The Resident Who Is Impaired on Shift
You are the attending on a busy evening shift. A second-year resident you are supervising has been increasingly disorganized over the past week. Tonight, at 21:00, you notice slurred speech, pinpoint pupils, and a nod during handoff. He denies any problem, says he is 'just tired,' and asks to finish his shift because 'I need the hours.' He is responsible for 8 patients, including two pending admissions. A nurse quietly tells you she saw him in the stairwell earlier and thought he 'looked off.' You have no proof of substance use. He is a valued colleague and a friend.
1. What are your immediate obligations, and how do you act on them without proof?
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Patient safety is the non-negotiable priority. You do not need proof of impairment to act on observed signs - slurred speech, pinpoint pupils, and nodding off during handoff are objective findings that raise concern for opioid intoxication (or another cause: hypoglycemia, stroke, fatigue, medication effect).
Sequence:
- Remove him from patient care immediately - reassign his 8 patients and the pending admissions to yourself or another clinician. This is not optional and does not require his agreement.
- Get him evaluated medically. Pinpoint pupils plus sedation warrant consideration of opioid toxicity; ensure he is medically assessed (and, if overdose is suspected, that naloxone is available). Do not let him drive himself.
- Notify the appropriate chain - program director, department chair, and the hospital's employee health/physician health program. Most institutions and states have a physician health program designed for exactly this; it is the appropriate, confidential pathway.
- Do not investigate or interrogate. You are not a detective; you are a supervisor ensuring safety and directing him to help.
Exam point: The right answer acts on observed behavior, protects patients first, and routes to the proper program. The wrong answer waits for proof, covers for a friend, or confronts him alone in a way that risks escalation or abandonment.
2. He becomes angry and says, 'If you report me, my career is over. You're my friend.' How do you respond, and what do you document?
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Response: Be direct and compassionate. 'I'm not doing this to end your career. I'm doing it because you're not safe to care for patients right now, and because getting you help is the priority.' Emphasize confidentiality protections: physician health programs are designed to facilitate treatment and monitoring, and many states offer confidentiality for participants. Do not promise outcomes you cannot control.
Do not: agree to keep it between you, let him finish the shift, or delay notification until morning.
Documentation: Keep it factual and minimal in the medical record (his patients' records are not the place for this). Document in the appropriate confidential channel: the observed findings, the time, the actions taken (removal from duty, reassignment, notification of leadership/physician health), and the safety plan. Avoid diagnostic speculation in the chart; describe observations.
Exam point: Loyalty to a colleague never overrides patient safety, and the professional response is supportive but firm. The wrong answer is either 'I'll cover for you tonight' or a punitive public confrontation.
3. What system-level safeguards should exist so this situation is handled well the next time?
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A department should have, in advance:
- A clear impairment policy with a defined reporting chain and after-hours contacts (program director, chair, house supervisor, physician health program).
- Training for supervisors on recognizing impairment and on the non-punitive purpose of physician health programs.
- A culture that destigmatizes self-referral - fatigue, burnout, and substance use should have a safe pathway before a crisis.
- Peer support and fatigue-management policies (shift limits, backup coverage) that reduce the conditions that contribute to impairment.
- A just-culture framework distinguishing human error, at-risk behavior, and reckless behavior.
Measurement: Track whether staff know the reporting pathway (e.g., annual attestation), whether referrals occur early, and whether there are barriers to self-referral.
Exam point: The best answers move from 'what do I do tonight' to 'what would make tonight's response routine and safe.' Naming a specific program and a measurable safeguard beats generic 'education.'