Empirical findings of fitness-for-duty evaluations

This article was migrated. The article was marked as recommended. Background:The ability of physicians to practice appropriately is often evaluated by a fitness for duty exam. This report reviews the empirical literature on fitness for duty evaluations. Methods: A literature review was performed on PubMed using the terms physician, impairment, burnout, fitness to practice and fitness for duty. Results: At least one percent of physicians are referred each year for possibly serious difficulties. Surgery and its subspecialties and psychiatry may be at higher risk. Variables associated with fitness for duty evaluations include educational, personality, culture and emotional illness. Conclusions: Risk factors appear to vary between modifiable (training, culture and treatable emotional illness), less modifiable (personality) and likely unmodifiable (specialty). Fitness for duty should be part of the training of all psychiatrists.


Introduction
Medicine is a self-regulating profession in that it attempts to ensure that its practitioners are practicing within accepted standards of care.The question of whether a given decision or situation is within the standard of care is usually determined by specialists in that profession (e.g.surgeons assess surgeons, internists assess internists, etc.)However, when broader issues of functioning are to be assessed, a psychiatrist may be required to perform a fitness-for-duty evaluation.This report examined the empirical literature on this subject relevant to physicians.

Methods
A literature review was performed on PubMed using the terms physician, impairment, burnout, fitness to practice and fitness for duty.References from articles identified by PubMed were also reviewed to find other relevant articles.Potential articles selected for this review were those that focused on fitness for duty, were empirically based, had a well described sample and a sample size greater than five.The findings were summarized and then applied to the educational vignettes given below.
Vignettes #1 Dr. X was a psychiatrist who successfully finished his residency training but never took his boards.After residency, he worked for a few community mental health centers before going into private practice.His private practice, largely focused on the medication treatment of psychiatric patients.Dr. X had a stable marriage as well as a close relationship with a fellow psychiatrist who lived a short distance away.In the evenings after work, he would stop at his friend's house, where they would have a drink and discuss medical cases and non-work issues.
Things went well for Dr. X for a number of years, until his friend died.After his friend's death, a number of complaints were made regarding Dr. X; his practice was described as being "a bit off," although no urgent patient issues were reported.Problems related to billing were also reported, such as his liberal interpretation of medical billing codes for re-imbursement.
The medical board assigned Dr. X a supervising physician.Observation took place during Dr. X's work hours.The supervisory physician noted that Dr. X would occasionally discuss a patient's issues with the patient while the two were within earshot of other patients.Although the recent problems with billing and the discussion of sensitive health information in public settings were of concern, the supervising physician believed these issues were correctable.
A meeting was held with the medical board, Dr. X, and the supervisor.During a discussion of patient privacy, Dr. X became defensive, stating that he believed that all patients should be able to hear the details of all the other patients' issues.The supervisor pointed out to the board (and Dr. X) that this was not what he had observed; rather, the supervisor reported, Dr. X did attempt to maintain privacy, but his attempts were at times unsuccessful.Dr. X then admitted that the supervisor's observation was correct.
The board had Dr. X continue in supervised practice until the deficiencies in his ability to maintain patient privacy were corrected.Eventually Dr. X was allowed to practice without supervision.

#2
Dr. Y was a married, board-certified general surgeon who did well in medical school and residency and was respected by colleagues in his private practice.His wife of many years helped organize the couple's social life.At some point the marriage began to deteriorate.As a result, the couple's social life also declined.This was more of a problem for Dr. Y than his wife, who had her own friends to socialize with.Dr. Y began to spend more time at the office, where he felt appreciated by his colleagues and patients.Unfortunately, Dr. Y's increased time at work further isolated him socially, and he began to drink more alcohol in the evenings.Dr. Y used the drinking as a means of helping him deal with the frequent arguments he had with his wife after returning home from work.
After one particularly nasty fight, Dr. Y told his wife he would sleep at a friend's vacant apartment.Dr. Y began driving to his office and soon realized he had forgotten to bring along some food and other items.Rather than return home, Dr. Y drove to a supermarket.After selecting the items needed, Dr. Y realized he had forgotten his wallet at home and had only a few dollars in his pocket.Dr. Y was reluctant to return home for his wallet, decided to put some of the items in his pockets, and was subsequently arrested for theft.The incident was reported to the medical board after the arresting officer realized Dr. Y was a physician.Dr. Y's license was placed on probation during the medical board's investigation.During this time, Dr. Y engaged in psychotherapy and medication management for major depression and marital issues.Alcohol education was also provided.Dr. Y ultimately divorced, came to terms with his emotional issues, and was removed from probation.There were no patient complaints prior to or throughout the medical board's involvement with Dr. Y.

Results
Scope of the problem.Questions about a physician's ability to practice are common and are of concern to both the public and the physician involved.In the United States (US) in 2015, the Federation of State Medical Boards (FSMB) took 7,942 actions (2016).Over 1,200 of these actions involved the restriction of physician licenses.Even more accurate tallies are available from the United Kingdom (UK)'s National Health Service.In 1994, Donaldson found that, over a five-year period, 6% of senior physicians working in the northern health region of the National Health Service were referred for questions of fitness-for-duty (Donaldson, 1994).In 2009, the General Medical Council of the United Kingdom found that approximately 2.5% of physicians were referred for a question of fitness-to-practice (2010).Around half of these referrals were determined to be minor or insignificant; however, the remainder required some level of investigation.The frequency of disciplinary actions in the US, and data from the UK, suggests that questions surrounding the fitness-to-practice medicine are a frequent occurrence.
Findings from studies of medical students.Performance in medical school may be an early indicator of future problems related to fitness-for-duty.A small minority of medical students run into disciplinary problems in medical school.Braatvedt, (Braatvedt et al., 2014) found that only 5.5% of medical students received fitness-for-duty evaluations while Howe et al. reported 3% (2010).It is important to note that, with counseling, virtually all of these students managed to return to good standing.
Howe's research provides the most comprehensive summary of specific deficiencies leading to fitness-for-duty referrals in the medical student population (Howe et al., 2010).Regarding reasons for referral, Howe reported unexplained absence at 26%; tutor reports unsatisfactory behavior at 21%; lack of meeting responsibilities at 16.4%; plagiarism at 12.3%; other behavioral at 12.3%; and falsification of signatures at 4.1%.Of note, Howe's list includes infractions covering a wide range of behaviors, and there do not appear to be specific behaviors relative to a fitness-for-duty referral.Rather, unprofessional behavior in general appears to be the common link among fitness-for-duty referrals.
Regarding the association of demographic and personal characteristics with fitness-for-duty referrals during medical school, Braatvedt and colleagues found that referrals most often involved males in their clinical years (Braatvdt et al., 2014).Papadakis et al. found that disciplinary action was significantly associated with prior unprofessional behavior in medical school (OR = 3.0) for a population-attributable risk of 26% (Papdakis et al., 2005).The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (OR = 8.5) and severely diminished capacity for self-improvement (OR = 3.0).Low MCAT scores and poor grades during the first two years of medical school were also associated with discipline but had very low attributable risk.An examination of five medical students, who each received two fitness-for-duty referrals, revealed that a poor relationship with the health care team was the most prevalent reason for referral (Papadakis et al., 1999).In their examination of medical student personality factors, Dowell and colleagues found that students who did not rate on the extreme ends of personality measures tended to higher scores on measures of professionalism (Dowell et al., 2011).It is worth noting, however, that the study by Dowell and colleagues had some limitations that included a high dropout rate and the use of study instruments with questionable validity.These data, and those obtained by Papadakis et al., indicate that deficiencies in professionalism factors may play a significant role in early medical school difficulties (Papadakis et al., 2005).
Medical students referred for fitness-for-duty evaluations almost invariably return to the regular education process with counseling.However, there is evidence suggesting that a history of referral for a fitness-for-duty evaluation during medical school serves as a harbinger of future problems.For example, in the case control study performed by Papadakis et al., problematic behavior during medical school was associated with subsequent medical board discipline (Papdakis et al., 2004).Most notably, a logistic regression (p = .02)showed that the variable of "Concern/Problem/Extreme" excerpts in one's medical school file was the only significant predictor of medical board discipline.Teherani et al. carried this analysis further in an attempt to identify specific personality factors that associated with later medical board discipline.Three domains of unprofessional behavior significantly related to later disciplinary problems were identified: 1) poor reliability and responsibility; 2) lack of self-improvement and adaptability; and 3) poor initiative and motivation (Teherani et al., 2005).Thus, the literature indicates that personality factors can play a role in professional difficulties during medical school and beyond.
Findings from the empirical literature on physician fitness-for-duty.It is reasonable to ask: Do some specialties tend toward more fitness-for-duty difficulties?Donaldson examined a group of 49 out of 850 UK physicians who were considered "problem doctors" and found the following results (%): Anesthesiology: 14; General Medicine: 4: General Surgery: 8; Geriatrics: 8; Obstetrics and Gynecology: 10; Other Medical (including Pediatrics): 12; Other Surgical: 18; Psychiatry: 22; and Radiology: 2 (Donaldson, 1994).Campbell's research group provided specialty figures for a representative sample of UK physicians (%): Anesthesia: 1; General Practice: 2; Medicine: 2; Non-General Practice/ Specialist: 1; Obstetrics and Gynecology: 4; Ophthalmology: 2; Pediatrics: 2; Pathology: 1; Psychiatry: 5; Radiology: 1; and Surgery: 4 (Campbell, Hodgson Rollin and Smith, 2013).Finlayson and colleagues examined physicians referred to the Vanderbilt Assessment Service and found that the largest represented specialties were (%): Internal Medicine: 41.4; Surgery: 13.7; Family Medicine: 10.9; and Pediatrics: 8.7 (Finlayson et al., 2013).Based on these data, it appears that physicians practicing in surgery and its subspecialties, and psychiatry, may be at higher risk for professional problems.
Characteristics of those referred for evaluation.Finlayson and colleagues documented the mental health diagnoses of those referred for fitness-for-duty evaluations at the Vanderbilt Assessment Service.Of those assessed (%), 36.7 had one Axis I diagnosis; 20.5 had two; 10.5 had three; and 1.8 had four (Finalyson et al., 2013).These data show that a majority of those evaluated (69.5%) had a diagnosable emotional illness.Of note, the presence of an Axis I diagnosis reduced the chances of being found fit-for-duty.Physicians presenting with disruptive behavior were significantly less likely to be assessed as unfit for practice when compared to persons with a history of problematic substance use, mental health concerns, and/or poor sexual boundaries.There is evidence suggesting that training and/or competence can help predict which physicians will be referred for fitness-for-duty evaluations.Humphrey et al., (Humphrey, Hickman, Gulliford, 2011) examined a group of physicians in the UK and found significantly higher levels of discipline reported at all levels for physicians who trained outside of the UK as opposed to those trained in the UK (Humphrey, Hickman, Gulliford, 2011).In this case, the authors appear to suggest that location of training is a proxy for the quality of training, and that poorer training (in this case, considered training outside the UK) resulted in more referrals for fitness-for-duty evaluations.A study by Yates examined UK medical school graduates with proven misconduct by the medical board.It was found that these physicians had experienced significantly increased incidence of academic difficulty during medical school (Yates, James 2010).
In their study of US physicians who entered internal medicine residency training from1990 to 2000, and who went on to become board certified internists, Papadakis et al., (2008) reported that high performance on the American Board of Internal Medicine (ABIM) certification examination was associated with lower discipline by state licensing boards (Papadakis et al., 2008).A retrospective follow up study by Lipner et al. involved physicians enrolled in accredited internal medicine residency programs within the US and showed that disciplinary actions were lowest for those achieving board certified status in internal medicine, slightly higher for those with certifications in other disciplines, and significantly higher for those who had not achieved board certification in any area of expertise (Lipner et al., 2016).The available data from the UK and US suggests that higher levels of training may protect against referral for a fitness-forduty evaluation.
Demographic variables may also affect fitness-for-duty evaluations.Unwin and colleagues' examination of sanctions against physicians registered to practice in the UK found that female physicians had nearly one-third the odds of receiving sanctions as compared to males, although this finding varied by specialty (Unwin et al., 2014).Yates' study of UK physicians with serious medical misconduct found that men, and physicians from what were considered to be lower social classes, had a higher likelihood of misconduct (Yates, James, 2010).
Findings from the literature on how to perform fitness-for-duty evaluations.Fitness-for-duty evaluations are, at their core, psychiatric evaluations.As such, these evaluations should meet the standards of a high-quality psychiatric evaluation along with collection of a thorough history, collateral information, and job performance data.In addition, if indicated, psychometric and laboratory testing should be performed.
In a patient psychiatric evaluation, the interests of the evaluator and the client are relatively in sync.That is, both doctor and patient are focused on treatment and improvement in functioning.However, a fitness-for-duty evaluation is fundamentally different from evaluations performed by treatment providers.It is important that the professional under evaluation is made aware of the nature of the interview, the associated limits of confidentiality, and the fact that the evaluator is not acting in the role of a treatment provider.Any issues of potential bias on the part of the evaluator should be disclosed in advance.It is also advisable to clarify the questions in writing with the person who referred the physician for treatment.
In general, fitness-for-duty reports should provide an opinion on the presence of an emotional disorder and whether the disorder interferes with the physician's job performance.Final decisions as to whether a physician can perform his or her duties will ultimately be decided by physicians with a similar professional background.Reports should include pertinent positives and negatives relevant to the evaluator's opinion; however, evaluators should give some consideration as to who will have access to the report, and keep confidentiality concerns in mind when deciding on the level of detail to include regarding case-specific issues.As is the practice when completing forensic reports, care should be taken to ensure that confidential health information is not inappropriately distributed.

Discussion
The literature reviewed indicates that small but significant numbers of physicians will be referred for fitness-for-duty evaluations and, of these, perhaps one percent with relatively serious indications.We know that prior performance of some physicians, dating back to medical school, can serve as an indicator of future unprofessional conduct.The key factors associated with deficiencies in professionalism relate to personality (e.g. an inability to learn from mistakes and/or a poor display of responsibility, initiative, and motivation.) and culture (professionalism).As we move from medical student to full-fledged physician, factors such as quality of training, emotional health, and choice of subspecialty are associated with varying levels of risk.It is our hope that this review may lead to improvements in the identification and treatment of physicians whose struggles are negatively impacting their professionalism and the level of care provided to their patients.
This brings us back to our two vignettes, which were based on the authors' experiences when working with colleagues in need of a fitness-for-duty evaluation.The first vignette touched on a number of risk factors: psychiatric specialty; personality traits (e.g., over-sensitivity and reactivity); and somewhat marginal training (e.g., never became board certified).This example showed how some limitations can be overcome with support.The doctor in this vignette never had difficulties prior to the death of his colleague and close confidant.In this case, some guidance from the medical board was all that was needed to bring the doctor's practice up to the appropriate standard of care.Of note, despite the presence of some risk factors that tend to be less amenable to change (e.g., personality), the physician was able to respond at a level that allowed him to practice medicine independently once again.
In our second vignette, the protective effects of solid training and aptitude kept this physician from displaying obvious impairments, until the point when his life essentially fell apart.As in the first vignette, this physician also experienced a reduction in level of social support.However, the concomitant development of a significant mental health syndrome, compounded by his marital difficulties, eventually led to the physician behaving in ways that jeopardized his career.
Fortunately, these factors were remediable with support, and he was able to return to successful practice.
Overall, a well performed fitness-for-duty evaluation can be beneficial to the doctor, his organization, and the public.

Take Home Messages
Fitness-for-duty referrals are commonat least one percent a year for physicians.
Risk factors for fitness-for-duty evaluations include training factors, personality factors, cultural factors and emotional disorders.
Many risk factors can be modified or improved with training or modifications.These include deficiencies in training, cultural education and treatable emotional disorders.
Most physicians with fitness for duty issues eventually return successfully to practice.

Richard Hays
James Cook University This review has been migrated.The reviewer awarded 4 stars out of 5 I found this paper both interesting and sobering.The topic is so important that I am surprised that it has drawn little comment.The review appears comprehensive and provides evidence that confirms most of the professions' views and fears.I have some tips for possible improvement.First, the context appears to be US-focused, although it is not really when the literature is reported and analysed.It may be more appealing internationally if terms were explained.For example, is "fit-for-duty" the same as "fitness for practice"?Second, the use of the vignettes, which appear sound, amidst a literature review is potentially confusing.Did they guide (even constrain) the literature search, or ar they designed as educational strategies based on the review?I think it is the latter, but their location before the results are presented makes this less clear.Third, why was only PubMed searched?There are other sources.Fourth, how did the clinical background of the author (psychiatry) influence the review?It is possible that there was a focus on mental health when there may be other causes.Finally, readers would benefit from some discussion on implications for teaching practice, based on the review.Overall I think this is a useful contribution that might guide readers to summaries of available evidence.

Table 1 .
Empirical results of studies examining medical students who have possible impairment in their roles as physicians.

Table 2 .
Empirical results of studies examining physicians who have possible impairment in their roles as physicians.
Donaldson described the reasons for referral (%) as 1) Poor attitude and disruptive or irresponsible behavior: 65; 2) Lack of commitment to duties: 42; 3) Poor skills and inadequate knowledge: 39; 4) Dishonesty: 22; 5) Sexual matters: 14; 6) Disorganized practice and poor communication with colleagues: 10; and 7) Other problems: 2 (Donaldson, 1994).Papadakis et al. reported similar findings in that, among board certified internists in the United States, those with lower ratings for professionalism experienced higher levels of discipline by state licensing boards(Papadakis et al., 2008).
James Reich, MD is Clinical Professor of Psychiatry at UCSF Medical Center and Consulting Porfessor of Psychiatry at Stanford Medical School.He is the founder of the Association for Research in Personality Disorders (ARPD) and has published in the areas of anxiety, personality and forensic medicine.Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board.Acad Med.79, pp.244-249.Reference Source Papadakis, M.A., Osborne, E.H.S., Cooke, M., Healy, K., et al. (1999) A strategy for the detection of unprofessional behavior in medical students.Acad Med.74(9), pp.980-990.Reference Source Papadakis, M.A., Teherani, A., Banach, M.A., Knettler, T.R., et al. (2005) Disciplinary action by medical boards and prior behavior in medical school.N Engl J Med. 353, pp.2673-2682.Reference Source Teherani, A., Hodgson, C.S., Banach, M. and Papdakis, M.A. (2005) Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board.Acad Med.80(10 suppl), pp.S17-S20.Reference Source Unwin, E., Woolf, K., Wadlow, C. and Dacre, J. (2014) Disciplined doctors: Does the sex of a doctor matter?A cross-sectional study examining the association between a doctor's sex and receiving sanctions against their medical registration.BMJ Open.4: e005405.Reference Source Yates, J. and James, D. (2010) Risk factors at medical school for subsequent professional misconduct: multicentre retrospective casecontrol study.BMJ.340, pp.c2040.Reference Source © 2019 Hays R.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.