Model Program for Wellness
The purpose of this document is to provide information on key wellness issues affecting the profession today. Useful background information is provided first; a model wellness program follows. Health issues of major concern and addressed within this model program include chemical dependence, eating disorders, compassion fatigue, anger management, stress, profession burnout, depression, anxiety disorders, and suicide.
Programs should be in position to protect the health and function of veterinary community members through five primary ways:
- Education and early detection
- Investigation and intervention
- Referral for evaluation and treatment
Through established programs, it is hoped that individuals with problems will be detected early, rehabilitated, and monitored in a confidential manner in an effort to avoid potential disciplinary investigation and action; confidentiality and monitoring are key essentials as they promote early detection and improve long-term outcome, respectively. Programs should be structured to assist veterinary professionals based on their diagnosis, treatment history, successful participation in an aftercare program, and continued compliance with the treatment recommendations. It is also likely that programs will be of assistance to veterinary professionals whose license to practice is under a restriction or condition imposed by state or federal licensing authorities.
The AVMA recognizes that impairment of veterinary professionals occurs throughout the profession and across the country. Furthermore, the AVMA recognizes and supports the importance of wellness programs that are active and serve members of the veterinary community in each state.
In an effort to address the issue of impairment of veterinary professionals, in 1992 the AVMA created the first model program to assist chemically impaired veterinarians, students, veterinary technicians, and their families. The scope of this program dealt only with impairment as related to drug and alcohol abuse. The new model program, developed by the AVMA Committee on Wellness in 2004, recognizes that impairment can also occur due to physical, mental, or emotional illness, chemical addictions, stress related disorders including depression and compassion fatigue, eating disorders, pathological gambling, and other health problems. The AVMA Committee on Wellness recommends that this 2004 model program be used as a template for state programs.
Problems that cause impairment among veterinarians, including physical and mental illnesses and substance related disorders, are common and deserve attention. Veterinarians have an ethical responsibility to take an active role in helping their colleagues in this regard. This model program provides assistance for veterinarians experiencing problems with substance abuse or dependence, or mental or physical illnesses. The intent of the program is to encourage veterinary professionals to enter appropriate evaluation and treatment, in lieu of disciplinary action, as long as safety can be assured. Veterinarians who are aware of a colleague's possible impairment may seek confidential information and support on how to assist these individuals.
As noted above, problems that cause impairment among veterinary professionals are quite varied and of sufficient importance to be addressed by organized medicine. In addition, the AVMA recognizes and supports the importance of overall wellness throughout the veterinary community. The AVMA supports the belief that every member of the veterinary community has both an ethical and humanitarian responsibility to take an active role in helping their fellow colleagues. In order to provide the greatest amount of assistance, it is the position of the AVMA that each state organize, develop, and fund a Veterinary Wellness Program. In addition to the information set forth herein, please refer to the "Guiding Principles for State Veterinary Wellness Programs" prepared by the AVMA Committee on Wellness. A list of links to wellness-themed Web sites is available at www.avma.org. This area is accessible to AVMA members only.
Specific Wellness Issues Include:
Chemical dependence is a primary disease or disorder characterized by, among other things, continued compulsive use of mood-altering substances despite adverse consequences. (See the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association for detailed diagnostic criteria.) Studies have shown that 10-15% of health professionals are affected by chemical dependence at some point in their professional careers. Alcohol is the most common drug involved, but veterinarians and other members of the veterinary health care team have a high rate of self-administering mood-altering prescription and illicit chemicals. Veterinary professionals usually use drugs to relieve stress in a vain attempt to feel normal rather than to get high. Progression of the disease is characterized by increasing the dose of alcohol, opiates, or other sedative or stimulant drugs to achieve the desired effect. As a result, more and more of the professionals' time is consumed in the pursuit of the drug's effect at the sacrifice of family, social interaction, and the practice of veterinary medicine. Tolerance may be significant such that large doses are taken on a daily basis.
Documented scientific data is limited related to the incidence of various psychiatric diagnoses in veterinary populations; however, since their inception during the 1970's, impaired professionals committees and programs in the US have been called upon to offer services to professionals impaired by various psychiatric illnesses.
In general, a referral is made when the veterinary professional's behavior is significantly affected and the individual is unwilling or unable to seek assistance when experiencing distress. Data suggest that members of the veterinary profession and their counterparts in human medicine, are extremely reluctant to acknowledge a need for help, and that their colleagues and supervisors are equally reluctant to intervene.
Assistance may be provided for problems such as depression, anxiety, personality disorder, compassion fatigue, anger management and others, by referring to appropriate professionals. These professionals must have the ability to provide an immediate referral to a person in crisis. It is also of tantamount importance that state wellness programs have immediate access to suicide prevention resources and referrals. While the data do not indicate that veterinary professionals have a higher occurrence of suicide compared with other professions, the veterinary community is not immune. The AVMA does not suggest or recommend that state wellness and peer assistance programs actively engage in suicide prevention (unless individuals have specific training in suicide prevention). Instead, it is recommended that trained personnel be contacted immediately if suicide ideation is present.
Chemical Dependence with Accompanying Psychiatric Illnesses (Co-Occurring Disorders)
As treatment programs for chemical dependence become more sophisticated and more oriented to relapse prevention, an increasing number of addicted patients are found to be suffering from one or more underlying psychiatric conditions. Statistics from the general population indicate that undiagnosed underlying disorders increase the likelihood that patients will relapse following addiction treatment.
The treating psychiatrist must be thoroughly familiar with addiction disorders, issues of chemical dependency, and the importance of ongoing involvement in a twelve-step or alternative mutual-help group during the recovery process. Careful attention should be taken to make the patient aware of additional diagnoses and the fact that medications for one condition may affect another disorder. Frequent monitoring is recommended.
Anorexia nervosa, bulimia nervosa, and compulsive over-eating are being diagnosed more frequently among members of the veterinary community. Eating disorders, although reported more often in females, occur in both sexes and in all age groups. The increased frequency of reporting these disorders may reflect an increased awareness among the public and among mental health care providers. Food addiction, however manifest, impairs the veterinary profession similarly to other addictive diseases.
The Wellness Program is available to assist with recommendations for the evaluation, treatment, and management of recovery based on a twelve-step or similar program.
Anger is a normal emotion that varies in intensity from mild irritation to intense fury and rage accompanied by physiological changes such as increased heart rate and epinephrine release. It is a natural, adaptive response to threats, which allow us to fight and to defend ourselves when we are attacked. However, when anger gets out of control it can lead to problems in the workplace, in personal relationships, and in the overall quality of life for a member of the veterinary community.
Three common approaches to relieving anger are expressing, suppressing, and calming. Expressing your angry feelings in an assertive, non-aggressive manner is the healthiest way to express anger. Being assertive is not being pushy or demanding—it's simply being respectful of yourself. Anger can also be suppressed, and then converted or redirected. This happens when you hold in your anger, stop thinking about it, and focus on something positive. The aim is to inhibit or suppress your anger and convert it into more constructive behavior. Unfortunately, this does not allow outward expression and may lead to high blood pressure or depression. The last coping mechanism is called calming, which means not just controlling your outward behavior, but also controlling your internal response as well. An example of this type of mechanism would be meditation.
When these measures fail to maintain a person's ability to cope with their emotions, professional advice should be sought.
Burnout is a syndrome characterized by emotional exhaustion, cynicism, and depersonalization caused by chronic stress in a demanding environment and/or the inability or desire to meet those demands. Other symptoms of burnout are as varied as the sufferers. Some individuals become angry or resort to blaming any annoyance on external factors. Others become quiet, introverted and isolated, indicating the start of depression. Burnout can also manifest as under- or overeating, abusing alcohol or other mood-altering substances, as well as a range of physical symptoms, including chronic illness, high blood pressure, and frequent headaches.
A predisposition to burnout is common for people in the veterinary profession. Personality traits such as achievement orientation, high focus, and autonomy are found in people among the profession and in those admitted into veterinary colleges. Veterinary medicine is demanding and often requires much of an individual's time and energy. This takes away from other parts of an individuals' life such as family, partners, and other areas important to that person. For those who cannot cope with the demands of their occupation, professional advice can be very helpful. It should be kept in mind that people who are best protected from burnout have a strong sense of self-esteem and are confident, maintain a good social support system, and a network of friends.
Compassion fatigue is a type of burnout characterized by deep physical, emotional, and spiritual exhaustion accompanied by acute emotional pain. People experiencing compassion fatigue continue to give themselves fully to their patients, finding it difficult to maintain a healthy balance of empathy and objectivity. The veterinary profession with its tremendous physical and emotional demands, naturally predisposes those in the community to compassion fatigue. Compassion fatigue takes a toll, not only on the individual, but also on the workplace, causing a decrease in productivity, an increase in the number of sick days, and a higher employee turnover.
MODEL WELLNESS PROGRAM
Wellness programs are typically administered and managed by the State Veterinary Medical Association's Wellness Committee with appropriate liaison with the State Board of Veterinary Medicine. If possible, it is desirable to obtain state legislation that provides immunity for the Program and confidentiality of all Program records. Wellness programs are effective means of managing problems of chemical dependence, mental illness, and other impairments. Such programs are based on interaction and cooperation between governmental agencies, professional associations, health care providers, and members of the recovery community. Many states have found it beneficial to form coalitions with other health professional organizations in the state, not only to leverage resources, but to identify best practices and successful methods.
Strongly structured Wellness Programs provide:
- Immediate availability, which shifts the burden of evaluation from the reporting individual(s) to the program
- Experienced and confidential evaluation and treatment recommendations (veterinarian-staff conflict can be curtailed, patient safety enhanced, malpractice suits avoided, and often proceedings can be kept out of the public record)
- Established guidelines for re-entry into the veterinary medical practice (the program enables affected individuals to return to a productive status in most cases)
- Discreet evaluation of each case and anonymity of the veterinarian and others associated, whenever possible
- A contractual agreement between the affected individual and the program, which lessens the probability of relapse and provides for early detection and management if relapse does occur
- Education for staff and other groups and assistance with organization of wellness activity
- Assistance to families of the veterinary community during the recovery process
Keys to this cost effective and safe method are the use of volunteers, geographically selected monitoring networks, and a system of checks and balances.
Scope of a Model Wellness Program
All veterinarians, residents, veterinary medical students, and veterinary technicians are within the scope of (State Wellness Program). Veterinarians identified to (State Wellness Program) may be referred by fellow veterinarians, friends, families, staff, or others. Self-referrals are encouraged. The (State Veterinary Board) may also refer veterinarians who have impairment in medical practice. (State Wellness Program) assistance in achieving recovery can be instrumental in these circumstances in preserving the veterinarian's medical license, assuring patient safety, and public confidence.
If the professional agrees to accept help and/or monitoring from the (State Wellness Program), the director, or designee will formulate an action plan based in large part on the suggestions of the provider performing the evaluation and/or treatment. This may include further medical or psychiatric evaluation to clarify the diagnosis or to make more specific treatment recommendations. Direct referral to inpatient or outpatient treatment may be recommended. Special medical examinations may be requested to determine the nature, presence, and extent of impairment. Results of this evaluation will be used to determine the level of (State Wellness Program) participation and to develop treatment and monitoring plans.
The (State Wellness Program) does not engage in evaluation or treatment. Referral and close liaison will be maintained with a recovery or rehabilitation program for each program participant by the director or his/her designee in consultation with the reported veterinary professional, those treating him/her, his/her close associates, and others as appropriate.
Treatment may include inpatient or outpatient services for detoxification, rehabilitation, psychiatric care, and/or attendance at self-help and peer support groups. Urine drug screens may be required for documentation of continued recovery as may be needed for the (State Veterinary Board), hospitals, other groups, and liability insurance companies. Monitoring significantly improves the prognosis and successful outcome. Significant changes in the treatment protocol should be approved by the director of (State Wellness Program).
Treatment Provider Criteria-Chemical Impairment
The (Wellness Program), in cooperation with its state Board of Veterinary Medicine, maintains a current list of approved treatment facilities to whom referrals can be made for evaluations/assessments of veterinary professionals. The following criteria are recommended:
- Providers performing evaluations/assessments should have demonstrable expertise in recognizing the unique characteristics of health professionals involved in the disease of chemical dependence. To avoid the appearance of conflict of interest, a member of the professionals wellness committee should have no vested interest in the provider offering the evaluation/assessment.
- Providers should be familiar with the Wellness Program and strongly encourage the patient to release to the health professional/(Wellness Program) any records pertaining to the identity, diagnosis, prognosis, or treatment of such patient that are maintained in connection with the performance of any program or activity relating to substance abuse education, prevention, training, treatment, rehabilitation, or research.
- When assessment for chemical dependence requires residential or hospital inpatient care, it should be for an appropriate period of time to observe for withdrawal and to complete the evaluation—generally a minimum of (3) days.
- The individual may undergo a complete medical evaluation, including appropriate laboratory and physical examinations. Laboratory examinations should include appropriate urine and blood drug screens and should be conducted by a physician with demonstrable knowledge of chemical dependence.
- Evaluation may also include in-depth interviews from collateral sources of information including referent, family, associates, spouse(s), or anyone else that knows about the individual and their habits.
- The psychiatric history and mental status examination should be performed by a psychiatrist knowledgeable in addictive disease.
A comprehensive psychological assessment may include:
- Neuropsychological testing performed by a qualified clinical psychologist or psychiatrist
- Testing shall give an indication of personality structure, including but not limited to assessment of memory and cognitive understanding
- The assessment instrument(s) used should be specified In the psychologist's report
- Upon completion of the evaluation, release of all evaluation results AND THE RECOMMENDED TREATMENT PLAN will be made to the (State Wellness Program).
All veterinarians who refuse recommended treatment and or further evaluation or second opinion will be subject to notification of the Board of Veterinary Medical Examiners by the (State Wellness Program).
Drug Testing Procedures
- (State Wellness Program) participants may be required to submit to observed and chain of custody urine, hair, blood, or other body fluid screens upon random request of (State Wellness Program), treatment providers, hospitals or employers, and (State Wellness Program) members. Such a provision will be specified in the participant's assistance agreement.
- As a rule, urine specimens will be used to perform the screens. Blood screens for drugs may be requested depending on the situation.
- The criteria for an immediate request for an observed urine drug screen are as follows:
- Obvious attempt at adulteration of the specimen
- Previous positive test
- Dilution suggested as may be evident by low specific gravity or creatinine level
- Specimen temperature out of range
- Obvious clinical signs suggestive of being under the influence
- The participant will be asked to list any medication (prescribed and OTC) he/she may be taking prior to submitting the specimen.
- The performing laboratory must be Substance Abuse and Mental Health Services Administration (SAMHSA)-certified or be a recognized equivalent certifying organization, which establishes approved testing protocol and positive thresholds for satisfactory cut-off levels for various drugs.
- The location where the (Program) participant will have urine/blood drug screens collected will be specified to the participant.
- When a request is made to a participant to submit a drug screen, a 24-hour period will be given to submit a urine specimen, and a 4-hour period for blood specimen.
- On occasion, the participant may be requested to provide a urine drug screen or breath alcohol test immediately. If a participant fails to respond to the request within the specified timeframe without justification, the test will be considered positive.
- The frequency of urine/blood screens will vary in each individual (State Wellness Program) participant depending on the individual's agreement.
- Results of all urine/blood screens will be forwarded to the (State Wellness Program).
- All positive screens will be immediately reported to the (State Wellness Program).
- All costs involved in performing urine/blood screens will be the responsibility of the participant.
- (State Wellness Program) recognizes the value of cost containment. A list of commercial laboratories which currently offer the benefit of reduced costs, SAMHSA certification, or equivalent certification, and who understand the assistance process of the (State Wellness Program) system will be maintained and periodically updated.
Therapeutic Monitoring Groups
Wellness Programs recognize that accurate monitoring and progression in recovery is not always possible. Therefore the program must receive reports from a reliable resource on a regular basis. Thus, the use of Therapeutic Monitoring Groups (TMG) may be utilized in some situations.
Therapeutic Monitoring Groups may include and/or accomplish:
- Report and document progress/or relapse
- Provide a professional support network
- Require alcohol/drug screening
- Receive self-reports from the individual
- Use of a work site monitor to which the individual is accountable
Appropriate release of information forms will be signed by the participant in compliance with Federal and State laws.