But when that conversation does happen, Dr. Andrew said, physicians can have a huge impact on colleagues who feel isolated. “We have a peer-to-peer counseling system that can be of use to members experiencing burnout, but we have not had any requests for support relating to impairment issues,’’ she said. “We also have a Wellness Section … but again, not a great deal of interest in (substance abuse) or impairment is evident.”

There are signs that more emphasis on impairment is needed.

A study of 16 state physician health programs that examined 904 physicians who had been placed under monitoring for drug abuse found more than half of the physicians were in five medical specialties. Emergency medicine ranked fourth, after family medicine, internal medicine, and anesthesiology. Psychiatry ranked fifth. The 2009 study was conducted by researchers at the University of Florida.

Aside from their own inhibitions and pride, physicians may be reluctant to seek help for practical reasons.

“There may be a conspiracy of silence in the workplace and the home, limiting involvement by friends, family members, and colleagues,’’ according to a February 2010 article in Minnesota Medicine. If the physician is in a position of power, other employees may fear for their jobs and careers if they mention the possibility of addiction.

“Family members may know of the addiction before co-workers do but may hesitate to act for fear of financial consequences,’’ wrote the authors, Dr. Marvin D. Seppala and Dr. Keith H. Berge. “Fear of litigation can limit appropriate attention to this disease as can the misunderstanding that addiction is a choice and not an illness. Stigma and bias also come into play, as people often cannot believe a physician could have an addiction or believe addiction occurs only in the lower socioeconomic classes.’’

But the stakes are high if impaired physicians continue to practice, and not just for the doctors themselves. “Research has shown that when such behavior is permitted, the patient suffers,’’ said Marilyn Bromley, Director of ACEP’s Emergency Medicine Practice Department.

That is one reason the Joint Commission on Accreditation of Healthcare Organizations now requires accredited facilities to have a code of conduct “defining acceptable behavior and specifying which behaviors are disruptive and inappropriate, and to have a process or action plan for managing disruptive staff members,’’ Dr. Linda M. Worley said at the American Psychiatric Association’s Institute on Psychiatric Services last fall.

Physicians who come forward with problems may find that the consequences aren’t as bad as they fear. In particular, non-disciplinary physician health programs can offer a third-party solution that satisfies employers and obviates the need for action by state licensing boards, so physicians can get treatment while protecting their licenses.