Physician assistants (PAs) practice medicine, but like everyone else, they can suffer from diseases, including substance use disorder. Rates of substance use disorder among practicing PAs and PA students appear to be about 10%, similar to the rate in the general population.1-4 One article suggested the rate of substance use disorder for healthcare providers may be as high as 40%.5 As of December 31, 2014, the United States had nearly 102,000 certified PAs, with an estimated growth rate of 38% through 2022.6,7 With such growth in the profession, those suffering from substance use disorder represent a significant and growing number of PAs—and a threat to the public good when substance use disorder in the profession is undetected or ignored, or when PAs cannot get appropriate treatment.
REGULATORY RESPONSE TO PA IMPAIRMENT
The American Academy of Physician Assistants defines PA impairment as “any physical, mental, or behavioral condition that interferes with the ability to safely engage in professional activities.”8 Substance use disorder falls into the category of impairment.8 In 1981, the Michigan Academy of Physician Assistants created the first committee to address serious issues of PA impairment in the state.9 Similar committees exist in all states today, usually are composed of PAs, and have various goals related to assisting impaired PAs and protecting public health.3,8,9 These committees and their work with voluntary participants preceded state legislation for mandatory monitoring of impaired PAs.
Individual states have promulgated laws and regulations with varying degrees of PA peer review to oversee the monitoring of treatment for licensed PAs.10 Kober points to peer review as essential when addressing impairment within the profession.10 Although PAs might be permitted to have monitoring programs separate from other healthcare professionals, they often are monitored in physician health programs along with other health professionals such as veterinarians or dentists.3,11 Other health professionals who could suffer from substance use disorder, such as nurses, may seek to self-monitor.12,13
MONITORING NORTH CAROLINA PAs
In 1985, the North Carolina Academy of Physician Assistants (NCAPA) formed its health committee to address PA impairment through education and support; state legislation followed in 1993 allowing intervention, treatment, and monitoring of licensed PAs with addiction illness.3 The NCAPA contracted with the North Carolina Physician Health Program (NCPHP) to monitor PAs with substance use disorder, in part because of the extremely high success rates of physician participants in the program.3 Across the country, various healthcare professionals have been monitored by the same type of organization.2 NCPHP uses a model of treatment and monitoring recommended by the American Medical Association (AMA) and shown to be effective; yet, when studied, this success did not translate into good results for monitored PAs in North Carolina.3
The only research related specifically to PAs with substance use disorder is a 6-year retrospective study in North Carolina.11 This study found that although 91% of monitored physicians with addiction in the NCPHP had good outcomes, only 59% of monitored PAs did. Good outcomes without complications were defined as completed contracts from NCPHP or from another state, good outcomes with complications were defined as completed contracts with incidents of recurrent use, and poor outcomes were defined as contracts not completed for any reason. NCPHP contracts last 3 or 5 years depending on severity of disease determined by assessment. For an as-yet-unidentified reason, physicians had much higher success rates than PAs.
An e-mail correspondence with Dr. Ganley revealed that the study is about 9 years old and the specifics not outlined in the paper (such as actual data related to severity of PA substance use disorder before detection, and outcomes related to PA comorbidities) were somewhat vague. He reiterated that the numbers were too small to give any meaningful answers to why PA outcomes were so poor (personal communication, May 5, 2014). The authors made it clear when they published in 2005 that little research existed on PAs and similar work should be done in future by other monitoring programs.11
LIMITED RESEARCH AND INFORMATION
A recent review of data showed that little work has been done in this field since the Ganley and colleagues study. Two thorough online medical searches using various search engines were performed by two separate university librarians during the first 4 months of 2014. All articles that specifically addressed PAs with substance use disorder have been included in this paper. The Ganley and colleagues retrospective chart review, though flawed, remains the only study of monitored PA outcomes.
Professional organizations were contacted and various websites were reviewed for more information about PAs with substance use disorder. Data were identified from another physician health program that monitors PAs and physicians, as well as PA and medical students. The Colorado Physician Health Program publishes very favorable statistics on its website: of 126 PAs in the state monitoring program from 1992 to 2013, 97% had treatment success.14 These statistics are a dramatic improvement over the NCPHP program. Yet, of these successful outcomes for monitored Colorado PAs, only 27% of PAs monitored were listed as substance abuse, and 9% were listed as driving under the influence or driving while ability impaired.14 In North Carolina, Daniel Mattingly, PA-C, PA advisor for the NCPHP and member of the NCAPA health committee, reported that 24 of the committee's 29 active cases (about 83%) are substance use-related (personal communication, April 21, 2014). Because the two state programs consist of such different populations of monitored PAs, comparing the results is impossible.
Furthermore, the Colorado program's medical director, Dr. Doris Gunderson, e-mailed Dr. Joseph Jordan of NCPHP on my behalf that PAs in the Colorado program were inclined to suicidal ideation at a higher rate than physicians, but that this was a preliminary finding (personal correspondence, March 24, 2014). This could indicate that more advanced disease or comorbidities in Colorado PAs may not always correlate with poorer outcomes in treatment as speculated in the Ganley and colleagues study. However, because the North Carolina and Colorado PAs being monitored are so different, no comparison can be made.
Data were sought from the profession's national organization. Hannah Watson of the AAPA reported that the academy has never collected data related to PAs with substance use disorder (personal communication, March 24, 2014). Hari Gupta, director of operations for the North Carolina Medical Board, reports that the state has 5,238 licensed PAs (personal communication, May 6, 2014). We assume that about 524 (or 10%) of these licensed PAs have substance use disorder, but only 0.46% of North Carolina PAs are being monitored for substance use disorder. This percentage is even lower than the 1.1% of PAs monitored in the Ganley and colleagues study. Again, it would appear that many providers with addiction are not detected, not reported, or ignored, and that the percentage of licensed PAs identified with substance use disorder and being monitored is shrinking.
The North Carolina nursing profession also appears to be detecting very few in its ranks with addiction. Kathleen Privette, RN, MSN, NEA-BC, FRE, manager for regulatory compliance for the North Carolina Board of Nursing, reported that 145,000 nurses are licensed in North Carolina, yet the monitoring program only has about 250 participants (personal communication, April 21, 2014). This means that assuming about 14,500 (or 10%) of licensed nurses in North Carolina have addiction, only 0.17% are in the monitoring program. If most nurses with substance use disorder avoid detection, except those with advanced disease, one might expect that nurses participating in the monitoring program would have poorer outcomes, depending upon the specifics of the monitoring contract and its enforcement. Still, these nurses have high success rates.
Because of a small sample of participants and unequal metrics, the only comprehensive chart review of PA outcomes being monitored is unable to point to why PA success rates appeared significantly lower than physician success rates in NCPHP.11 Direct comparisons with Colorado PAs, who also were monitored by a contracted organization with other healthcare professionals or nurses in self-monitoring programs, also is not possible.
Future studies are needed and might incorporate key indicators of relapse, described by Long as regular and meaningful 12-step participation, appropriate use of Alcoholics Anonymous or Narcotics Anonymous sponsors and professional mentors, spiritual development, exercise, and leisure activities.2 Kim Lamando, director of NCPHP program operations, reported that a pilot study is under way with the same NCPHP population using the Maslach Burnout Inventory (personal communication, May 20, 2014). The Maslach Burnout Inventory is a survey that uses 22 items to evaluate emotional exhaustion, depersonalization, and personal accomplishment to assess professional burnout.15 This new study may offer insight into treatment outcomes of participants in the monitoring program juxtaposed to the factors studied by Ganley and colleagues, such as substances used, comorbidities, participant age at time of entry, and professional degree.
Much-needed future studies should strive for accurate comparisons of treatment outcomes by using universal terms and metrics with respect to detection rates, treatment provided, monitoring requirements, and enforcement in similar programs, such as state physician health programs. Studies also should compare self-administered professional programs to contracted multiprofession programs. Without these studies, accurate comparisons are impossible.
THE PA PROFESSION'S RESPONSIBILITY
The AAPA acknowledges its responsibility to protect patients by encouraging research in this field—and yet, AAPA does not collect data on PAs with substance use disorder.8 As the AAPA supports the amazing growth of the profession and take steps to ensure the production of high-quality clinicians with superior education and training, the national organization also should promote the need for healthy PAs and public safety. This includes accurate detection of substance use disorder within the profession and, when indicated, appropriate treatment and monitoring with measurable results. PA outcomes in the Ganley and colleagues study may not accurately reflect the quality of treatment and monitoring of the NCPHP, but the literature, or lack thereof, may indicate that as a profession, we have much to do to ensure the health and wellness of PAs suffering from substance use disorder.
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11. Ganley OH, Pendergast WJ, Wilkerson MW, Mattingly DE. Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000. J Addict Dis