It happened almost overnight.

It was March 1992, and psychiatrist Michael Elinski, M.D., then 37, knew he was HIV positive. So far he had few symptoms. But suddenly he developed high fever, encephalitis, and dementia.

The dementia became so bad, recalled Elinski, that "patients started to laugh at me because I would forget something they had told me in the last session." One frightening night he became lost while driving home on a route he had driven for years. Only after hours of driving around was he able to find his way back home. A physician he was consulting told Elinski that he must stop working indefinitely. It was March 23, 1992. At the time he had a thriving solo practice in New York City. He has not worked since.

"It was terrible. One day I was working, and one day I was not," he said.

"When I suddenly one day went from being a 37-year-old working physician to an impaired, disabled physician, I had to deal not only with physical illness, but also financial devastation. Within one year of stopping work, I had to file for bankruptcy due to overwhelming medical bills. What a humbling and humiliating experience."

Although life has been a struggle, his health is good enough that he was able to travel this year to both APA’s annual meeting and Institute on Psychiatric Services on a scholarship from APA’s AIDS Program Office. Elinski thanked the office and project assistant Diane Pennessi for their "kindness, compassion, and generosity," adding that he looked " forward to attending these events to help maintain my identity as a doctor and to try to stay as current as possible in medicine, given my limitations, should I be able to one day return to work."

On some days, said Elinski, "I feel as if I am finally reaching a state of acceptance where my inability to ever practice medicine again is OK. My whole identity is no longer that of a physician. I do have a whole other life, and who knows where it may lead me."

Linda Logsdon, M.D., chairs APA’s Committee on Physician Health, Illness, and Impairment. In Michigan, where she practices, and in a number of other states, there are organizations on impairment linked to the state medical societies, but there are no hard data on how well they are working, according to Logsdon.

"The problem I have is that any system that requires the physician to identify him- or herself is very vulnerable to the willingness and ability of the physician to identify his or her disability." That hesitancy could stem either from denial of the seriousness of an impairing condition or simple fear of losing the right to practice medicine, she observed.

She wants the APA committee "to be available through the existing APA toll-free number so that a physician concerned about a medical disability issue or his or her own impairment could call and be routed to a staff person," who would then contact Logsdon.

To date she has had contact with two APA members concerned about conditions that are causing impairment. In both these cases, the physicians in question contacted the committee after confronting challenges regarding their capacity to continue working.

Michael Myers, M.D., is clinical professor in psychiatry at the University of British Columbia and a corresponding member of the APA Committee on Physician Health, Illness, and Impairment. Myers has a private practice that is entirely focused on medical students, physicians, and their families who "have mental health problems." He has treated more than 2,000 medical students and physicians during his 25 years in practice.

"What I have found is that the way situations like Elinski’s are handled varies tremendously from state to state or program to program," said Myers, who is also APA’s Area 7 trustee. "In some cases, you hear that the physician has been treated very well, that the humane element is front and center, and that all of the players have been very fair as to whether or not the physician can continue working safely. In other cases, what I’ve heard is very chilling, where the sense is that the individual hasn’t been fully assessed or given an opportunity to enter, for example, a rehabilitation program or given an opportunity to work under supervision."

Elinski’s existential struggle regarding whether he must resign himself to not practicing medicine comes up often in therapy with doctors confronting an impairing condition, said Myers. "What the therapist must do is to help such individuals accept that their human identity encompasses far more than their professional identity," Myers explained. "It’s very important for the treating physician to understand that. It’s not just a matter of saying ‘you’re demented, you’re impaired, and you can’t work any more.’ "

The underlying issue is that "too many of us in medicine are totally defined by what we do," Myers said. "What Michael is saying is that there is more in life than just being a physician. What he is having to do at a young age is what virtually all physicians will have to do as they near retirement."

Francine Cournos, M.D., is a professor of psychiatry at the Columbia University College of Physicians and Surgeons and vice chair of the APA Commission on AIDS. "Physicians are known to be terrible patients," she commented. "We have a hard time in that role."

For a physician confronting a serious and impairing illness, whether psychiatric or other, there is the issue of role reversal, of being a patient and depending on a physician as opposed to vice versa, and of facing the existential issue of possibly having to find an identity outside of professional life, Cournos observed. She recently completed a two-year term as chair of New York’s state medical board and has seen the issue of the impaired physician from the perspective of both therapists and regulators. In New York licensing and disciplinary actions are handled separately, with the state education department responsible for licensing and the health department for discipline.

Christine Smith is a spokesperson for the New York health department. "The psychiatric issues can be among the most problematic because these may involve very dedicated physicians who do not realize they have a problem and who continue to practice and put patients at risk," said Smith. "We put as our highest priority protecting patients but want to be as sensitive as possible to the problems a physician with a psychiatric disability is facing. We don’t want to be punitive."

The preferred approach, she said, is a "voluntary surrender" in which a physician agrees to surrender his or her medical license while receiving treatment. Then, he or she must reapply to the board for the reinstatement of his or her medical license with the burden on the physician to prove that he or she is no longer impaired.

"Most often there is some period of monitoring or probation after the license is restored," said Smith. If the board must act because a physician will not voluntarily surrender a license, "we will go the disciplinary route." Such cases are difficult, she noted, and would require "credible evidence" that a practicing physician is impaired.

James Winn, M.D., is the executive director of the Federation of State Medical Boards. State medical boards have three priorities—"I call them the three p’s of the medical board’s responsibilities," said Winn. They are responsibility to the public, the profession, and the person, "in that order of priority," he explained.

"The medical profession prides itself on self-policing, and in most cases physicians remove themselves from practice when they recognize they are impaired," said Winn. In other cases, colleagues intervene and say, "Joe, it’s time to hang it up," he added.

Winn suggested than any physician who knows he or she is impaired should take the initiative in notifying the state medical board and follow the board’s recommendations.

For someone like Elinski, said Winn, "I would encourage his colleagues to try and find a way that he can stay in contact with medicine because it does mean a lot" to be able to do so.

In most cases, physicians with a psychiatric disorder do not come to the attention of a medical board unless a situation has occurred in which there was clear evidence of harm or potential harm to a patient, said Winn. "The board is not out there beating the bushes trying to identify doctors with psychiatric illness," he stressed.

Cases like Elinski’s "lend weight to the argument that medical licenses should be time limited," said Winn. "What concerns physicians right now is that they don’t know what would happen if they give up their license and what they would have to do to get it back."

Winn believes that eventually the public may demand the periodic recertification of physicians. "If we had that system, this doctor would be able to go to the sidelines in a very graceful manner and reenter the game when he could show he was prepared without any stigma associated with it," Winn said.

At present, he noted, state boards do not require that physicians show current knowledge when they periodically renew their state registrations.