The Florida Impaired Practitioners ProgramRoger A. Goetz, M.D.Roger A. Goetz, M.D. is Medical Director of the Florida Physician's Recovery Network. This article is reprinted with permission from the Federation Bulletin: The Journal of the Medical Licensure and Discipline. Goetz RA. The Florida impaired practitioners program. Fed Bull: J Med Licens Discipl. 1995; 82:131-133. Failure, fear, frustration, and fragmentation of care—all of which may have endangered the public, the profession, and the physician—ultimately led to the Florida system for the management of impaired practitioners. Florida's system is the logical and necessary extension of the efforts begun in 1979 by the Florida Department of Professional Regulations (DPR) and the Florida Medical Association (FMA). After futile attempts by the DPR and concurrent, independent attempts by practicing physicians to form an impaired practitioners program, the DPR and FMA joined efforts in 1985 to develop the policies and procedures presently administered by the nonprofit Physicians Recovery Network (PRN). Prior to the collaboration, the regulatory agency's program was misperceived as too public and punitive, and the medical association's program was misperceived as secretive and an extension of the "conspiracy of silence." FundingPRN is funded by charitable contributions and through a contract with the Florida Agency for Health Care Administration, the successor to DPR, to implement the statutorily required Impaired Practitioners Program. Physicians and other health care providers are not charged for PRN services. The PRN program has no financial relationship with any treatment program, provider, or individuals. All money for the Agency for Health Care Administration is obtained through licensing fees, and no tax revenue is involved. The program does not provide medical services. Physicians pay for their own medical care, and a loan fund and charitable services are available for those individuals without resources. ParticipantsConfidentiality of medical records and participation in impaired
physician programs is essential to the successful protection of the
public. Confidentiality permits open and honest communication and early
treatment prior to public harm. The Florida Medical Practice Act permits
the confidential treatment of physicians with impairments. Approximately
84% of all referrals to the PRN occur prior to any violation of the
Medical Practice Act or any evidence of patient harm. Participation
is confidential unless there is failure to progress in recovery. The
PRN program provides treatment, support, and referral for physicians
in lieu of discipline, prior to discipline, or during discipline and
post-discipline. The PRN is a "broad brush" program handling physical
disorders (in Network For TherapyFlorida is the fourth largest state in the Union. It has an ethnically and geographically diverse population. It is a major population growth center with a complex influx of physicians of various nationalities, training, and political backgrounds. To ensure adequate, cost-effective, and comprehensive coverage, the Physicians Recovery Network includes three cooperative groups: 1. Committees of organized professional associations that formally provide the political basis for the organization's interaction with PRN (examples of organizations include the Florida Medical Association, the Florida Pharmacy Association, the Florida Dental Association, and the Florida Veterinary Medical Association); 2. Treatment experts who provide a network to actively manage participants (examples include physicians and hospitals); 3. Recovering community volunteers who assist in monitoring, identification, and communication to provide a continuum of contact and assurance to program participants. Additional identification and assistance is provided by informal cooperation among various field offices of regulatory agencies. Each of these statewide networks interacts through the Physicians Recovery Network offices in an overlapping vertical and horizontal communications system to protect the public and provide a net to the falling professional. The Florida PRN has a network of local group therapy meetings. These meetings are in addition to required attendance at 12-step groups for chemically involved physicians and other appropriate diagnostic groups. The therapy groups are self-supporting, paying their own therapist. The therapist is approved by and accountable to PRN. In addition to its monitoring functions, the group assists in forming a bond within the recovering community. This has been an extremely successful method of early detection of impending problems in group members and other health care workers. The advantage of this system is the constant interaction between participants in the PRN program and the practicing medical community. Psychotherapy may be recommended for both chemical dependency and psychiatric conditions. Psychotherapy by a psychiatrist or other therapist under the direction of a psychiatrist is required for all non-chemical abuse or addiction participants. PRN does not interfere with psychotherapy but requests that the psychotherapist report progress and cooperation. If the physician fails to progress, discontinues medication, alters therapeutic patterns, or becomes a danger, the psychiatrist is expected to engage the services of the PRN office to mandate re-establishment of the psychotherapeutic relationship. PRN is totally confidential from the medical society and board members. Initially, impaired practitioner committees of the board or the medical society discussed and attempted to manage individual cases. This practice presented certain risks because membership of the committee changed, compromising confidentiality, or levels of expertise varied. Philosophies were divided, and issues of transference and counter-transference interfered. The Florida PRN now reviews its policies, procedures, and actions for the public at open meetings of overseeing boards, while confidentially managing individual physicians with a professional staff. This has been a source of reassurance to prominent physician participants. Public ProtectionFlorida has a "snitch law." The law recognizes treatment prior to public harm as an exception if the treatment is under PRN direction. Should other problems or patient harm occur, discipline may be imposed concurrently. The disciplinary process remains confidential unless the licensee waves confidentiality or probable cause is found. However, if a complaint concerns a matter of immediate and serious threat to the public, an emergency suspension may be requested by the director of the PRN. This power has been used successfully as a motivational factor to participants. The public nature of the process works as a control of the PRN. Every case that does not progress becomes disciplinary, and the entire record of the impaired physician is open to review by the public and the press. HIV IssuesThe only alleged documentation of transmission of HIV to patients occurred in Florida in a dental practice. This event assumed national attention and received extensive study. The populace urged regulatory management of HIV-positive practitioners in Florida. All agreed that the HIV-infected health care worker had a physical condition which could interfere with the public safety. There also was concern about the mental status of practitioners with HIV infections. The PRN program assumed responsibilities in this matter and provided a confidential, credible, accountable system for management of HIV-infected health care workers. This program has been successful in maintaining the confidentiality of the HIV-infected practitioner who presents no danger in practice, while assuring regulatory authority and control should conditions deteriorate. Scope Of The ProgramThe Florida PRN has grown from a program designed for only physicians to one that covers the entire spectrum of health care workers. The success with health care workers has led to the institution of similar programs for attorneys and educators. The result of this growth has been communication among the legal, medical, and health care teams. Referrals from knowledgeable members of all disciplines ensure that the entire professional system in Florida can provide help to otherwise qualified individuals and protect both the individual and the public from the consequences of untreated or unrecovered impairments.
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