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Physician Impairment and Support Resources Policy:

ACGME Guidelines: Institutional Requirements

Section II, D, 4 (Page 8)

  • Counseling Services: The Sponsoring Institution should facilitate resident physicians' access to confidential counseling, medical and psychological support services.
  • Physician Impairment: The Sponsoring Institution must have written policies that describe how it will address physician impairment, including that due to substance abuse.

Policy Purpose:

Graduate Medical Education (hereinafter GME) is committed to quality resident education and providing quality and safe patient care, which can be compromised if a resident physician is suffering from physical, psychiatric, and/or emotional conditions that impair his or her ability to learn and provide patient care safely and competently. Mount Carmel Health System (hereinafter MCHS) has a Medical Staff Impairment and Health Policy that addresses physician impairment and related issues. As associate members of the Medical Staff, resident physicians shall refer to the policy for detailed information whenever deemed necessary.

In addition, GME has established the following policy that is intended to provide GME specific guidance to resident physicians regarding physician impairment issues, and to provide procedure guidelines to residency programs, resident physicians, and other Medical Education associates in dealing with physician impairment issues.


  • Specific education and reference materials shall be provided to resident physicians regarding physician impairment, including the recognition of impairment in physicians, and proper procedure to assist a resident physician when there is a concern for possible impairment.
  • All concerns of this nature shall be brought directly to the Program Director of the impacted resident physician. Further management of the situation shall be at the discretion of the program and its leadership. The Vice President of Medical Education (hereinafter VPME) shall be immediately informed of the concern(s) and the plan for assisting the impacted resident physician.
  • Resident and staff physicians have the moral and ethical obligation to report an impaired resident physician to protect patient safety and the integrity of the institution. Such reporting will enable the residency program and GME leadership to address the impairment issue in a timely manner, which may not necessarily result in punitive action against the impaired resident physician.
  • GME and the residency program leadership shall empower and ensure confidentiality to those resident physicians who bring forward the issues of impairment, and protect the confidentiality of those resident physicians who struggle with impairment issues.


    • The resident physician who is suffering from an impairment that affects their education is encouraged to voluntarily bring the issue to the Program Director so that appropriate steps can be taken to protect their patients and to assist the resident physician.
    • If any associate within Medical Education has a concern that a resident physician has an impairment issue that may affect their education and ability to provide patient care, a confidential report shall be submitted to the Program Director and the VPME, who shall appropriately document the report.
  • If any associate within Medical Education or the Hospital System has a concern that a resident physician is unable to provide safe and proper patient care due to impairment issues, an immediate response is necessary in order to protect the safety of patients. This associate shall immediately notify the resident physician's Program Director and/or the VPME. The Program Director shall assess the resident physician to determine if the concern is valid.

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