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Programs to Help Doctors Are Rife With Problems

Do programs to help doctors with substance abuse treat them fairly?

Key points

  • State physician health programs (PHPs) are supposed to help clinicians deal with mental health and substance use disorders.
  • PHPs often have little external oversight and generally lack inexpensive or timely avenues of appealing their recommendations.
  • PHPs often mandate evaluations and treatment in facilities with which they have financial and other conflicts of interest.

If a doctor has a substance abuse issue (or is suspected of having one) or needs mental health care, he or she is often referred to something called a Physician Health Program (PHP). In principle, these programs are intended to help doctors with substance abuse disorders and mental health problems.

But that’s not always what happens.

I teach psychiatry and bioethics at Baylor College of Medicine. Before my recent move to Texas, I was on faculty at Harvard Medical School and worked closely with physicians who have substance use disorders. And for six years while I lived in Massachusetts, I was an associate director for its state PHP.

During my time in the Massachusetts PHP, I began to have doubts about PHP standard operating procedures.

Since then, I have taken a closer look at how PHPs work across the country, publishing papers in medical journals analyzing their lack of due process, their conflicts of interest, and lack of oversight. I also served as expert consultant in the state of North Carolina’s audit of its PHP in 2014 and as an expert witness in several lawsuits concerning PHPs.

Why should you care about this issue? Because some good doctors are being prevented from practicing medicine and others may be forced to go through a deeply unfair process to keep their license.

How does a PHP work?

Many PHPs had humble origins in the 1970s, with doctors reaching out to help other doctors. Over time they became more and more formalized, eventually evolving into corporate entities with close ties to their state boards of medicine, as well as to an array of evaluation and treatment centers across the country. At present, 47 states have PHP programs.

If a physician seems impaired in some way in the workplace—behaving erratically or smelling of alcohol, for example—then a clinic chief or chief medical officer might demand that the physician meet with someone in the state PHP. Or, if the state licensing board gets wind of a potential problem, they too might insist that a physician meet with a PHP.

After an initial meeting with the PHP, physicians are often referred for a four-day evaluation, which can cost upwards of $10,000 and is generally not covered by insurance.

Most PHPs, even in states with excellent medical schools, refuse to allow academic physicians or medical centers or other highly-trained specialists to perform these evaluations. Instead, PHPs insist that physicians go to “preferred evaluations centers,” which very frequently have financial ties to PHPs and a significant financial incentive to insist on more treatment. (See this link, which shows that many of the centers that PHPs have on their “preferred list” are exhibitors at and sponsors of the annual meeting of the national federation of PHPs.)

As a clinician, by the way, I have never seen any four-day evaluation produce anything substantively different than I could glean after meeting with a client for one to two hours, obtaining a urine and/or hair sample for drug testing, speaking with people who know and work with the individual, and then conferring with my own colleagues if needed.

From evaluation to treatment

If substance abuse is suspected—and sometimes even if it’s not—the evaluation center will often recommend up to 90 days of inpatient treatment, which can cost $50,000 or more. Many of these evaluation centers also offer treatment. Like the initial evaluation, this is usually not covered by insurance, generally because coverage for substance abuse and mental health services tends to be poor. But another reason insurers might state is the relative lack of scientific evidence to support this length of treatment.

If a physician balks at the cost, centers often offer to set up a payment plan. These centers have a financial incentive to have as many of their evaluees stay for treatment as possible. Many of these evaluation centers depend on PHP referrals to remain financially viable. Given their financial interdependence, all of these interactions between PHPs and these centers should be scrutinized, although apart from some things I’ve written along with a handful of others, little has been forthcoming.

When evaluation centers report their findings and recommendations, the PHP then usually adopts those same recommendations as its own for the client. If the physician fails to follow any or all of these recommendations, the PHP then often reports the physician to the state board of medicine for noncompliance. When that happens, the medical board often suspends the physician’s license to practice.

There are generally very few ways for a physician to meaningfully object to a PHP recommendation. The result is that physicians often have to fully comply with any and every PHP recommendation, no matter how punitive or costly, if they want to have a chance at continuing to practice medicine.

Ultimately PHPs have tremendous power over physicians who have been referred to them and are rarely subject to any genuine oversight. In some states, the medical society or board of medicine is charged with overseeing the PHPs. However, the reality as I know from both my personal experience and research, is that they often receive very little external scrutiny. Indeed, PHPs are often given a free pass because they are seen from without as benevolent in nature. Many physicians I’ve heard from feel exactly the opposite about PHPs after they’ve been forced into them.

PHPs generally tout success rates of 75-80%, but there are several reasons to question these high numbers. First, these data are produced by proponents of PHPs who are motivated to produce the highest numbers possible. Also, these data generally exclude people who drop out of the program or commit suicide while in PHP monitoring agreements.

Additionally, if a physician who doesn’t actually have a substance use disorder gets railroaded into a monitoring agreement and then remains totally clean and sober while they are being monitored, PHPs consider them a success even though they never had a problem in the first place.

National standards are badly needed

Make no mistake: If a physician is impaired, he or she ought to be compelled to undergo treatment and be deemed safe to practice by a reputable entity prior to being allowed to return to work. Anything short of that would endanger the public as well as the physician.

But the process of evaluating that individual ought to be transparent, fair, free of bias, not driven by a profit motive, and have legitimate avenues of appeal if the physician feels he or she has been treated unfairly.

National standards are overdue. Regular external audits of PHPs need to become normative. In response to criticism and, more importantly, in order to stave off a North Carolina-style audit, several state PHPs have hired one individual to “audit” their programs, but the “auditor” that they all hired is a PHP insider (a former director of a state PHP and also past president of the national federation of PHPs), not someone actually from without.

Additionally, the use of evaluation and treatment centers with close financial ties to PHPs needs to cease. Effective means of appeal outside of PHPs needs to be implemented.

Doctors need to know that recommendations and mandates they receive for suspected or actual impairment are fair. Unfortunately, in the middle of 2021, that is still not the case.

This post is an updated version of my piece in the Conversation from 2016.

References

Boyd, J.W. and Knight, J.R., 2012. Ethical and managerial considerations regarding state physician health programs. Journal of Addiction Medicine, 6(4), pp.243-246.

Boyd, J.W., 2015. Deciding whether to refer a colleague to a physician health program. AMA Journal of Ethics, 17(10), pp.888-893.

Lawson, N.D. and Boyd, J.W., 2018. Flaws in the Methods and Reporting of Physician Health Program Outcome Studies. General hospital psychiatry, 54, pp.65-66.

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