ASAM Responds to 'Physician Health Programs: More Harm Than Good?'
To the Editor:
We are writing on behalf of the American Society of Addiction Medicine (ASAM) regarding the Medscape 08/19/15 article "Physician Health Programs: More Harm than Good?" authored by Pauline Anderson. ASAM is a professional society representing more than 3,600 physicians and associated professionals dedicated to increasing access and improving the quality of addiction treatment. We have a robust body of policy statements supporting the role of physician health programs and an active Physician Health Committee, which includes current and past directors of state physician health programs (PHPs), as well as current past leadership of the Federation of State Physician Health Programs (FSPHP). ASAM believes this article does not fully represent the outstanding, professional, ethical and honest work done by our states' PHPs.
This recent Medscape article reviews the complaints of several individuals who, in one fashion or other, have become dismayed with their state Physician Health Program (PHP). The article reviews their allegations in some depth and goes on to discuss investigations of PHPs in Michigan and North Carolina, with emphasis on the latter. The article reviews concerns over lack of due process, out of state treatment requirements, cost of treatment, "expensive contracts," treatment center demands for payments, lack of PHP oversight, conflicts of interest, etc. All in all it presented a very disparaging view of state PHPs.
Physician Health Programs were created in the 1970s after an article featured the high numbers of suicides among Oregon physicians following licensure revocation for addictive illness. Both the AMA and the Federation of State Medical Boards (FSMB) called on individual states to develop programs to assist these physicians. Early PHP work involved addiction alone and later grew to include all psychiatric illness when PHPs identified significant psychiatric comorbidity among their addiction participants. Some PHPs with expertise and funding also assist with the "disruptive" or more accurately, the "distressed physician," typically a physician in need of interpersonal coaching to improve communication. Others assist physicians who have engaged in sexual boundary violations and for whom there is an underlying, untreated psychiatric disorder at play.
The author failed to note the national study of PHPs called project Blue Print. This study revealed that nationally, PHP participants demonstrate a 78% success in recovery without relapse at an average of 7.2 years of monitoring. If we consider those who suffer a brief relapse and then enjoy success, that number exceeds 90%. The only other organization that shows that level of effectiveness is the airline industry, which, like medicine, employs safety sensitive professionals. These organizations have raised the bar for those treating addictive illness around the country. Is there a reason the author failed to even mention this?
The author communicates that those involved in a PHP have no due process. This is a mischaracterization. Before PHPs, physicians with these illnesses dealt directly with their state medical boards and were often disciplined merely for being ill. The PHPs have, in effect, been allowed to serve as a "buffer" to this system. The PHP offers the physician with potentially impairing illness an opportunity for a multidisciplinary evaluation at a choice of nationally recognized facilities. If treatment is indicated, they are given options for centers equipped to provide treatment. If they disagree with the evaluation, they are given the option of a second opinion evaluation. The PHP itself, with one exception, does not independently diagnose or treat. At any time — from the initial contact with the PHP and thereafter — the physician has the right to present their case directly to the state Medical Board. If they are being mistreated or unfairly diagnosed, they have complete due process with their Medical Board. PHPs do not exist to judge "guilt and innocence" or to determine what medical practice act statutes were violated. They exist to provide assistance and support to a physician who is ill and to support that physician's restoration to wellness and a safe return to practice.
One of the author's sources highlighted the North Carolina Audit — an exhaustive investigation. The Audit reviewed the NC program from stem to stern, including the details of over 100 cases. Their findings were released in April 14, 2015. There were NO instances of abuse by the program, misappropriations of funds or conflicts of interest identified by two subject experts employed by the State and independent of the PHP. The auditor made recommendations which the program has since instituted to protect itself and protect against even the appearance of impropriety. That's it. To me, that feels pretty close to exoneration.
The author's sources allege PHPs can be heavy-handed or demanding, "forcing" doctors into expensive out of state treatments, requiring "expensive" contracts and the like. If you are a physician with addictive illness characterized by denial of that illness due to fear and shame, the process of evaluation and the introduction to treatment, when indicated, can feel intimidating. When a physician is afflicted with a potentially impairing illness, the privilege to practice medicine may be lost, in the absence of restorative treatment. While Medical Boards employ discipline to protect the public, PHPs offer an alternative to discipline. Namely, PHPs support physicians by directing them to evaluators and treatment programs with the requisite expertise to care for professionals in safety sensitive employment. Physicians, when they are patients, should not expect to dictate where, when and how their treatment will take place. Self-diagnosis and self-treatment is uniformly discouraged in the medical profession. However, physicians may pursue second opinion consultations, just as patients in the general population are encouraged to do.
Once successfully treated, the physician engages in a contract with the PHP which entails careful monitoring of the health condition and accountability. In turn, the PHP can confidently advocate for the physician's return to practice before their regulatory board, hospital credentialing bodies, malpractice carriers and others. Is it too much to ask that a physician recovering from illness be accountable to a PHP and in doing so, obviate the Medical Board's need to discipline? If a doctor is going to take my daughter to surgery, I would appreciate the assurance that the doctor is safe to do so.
PHPs are highly effective. Were it otherwise, they would have ceased to exist years ago. Are they accountable? They are held to account every day by their state medical boards and professional associations, their state hospitals and the partners of every doctor they work with. A single incident of patient harm by a PHP-monitored doctor would result in public outrage, and in all likelihood fuel one-sided, misleading articles like that produced by Ms. Anderson. There would be tremendous pressure on the medical boards to abandon the PHP model and start revoking licensure. That could easily happen. It would take us back to the licensure revocations observed in the 1970s, destroying the careers of physicians and denying the public access to an important resource, particularly at a time we are encountering physician shortages.
We submit, you will find no group of professionals in the country who have done more for physicians with potentially impairing illness than the state PHPs who comprise the FSPHP. They devote their careers to the task of assisting colleagues who, without their help, would certainly no longer be practicing medicine and in many instances would be dead of their disease. They are most often led by professionals who are devoted to helping those colleagues who are suffering and at risk for suicide. Day after day, they man the gate of help and hope and do all they can for the doctors who need them while fending off detractors, including organizations in favor of abolishing PHPs and shaming ill physicians through public discipline. In my view, the loss of PHPs and the safety they provide to physicians in crisis would do "More Harm than Good." PHPs exist because they work. For every doctor the author interviewed to disparage their work, there are thousands who would attest to the benefit derived from their involvement with a PHP.
ASAM believes this article was not representative of the outstanding, professional, ethical and honest work done by our states PHPs. We, and all our patients, are fortunate to have them. Their success rate with complicated illnesses raises the bar for our entire field. They remind us that such success in treating these illnesses should not be the exception — it should be our expectation for all our patients.
R. Jeffrey Goldsmith, MD, DLFAPA, FASAM
President, American Society of Addiction Medicine
Gary D. Carr, MD FAAFP, FASAM, DABAM
Chair, ASAM Physician Health Committee