant. Just don't think of a pink elephant. How many of you are thinking of something other than a pink elephant? It could be you're just, you need lunch,  and you're tired, and you're jet lagged, and all of that. But the reality is this is what we're doing with burnout. We're telling physicians and physicians in training,  whatever you do, don't be burned out. But what is our brain hearing? Burnout, burnout. So this is an important thing.  I'm convinced that for us to really think about connecting burnout and substance use, we need to get a little more nuanced of what we even mean by burnout.  We've become so accustomed to using this phrase. It's all over the media. People are burned out on online dating. They're burned out on going to the grocery store, right?  You know, physicians, we've become comfortable using this term, but what I experience is so often physicians are experiencing something different than burnout  when they use the term burnout. Maybe they're severely depressed, right? Maybe they are struggling with addiction, and that is too shameful to share,  and so they say, oh, I'm burned out, right? And the more we can think about the different meanings of burnout, the more we can have ways to map onto that.  One of those ways is to think of maybe burnout as moral injury. That's an important frame, not the only one, and it helps us think about the systems in which we work and we train.  The other is, could burnout be that we've lost touch with meaning in our work, a connection to the why? Could burnout be that we're grieving, or maybe we've put up so many walls  between ourselves and the patients we provide treatment to because we've needed to in order to operate in these fast-paced dehumanizing systems in which we work?  And I'm a little biased. I study grief, I should warn you of that.  Some people call burnout, but maybe they're bored. Maybe the line of work they went into is not as fulfilling as they thought it would be, and the more we can think of those,  the more we can start to map our treatments onto those. The next is what has been done so far, and I think this is tricky. I like to use the phrase,  the straw that broke the camel's back, to help bring together a lot of complex interventions, and we've all heard that expression, yes? Yeah, and so in this one, in some sense,  we initially start out with burnout mitigation by making the camel stronger. Teach that camel to meditate, teach that camel to sleep,  the camel to sleep better, to exercise more, to do yoga. And what are we doing when we do this? We're actually both blaming the victim, right?  But we're also building a stronger camel, and if we build a stronger camel, what can that camel hold? More straws, more straws, right? So then we said, oh gosh,  we gotta move a little bit away from that. So we said, let's fix the camel's habitat, right? And so let's address the electronic health records,  which really do need to be addressed.  Let's think about how to have our leaders be more empathic, more compassionate, more thoughtful. Let's think about how to make things more efficient in the system so people can work  to the top of their license. All of that's important, but in all of that, we did a little bit of finger pointing, and I think we need to be careful to make sure we do all of this,  but we also don't burden individuals in systems, especially trainees, to delude them into thinking that while in training, they're supposed to fix these huge, complex problems,  because doing that sets them up to be burned out.  In terms of, I'll go right to the how and then switch over to wellness. In terms of the how, there's so many. Number one, two, and three is we need to make sure  there are robust and accessible, formalized mental health services.  The other is we need to work harder on peer support initiatives. These can be tremendously helpful for everyone struggling with burnout,  especially those who have struggles with addiction, because to be paired is, building on your comments, with someone who has been in your shoes, who understands the profound shame,  who understands the layers of the implications of having an addiction while being either in training or a physician is hugely important. There's a lot of focus on education,  and I think we need to really focus on different meanings of burnout, but we need to include in this addiction. We don't talk enough about addiction when it comes to burnout.  Coaching interventions, which I can answer more about, elaborate on during the questions, I think we need to focus so much more on meaning.  What connects us all to why we do what we do? Foster connections.  Think of how can we create flexibility, autonomy in these systems in which we train people when we work? Also, process sessions, especially after adverse events occur.  The layers of shame that come with adverse events can be quite layered. Two minutes? Sure. So let me switch now, with two minutes,  to how can we promote wellness in trainees and physicians to avoid substance use disorders to then also help prevent relapses? I'll start with the quote-unquote easier one,  to prevent relapses. With that, I think we need to make sure that mental health resources are not just provided, but that people are so aware of them,  that we make sure that there's mental health resources that are confidential, anonymous, and hopefully outside of the systems in which people train and they work.  I think we can get creative about education, building it into what already exists. Imagine grand rounds for internal medicine, for surgery,  that it always started with maybe everyone looking at a piece of work, or had a little five minutes of education about common themes of one's mental health,  one's humanity, one's possible experience with burnout. So we can get more creative about that. We need to think of ways to reduce shame, and we need to really pair people  with people who have been in their shoes before. In terms of avoiding the development  of substance use disorders by promoting wellness, this one's tricky. I can't do it in one minute and do it full justice, but I'll do my best.  And so with that, I already spoke to education. But what I mean by this is, I don't think doctors coming into training know that their rates of addiction are higher  than the general population. You're all the experts here, but 10 to 15% of physicians will struggle. I don't think they know this, and I think we need to do better,  do better sharing resources, do better even explaining consequences to one's career and one's life. It's so important to bring in physicians  who have struggled with their own addiction and have come out on the other side so that we introduce them to our trainees, that we have them be mentors to our trainees.  We can do so much more with developing self-awareness. I may be inching just a little bit past my one minute, but I want to share a word on this if it's okay.  We don't tend to our psychological needs as doctors as much as I think we should. The traits that get us into medicine come with such a price, traits of perfectionism,  traits of desiring control. And so we can think creatively about how do we help people be more introspective, have more of a rich interpersonal life,  an intrapsychic life with awareness, to think of connecting people once again to their why, the meaning of this, and really create healthier systems that really foster connection,  they foster comfort with vulnerability, and they really foster our own humanity so that we can be present for our patients. So thank you so much. Thank you.  So we really want to try to encourage an interactive discussion. Come up to the microphones to ask questions, but if we, I don't know if this will work in terms of the recording,  but if we even engage each other in discussion from the,  from our chairs, that's fine too. Dr. Rosenberg, please start. Just really great. Very, very important. Quickly, could anyone tell me about the data,  the current data on physician help programs?  You know, if a physician's in a program for five years, how well they do compared to any kind of control study there is?  Why isn't there one in California?  So, hi there. Just to answer your question. Oh, great. The data suggests that when physicians have gotten involved with treatment, adequate treatment,  peer-involved treatment, as Karen was saying, and enroll in PHPs, the biggest study we have, it's old now, but I'm sorry, I'm Laura Moss.  I'm with the Washington Physicians Health Program, and this is my passion. I'm an addiction psychiatrist, and I get up joyful because I can help people and my peers.  And so the data suggests that actually, and we're working on new data, that for folks that are in treatment and enrolled in five years of monitoring for a substance use disorder,  at five years, around 70 to 80% of them are sober, licensed, and working. So the data, we know what the general population data is. You go out there and you do treatment as usual.  In six months, probably 50% of you have already relapsed to use. So it's great outcomes, and really what it is is exactly what you all have been talking about. It's mentorship.  It's reducing shame. It's community. It's advocacy. We do a lot of advocacy, and I think of physicians as being a vulnerable population, you know,  in that we're fearful of asking for help, and sometimes we don't get what we need. And our PHP actually can help reduce the negative consequences of use  by recommending people go into a medical leave of absence, apply for FMLA. This is a health condition, and if someone's on a focus of concern,  oftentimes that allows the resident to go out, get some help, and come back to work and be successful. So, and residency is a perfect time to take a pause  to take care of your health because it's not gonna have this huge impact on a longer career or something like that. So I just had to say that. Thanks for having this topic.  It's so important. Thank you so much, Laura. Thank you.  I think what the last speaker said about the distance we create with our patients and the need to break down some of those barriers, I think about our AAAP,  and I suspect that at least 10 or 15% of the people in this room have had a substance use problem in their lives, and a lot of us have gone to 12-step meetings,  and I've never had a teacher who told me that he or she had a substance abuse problem. And I think there's a problem in that we, it was like the last speaker said  that we're supposed to be tough and strong, and we create a distance between ourselves  and our patients and ourselves and our students and our colleagues. I mean, I can think of colleagues who've said to me over the years that they've had a substance use issue  but they don't talk about it with other people, and it's only when we're very close and in intimate situations. I know that there are meetings here at the AAAP.  I wonder how many people actually go to those, and I wonder what the panel thinks about ways that we can be more honest with each other and more vulnerable and whether that's a way  that we can fight burnout. Thanks.  There's certainly a variety of attitudes in that regard.  I mean, ranging from, these are two physicians here that I know well, one of whom is very happy and pleased  to tell his story so others can learn from it. And as bad as his experience was, in a way it's an inspiration for people to realize that I can come back from a very bad problem.  The other is a colleague who,  it's only after some years that he actually revealed to me that he was in recovery, and is somewhat ambivalent about revealing that  even though he's worked with us in terms of training for 12-step and the like.  But there's a wide range, and I think people have to accept, depending on how much the individual person wants.  I just wanna thank you for those comments. I have a couple thoughts. Number one, I think we can codify this in institutions. We can create programs by which we move away  from thinking so singularly that mentorship should be about career, and move towards mentorship should be about life and humanity.  And I think if we can shift and broaden our notion of mentorship, we can then think creatively about how we create programs in which students can be paired with someone  based on various life experiences, and one of which could be their physician's own experience with addiction. In terms of one thing you said, it's a little bit different  than the last question you ended with, but to think about the informal curriculum in education, and I think one of the big struggles we have  with these themes is that one of the main contributors to burnout in physicians is when they put up their walls between themselves and their patients.  And the two conditions where I think we do this the most, one is what we're talking about here, which is addiction, treating patients with addiction,  and the other is patients who have personality pathology. And so if we really wanna think about the informal curriculum, for us to think more broadly,  how do we empathically teach about these two entities? I think that one of the fears and one of the reasons people, especially physicians, put up walls  between themselves and their patients with addiction is that addiction is so common. Every family has a member who has addiction. Yes, if you really think about your own families,  there's someone, if not someone's, and if not someone's, really dearly important. And so it's so evocative, and I don't think we teach nearly enough  psychological skill sets to help our trainees, who are eventually our colleagues, to learn about how to live with that, how to deal with our own countertransference reactions,  and not to put up walls that then contribute to a whole sequelae of dangerousness. So thank you.  Hello, I'm Shannon McGuire from St. Louis, Missouri. I am a psychiatrist there, and I just graduated from residency about six months ago. And while I was in training,  our graduate medical education office paid for free therapy for any trainee who wanted to have it. And I can honestly say that's the only reason  I was getting therapy during training. And so I guess my question for you guys is, these treatments that you're discussing to help with burnout,  and also for clinicians with substance use disorders, who is paying for them?  Who is paying at the state physician health program level, or who is paying at the GME level?  Well, I know some GMEs, and I think Washington is one of them. The GME has created a fund for evaluation and testing for physicians. I believe Massachusetts, if anyone's here from,  so I think it's really state by state who has the resources to do that. Who has the resources, who can provide and is providing the resources,  but very important area to ensure that  there's an open door for treatment. And it's not just, oh my goodness, I can't cover the cost of this, yeah. And in terms of burnout mitigation and wellness,  I mean, this is so complicated. The way I view it, it's like a pie made of tons of slivers. Some overlap, some don't, and people usually have to get really creative  at the ground level. But the hope is that we are all part of institutions who understand the profound sequelae of not addressing this.  But the funds come from a combination of philanthropy and med ed funds, both at the undergraduate medical education level, the graduate medical education level,  and then really the piecemeal approach  to formalize mental health care. I can focus on the trainees, but our physicians are the same. Where once you get into that arena, it's so layered, right?  In terms of who has what insurance. The more diverse our medical trainees are, the more we are finding that more students are opting for Medi-Cal, even though they could opt in,  but it costs money to pay for more robust insurances. So it gets very complicated very fast when it comes to paying.  Well, your question also illustrates the problem that people aren't assured of getting treatment they need  in the addiction field. And parity was a victory of ours for a very long time,  but what we found out was that parity means  parity for the most minimal treatment that could be available. So I think it's illustrative of how we have to really be active in promoting our country  to provide treatment that's needed.  One thing I was going to suggest is this is why we need to get out there and network with people.  This is why we need to show the great outcomes that we do, you know, with the work that we do.  And if it's, you know, if it's a value, if they want to, if they want their employee to remain employed, if they want their student to be successful, you know,  how can we work together, I mean, we do a lot of networking with providers in the community. Some of them are willing to provide reduced cost treatment for trainees, you know,  for a number of sessions for a few people.  But really, the only reason that we were able to get the University of Washington GME to agree  to fund evaluations and testing for residents really was by doing a lot of collaboration and showing them the good outcomes, and at that point, it made sense to them.  So it does take work. I just want to say that.  Thank you. Thank you. Dave Cundiff again. Putting on my public health hat, our country is desperately short of physicians in almost every specialty, and the number one bottleneck  in physician training is admission to residency.  We have many medical students, particularly minorities and international medical graduates who can't get into a residency program at all.  And every physician accepted into a residency program,  that's a resource we cannot get back again under current funding models. So this is so important to make sure that every trainee succeeds,  gets trained up to where we need them, and succeeds in life and in their career. And by the way, is not lost to either addiction or to suicide.  A comment about this patient, it looks as if the results on escitalopram have been less than impressive.  In our world, we don't have a month go by that we don't have multiple patients say, gee, I wonder why I never got this careful a psychiatric evaluation before.  Maybe that bipolar disorder that the other people missed is why I've been relapsing. Why don't we give this a try?  So every time you're not getting the expected results, rethink your diagnosis. And if there's time, I'd love to hear our Washington colleagues talk  about how their procedures may differ for resident physicians than for physicians in community practice. I don't know if time will allow that or not, but thank you.  Hello. Just about Dr. Gallanter's comment regarding 12-step programs.  It might be useful to remember that AA was founded by a stockbroker and a physician,  proctologist in Akron, Ohio.  So that's something to remember. Second thing to remember, Dr. Silkworth has a comment, the doctor's opinion in the AA book. He characterized alcoholism as an allergy.  An allergy. How could it be an allergy? Well, an allergy is an unusual, uncommon, maybe somewhat unpredictable response to something, setting up the phenomenon of craving.  And that's where he sort of differentiated the normal drinker for an alcoholic drinker.  So it's these little historical things that a lot of people forget.  And probably should be emphasized, I think, with more freedoms, not telling people what to do, not requiring people to go to 12-step meetings,  it's probably an error because it's also free and frequent.  There's no charge. You can find a meeting every day, everywhere.  In fact, I think every night at the end of this meeting, there's a recovery meeting  where people can go to find out about this, to witness a meeting,  if they need a meeting, they can go to.  So just something to sort of emphasize.  Thank you. Yeah. Well, I mean, your points is obviously, or a couple of points are obviously well taken.  First is that the treatment, particularly in terms of, say, this resident is so fractionated. Her having been in different programs without continuity, really, that AA is valuable  because at least it provides continuity. She had different doctors and staff in each of those several programs that she was in.  And so the other thing is that AA is around 90 years old, and actually, it's held up pretty well.  I don't know, it's hard to find anything that is supposed to help people that's organized that can last that long, and some of it has to be rethought and readapted  without changing the basic tenets of it. And I think that a good example of that is that how attitudes toward the word God have been flexible  as we understood him, and that it's evolved over time. But we have to have a little flexibility in terms  of understanding how 21st century 12-step works relative to 20th century 12-step.  And IDAA has meetings online, so if she were to move from one state or location,  there's really a, like you said, the continuity, a community that she can be with in those IDAA meetings. Thank you.  Yeah, I'd like to ask a question about community and AA in this particular case, in that she was of Asian descent, Asian ethnicity.  And in any way, does that influence how we want to approach modifications or targeting her treatment, as well as having been a victim of assault  and possibly having trauma as a result of that? How might that influence her participation or involvement in treatment, if at all?  Well, you know, to build on what you said, and the availability of meetings through the internet has really been transformative and very useful, because the,  like, we've been studying people in AA, and I've sat in on some of the internet-based AA meetings. And not only are people manifestly, when they speak, providing tribute  for what's being offered them, and very sincerely. But you can have 50 people in a Zoom call, and each of them really is there to get help, and it's very adaptable.  Like, I have a patient who has been involved with varying degrees in AA for many years, and she goes on to these Zoom calls while she's waiting  for her daughter to finish a dance class.  I mean, that's adaptability, and it's certainly 21st century adaptability.  And also, that larger net, having a sponsor that understands her cultural experience and her family's views of her addiction, I think, is so important.  So to be able to find a therapist that she can identify, or a sponsor that she can identify,  can really move the treatment in a direction where it's stuck. So appreciate you bringing us back to that point. Thank you.  So I was the last graduate of the California program 18 years ago, and I don't know if I would have made it if I didn't have that program. I'm very sad we don't have it anymore.  And I'm very transparent about my condition with my patients, with my colleagues. But you go to fill out a renewal for your hospital application,  and they say, have you ever had a problem with alcohol or drugs? And I lie, because I don't know what that repercussion's going to have for me  in my professional sense in the administrative community. In a time when budgets are getting cut and everything else, it feels very punitive.  And I feel that the stigma is still there in a systematic way, tremendously. Even though there's acceptance amongst my colleagues, and certainly amongst my patients,  I don't feel that I'm accepted administratively in the medical profession. And I think that there's still, especially, I feel that medical people are held  to a higher standard, and we should not be struggling with this, because we should know better.  You know? And I think that's something that we have to overcome, because we have diabetes and cancer and heart disease and addiction, just like all humans, you know?  Yeah, but there's still a stigma associated with it. And actually, ASAM has been very active in lobbying to have a question like that removed  so that people aren't stigmatized when they're in recovery from addiction. I just wanted to thank you for what you do for all of your patients and your colleagues,  and for sharing this. This is such a reminder to all of us of the importance of advocacy at system levels and larger than our own institutions, but including our own institutions.  And to really help leaders in hospital systems to understand that these measures that are there, these questions that are asked when you are credentialed,  can actually prevent individuals working in those systems from actually getting the right support and the help,  and can have tremendous negative consequences for everyone involved as a result. So, thank you. Thank you for a great discussion. I'm Dr. Sinha. I'm at the Mayo Clinic in Arizona.  I trained at Mayo Clinic in Rochester, and we had a great program for impaired physicians and the nursing staff.  So, they will come every week for a process group, and it was just those professionals, physicians and nursing, and the group will be actually facilitated  by another addiction psychiatrist, and then with the social workers. So, I think that really encompasses what we are talking about, you know,  touching the intrapsychic challenges, the spirituality, and the doctors can also understand what peer can be going through. And that's also part of the entire program.  So, we have a residential program, then early recovery program, recovery maintenance program. So, everything is very, you know, in the co-located and very comprehensive.  We saw a great success rate, and the patients will be driving from neighboring states to attend those programs.  And it takes a while for the physicians to talk about their challenges, because their defense is so strong, you might have to like wait for three  to four months before they actually start talking about their feelings. So, having the opportunity to be here with their colleagues,  and including nursing colleagues, we saw a great success rate. And I agree that we try to focus too much on the pharmacotherapy, and not pay attention to the spiritual needs.  And, you know, often the surgeons would be really burned out. We have seen, you know, in the Midwest, some of the remote clinic, the surgeons are on call every single night.  And they would happen to have a drink or two, and ended up having a DUI, and, you know, all those things, so the burnout is a major, major trigger for their substance use.  So, that's kind of my experience, and those programs are very helpful.  Thank you.  Hi, Charlie Silberstein from Martha's Vineyard. Two quick comments. First, I just want to thank the person who was the, one of the last graduates  of the California program about, for your honesty and openness. I have a patient who is a physician on Suboxone.  And she's a member of a Suboxone support group that I run, and she's afraid to tell the people in the group that she's a physician, because she's afraid  that there will be consequences if anyone finds out.  And, in fact, when she moved to Massachusetts, she contacted, and I contacted the Physician's Health Service there.  And it wasn't clear that it was a good idea for her to enroll in it, because she was afraid  that then she would have to acknowledge on those forms that she had a substance abuse problem.  And I really appreciate the discussion, because it highlights the shame and the problem that we, that we're, that our system engenders. So, thank you.  Thank you. And some of the regulatory boards in different states actually prohibit doctors  or health professionals in general. So, it varies by state by state on being on medication for their opiate addiction. So, very tragic.  I'm Ryan Hardman. I'm an addiction psychiatrist at the Salt Lake City VA, affiliated with the University of Utah.  I am a success story of the Physician Health Program in Utah, actually during residency.  And I really like the idea of the funding for trainees. I think that was a big stressor for me, not having the funding during that time.  But I did have a really supportive family, and that was really helpful for me. And I've been in long-term recovery since then.  I think that I'm not really open with a lot of colleagues about being in recovery or my patients. I kind of experimented with that.  And part of that comes from when credentialing comes up and people have to fill out the form that says, do you have knowledge of this person and their, you know,  have they had problems with substances or mental health or that sort of thing? And to, or if I have unexpected leave or something like that,  I don't want people to make assumptions that it's because of a return to use or something like that.  And so I think it, but as far as the connection with patients, I think that being able to communicate that empathy is there, that understanding.  And I don't think that that's unique to having experienced it myself. I think all of us that really care about patients can express that.  And so I don't, I haven't disclosed that with patients per se. The other thing that I wanted to share was about the randomized urine screens as a form of treatment.  That was one of the most helpful parts for me in, beyond the five years. I decided to continue to do that just for accountability. It was helpful for me.  It was helpful for my family. And I wonder about increasing that availability for people that have interest. And that was the comment that I wanted to share. So thanks.  Yeah. By the way, thanks very much for being open because we're going to learn from people like yourself that we can't just speak about our own expertise.  And the vigilance that you live with each day, thank you for sharing that. The stigma is real. The systemic stigma is real. Thank you. Thank you to a great panel.  Great presentation by Dr. Passad. What a wonderful and heart-provoking case and discussion. And thank you all.  And thank you for people who shared their stories and gave us some ideas. Okay. I think most of you are ready for lunch. So all of you know you will need a ticket.  And then there are some committee meetings between 12.45 and 1.45. And we also have workshops starting 2 p.m. So enjoy the lunch. And see you all later on in the afternoon.
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