Should physicians undergo random drug testing?

Lucian Leape MD, a public health professor at Harvard, wants to subject doctors in America to strict random and periodic drug testing to help identify those physicians who are impaired. All in the name of patient safety, of course:

“I’m very much in favor of random testing,” Dr. Leape says. “We have a responsibility to identify problem doctors and bring them into treatment.” And to protect patients in the process.

Ok, I get it. Impaired physicians are bad. We don’t want strung out cokeheads and stumbling alcoholics roaming the halls of our hospitals. But random drug testing?

Consider the following:

1. A doctor who is on vacation with extended family in the Outer Banks. After a day of surfing and tanning and several cold frosty beers, one her cousins busts out a joint late night on the back deck while the ocean rolls into shore. And let’s say she partakes in such activities 3 of the next 4 nights in similar fashion. That THC will be floating around in her system for the next 30 days, potentially. What if she is called to give urine a week after the trip?

2. Let’s say an internist goes to a Super Bowl party with friends. The day turns into an all night fiesta as they celebrate the Browns’ first ever world title. Many beers are consumed. Knowing that it was going to be a long night of carousing, the doctor had canceled his office hours for the following Monday morning, planning to just drop by the office in the afternoon to do some charting. The next morning, his office manager calls at 8 AM sharp and tells him he has to have his urine/blood sample in by 10AM. He stumbles out of bed, still hung over, and rushes into the hospital. The result shows his blood alcohol is 0.09 (enough to get you a DUI). What do you do with him?

What are the consequences? Do you lose your license? Are you reported to the medical board? Are your privileges at hospitals suspended? Does your name wind up on the police blotter section of your local Sunday paper?

To be clear — I am strictly against the idea of physicians practicing medicine while impaired. But this totalitarian encroachment on what a man or a woman chooses to do in his/her free time is rather disturbing. As a professional class I think it is our own responsibility to identify and report those doctors who have a problem. An impaired physician cannot hide for very long. We just need to stop being such timid cowards and do a better job of self-policing ourselves.

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.

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  • Chris

    I agree JUST for hospital physicians/residents/interns on shift, surgeons at the OR and ER physicians. I would like to add the rest of the essential emergency personnel (P.A.s, R.N.s, etc).

  • http://browncoatemt.blogspot.com/ Browncoat EMT

    In my opinion, I see that no difference should be made between any medical professional. EMS personnel along with quite a few nurses are already subjected to random drug testing. The guidelines are already set aside for most that alcohol shouldn’t be consumed within 8-12 hours of a shift, and all other substances that show up on a test should have a reasonable explanation.

    I don’t see that a doctor could be held accountable for having an above normal alcohol level if they are responsible enough to call in for their shift or consume it at a time when they won’t be working soon.

    For all the other substances, without a prescription written for them (in this case, by another MD), they are still considered illegal. Just because someone has a higher ranking position in any field does not mean they should be held above the standards of the law.

    • hypnoid

      But the illegality of the substance is NOT THE POINT. The question is the presence of impairment. Are you looking for impaired physicians, or are you looking for lawbreakers? You’ve conflated the two rather badly.

    • Vox Rusticus

      And depending on which state you reside in, those “other substances” are not necessarily “illegal”. Moreover, one is permitted to freely travel to friendly, cheerful European cities where those products are legal to use.

      • http://www.twitter.com/alicearobertson Alice Robertson

        And depending on which state you reside in, those “other substances” are not necessarily “illegal”. Moreover, one is permitted to freely travel to friendly, cheerful European cities where those products are legal to use. [end quote]

        Hmmm……..hangin’ out in Amsterdam during your time off? :)

        • Vox Rusticus

          Oh, . . . I sometimes wish.

          Dr. Leape seems interested in screening for drugs use yet I don’t see the causal connection or really any cogent reason. Is there really evidence that doctors are practicing under the influence to such a degree that random “screening” is going to helpfully identify who is and who isn’t using? Hell, there were times I was made to work over 130 hours in a week and I was way worse off in that state than I might have been after a few drinks . . . or a blunt.

          This seems like a really ill-considered recommendation on the part of Dr. Leape, almost as if he was cornered into making some kind of recommendation without fully thinking it through.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    I just love the guys & gals from Harvard. The air is so thin in the ivory towers.

    While we’re at it, how about some random ethics testing for hospital executives?

    The questionaires could be short. Ten questions or less. Of course, it would need to be a proctored exam because we can’t trust anyone to be who they say they are.

    • http://www.twitter.com/alicearobertson Alice Robertson

      Mary you may have seen this quote before, but it ties in. I was reading Mum and Pup this summer (from Bill Buckley’s son…a humorous read). He quotes his dad on Harvard (gotta take into account what a huge conservative his dad was to put this in context):

      I’d rather entrust the government of the United States to the first 400 people listed in the Boston telephone directory than to the faculty of Harvard

  • http://www.pacificpsych.com/ pacificpsych

    First let’s have all politicians and hospital admin, i.e. all the useless people, go through a monthly test to include:

    1)Testing for STDs
    2) RPR
    3) A psychiatric evaluation, along with neuropsych testing and fMRI brain imaging (never mind that it’s still only useful in research), to gauge sanity and extent of functioning brain cells.

    This country is puritanical, hypocritical, totalitarian – and it sure does like to beat down physicians, till there’s nothing left of them but little quivering slivers of obedience.

    Wake up. You can’t have someone be in charge and quivering in fear at the same time. It’s too much of a contradiction to handle. This corporate minded, nit-picky, totalitarian attitude is driving many thinking physicians out of medicine.

    Oh, and yeah, doctors shouldn’t use crack, should drink in moderation only, and shouldn’t drink anywhere in proximity to work time. Duh.

  • http://www.twitter.com/alicearobertson Alice

    Hmmm……..using facetiousness to bring about truth?
    Mary ……they could go a step further and administer lie detector tests, and random truth serum? Ack! Isn’t this quite the ethical dilemna? In truth, even if my doctors drug test results were available I would not care (he is terrific) but I remain convinced a doctor who made a terrible error (and claims he was overwoked) was on drugs. Gotta watch the docs for dilated pupils? The doctor I love keeps almost continuous eye contact, while dopey doctor would not look you in the eye. Sigh!

  • Claire

    What makes more sense, although it sounds like a time-sink, would be start-of-shift mental performance testing. Or something of that ilk. And to everyone arguing that other people have to deal with random drug tests on the job, I don’t think those make much sense either, for anyone. No one should care if you drank last night as long as you’re sharp and aware now, at work. This kind of testing for docs would also help with the oft-discussed issue of sleep deprivation and fatigue in residents, for example. It’d be simple: if you’re too stoned, buzzed, distracted, or exhausted to perform well enough on a simple, standardized mental agility test, you can’t see patients.

  • Vox Rusticus

    I practiced for several years in the military, including as an intern. It seemed then that every other week someone wanted bodily fluids. It was annoying, but I knew to expect these kinds of things when I signed up, and they were signing my paycheck.

    I will listen to Dr.Lucien Leape when Harvard requires random drug testing of all of its faculty and Dr. Leape puts himself is first in line.

    Of course, I would like the good Crimson doctor to provide me some reputable, peer-reviewed evidence that a program of said random drugs testing has a clear, irrefutable, positive benefit when applied to doctors in a civilian setting, nothing less than that, please.

  • http://paynehertz.blogspot.com Payne Hertz

    I’m curious where doctors here stand on the issue of chronic pain patients being forced to submit to drug testing as a condition of receiving pain treatment, or signing “contracts” which say they can be taken off pain meds for missing two or more appointments, or which allow the doctor to interrogate members of your family to find out if you’re using street drugs.

    Considering there is a lot more at risk from an impaired physician at work than an impaired chronic pain patient sitting on his couch at home, do you think doctors should be subjected to the same level of scrutiny as chronic pain patients? Should they be fired for missing two or more days of work? How about your boss interviewing your family members to make sure you’re flying straight while off duty?

  • http://www.tjgmd99.wordpress.com Thomas Gerke, M.D.

    no one should undergo drug testing unless they job affects public safety..america is becoming the 21st century version of the SALEM WITCH TRIALS!!!

  • http://www.pacificpsych.com/ pacificpsych

    This is but another example of the continuing attempt–a successful attempt, unfortunately–to devalue physicians and diminish them. It’s disrespectful. “Pee now!” is incompatible with being a physician. How can everyone be so blind as to not see this?

    Sadly, just like with every other nonsensical dictate from the central bureaucracy, if this comes to pass physicians will go meekly along, afraid to speak up.

  • Anon

    When Congress agrees to random drug testing, I too will gladly submit

  • skepticus

    Doctors make life and death decisions that drug use can impair. So the cost benefit trade-off is as follows:

    a few doctors get their liberties somewhat implicated and can’t smoke as much pot as they want vs. x number of dead patients.

    So the question for Drs. Park, Johnson, et al. is what is that value of X? Are 15 dead patients worth yr right to smoke pot and indulge in drinking, 350 . . .. well as you guys kill 100K+ per annum by the INstitute for MEdicine’s estimation, I suppose x=a very high number

    • Vox Rusticus

      Not true. Random drug screens inconvenience and affect everyone subject to being screened, not just those who use drugs that are being screened-for and who might have to discontinue even casual use.

      This would be an intrusive and unprecedented measure, for which there is no evidence of a benefit. Let the illustrious Dr. Leape subject his colleagues at Harvard’s hospitals to his fine idea and let’s compare that to a system elsewhere not so burdened by testing to determine whether this kind of testing has any benefit in outcomes.

  • Dharma

    While I’m not a big fan of big brother tactics and I don’t know what the best answer is, I do know that innocent patients have a right to expect that their physician isn’t abusing drugs. Reading comments from other posts, it may be fortunate for me that I’m not a health care professional because I ended up finding myself in a position (it’s a long story) with a couple friends one of which is a doctor apparently thinking they were going to impress me with their drug abuse because I don’t think they really thought of it as drug abuse, but I felt like I was watching two addicts and as an unintended bonus I actually got to witness someone stop breathing briefly.

    Before I knew about the substance abuse, I knew of another behavior that wouldn’t be condoned by medical boards, but I didn’t see the harm in it so I was just keeping my mouth shut. Others in the doctor’s office knew of that behavior also including at least one physician colleague and no one had stopped it or reported it.

    It was a gut wrenching decision for me to decide to report it, but it would have eaten me up even more inside if I didn’t report it and someone ended up dead down the road because of it. I felt my friend needed help because what I saw wasn’t safe and it was beyond my ability to effectively provide that help.

    Problems often start as baby steps and the longer it goes on it can become a slippery slope and cascade into bigger lapses in judgment that given enough time will cause harm to patients. I feel quite fortunate that I didn’t end up with an accessory to manslaughter charge that night.

  • bev M.D.

    Wow, I must say Dr. Leape’s assertion (if it was not taken out of context) surprised me – it is a needle in a haystack phenomenon and would cost considerable $$ in this era of cost containment. However, my hospital’s medical staff had to deal with one chronic and repeat drug abuser who took full advantage of his colleagues’ inclination to give him a break. In retrospect we should have thrown him off the staff much sooner.

    To me the operative quote in the post is this:

    ‘As a professional class I think it is our own responsibility to identify and report those doctors who have a problem. An impaired physician cannot hide for very long. We just need to stop being such timid cowards and do a better job of self-policing ourselves.’

    This squares with a recent article, I forget where, indicating that docs do NOT report impaired colleagues, and many think it is none of their business! We need to step up and fix that – and fast – or else Dr. Leape’s recommendation will prevail.

  • http://www.epmonthly.com/whitecoat WhiteCoat

    I’ll do random drug testing – no problem. Just as soon as they pass the same rule for anyone on the public dole. Elected Officials. Cops. Firefighters. Medicare and Medicaid patients. Social security and welfare recipients. Fail the test, lose your job and/or benefits.
    In fact, I was actually thinking about suggesting that our Congressman introduce a bill to allow random raids on people’s homes to look for any items of concern.
    Of course, the raids would be organized through JCAHO.

    More and more of these “rules” are going to get passed until physicians get a backbone and an organization that truly represents our interests.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    I am well aware, Skepticus, of the fact that impaired and/or incompetent doctors are out there harming patients. Perhaps you’ve visited my blog and know what I’ve endured for reporting one of them (he was not on drugs)?

    Oh, and the patient didn’t die. Because I was there.

    Hello, Bev. I stepped up. Been there done that. Gave at the office.

    And I got twelve years of nothing-but-woe. Will likely file a lawsuit against the state soon (oh joy) because no one in the MSM has seen fit to shine light on corruption.

    And, in all of that time, were was that public/oh-so-noble press now clammering so loudly for accountability and change?

    We’ve got to stop the police-state mentality that everyone is a bad apple – be it with with the way we do Board recertification – or screen people for bad behavior.

    Maybe, just maybe, we should be more sensitive to evidence of bad behavior and report it. And maybe we should make the reporting easier.

    It would have been nice if my guts had not been splattered all over hither and yon.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Why stop with physicians? If this is a good idea, we should extend it to nurses, hospital administrators, veterinarians, attorneys, personal trainers, sanitation workers, butchers (they use sharp knives) and congressmen. In fact, shouldn’t every citizen submit to this scrutiny so we will know that none of us are impaired?

  • http://www.twitter.com/alicearobertson Alice

    My daughter is a nurse and her employer does do random drug checks, and I believe in some states the teachers do to (a teacher was fired for her Facebook pics of her vacation. Reallly terrible stuff……..she was holding a pint of ale…. Ack! I am clueless if she able to appeal or not because the media reports the news, but rarely outcomes of situations like this).

    I can understand why doctors see this as more invasion, more government regulation, but I will say the pot smoking example didn’t qualm anyone’s fears, nor make a good argument. I know I don’t want visions of our doctor with a joint in his mouth from the previous weekend, on my mind when he’s doing surgery on my child.

    Cleveland Clinic has a no smoking policy for employees. If you smoke you aren’t hired, and if you did smoke you can walk to the ghetto to do so. My relative was just refused elective surgery because she confessed to being a smoker. They said to come back in three months when she is off the cigarettes. I believe they will hit the doctors weight soon. I hear in some places employees will be paying more for being over-weight (many employers have already started making smokers pay the extra $100 a month on their insurance if they smoke, and the particular employer I am thinking of is a medical employer and sniffed the employees out with a……ta da…..random drug test).

    As a parent I fight for parental rights and no matter how well-intentioned I think regulation is taking over our lives. And, yet…..considering the magnitude and consequences……I understand the feet in concrete stance…………but the suggestion that you police yourself is nice in a romantic sorta a way……sounds like that was in the air one night…..on a hot summer’s eve………when all was well…….:)

    • Anonymous

      Cleveland Clinic has a no smoking policy for employees. If you smoke you aren’t hired, and if you did smoke you can walk to the ghetto to do so. My relative was just refused elective surgery because she confessed to being a smoker. They said to come back in three months when she is off the cigarettes.

      Wouldn’t be surprised if this has to do with insurance / benefits / liability concerns and costs. Smokers’ medical expenses are higher, and employers are trying to slow down this rapidly growing (for them) medical benefit expense. And since smokers tend to heal less well after surgery, the risk of problems and liability is greater when doing surgery on a smoker.

  • bev M.D.

    Well, I ran this by my volunteer group, a bunch of 60 something well educated women, and got the blunt response – “they do it for everyone else, why do doctors think they should be any different?”
    I had nothing to say….

  • PAULMD

    “Back in the US
    back in the US
    back in the USSR.”

  • Recovery Doc

    Random drug testing for all physicians will never happen. It won’t work because:

    1. It’s expensive. The test used by American Physician Health Programs is about $150. Also, there is a variable fee for the test site. Depending on how often this I guess the physician has to pay for them as a cost of doing business. At weekly intervals, well do the math.
    2. It’s inconvenient. For docs who have no history of abuse or suspicious behavior it is not fair to ask them to drop everything and submit for a test. The approved test sites are few and far between. Rural docs have to drive sometimes an hour each way, and wait in line holding their pee at the test site. All of this being done randomly means they cannot plan their schedules around it, so patients are inconvenienced by the wait. It’s ok to inconvenience the doctors, but the patients will have a problem with this arrangement. Grandma drives in an hour to see her doctor, and has to decide if she wants to either wait two hours extra or reschedule for another appt, when it could all happen again, since it is random.
    3. The tests have to be observed by a same sex observer to verify the sample is adequate and not tampered with. This is not always possible, and sometimes even prevents good doctors who actually are in good recovery from traveling. Waivers can be asked for, but not always granted. This is a fair situation for doctors in recovery as a part of their monitioring, but not fair for everybody. Recovering addicts seldom take issue with it because we are eager to document/prove our sobriety, but for the non-addict physician, this would be unfair and humiliating.
    4. The tests are fallable. Doctors in recovery are not allowed to take anything not prescribed by their physician, even over the counter meds. So many false positives occur. A follow up test can be run (mas spec, etc) on urine or hair to identify specific drug metabolites, but the cost is incurred by the person donating the sample. Dilute samples are considered suspicious and all kinds of followup test (sometimes including a polygraph) must be done to verify.
    5. The metabolites stay in the urine for a long time. Drug metabolites can be detected for weeks. Alcohol metabolite (Etg) can be detected for up to five days. Since nobody works five straight days, how relevant are the test results? And if a doctor has a prescription for their xanax or hydrocodone and use it appropriately, not at work, they still show up as a positive on their test. What then?
    6. Doctors are too smart. They get caught, yes. Eventually they usually get caught. By forcing random drug testing on everyone, the addict docs would come up with ways around the tests and ways believably explain their suspicious results (eg, a hydrocodone addict will have a script for ten written, although he takes ten a day. ‘of course the urine was positive, I have a script for that!’

    I’ve heard this same argument for welfare…”Drug test them, if they fail take away their welfare checks” For much the same reasons above it won’t work.

    I would not be adverse to random drug testing if it is applied like Michael Kirsch MD said above. I like that approach.

    I am in recovery, practicing good medicine and I do my best to educate my peers about the issue of addictions in physicians. But, as a doctor in recovery, I have to tell you that the idea of random drug testing on me prior to getting into recovery wouldn’t have stopped me.

  • Skeptikus

    Well, a lot of comments later and still no answer to my question: what does x equal? The posts show drug tests have costs in terms of doctors dignity (although they tell people to pee in cups for a living so I don’t see the big deal) and minimal cost as far as the test itself.

    But if the tests save lives, the costs seem to be worth it.

    everyone takes drug tests these days: pilots, student athletes, firemen, why not doctors.

    • Vox Rusticus

      Don’t assume any lives will be saved or anyone except the companies that do drug screening will benefit. If Dr. Leape really does believe random drug testing has any benefit, he should first do a significant study to show why that idea is worthy of recommendation.

      I happen to think it is worthless, and the clever and determined users are the first to find ways to avoid being caught. But if a powerful controlled study can be done to show otherwise, my mind could be changed.
      For now, I take the null proposition: random mandatory drugs testing of physicians has no statistically-significant benefit to reducing patient morbidity or mortality. Forget about what your x equals.

  • Dr Lemmon

    The false positive rate is not zero. Even with confirmatory testing it is not zero. Some innocent physicians will be tagged.

    No one should be subjected to this. Not even the President of the United States. It is an invasion of privacy. There needs to be cause.

    I wonder what the ACLU would say about this.

  • Dr Lemmon

    Here is what the ACLU says and it is worth reading. See the section on reliability of drug testing.

    http://www.lectlaw.com/files/emp02.htm

  • madoc

    If the persons with the money say we get drug tested then we will be drug tested.
    Thank you. If they say a patient every
    5 minutes then it will be every five minutes. We are gradually becoming enslaved.

  • Staceyjw

    Drug testing at random is expensive, unnecessary and a total privacy violation! No one should be tested unless their bad behavior demands it- though even then, I think its better to discipline someone for their actions on the job, not what they do on their own time.
    Most higly paid professionals don’t have to deal with this because they have more power and choice, Its the blue collar workers I feel for. ever since I moved up in my career and pay, Ive never had a job mention drug testing!!! of course, they need good sales managers, and would lose quite a few if they did random screens.
    One more reaso its stupid- there is not an addict out there that doesn’t know how to beat a test, and when they think they are under scrutiny, they are generally prepared. (learned this back in the day before I became a responsible adult, lol).