An Impaired Physician With Complex Comorbidity
Dr. Petersen-Crair
Dr. A, a 36-year-old married male internist, was referred to G.O.G. from his state’s physicians’ health program for a comprehensive diagnostic assessment, including evaluation of his ability to practice medicine. The referring physician had concerns about a personality disorder and the potential for a mood disorder, in addition to known substance abuse, which precipitated surrender of Dr. A’s medical license in two states.Dr. A’s mood symptoms had begun when he experienced feelings of depression as a child. His mood seemed to improve as he aged, but in college he had periods of depression for a few days at a time. His first treatment for depression occurred when he was a first-year medical student. One of his clinical teachers offered him samples of fluoxetine, which he took for 6 months. During his internship, he tried another antidepressant for a period of time as well. When he was in his last year of his internal medicine residency, he was treated with nefazodone, which he ultimately discontinued on his own. In recent months, he prescribed venlafaxine for himself. Dr. A had no history of clear episodes of mania, but he had some symptoms of hypomania when his venlafaxine dose had been increased to 300 mg/day.Dr. A’s history of excessive drinking began at age 17, when he started experiencing blackouts every 3 to 4 months during binge drinking episodes. He continued to drink heavily intermittently throughout college and medical school. By the time he was a resident, his drinking had escalated to the point at which he was intoxicated most weekends when he was not on call or moonlighting. He became worried that he would become an alcoholic like his father, and he entered a residential rehabilitation program midway through his residency that led to approximately 3 years of abstinence from alcohol.After the completion of his residency, he worked as a solo practitioner in a private office and was reasonably successful. However, he developed tension headaches, so he prescribed tramadol for himself. Over a period of 8 months, he increased his dose of tramadol to approximately 1.25–2.5 g/day. He had been attending Alcoholics Anonymous (AA) meetings regularly and had remained abstinent from alcohol. However, as he increased his tramadol dose, he experienced euphoria, and he realized he no longer needed to attend AA meetings in order to feel good. During the next 2 years, he increased his tramadol dose to an average of 5 to 6 g/day. On one occasion, this dose of medication induced a grand mal seizure while he was performing a minor medical procedure. Dr. A then medicated himself with primidone to prevent further seizures and to control an intention tremor in his hands.For 3 years, he continued to abuse tramadol but remained abstinent from alcohol. After he was accused by his hospital medical staff of incompetent management of a complicated hospital patient, he relapsed and drank on three separate occasions. He left the hospital and worked at two different emergency rooms, requiring long hours away from his wife and an erratic sleep schedule.Dr. A moved to another state to take over the internal medicine practice of a retiring physician. His wife stayed behind because of employment commitments. He reported being lonely in this new setting, and he started drinking heavily again while continuing to abuse tramadol. At this point, he was spending $1,000 a month to sustain his habit. He eventually came to the attention of the licensing board of this new state when he was arrested for being drunk and disorderly. He again entered a residential rehabilitation program, where he stayed for 3 months. He dreaded going home on weekend passes because of the stress of his marriage. He reported that his wife yelled and screamed at him, and he felt he was reexperiencing the violence of his childhood. On one occasion while he visited his wife on a pass, they had a fight, and she threatened divorce.He was then transferred to a halfway house, where he stayed for only a few days. While there, he asked one of the female patients to have sex with him, thinking that sex would elevate his mood after his wife threatened divorce. He was also involved in a physical altercation with a male patient, although Dr. A described the incident as follows: “I was on the phone, and this guy came up and hit me.” Dr. A was hauled off by the police and then thrown out of the halfway house. He found another halfway house, where he was able to maintain abstinence and was able to visit his wife on weekends.Dr. A’s developmental history is notable for its extensive trauma. He was the oldest of four children, with one younger sister and two younger brothers. His father was a truck driver who was on the road most of the time. While he was away, his mother had multiple affairs; Dr. A reported that he witnessed his mother having sex with a number of different lovers. He also witnessed extreme violence between his mother and her lovers. Eventually, social services removed him from his mother’s household, and his father then raised him. Dr. A described his father as an alcoholic, but he said they had a reasonably good relationship, and Dr. A felt supported by him. He has an extensive family history of alcoholism that included both paternal grandparents and a maternal grandmother.Dr. A was aware that he had a strong inclination to heavy drinking, so he deliberately chose a small religious college where he would not be tempted to spend each weekend partying. Nevertheless, his pattern of alcohol abuse continued. He married his wife during his residency, and the marriage gradually deteriorated when his wife discovered that he was using tramadol extensively. They repeatedly engaged in verbal arguments and occasionally became involved in physical altercations. Many of Dr. A’s relapses occurred after these fights. He and his wife did not seek consistent marital therapy for their difficulties, in part because his wife felt that the problems were his. Dr. A acknowledged his fear of abandonment by women and realized that he may unintentionally drive away women before they abandon him first.Dr. A’s medical history is positive for mild hypertension, intention tremor, allergic rhinitis, obesity, tinnitus, gastroesophageal reflux, and irritable bowel syndrome. At the time of the evaluation, his medications included venlafaxine (sustained release) 225 mg/day; divalproex, 500 mg b.i.d.; doxepin, 75 mg/day at bedtime; and hydrochlorothiazide, 12.5 mg/day. He had not taken tramadol for approximately 4 months at the time of his evaluation.At his mental status examination, Dr. A was a casually dressed, moderately obese man who appeared to be his stated age. He was oriented to place, person, time, and situation. He was cooperative and polite throughout the evaluation. He had good eye contact and revealed no motoric abnormalities. His thought processes were well organized but slightly slowed and somewhat overinclusive in the number of details he provided. He showed no evidence of a thought disorder or a flight of ideas. His mood appeared euthymic. His affect was constricted, with only rare expressions of emotion. He reported no suicidal ideation.
Dr. Harper
Dr. Marangell
Dr. Flack
Dr. Gabbard
Footnote
References
Information & Authors
Information
Published In
History
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
There are no citations for this item
View Options
View options
PDF/ePub
View PDF/ePubGet Access
Login options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).