I am hesitant to report him, because I am the one who reported him 20 years ago, and the blowback was terrible. Name Withheld

It’s awful but, alas, not at all surprising that you suffered as a result of reporting this man’s behavior 20 years ago. Fortunately, it hasn’t stopped you from recognizing that you may need to do something again. My impression is that colleagues and friends are often too embarrassed to undertake the hard task of trying to intervene with people who are dealing with alcohol and drug abuse. Like driving, medical practice is not best done under the influence. And in both cases, the consequences of our failure to intervene can be disastrous for third parties. But I think two issues need distinguishing here. If this doctor’s drinking problem puts his patients at risk, he needs to be reported to the state medical board. If you think that the patients are fine — as you evidently do — but that he’s a danger to himself and to others on the road, what’s needed is an intervention by his family or friends. Given your history, that probably doesn’t mean you.

As a physician administrator, I have to manage physicians. Recently I had a conversation with a doctor who had been employed for many years by the health system I work in. He told me that our health system promised to market his practice, hire him partners and several other things that have not taken place because of market realities. These promises were made years ago, by other administrators, and in some cases when the health system was under different leadership. How dutybound am I to uphold others’ (sometimes unrealistic) promises? The commitments that this physician related were not part of any contract, just what he came away feeling that he was promised. Name Withheld

I can’t give you legal advice. But two things strike me. First, it would appear that, for years, this physician has been denied what he says he was promised and that, for years, he has stayed on the job despite this. Second, the promises were never formalized in writing. To be sure, that an agreement wasn’t written down doesn’t invalidate it, but you can wonder about how much weight to give his claims: Were these outright promises, or were they in the whiffier managerial realm of Things We Hope to Do? All you have is one man’s say-so.

Your own primary obligation is to the health system you help administer. An organization can certainly incur obligations that extend beyond the tenure of any particular manager. When someone’s expectations have an unclear basis, though, you can’t be obliged to compromise the organization in order to fulfill them. But here’s a thought: Maybe some of your colleague’s requests would be worth implementing. Could they have been promised to him because they would have been beneficial for the overall health system? Why not consider telling him that you’d need more evidence to act on those earlier offers, but that you’re always willing to work with him to develop his practice in ways that would be good for patients and the health system as well as for him? Looking forward is often more productive than looking back.