Although the nature and scope of addictive disease are commonly reported in the lay press, the problem of physician addiction has largely escaped the public's attention. This is not due to physician immunity from the problem, because physicians have been shown to have addiction at a rate similar to or higher than that of the general population. Additionally, physicians' addictive disease (when compared with the general public) is typically advanced before identification and intervention. This delay in diagnosis relates to physicians' tendency to protect their workplace performance and image well beyond the time when their life outside of work has deteriorated and become chaotic. We provide an overview of the scope and risks of physician addiction, the challenges of recognition and intervention, the treatment of the addicted physician, the ethical and legal implications of an addicted physician returning to the workplace, and their monitored aftercare. It is critical that written policies for dealing with workplace addiction are in place at every employment venue and that they are followed to minimize risk of an adverse medical or legal outcome and to provide appropriate care to the addicted physician.

A pproximately 10% to 12% of physicians will develop a substance use disorder during their careers, a rate similar to or exceeding that of the general population. 1,2 Although physicians' elevated social status brings many tangible and intangible rewards, it also has an isolating effect when they are confronted with a disease such as addiction, which has a social stigma. This isolation can lead to disastrous consequences, both in delaying the recognition of and in intervening in the disease process, as well as in the attendant risk of death by inadvertent overdose or suicide. 3 Further causes for delay in diagnosis include fear on the part of the physician that disclosure of an addictive illness might cause loss not only of prestige but also of his or her license to practice medicine and thus livelihood. Additionally, a physician's family members and coworkers will often participate in a "conspiracy of silence" in an effort to protect the family or practice workers from economic ruin by the loss of the physician's job and income.McLellan et al 2 conducted a 5-year longitudinal cohort study of 904 physicians, 87% of whom were male, who were enrolled in 16 state physician health programs (PHPs). Alcohol was the primary drug of abuse in 50.3%, opioids in 35.9%, stimulants in 7.9%, and other substances in 5.9%; 50% reported abuse of multiple substances, 13.9% a history of intravenous drug use, and 17% previous treatment for addiction. The authors found that certain specialties, such as anesthesiology, emergency medicine, and psychiatry, appeared to be overrepresented in these programs relative to their numerical representation in the national physician pool. Indeed, other investigators have

Brain death determinations have been challenged in courts, but no systematic study has been published in the medical literature. Court cases on brain death determination could provide some insights for the clinical practice of physicians. We reviewed legal cases between 1980 and 2010 involving neurologic criteria for death since adoption of the Uniform Determination of Death Act. Court rulings on brain death determination are uncommon, but 2 major themes emerged: consequences of documentation of the time of brain death and family-physician discord on withdrawal of intensive care support. All court rulings upheld the medical practice of death determination using neurologic criteria according to state law, irrespective of other elements of the rulings. Nothing in the court cases suggests a need to alter the current medical standard of brain death determination. Jurisprudence to date emphasizes that the timing and accurate diagnosis of brain death has important weight in the resolution of conflict between practitioners, hospitals, and family members.