Assessment and Treatment Contract for Residents in the Department of Medicine
Liza Donlon, MD has agreed to participate with residents in Medicine and the Medicine
Program leadership to provide confidential assessment and referral for treatment to help
residents in medicine who self refer on a voluntary basis or who are referred on a
mandatory basis by his/her physician supervisor (the Program Director or Associate
Program Director of the Department of Medicine). Dr. Donlon may also make use of the
Berkshire Medical Center Practitioner Health Committee whenever she would like
additional consultative support. Her evaluation will result in one of four
recommendations:
1) Assessment and no treatment recommended.
2) Assessment and specific treatment recommended.
3) Assessment and referral to the Physician Health Services (of the Massachusetts
Medical Society) recommended.
4) Assessment and referral to the Physician Health Services required or the
physician will be reported to the Board of Registration in Medicine for possible
impairment evaluation according to the Massachusetts Board of Registration in
Medicine regulations (MGL c. 112.5F).
When a resident asks for help from Dr. Donlon, she will ask if the matter is related to an
administrative referral or is independently sought by the resident. If the request is entirely
initiated by the resident, the matter remains totally confidential unless: there is a risk of
inability to care for self; risk of serious harm to the resident or someone else by virtue of
mental illness or substance abuse: or risk of serious harm to the resident’s patients by
virtue of mental illness or substance abuse. In that case Dr. Donlon will do whatever is
necessary to engage the resident in a safer course of action.
If the referral is related to an administrative concern, the physician supervisor (Program
Director or Associate Program Director) making the referral will explain below to the
referred resident and Dr. Donlon the reason for the referral (eg., to assess if there are any
health related issues that if addressed will make it less likely that the physician engages in
disruptive behavior; to assess whether anxiety is interfering with job performance and
learning).
Program/Associate Program Director’s reason for referring the resident to Dr. Donlon:
Program/Associate Program Director’s Initials:______________
In addition, Dr. Donlon may ask for the Program/Associate Program Director to meet in
person with her and/or the resident in order to clarify the purpose of the assessment.
This document will serve as a release for Dr. Donlon to let the physician supervisor know
the broad category of evaluation 1-4 above that was determined. The physician
supervisor and the referred resident will agree upon one of two conditions in the release
of information:
1) No specifics beyond the category 1-4 will be reported to the
administrator._________Initials.
2) The specific category will be reported to the program supervisor and whether the
recommended treatment is followed. Again, no specifics will be reported to the
supervisor except whether the physician is in compliance with the
recommendation. In cases where the resident chooses to use the Physician Health
Service the resident will sign a release for the Physician Health Service to let the
Chairman of the Practitioner Health Committee know that the physician is in
compliance with the Physician Health Service’s recommended plan.
________Initials.
The intention of this assessment, treatment and monitoring program is to improve the
health and function of the resident, to promote his/her professionalism and to promote the
safety and quality of care they provide their patients. In light of these goals it is expected
that in almost all circumstances the resident will agree to items one and two above
regarding the release of information. The resident is asked to initial items one and two
above as part of his/her agreement to participate fully in this process.
Once filled out and signed, Dr. Donlon will hold the original copy of this contract and
will give one copy to the resident.
I have read the above contract, and I am in agreement to carry out my part in this process.
Resident name:
Resident signature:
Date:
Program Director/Associate Program Director name:
Program Director/Associate Program Director signature:
Date:
Elizabeth Donlon, MD
Dr. Donlon signature:
Date:
Sample Letter Back to the Program Director
Date:
Dear Dr. ______________:
As requested by you and Dr. __________ I have met with Dr. _________, and
completed my assessment.
I have recommended the following approach (circle the number chosen):
1) Assessment and no treatment recommended.
2) Assessment and specific treatment recommended.
3) Assessment and referral to the Physician Health Services (of the Massachusetts
Medical Society) recommended.
4) Assessment and referral to the Physician Health Services required or the
physician will be reported to the Board of Registration in Medicine for possible
impairment evaluation according to the Massachusetts Board of Registration in
Medicine regulations (MGL c. 112.5F).
In regards to reporting back to you on progress, (circle one of the following):
Dr. _________ is in compliance with recommended treatment.
Dr. _________ has completed recommended treatment.
Dr. _________ has unilaterally decided to discontinue treatment.
Sincerely,
Liza Donlon, MD