Applies to: Residents and fellows in all accredited post-graduate medical training programs (residency and fellowship) and non-accredited clinical fellowship programs in WSU Elson S. Floyd College of Medicine Graduate Medical Education (GME) Sponsoring Institution.
GMEC Approval: March 18, 2025
1.0 Policy Statement
It is the policy of the WSU College of Medicine Office of Graduate Medical Education (GME) to create an environment to assist residents in maintaining wellness in proactively addressing any health condition or impairment that could potentially affect their health, well-being, performance, and safety of themselves and others. The purpose of this policy is to outline the protocol for program leadership, residents, and fellows when there are concerns about an ability to practice safely due to impairment. Physician health is essential to high quality patient care. An impaired healthcare provider is a risk to patients, themselves, and to their colleagues. We all have the responsibility to report incidences of impairment for patient safety and provider well-being. Timely identification and diagnosis of an impairment may be both career and life saving.
2.0 Definitions
Accreditation Council for Graduate Medical Education (ACGME)
Accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of importance in graduate medical education.
Designated Institutional Official (DIO)
The individual in a Sponsoring Institution who has the authority and responsibility for the institution’s ACGME-accredited programs.
Fatigue Mitigation
Methods and strategies for learning to recognize and manage fatigue to support physician/caregiver well-being and safe patient care.
Impairment
Impairment includes (but is not limited to) any physical health, mental health, substance use/abuse, or behavioral condition that has the potential to adversely affect the practice of medicine and/or hinder performance.
Per Washington State Legislature RCW 18.71.300 impairment is the “inability to practice medicine with reasonable skill and safety to patients by reason of a health condition.” Examples of conditions that may cause impairment include, but are not limited to:
- Mood disorders such as major depression or bipolar disorder
- Anxiety disorders
- Sleep disorders
- Stress disorders
- Substance use disorders
- Neurodegenerative disorders
- Concussive syndromes and traumatic brain injury
- Chronic or uncontrolled pain
- Non-psychiatric medical conditions and/or their treatments
- •Suicidality or suicidal ideation
Concerns of impairment may manifest as clinical performance deficits, lapses in professionalism, failure to follow institutional policies and procedures that support quality and safety, recurrent performance, or behavioral problems not amenable to remediation efforts, and/or subtle or more overt manifestations of illness.
Program Director (PD)
The individual designated with authority and accountability for the operation of the residency/fellowship program.
Resident
A physician-in-training at an ACGME-accredited graduate medical education program. In this policy, the term includes interns, residents, and fellows or other trainees enrolled in an educational program whose education falls under the purview of the WSU College of Medicine Office of Graduate Medical Education.
Washington Physicians Health Program (WPHP)
WPHP is an independent, physician led, nonprofit organization providing critical support to health professionals in Washington.
3.0 Responsibilities
Program Director, DIO
4.0 Procedures
Monitoring for Signs of Impairment
The Program Director in each program must ensure that residents and fellows are monitored for signs of impairment, especially those related to depression, burnout, suicidality, substance use, and behavioral disorders. The program director utilizes program faculty, leadership, peer residents, and other personnel to assist in monitoring.
See Appendix A: Examples of Possible Impairment.
Education
Each training program must provide education to its residents and faculty regarding physician impairment, including:
- Identifying the signs and symptoms of impairment in self and others.
- Steps to take if impairment is suspected
- Reporting and notification of impairment if suspected
Each program should have a curriculum in place to educate residents about attending to their own wellness, seeking help for health-related problems (including suicidal thinking), legal and ethical obligations for identifying and responding to concerns for impairment in oneself and peers, and available resources to support health and well-being.
Additionally, programs must:
- Educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation;
- Educate all faculty members and residents in alertness management and fatigue mitigation processes; and,
- Encourage residents to use fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning.
Intervention
Once concern is raised about a resident or fellow, the Program Director should act quickly to perform a workplace intervention. In the absence of the Program Director, the Associate Program Director may perform a workplace intervention. The intervention may include a referral to WPHP. When possible, programs should consult with the GME Office if there are any concerns and before making a WPHP referral. The GME Office can advise programs regarding support and best practices. If the resident, patients or others are at risk of harm due to suspected impairment, the resident or fellow may be removed immediately from patient care duties and referred for emergency evaluation and treatment.
Referral and Evaluation
If it is deemed appropriate following a workplace intervention that an evaluation must take place, the evaluation may be performed under the oversight of WPHP. A referral can be made for the resident, or the resident may self-refer. Once a resident is found to be impaired or at significant risk for impairment, only the WPHP may determine if the resident is safe to return to work and resume patient care responsibilities. Evaluation, treatment, and enrollment in a health support agreement (when indicated) will be performed under the auspices of WPHP.
The resident’s Program Director is the main point of contact for WPHP. This individual will provide and receive WPHP progress updates. The Program Director may delegate this to an Associate Program Director or Assistant Program Director.
When a resident is referred to the WPHP for assessment and evaluation, the resident is asked to provide a release allowing WPHP to disclose information to the Program Director and the GME Office. WPHP disclosures to the Program Director or GME Office are intended to provide general status updates and to coordinate logistics. Resident privacy and confidentiality are of utmost importance and only that information necessary
is shared. If release is not signed, WPHP will maintain confidentiality per WPHP policies and guidelines.
WPHP is solely authorized to determine fitness for duty and endorse the return to work (i.e., the resumption of training and clinical care responsibilities) of all WSU College of Medicine residents referred for concern of impairment.
As a condition of appointment, all residents are required to comply with the Program Director’s decision to remove them from participation in clinical duties and other professional activities and to refer them to WPHP should impairment be suspected and/or confirmed.
If WPHP determines that the resident is not impaired, mention of the impairment concern shall be removed from their records and the resident will be allowed to return to work.
Should WPHP conclude that a resident is impaired or at significant risk for impairment, the resident may be required to complete additional assessment and/or treatment with a WPHP approved provider. In this case, the Program Director must immediately take appropriate action, which may include:
- Suspension from Clinical Duties: This action will be considered if a health condition may adversely affect the resident’s ability to provide safe patient care or may otherwise put the individual at risk for hurting themself or others. The program may assign other educational/training responsibilities to the resident during this time in consultation with WPHP and the GME Office. Suspension should include limiting access to patient care environment and patient care systems including electronic health records.
- Leave of Absence: In some cases, recommended treatment will be at a level of care or for a duration of time that requires a leave of absence from the program. The GME Office will coordinate with the program and the resident and help facilitate the appropriate leave type.
Evaluation by WPHP is at no cost to the resident or referring program. If WPHP determines further assessment or diagnostics is required, the resident will be referred to WPHP-approved providers. Residents may be financially responsible for diagnostics and evaluation performed at a facility other than WPHP. If treatment is recommended, treatment costs will be the responsibility of the resident. Medical insurance may cover some of these costs.
If an assessment or evaluation is requested by another agency (i.e., the Washington Medical Commission), all associated costs and subsequent treatment costs will be the responsibility of the resident.
Return to Work
Residents who have been on medical leave due to a medical condition identified in evaluation by WPHP, must be approved by the WPHP and their personal healthcare provider before the training program can consider their return to training. The resident must submit any required healthcare provider documentation to the WSU Disability Services Office confirming they are cleared to return to work. Residents will be required to agree to and sign a WPHP Return to Work Agreement, which outlines the terms under which the resident is allowed to return to clinical and/or other training duties. In some cases, residents may undertake limited duties as a part of a return to work Agreement.
Residents who are deemed able to return to training will be required to commit to the requirements of a health support agreement as determined by the WPHP. The WPHP will be responsible for implementing health support and verification activities that allow for the endorsement that the resident is safe to practice. The program may allow reasonable accommodations for residents to meet the requirements of their health support agreement. If additional disability accommodations are required, the GME Office will work with the resident and the WSU Disability Services Office.
In some cases, the risk of illness recurrence and safety to the resident and/or patients is such that a return to training is not recommended. In such cases, WPHP and the GME Office will work with residents to consider alternatives.
Well-Being
Program directors must ensure policies and programs that encourage optimal resident and faculty member well-being and demonstrate efforts to enhance the meaning that each resident finds in the experience of being a physician, including:
- protecting time with patients;
- minimizing non-physician obligations;
- providing administrative support;
- promoting progressive autonomy and flexibility, and;
- enhancing professional relationships.
- attention to scheduling, work intensity, and work compression that impacts resident well-being;
- evaluating workplace safety data and addressing the safety of residents and faculty members;
5.0 Related Policies
- Promotion and Appointment Renewal
- Corrective, Disciplinary, Grievance and Due Process
- Trainee Appointment Policy
- Safe Transportation Home
- Vacation and Leave
6.0 Revision History
GMEC Approval: March 18, 2025
Revision/Review Date(s): June 16, 2021, March 13, 2025
Responsible Office: WSU College of Medicine Sponsoring Institution
Policy Contact: Designated Institutional Official
Supersedes: N/A
Appendix A: Examples of Possible Impairment
Patterns and clusters of observations are more important than isolated events.
Irritability: change in personality or interactions with others
- mood swings
- negative attitude
- unprofessional behavior
- interpersonal conflict
- defensiveness
Irresponsibility: change in reliability
- manipulates schedules to avoid work
- hastiness
- takes shortcuts
- increase in personal distractions
Inaccessibility: change in availability
- tardiness & absenteeism
- missing or late responses to calls
- early departure
- frequent or extended breaks
- sleeping on the job
Inability: change in work performance
- failure to meet quality or performance expectations of position
- difficulty adapting to change
- increase in complaints
- failure to follow policies & procedures
Isolation: change in social interactions
- avoidance of meetings/events
- volunteering for duties where observation by others is less likely
- appearing withdrawn or less socially engaged
- poor eye contact
Incidentals: change in appearance and other behaviors of concern.
Examples include:
- Facial Appearance:
- bloodshot, puffy, or glassy eyes
- dilated or constricted pupils
- red and bulbous nose
- frequent runny nose
- Physical Appearance Changes:
- poor grooming
- tremulousness
- bruising
- sleepiness
- sudden or significant weight loss or gain
- Verbal Changes:
- fast speech or unable to interrupt
- slurred or slowed speech
- incoherent or bizarre remarks
- talking about hopelessness or suicide
- Smell of:
- alcohol or cannabis
- excessive fragrance, mints, or mouthwash
- body odor
- bad breath
- Emotional Changes:
- crying
- arrogance
- flat or inappropriate affect
- easily overwhelmed
- low frustration tolerance
- Behaviors:
- observed or reputed heavy alcohol or substance use
- inappropriate boundaries with patients/staff
- sending unusual texts, emails, or social media posts
- forgetfulness
- confusion or disorientation
Appendix B: Guidelines for performing a workplace intervention for a resident with suspected impairment
A workplace intervention should be conducted by the Program Director or other faculty member as soon as possible when a reasonable concern for impairment has been identified. This intervention is an opportunity to express concern and support the safety of the resident and patients.
Aims of the Intervention
- Provide support and assistance to residents who may be engaged in the dangerous use of substances.
- Prevent patient harm as the result of being cared for by an impaired physician.
- Facilitate further evaluation and treatment in a manner that allows the resident to protect their medical license and avoid disciplinary action by medical regulators.
- Protect the resident’s privacy and confidentiality to the maximum extent provided by existing state and federal law.
Step 1 – Planning the Intervention
The Program Director and/or faculty member(s) undertaking a workplace intervention must be completely clear about the anticipated outcome of the intervention before embarking upon it. This requires some prior planning. If a faculty member is conducting the intervention, inform the Program Director of the intervention as soon as possible.
- Review the information that has raised the concern. Discuss the case with a member of the GME Office, preferably the DIO. If the DIO is not available, review with the Institutional Manager.
- If needed, consult WPHP for advice on managing the situation. In most cases, WPHP will want to see the resident with suspected impairment and will advise on the timeframe for this.
- Arrange for the resident to be relieved from assigned duties that may interfere with timely completion of a WPHP evaluation.
- Set up the workplace intervention for the earlier part of the day, ideally. This allows time for the resident to contact WPHP immediately afterwards. If possible, avoid doing the workplace intervention at the end of the day or on a Friday afternoon.
- Select a suitable space where the conversation will be private.
- Identify one other faculty member to keep notes of what happens during the intervention, if desired.
- Discuss what will be said during the intervention and what is the desired outcome of the intervention with the other faculty member.
- Set an appointment for the resident with WPHP for soon after the workplace intervention (unless advised otherwise by WPHP). The time period between performing the workplace intervention and the resident making initial contact with WPHP should be minimal. This promotes continuity and adds additional support for the resident in the time between being confronted about a possible problem and being placed in contact with added supports. This is best accomplished by coordinating with WPHP before conducting the workplace intervention.
- In some circumstances, especially if the resident is very distressed because of the intervention, the faculty member and resident can contact WPHP together directly to speak with WPHP staff and coordinate next steps before concluding the intervention.
- Advanced coordination with WPHP in cases where intervention is anticipated to be very stressful for the resident can help ensure that WPHP staff are available to receive a call in conjunction with the intervention.
- Ensure that the trainee has safe transportation home and back to the intervention site.
- In some circumstances, especially if the resident is very distressed because of the intervention, the faculty member and resident can contact WPHP together directly to speak with WPHP staff and coordinate next steps before concluding the intervention.
Step 2 – Outcomes and actions following the Intervention
The workplace intervention should end with the resident having a clear understanding of whether the referral to WPHP is recommended or required. In some cases, it may be appropriate for the resident self-refer to WPHP with the understanding that, if problems do not resolve, referral to WPHP may be required. For required referrals, a timeline to contact and schedule an intake with WPHP should be clearly established before concluding the intervention.
If the trainee does not agree to referral to WPHP or adhere with WPHP recommendations for evaluation, treatment, or the terms of a health support agreement, they should be suspended from clinical activities. Washington statutes consider potential impairment to be any “condition, physical or mental, which may affect a physician’s ability to practice with reasonable skill and safety”. RCW 18.71.175 requires timely reporting to the medical regulator any resident with suspected or verified impairment referred to WPHP who fails to submit to recommended evaluation or treatment or who, in the opinion of WPHP, is probably unable to practice with reasonable skill and safety to patients. How and when to make this notification will be coordinated between the WPHP, Program Director and GME Office. In contrast, WPHP may assist residents without involvement or knowledge of the Washington Medical Commission so long as they follow WPHP recommendations and do not constitute a risk to public safety. This protects the resident’s privacy and confidentiality and precludes disciplinary action against their medical license.
Once a resident is found to be impaired or at significant risk for impairment, only the WPHP may determine if the resident is safe to return to work and resume patient care responsibilities.
Step 3 – WPHP Evaluation and treatment (if applicable)
Once the resident has contacted WPHP and initiated program involvement, WPHP clinical staff will advise about the next steps in the process.
If the resident requires a multidisciplinary, comprehensive diagnostic evaluation at a specially qualified facility, 2-4 weeks may be required to coordinate and complete the evaluation.
If a moderate-severe substance use disorder is identified via the comprehensive diagnostic evaluation, the resident may be required to complete 8-12 weeks of residential substance use disorder treatment.
At all times during the intervention, WPHP evaluation, and treatment, the resident’s privacy must be respected, and all details must be kept confidential.