Almost Addicted

The slippery slope of recreational drug use

Help for Doctors With Substance Use Disorders

If physicians are impaired, they should receive firm but fair treatment

If your doctor had a drug or alcohol problem, wouldn’t you want to know that help was available that your doctor would feel good about accessing? 

Approximately 10-12% of physicians will develop a drug or alcohol problem at some point during their career.  If physicians are impaired, they should be able to seek help from a firm but supportive and fair resource—one that demands sobriety and can determine when physicians are safe to practice. 

Physicians with substance use disorders often seek the assistance of a state physician health program (PHP). Some physicians engage willingly with PHPs, but most are compelled to do so either by their hospital or their board of medicine.  PHPs meet with, assess, and monitor physicians who have been referred to them for substance use or other mental and behavioral health problems.  In most states, physicians who comply with any and all demands of the PHP often may continue to work, provided their sobriety is ensured through drug testing and other means.  Many state boards of medicine rely completely on the PHPs for guidance about how to deal with impaired physicians.  PHPs are therefore extremely powerful. 

The problem with PHPs, though, is that despite their enormous power, they are generally barely known to most physicians and often operate with little oversight and no real means of appealing their recommendations.

Many PHPs refer physicians for evaluations at facilities around the country that specialize in working with professionals, often at great expense to the physician, and physicians who hope to be able to work have little choice but to comply with the request to go to the evaluation and then with any recommendations that might result. These evaluations often conclude that the physician should enter treatment, often for 90 days.   Because evaluation centers usually also offer treatment, there is a huge potential conflict of interest and at times this recommendation can appear suspect.  Nonetheless, physicians who want to work are generally compelled to comply in order to remain in the good graces of the PHP.

To compound matters, evaluation/treatment centers and PHPs are often financially dependent on one another:  Centers depend on referrals from PHPs for their viability and, reciprocally, PHP regional and national meetings are often heavily sponsored by these centers.

Because PHP practices are largely unknown to physicians until they themselves are referred to one, physicians who do register complaints about standard PHP practice are often dismissed as bellyaching.

Some voices of concern have been heard.  A couple of years ago, a colleague and I published a paper in the Journal of Addiction Medicine outlining our concerns about standard PHP practice, which included the points I raise above along with others.  (Prior to publication reviewers at 2 different journals said that the issues we raised were very important but that our paper should not be published, essentially because doing so might bring unwanted outside attention to PHPs—one of them wrote that we should withdraw our paper from the journal and instead present our findings to the national federation of PHPs' annual meeting.) 

More recently, after a group of North Carolina physicians complained about their state PHP to the state auditor, the auditor conducted an investigation and found poor oversight of the PHP by both the state medical society and the board of medicine, a lack of due process for physicians who disputed the PHP's evaluations and/or recommendations, and multiple instances of potential conflicts of interest. 

The national federation of PHPs ought to implement national standards for its members and commence routine audits of its members.  Other state governmental agencies ought to audit their PHPs as well, to ensure that their vast power is wielded judiciously and with oversight.

Doctors who are unsafe to practice medicine ought to be prevented from doing so, but every doctor who enters any kind of treatment or monitoring program should be treated respectfully and fairly, monitored appropriately, and have legitimate avenues of appealing decisions about their care.

Wes Boyd is on faculty at Harvard Medical School and is an Attending Psychiatrist at Cambridge Health Alliance and Children’s Hospital Boston.

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