All right. What's up doc? What's up with the doc? So my name is Melanie Swift. I'm an internist and an occupational physician. I practice at the Mayo Clinic in Rochester, Minnesota. And I have the honor of running a program for physicians who are having health problems impacting their ability to work. This is not a physician health program aligned with the state to monitor your sobriety, things like that. So I'm going to explain what it is. I have no conflicts to disclose other than I work for the Mayo Clinic, and the Mayo Clinic of course would love your referrals. And every time I give this talk people say, do you have a brochure? Do you have a card? Not a trade show. I did bring brochures if anyone would like it and would, you know, potentially send referrals. But that's not what this talk is about. This is an academic talk. Hi Terry. How are you? I'm going to start with a case. A 51-year-old OBGYN was referred to us by their employer for a fitness for duty evaluation. This physician had brought in a letter from their own PCP with a restriction that said, cannot practice OB, but can practice GYN. Anybody think that this restriction was written by an occupational physician? You would be right. And so when questioned by her chair, what's the deal? She says, well, I have this problem and I have kind of a neuropathy in my hands. She reports to the chair of surgery who says, well, if you can't do a cesarean section, how can you do a hysterectomy for cancer? I'm confused. Rightfully so. As we all know, this is not a functional restriction. And so the employer wants to know what is up. We're going to come back and circle back and I'm going to illustrate what we do in our program for cases like this. Here's another case. 42-year-old female gastroenterologist who was a former recreational runner, ran marathons in med school, and by the way, is the only female gastroenterologist in a three-county radius of where she lives and is in high, high demand by everyone with functional bowel disease, especially women in her district. She self-referred because she was struggling so badly and so alone. She had persistent right leg weakness and pain to the point that this 42-year-old otherwise healthy woman was on a walker. She was walker dependent for six months in chronic pain on opiates. This was causing problems. She said, you know, I have five minutes to get from the clinic to the hospital across the street to do my scoping and I just can't get there in time. I can't stand up through the whole colonoscopy and I asked for a chair and they said, well we only allow people to do seated scoping if they're pregnant. True story. And also, you know, I wish I could use the elevator but, you know, we're not allowed to use the front patient entrance where the elevator is. It doesn't open until 8 o'clock. I have to get to my office on the second floor through the back entrance, which is into a stairwell. This woman was coming 30 minutes early to drag herself up the stairs. I'm sorry, I get a little emotional about this. Her history, she had aplastic anemia as a teenager. She'd had Parsonage-Turner syndrome in the left shoulder, B12 and thiamine deficiency. She's a gastroenterologist. She's like, do I have malabsorption of something? What is going on? So her history was she'd woken up in med school with sudden onset leg pain and weakness. She had a little workup. She had some PT. She got better. She went back to running. It relapsed a year later. And she's like, well last time they didn't find anything. I just rested two weeks and worked that time too. And then it started worsening. She started to develop a limp. Through residency, she had to stop running. And then six months ago, she started to fall and trip. And she had a workup and she went to the nearest University Medical Center, which did a workup. She had an MRI, an EMG, lumbar puncture. Is this MS? What is this? Is this a neuromuscular disease, muscle biopsy? Maybe it's Guillain-Barre something variant. Let's try some IVIG. Made her feel a little bit better. She got some more PT. Transient symptoms persisted. What do you do with someone like this? What do you do for this person? Okay, so I throw these out at first to kind of illustrate some of the barriers and issues that we have. Why do we need a physician health center? Why do we need care specific to our profession? We have all the barriers everyone else does. You know, time constraints and schedules. But we also have professional relationships with the very physicians, specialists that we would need to see to treat and diagnose our own condition, right? And it is very difficult to maintain confidentiality depending upon your community, the size of the community, the number of physicians available, the fact that maybe half of their staff are your primary care patients when you go to see that psychiatrist, that neurologist, right? And so what do we do? Well, we've done some studies on this. My predecessors at Mayo have done a couple of surveys, and we've found that 60% or more of us just treat ourselves. I won't make you show your hands on this. I think we've gotten a little less. The self-prescribing has gotten a little less common. Still happens, though. Still happens. Or we do an informal curbside with your colleague, right? Hey, I got this thing in my hip. Do you think I have a cam deformity? What? And are you going to the conference? Let's just walk and talk, right? All right. Is this your friend? Is this your doctor? It's a froctor, right? And they're uncomfortable. I've been in this situation, you know, and it's uncomfortable. It's like, I really need to undress you to answer that question. I really need to examine you. I really need to get into your medical record. Okay. And we also have an aging physician workforce. As we all know, and we're working more and more, physicians are working with chronic conditions. So, and we're also seeing a demand from employers and other third parties. So licensing boards, physician monitoring programs, I'll talk about that. There is a growing trend of age-based credentialing requirements in hospitals for cognitive screening above a certain age. So we have a session on that tomorrow. I see Howard's in the room to talk about that. So I've got some colleagues who are going to be, I'll be introducing and they will be sharing information on that, including a trial attorney from the EEOC. So just heads up, come to that if you'd like. There are really limited options that are physician specific that are not for psychiatric conditions. You know, if you have a physician who is struggling with substance use disorder, we have programs for that, right? So you can go to tablets and you can go to, you know, there's other ones. I don't know the names off the top of my head, but there are some, right? There are specific psychiatric programs just for physicians. But what do you do for the intention tremor in a proceduralist, right? What do you do for the head injury in a PM&R doc, right? And these evaluations really need to happen timely and coordinated so it's not over weeks and weeks and months that you're getting information trickling in. They do need to be thorough. They need to be objective. And they must be confidential. What does the employer need to know? Only. So this program at the Mayo Clinic was founded for this purpose. And our goal is to optimize the health and safety and productivity of our own colleagues, physicians. And it's to provide comprehensive expert medical evaluations to figure out what you've got. Are you being treated right, correctly? Can it get better? How does this impact your ability to work in specific functions? What's the prognosis? Is this going to degenerate and you're going to need re-evaluation? Is this going to improve and restrictions may be more liberal? Is this what you've got and you're at essentially MMI? And an unbiased recommendation for practice. I'll come to that more later. So just briefly what the program does, we get referrals that are self-referred. We get them from employers. We get them from licensing boards. We get them from monitoring boards. And we actually provide a pretty wide scope. This can be a comprehensive, I've got six medical problems. I just want to get it all evaluated at once. I want a comprehensive medical evaluation. Or it can be targeted. And we see a wide variety of folks and we can do, we can coordinate a lot of specialty consultations. This program is housed in our occupational medicine section. And you know the consultations go everywhere. You know, neurology, gastroenterology, whatever we need. We own it. We have an occupational psychiatrist, and I don't know if he's in the room yet, but he will be here at the conference speaking tomorrow, Greg Couser. Double boarded in psychiatry and occupational medicine. So the functional impairment of psychiatric illness is in his purview as well as individual coaching regarding burnout. We have an immersive lifestyle medicine CME, but immersive self-care and lifestyle medicine training, which is part of the program as well. Customized simulations. We have an advanced simulation center. And we do a formal assessment of fitness for duty when needed. This is not an IME. So I don't know if you can read in the back, but this is a comparison of a traditional IME with our program. So, you know, an IME is going to do an extensive past medical record review, a focused physical exam, and may issue a causation opinion. What caused this, right? But they're not going to be doing the diagnostic testing and consulting specialists and putting your recommendations together for how to treat your condition, prescribing your work restrictions, etc. Facilitating your ongoing care now. So we are focusing on what's clinically relevant to your issue. Comprehensive physical exam is part of that. Never do we do a causation opinion, but we do all of these other things. Figure out what's wrong. Try to make it better. This is not a medical legal exam and we actually do not accept referrals that are in litigation. We are here to help figure out what's going on with you, make you better, help get you back to work, or establish if you can't or need a limitation. We are not here to create Exhibit A for your attorney. That's not our purpose. And this is also not, are you good at what you do? That's not what we're doing. We're not answering the question, you know, should this person have passed their boards? Are they clinically competent? Do they know how to do a Whipple? That's not what we're here to do. We are here to answer the question, first of all, do they have an impairment? And if they do, does their impairment impact their performance? Right? So lots of things can impact, of course, as you all know. I give this talk sometimes to, I could, I haven't actually given this talk, I could give this talk to non-OCDocs, so I have it on here. But weakness, tremor, sensory loss, vision impairment, or their ability to tolerate certain things could impact their performance. We do consultative mental health care. We do not have an inpatient involuntary admission unit. I've had that request. You know, we have someone actively suicidal that needs to move to another state because they're a prominent physician in our state. We can't do that. We don't have a locked unit. We don't have involuntary commitment facilities. We're nearby the Twin Cities. We can facilitate that elsewhere. And this is not a residential substance use program. But we do outpatient psychiatry consults for all the things that physicians have, just like anyone else would have. And we have a lot of resources. Gosh, I'm blessed to be here. You know, my colleagues who are board certified occupational medicine physicians, and we're hiring as well. We have a position left. If you also like to do pilots, I'm sorry. See me later. We have a program manager who has a lot of experience who manages our aviation practice as well, dealing with pilots who have some very similar specific demands and needs and concerns. And we have the ability to coordinate a schedule centrally. Lots and lots of consultants and specialists. We have a state-of-the-art simulation and procedural skills lab. Just a few pictures of the Sim Center. I'm going to show you a little bit more when we get back to case one at the end. But, you know, it's a high-fidelity, really state-of-the-art, like amazing facility where mostly training is done. But we have access for evaluations such as these. And so you can see there can be a hospital room. This person is sitting in the control room with a one-way mirror monitoring bedside. Input can monitor the medical record, has cameras all around with sound. So we can observe and we can have people in the room as well, serving as the nurse, the attendant, etc. We can simulate surgeries. We also have a procedural skills lab that use trainers and cadaver models for things like endoscopies. And just did one last week with pacemaker placement. So here's the process of how we run this. Before the visit, things happen. And they differ a little bit depending upon whether you're self-referred or this is a third-party referral. So if you're self-referred, we just do a pre-visit interview with our nurse. We pre-plan the itinerary, order that, schedule it so it's coordinated so you have minimal time away from your practice. If it's a third-party referral, then there's a process of getting documentation from the third party. What is the issue? What are the observed behaviors? Is there an objective documentation that something is wrong? Have you talked with the person and asked them what might be, you know, do they have a medical issue? Or what did they think, you know, is the problem? Not their diagnosis, but do you think you might need a medical evaluation or need an accommodation? And then arranging the authorizations. Who's going to, we have our limit of what we will share, but we do need to authorize that we will share that. And who's paying for this evaluation? I can answer some specifics on that later. Most of it is billed to private insurance. And with the mandatory ones, usually the employer is making it out-of-pocket zero for the referred person. And then the personal self-referred ones are just regular insurance. I can do details on that later. What I want to get to is what we found by evaluating people. And then when they come during the visit, if they only have a medical concern and no occupational concern, they get a comprehensive history and physical, some specialty consultations, testing, whatever's needed, and then wrap-up and care planning. So here's the recommendations going forward, right? Take these back and let's get you better. If it's an occupational concern, as two-thirds of them are, we do the same comprehensive history, physical, specialty consultations, and a formal occupational medicine consultation. I see Dr. Newcomb has joined us. He does a lot of these in our practice. Some observed simulations, as needed, and then a follow-up with that occupational physician to incorporate the information that's learned so far and write a formal recommendation for practice. So what I want to share with you is what we have learned with the first 150 or so patients through this program. And this is a publication that came out January, I want to say, and I'll give you the citation in a minute if you can look up and have the article. But we did a retrospective chart review of all consecutive new referrals with some exclusions if they didn't authorize their medical record to be used for research or if they had previously been evaluated, and so during this time frame, if they were not really new. And we looked at the reason. Would they just come for medical care or whether they had an occupational concern, either voluntary on their own they're concerned, or a third party was. And we looked at their demographics, the medical conditions, and what were the occupational outcomes? Did we say no restrictions are needed on your practice or we recommend you not take overnight call or what was it? This is the publication. It's called Outcomes from a Physician Health Center in the January issue of the Mayo Clinic Proceedings from this year if you would like to see more. So here's our demographics of this cohort, 153 or so people. They're 56 years old is the average range. You notice it ranges from 29 to 82. So we had some young people and we had some people that impressively were still practicing at 82 and I got to tell you the person who's 82 had no problems and actually was kicking ass. 27% female. And then by and large just allopathic or osteopathic physicians with a few other, you know, proceduralists and people with particular concerns that we also did evaluations for. They came from 34 different states. The majority of them did come from the Midwest, not necessarily Minnesota, but the Midwest region. Not too surprising. But they came from all over the country. They came from, you know, serendipitously 34 different specialties as well. And you can see the most common things, common specialties were family medicine, internal medicine, cardiology, radiology, ophthalmology. And these tend to be interventional cardiology, interventional radiology, procedural things, plus 25 more. So what kind of conditions? And this really differed depending upon whether they were presenting with an occupational concern or they were just coming for their own care. And these are rank ordered, and you probably can't see this in the back, but you have it in your slides in the app. So this is the overall frequency. That's how they're ranked here, overall combined frequency of condition. The occupational referrals are in the center column. And the leading reason for people coming for occupational evaluations were neurologic, specifically cognitive concerns. The next leading cause were psychiatric other than substance issues. So substance is down here, sort of middle of the chart. 3.4% of them were substance abuse related. Non-psychiatric, depression, anxiety, post-traumatic stress, etc. And I'll go into that in more detail. For the non-occupational, I would just like to come to Mayo Clinic, please. Multiple conditions, right? Nobody buys a plane ticket and flies to Mayo Clinic just because they've got high blood pressure. Right, makes sense. So here's a list. I think the animations didn't work, so I'm giving it to you all at once. But suspected dementia is a frequent reason for either the person to self-refer or for their institution to require that they come to us. I am scrupulously suspicious of this uninformed diagnosis. And here's what we've actually found. And yes, we have found, of course, people who did have early onset Alzheimer's or Parkinson's or something else. But hearing loss. They're not responding to teammates in the OR. Oh yeah? Because your teammate has a voice like this, and is wearing a mask, and this person's sick. Yeah, of course they can't. They can't hear them. That does not make them demented, right? Depression. Bipolar sleep disorder. And substance use disorder, etc. I won't read the whole list to you. Here's the real stuff. But I've also seen, nope, personality disorder. They're not demented, but they do have a personality disorder that is causing conflict in the workplace. Cultural differences. This person is scaring the staff. They wave their hands a lot when they talk loud. Well, that was kind of the norm in the country of origin and the culture in which this person lives in. Just miscommunications. Poor communications. Bi-directional, I would say. This is both from the physician and from whoever's talking to them about the problem. Or more often not talking to them about the problem, but talking about them in their institution. But this one comes up a lot. Must be demented. Can't learn epic. I don't know how many of you like Star Trek, but I'm a fan. I think he actually never said this exact thing on the show. I'll have to Google that. Yeah. Let's throw a new medical record at adult learners and tell them to do a set of modules online, because we don't know anything about adult learning theory. And we are not going to pay for them to have time for training. We're not going to invest in coaching. Yeah. Does not make me demented that I can't adapt to your system when you snap your fingers. Here are the outcomes for those who were occupationally referred. Two-thirds of these people came of their own accord. I'm concerned. I have a problem. So the case two was self-referred. In the end, most of them, we said you don't need any practice restrictions or work restrictions. You might need different care. We might recommend different care plan for you. We might recommend, you know, a number of things for them personally. But in terms of their work, no restrictions. And sometimes only a temporary restriction. And I say that because this is often just a, you've recovered from this head injury. We don't recommend that you go back to a full-time schedule. But you, we will gradually, we would anticipate you gradually get back. And so it's a return at a part-time role, limited hours, and increasing those hours over time as they recuperate. Or just hospitalized. You know, maybe they've just had a psychiatric hospitalization. It's not a great idea to go back to your busy ER shift with rotating shifts where you're not going to sleep and your medication has not been fully adjusted. Not a good idea, right? So temporary restrictions. Twenty-four percent, we did recommend that they discontinue practice. This was usually due to cognitive impairment. There were other neurologic conditions besides cognitive impairment. You know, MS, movement disorders that couldn't be controlled, that were degenerative, things on a procedural list, things like that. Lots of things, some very complex things. But, and 16% of them were able to practice with a permanent restriction that was very specific. You know, and it might be no overnight call. It might be, you know, a specific physical restriction, etc. We did a multivariable analysis to look at, you know, were there factors that were associated with these occupational outcomes. It really wasn't associated with their age. It really wasn't associated with whether this was a mandatory or voluntary evaluation. Whether they were at work or on administrative leave or on medical leave at the time of the referral or where they came from. So two types of conditions were associated. So a neurologic condition, whether cognitive or non-cognitive, was significantly associated with needing a permanent restriction or an inability to practice. So a high odds ratio there. A psychiatric condition was statistically associated with an increased odds of needing a temporary restriction. And obviously a lot of limitations when you do an observational evaluation like this. You know, this is a tertiary care center, so it's very skewed towards very high acuity. Again, you don't fly across the country to come to the Mayo Clinic because you sprained your ankle and you need two weeks of work restrictions, right? So what we're seeing likely represents a greater degree of impairment than most people would see. Obviously as an observational study, it's going to be subject to confounding. We also did not pull in people who did not allow their medical record to be used under the Minnesota Research Authorization Act. And this was not evenly distributed between the mandatory referrals and the self-referrals. And I think that probably comes as no great surprise. I don't want to be here. I don't trust you. My employer's making me come to you. Would you like us to use your medical record for research? No thank you. Right? So not at all a surprise. So let's go back to our cases. Good. This is the fun part. Alright, so we reviewed medical records. I did a pre-visit video with case number one. What's going on with you? Oh, you know, I've got this cervical disc and a lot of arthritis in my neck. And I get nerve impingement, but it's not all the time and they don't think that I need, the neurosurgeon doesn't think this is operative yet, but in a few years it might be. She'd had corticosteroid injections, a little bit of rest, symptoms would get better. Completely resolved. And she had a full workup. EMG's completely normal. Strength testing, normal. She would remain asymptomatic unless she had to endure prolonged extension or side flexion of the neck. And this was both sides. She had different levels on both sides, but, you know, so if you're doing this and overhead lifting, pushing, pulling kinds of things, kind of made sense. Why her physician had said, you can practice GYN, but not OB, was the nature of the practices, right? The OB practice, completely unpredictable. I'm getting in there. I've got to, you know, turn the baby and I've got to do an episiotomy. Ow, ow, ow, ow, ow. Right? Her surgical practice was largely on a da Vinci, on a robotic surgery, you know, or an open laparoscope. Forward flexion of the neck, opened up the facets. She was comfortable. Everybody's fine, right? Other ergonomic problems with prolonged static posture and forward flexion. I've seen a vascular surgeon fuse in a forward flexion position because of that. So that's a different issue, not her issue. So that's why her physician thought it would be a good idea if she stopped delivering babies and just did her GYN surgery. And you can see the logic to that. So we suggested we do a simulation. And this was a really interesting conversation and one that I think really illustrates the value of our specialty. What they requested was not an observation of her delivering babies. They want an observation of her ability to do the GYN robotic surgeries because that's what her doctor said she could do and that's what they were questioning. So they said, well, we want to simulate if she can really do those. You really don't need me to simulate that. I can have her sit in a room and hold her head forward for four hours and charge you for that. That tells you nothing. What I need to do is figure out what are the constraints on the limited part of the OB part. So we customized a simulation and we asked for photographs of the delivery, the labor and delivery area from different angles, etc. We set it up in the Sim Center to mimic the position of everything that was in her practice. And we simulated her watching the fetal monitor, her doing perineal dissage, routine deliveries and a precipitous delivery, which is just, can you catch things? An arrested delivery with shoulder dystocia, which requires repositioning of the fetus. I learned a lot of stuff in these because I didn't know about this. Episiotomy repair and bedside ultrasound. Objective measurements. This is a high-tech simulation center. And I took with me a really high-tech occupational medicine device. I had my plastic goniometer that could measure angles of things. I have a digital one, but I'm old school. I like the old school. So here's what we found. This, by the way, is the high-tech simulator who is scarily realistic. And I will tell you just quickly, as we were setting up, and this is one of our tech, he's pretending to be nurse. As they were setting up the room, and I was there ahead of time and planning and talking with the staff about, you know, when, which delivery are we going to do first. And I think she just blinked. And I thought, okay, I'm crazy. She looked very realistic. And then, oh, she blinked again. Wait a minute. Okay, y'all, are you punking me? And they said, oh, no, she blinked. She sighs, and you should hear her when she goes into labor. True. So realistic. I won't take up the time here, but I can tell you that story later. The whole deliveries were very fun. So here's what we found. When she was needing to monitor, the fetal monitor required craning her neck. And I'll show you another picture that illustrates that. Perineal massage, if she's seated, was a problem. But if she stood up to do it, was not a problem. The regular deliveries were actually well-tolerated and didn't cause her any problems. The shoulder dystocia. So here's what's happening. She's doing repositioning of the fetus because of shoulder dystocia. She's reaching up. And this actually has a sensor inside. So I tell the tech, you know, shoulder dystocia. And they start the delivery process, the contractions. And she's moaning, you know. And the descent of the fetus is stopped. And she's got to know, oh, okay, shoulder dystocia, what do I do? And she knows all the maneuvers to do. So she's got to get her hand up there, and she's got to turn. There's sensors inside to determine if she's moving it correctly. And then once she has done the correct positioning, it will allow further descent of the fetus. Right? And this is what she had to do to get up and do that. And I'm there watching. I took photos. And so she's got, during this, shoulder elevation of one side or the other, side neck flexion as she's trying to get torque to do what she needs to do. Episiotomy repair. I had to do these in med school. I trained at the med in Memphis. And as a medical student, I probably delivered, like, 17 babies. Right? Episiotomy repairs. Prolonged, you're looking in there, you're craning. What am I doing? Neck extension. Right? Because I've got to see, I've got to peer in there. Even seated, this is really hard for her neck. The worst thing of all of this was the bedside ultrasound. Bedside ultrasound, I learned, required 20 to 30 to sometimes 40 minutes or more. Seated, she would sit kind of next to the patient, facing the patient on the bed. And the monitor is here. Remember, we had mimicked the constraints of the room. And so the monitor is, like, here. She's got to be reaching here. So to see the monitor, she's got to look here and here. Anybody remember the maneuver I just did? Spurling. She had to do a spurling maneuver on herself. No wonder her cervical radiculopathy flared. Right? Oh, I don't have the two pictures. There he is. Here's the nurse who's, either the nurse or the patient's birth partner would be, this would be their spot. Here's the fetal monitor that she's trying to look at. Right? So every time they're going in to comfort mom, to talk, or to just stand there, she's trying not to interrupt that connection. But she's got to see around them. Right? So after this detailed report of what we did in the simulation, these are the restrictions that I issued. And some of this is based on exact measurements. Some of this is based upon my best medical judgment. Limit neck extension over 20 degrees, or rotation or side flexion over 45 degrees, to no more than 15 minutes at a time, cumulatively an hour a day. That's not evidence-based. I made that up. You know, but had to give them something objective. Occasional lifting, pushing, or pulling up to 20 pounds of force above shoulder height. No medical restriction on forward neck flexion, use of arms or hands, or below shoulder weight handling. A function, you will all recognize this, this is the kinds of restrictions you write for people with work injuries. Right? It's a functional restriction. And her employer, of course, questioned, well, can she do the da Vinci or not? We wanted you to simulate the da Vinci. Can she do it or not? I was like, well, you tell me. I don't do da Vinci. Does that require neck extension over 20 degrees? No? So we don't have to be the experts in what their procedure is, what it takes to do a splenectomy. We are occupational physicians, and we can give a functional restriction that can be applied to any activity. Objective. Case two, 42-year-old on a walker. So she had what I call the Mayo Rodeo, which is a week of going from specialty to test to specialty to test and coming back. Neurology, GI, rheumatology, ortho, PM and R. So her diagnosis ended up being a mild peripheral neuropathy, pretty significant bilateral gluteal tendinitis. But her main problem is a functional gait disorder, which is kind of a self-perpetuating condition. This is a maladaptive response to pain, which she was experiencing pain from the tendinopathy. And I think they gave her an injection or two on that. And it turns out we have a program that I did not know that we had, called the Behavioral Shaping Therapy Program. It's run by neurology, PM and R, PT and OT for functional gait disorders and other types of functional movement disorders. It involves one week of outpatient treatment, three to four hours of PT a day. So she did need to go back to her practice, make arrangements, come back for a week and do that program. And I managed her work restrictions through that. With a graduated return to work, starting with reduced schedule, no overnight calls, some accommodations, like maybe access to, I don't know, the elevator in the building where she works. Doesn't seem like a big ask. Allow her to perform endoscopies seated. Give her time to get between her clinic and the hospital. That's all she wanted. So she was weaned off the walker, weaned off opiates, back to full duty in three months' time. This is a career that could have ended badly. Back to working. She's now the only, still the only female gastroenterologist in a three county area, but at least those patients have access to her. So what have we learned? The wide variety of diagnoses that can impact physicians and our ability to perform optimally. Don't assume that physician health is all about psychological conditions, substance use or burnout. Majority of the self-referred physicians needed multidisciplinary care, which raises a whole different question and perhaps a whole different session later. How many of them have a PCP? We weren't asking that on the intake originally. We have adjusted the intake to capture that information, but in the audit of the notes that I did, about 50% of them had a PCP. For occupational concerns, most physicians with health issues, even those serious enough to come across the country or, you know, whatever, to the Mayo Clinic to be evaluated, they could safely return to practice. Significant cognitive impairment, of course, carried the highest risk of an inability to practice. Psychiatric illness usually only required, if any restriction, a temporary restriction. And there are advantages to having some resources in complex cases. So the Advanced Simulation Center, I would say we use it 10% of the time we're asked to use it. It's bright and shiny. It's an extra, I don't know, $4,000 to $5,000. And if the question is, is this tremor too severe for someone to safely suture, you know what, I got a suture kit in my office with the little silicone thingy. We really don't need to go to the Simulation Center for that. So we usually do not need it when customers ask for it or clients or referring physicians ask for it. I think the most helpful resource is having an occupational medicine physician. And we are very fortunate, I am blessed, Dr. Newcomb is here in the room. Dr. Couser, I think, is in the room. Dr. Couser, are you here? He's sitting in the corner with his head over his eyes. Is Dr. Cole here? I think Dr. Cole may have been here. Would you guys mind standing for a minute just so people see your faces and see what you do. And thank you so much for all that you do to help evaluate these patients. It's really a big team effort. Back home, you know, we have, and it's not the doctors, it's only, you know, we have a great team, a scheduling team that will bend over backwards to work with their schedule and reschedule. We have a nurse practitioner who places all the orders once we have conferred on what this person needs. And we have nurses that do these intake calls and will call out things. Hey, I think this might actually be an occupational concern, didn't come in that way. So I just want to thank the whole team for doing, for helping us get these physicians the care they deserve, the respect they deserve, the clarity that they need with dignity and protection of their privacy. So with that, I think we have 15 minutes, and I'm happy to take calls. And I might phone a friend, so Greg and Rick, don't leave. The microphone is right up here. If you would like to use that to ask questions, or if you want to holler, you can also do that. You said you teed me up, so. Well, thank you so much for sharing this and sharing your experience. I just wanted to ask you, you know, I think occupational health is not really understood still by a lot of people. They still call us occupational therapy sometimes. And I wanted to understand, like, how do you, what you do is extremely valuable, not only to the organization, but also to the individuals. But I think, you know, as healthcare organizations all have to look at financials, revenue, all these things. So how do you quantify the value of what you do with regards to your own organization? Or, like, if you have, like, corporate clients and you're not necessarily dealing with physicians, how do you explain that to them in, like, a value number? Easy question. It is a question that I grapple with constantly. I'll share what my perspective is over time. We would love to have numbers that show you return to work faster, you blah, blah, blah, you know, this many more days of, say. Our systems, especially our regular medical record systems, are completely inadequate to inform this. They usually don't even capture the person's job. So we are operating in what Dr. Hodgson calls an evidence-free zone. In the absence of evidence, I believe that the most impactful intervention we can do to raise awareness is relationship building. Centers that send me one physician get a phone call. What's going on? Let me ask some clarifying questions. They get their report back within a few days. They get their report before they get their bill, right? That's very key. And what we do at Mayo, because, you know, it sounds like a lot, seven, but in a big place like Mayo Clinic, it's not that many. So we've actually established an internal, we have a large primary care practice, you know, that takes care of the whole community. We've established this internal specialty consultation service that we've marketed to our primary care, general and territorial medicine, family medicine colleagues, to allow them to, we carry a service pager, call us up, send us a message, ask a question. We did the presentations, we call it, you know, the dog and pony show. And that word of mouth, when we respond with a really helpful piece of information, is absolutely transformative. So hey, you need to see, now the problem is, and this is what we have to work on as a specialty and as an organization, is they come here and they train, and then they go to their community and they say, you know what I need? I need an occupational medicine referral. There are no occupational medicine physicians in my area to get them to. So that's what we have to work on. That's why I'm so sorry this conflicts with the pipeline report. I went to Matthew Hamm's first part, but we do have to work on that as well. But I think it's relationship building, letting them understand the value of our specialty, why it's different. One thing too, this may be helpful as well. The other thing that Dr. Couser led for us is a three-part series on treating physicians as patients. And the first part of that is why are physicians different than any other patient? The second part of that is what is your role as a primary care physician? When do you need an occupational physician? And what hat is the person you're talking to wearing? Is that their supervisor? Is that a concerned colleague? Is that their friend? You need to clarify the situation before you dive in. And the third one is about psychiatric and substance disorders in physicians. And so the first part one is published this month, right Greg? Do we know when part two? Part two is the occupational piece. So a month or two? So in a month or two, on Mayo Clinic proceedings should be part two. And that's a document that may be helpful, we hope, for people to take back and say, you know, as you're approaching physicians as your patient and their occupational issues, think about this framework and here's some recommendations for when to refer. I hope that answered. You know me obviously, Norman Casada, Houston Methodist. So my question is what is the clinic's interaction with licensing board, especially with self-referrals in the, you know, if they've been referred, do you have their their HR? But in the worst outcomes where it's not going to get better and they're going to be off duty maybe permanently, what do you all do, if anything? Excellent question. So we, so what we're not is a physician health program, a safe harbor reporting program, is also known as with the state. Every state but one has a physician monitoring or physician health program, which is a safe harbor reporting. The safest thing to do is to pick up the phone and call that program. Disclose what's going on with it. So what we do when I think reporting is needed is that it should be self-reporting, right? I have have I had a case yet that refused to self-report? I had one that I wasn't sure of, but then I checked back and they actually had. But we try to do it actually in the room. So we keep, we maintain a database of all of the physician health programs in the different states and the contact people and the scope of what they monitor. And increasingly more and more of them will monitor anything else that's impairing, not just psychiatric conditions. I, when unsure, I have just picked up the phone and made a query. I have a person here and I'm not disclosing their identity, but here's the situation. What do you recommend? They're an invaluable source of guidance for in that state. What are the reporting requirements? But if they will, if they can engage with that program, they can have a confidential evaluation and their license need not be protected, might be temporarily restricted if need be. But mostly, if you're willing to voluntarily restrict your practice, they don't need to touch your license. And so Ed, there's a lot of fear around that. So I'm so glad you asked the question, Norman. So thank you, Austin Sumner from Vermont. My question is regarding the use of rescue medication that could potentially be impairing. So a specific example is I have a provider, has a seizure disorder, has been known for a long time, but potentially when they feel an aura coming on, they have rescue medicine that they take and that medicine makes them drowsy. And so how do you handle, how do you recommend handling providers that need to take in the moment medicine, maybe migraine medicine, maybe in this case, seizure prevention. How do you handle that from a safety sensitive perspective? How do you accommodate them so that they can take their medicine, but how do you remove them from patient care, potentially temporarily following the use of that medicine? So could everyone hear the question in the back? Okay. And Greg, Rick, feel free to pop your hands up too if you've dealt with this particular kind of thing or something similar. And I have had a physician, a surgeon with seizure disorder that I monitored who kind of fell into this. So two prongs, you know, one is therapeutic hat on here. What are things that lower your seizure threshold? Are you sleeping? Using alcohol? You got a new baby at home and you can't sleep? I had that. I had that. Is this a medication for which therapeutic drug level monitoring would be important? Because it's not necessarily routine, but in this case, because it impacted their ability, their risk for surgical procedures, we added this as part of their return to work plan. So that's one piece. Take care of the condition as well as you can to try to minimize the amount of time that that would happen. It reminds me a little bit, I've got another one who has a movement disorder that's triggered by certain things and can cause that movement disorder to display in the workplace. So one is job protection for absences. So FMLA for intermittent leave for flares of a condition, right? And the second is a statement of accommodation, of accommodation process. May need an unscheduled removal from duty for safety reasons. And that generally goes through the EEOC ADA accommodation process to figure out what that is. And basically have a plan B. And it would not be that similar, that different from I'm in practice and I feel queasy and now I'm vomiting and I need to leave, right? But if you anticipate that that's going to happen on a more or less regular basis, then requesting an accommodation and the combination would be have plan B for what happens to my patients that are scheduled that day so that it's not a giant emergency disaster that raises everybody's anxiety level anytime it happens. Yes, yes, yes, yes. And that is one piece of paperwork I will fill out for them. I don't do their long-term disability application. That's whoever's treating them. Do not send me your patients so that I can fill out your forms for you. But an accommodation request, absolutely, because I don't really know what that PCP might do. Or I have once or twice just picked up the phone and said, is it okay if I talk to your PCP about this? Yes, God, please, would someone talk to my PCP? We're so sort of HIPAA fearful that we like don't want to call people. But with the patient's permission, and I've done this with a patient in the room, I'll call your doctor and let's talk about this, you know, and I can coach them on that. But yeah, I've done those accommodation forms and did that for her for case two. I did her accommodation form. Yes. Thank you for the good presentation. So my question is about physicians diagnosed with blood-borne pathogens that were supposed to do exposure from procedures. How do you handle that? Yes, yes. So the Society for Healthcare Epidemiology has, SHEA, has a position statement on this which has been modified over the years. And so it includes an assessment of is this, and do they perform high-risk procedures of accidentally sticking themselves, exposing the patient? So basically, are their hands in a confined body space or cavity with both poor visualization and something sharp, right? And if they are, and they have one of these conditions, first of all, remember doctor first, therapeutic hat, are you being treated? Are you getting the care you need to get your viral load down, right? But then there's a whole outline in that paper in the Med Center Ock Health course. We just went over that and sent out those. And are you in the Med Center section? This is a hole in the middle of the Medical Center Ock Health section wheelhouse. So we can hook you up with resources and details on that afterwards. But basically, it's a review of what precautions they should take, what they should report, and then there's, if they've got an ongoing chronic blood-borne pathogen infection, periodic viral load monitoring with different thresholds for each virus, above which some restrictions would be needed on performing those high-risk procedures. And there's an agreement you should have the person sign, there's education that goes with that, etc. But it's a thing, it's like packaged up, and we can share it with you. Okay, I think this is, I know, I want to be respectful of everybody's time, and so, and Joe's, do you, let's let Joe's ask his question, shall we? He's been standing there patiently, so go ahead and then we will break. Hi, thank you for this great presentation. So how would you describe your experience with the willingness of the physicians to accept those restrictions as well as the employer to implement them? So I'm going to divide the question. The physicians are universally willing to accept these, and relieved as hell that someone has written it down for them and clarified it for their employer, and not them just saying, I think I need this, I think I need this, I think, okay, never mind, ow, right? The physicians are very relieved. Are there accommodations that are needed that employers sometimes choose not to make? Unfortunately, that does happen. Not the majority. Most, you know, if you look at the cost of replacing a physician versus, you know, this is the whole ADA reasonable accommodation process. It is usually much more reasonable to make the accommodation than not, right? But occasionally, especially very resource-constrained hospital who depends a lot on the revenue stream of this one neurosurgeon, and the restriction impacts their ability to cover the practice at the volume that's needed, at the pace that's needed, at the complexity that's needed, with the schedule that's needed, may say no. And then this is when it's very important for all of us and all the physicians that we speak with to make sure that your long-term disability insurance covers you not just for your profession as a physician, but specific to your practice, right? So if you can't do neurosurgery anymore, but you could prescribe Viagra over telehealth, right? That still should be, you know, a claim that can be made under long-term disability. So, and that's something for everyone to check. Certainly, we think we probably all hear that in residency, but you may forget it over time. You may think your employer's policy covers you. Double check that. Thank you all so much for your time and attention.

Dr. Melanie Swift

internist

occupational physician

Mayo Clinic

physician health programs

health issues

work restrictions

case studies

confidential care

healthcare providers