Arthur L. Caplan, PhD: This is Art Caplan from the NYU Langone Medical Center, where I direct the Division of Medical Ethics. Welcome to this edition of Both Sides Now. Today we are going to take a look at a controversial issue that evokes strong feelings from physicians, both pro and con: Should random drug testing be mandatory for physicians as it is now for airplane pilots and many other licensed professionals who are responsible for people's lives and safety?
Clearly, doctors who practice under the influence of drugs or alcohol risk endangering their patients, but how widespread is this problem and is testing the answer? There has been quite a bit of talk about this issue, particularly since 2014 when Proposition 46 appeared on the California ballot. One item in that initiative would have required drug and alcohol testing of doctors and the reporting of positive tests to the California Medical Board. The proposition was defeated, but the debate goes on.
The subject is likely to arise again. Between 10% and 15% of US physicians suffer from a substance use disorder. That is a rate slightly higher than of the rate in the US population as a whole. In Medscape's 2016 Ethics Survey of more than 7500 physicians, 41% said yes, —physicians should be tested; but 42% said no and 18% said it depends. But the practice of random testing of employees is growing in acceptance. According to a 2011 survey by the Society for Human Resource Management, 47% of employers of all sizes indicated that they would conduct random testing, compared with 39% in 2006.
Joining me now to talk about these divisive issues are Dr Cheryl Karcher, a board-certified dermatologist and expert on aesthetic medicine; and Dr Craig Klugman, a bioethicist and medical anthropologist at DePaul University in Chicago. Welcome to both of you.
The Upside and the Downside to Random Testing
Dr Caplan: Let me go right to the immediate question. Cheryl, why do you think drug testing is important? Why should we randomly test doctors?
Dr Karcher: First, as a deterrent. Second, because I believe that many more physicians and nurses are addicted than we would ever know, which leads to the third reason: for public safety. And fourth, to make sure the physician gets help.
Dr Caplan: Do you think there are some folks who do not even know that they might have a problem?
Dr Karcher: Yes. Addiction can start light and easy but quickly develop into a bad problem. There are a lot of people who are probably well on their way to addiction but do not know that they are.
Dr Caplan: Craig, what is the downside here? Why should we think harder about random testing?
Dr Klugman: The downside is that the tests are not very accurate, random testing is a huge violation of privacy, and we do not have any very good studies that show that random testing makes a difference, that it actually does deter the addict or that it actually protects patients' lives.
Dr Caplan: Cheryl, some people say, "Wait a minute—we do not have to randomly test everyone." After all, if a pathologist or an administrator is not directly caring for patients... Maybe we should highlight certain specialties that have more availability of drugs to abuse or physicians who are involved in direct clinical care. I am thinking of anesthesiologists, for example. Would that make more sense?
Dr Karcher: All of this makes sense, and I agree with Dr Klugman's points as well. The problem is, it would be very difficult to randomly test everyone in the hospital who is involved in direct patient care. I don't think it would work.
Dr Caplan: Why do you think it would be so difficult to test the specialties as opposed to just testing everyone? It might be cheaper.
Dr Karcher: That is one possibility. But this is a very deep, complicated issue. Compared with other physicians, anesthesiologists have a 2.5 times greater probability of becoming addicted[4,5] because of access. If we were to test everyone—all of the healthcare providers, physicians, and nurses—it would be too draconian. Physicians would not want to work at a hospital that tests everyone. They would be afraid of testing positive, not to mention that a lot of the drugs being abused are not even on the drug panel. It is a tough issue.
Dr Caplan: On the other hand, a lot of folks in a number of fields are routinely tested: pilots, train engineers, bus drivers, and big-city subway conductors. Are they freaking out about their privacy?
Is Testing Even Reliable?
Dr Klugman: In some circumstances they are. What we know is that an expectation of testing does not necessarily deter people as much as it helps them to get really creative. They figure out how many days they have to wait between using and getting the test. There are websites where you can buy urine or get chemicals that are supposed to help you pass the drug through your system faster.
Dr Caplan: We saw some of this with Olympic athletes—the Russian doping scandal, when male athletes were showing up with female urine. I know that in the National Football League, players have devised all kinds of ways to smuggle in urine from someone else and have a catheter device on the side so it looks like it's the player's sample. What about that? Is it actually impossible to test reliably?
Dr Karcher: Obviously it is not easy or it would have been implemented. As Dr Klugman said, we can be very creative. I know this personally from friends who have done this. I think that perhaps this is what New York State is trying to do—not having the hospital or the physicians implement screening, but when there is suspicious behavior or abnormal behavior, then implement testing.
Dr Caplan: They want some indication that there might be a problem, a report from someone else— that kind of trigger?
Dr Karcher: That also will have its critics because, what are you going to do—spy on someone and go after them all day long? It is a really difficult subject.
Dr Caplan: In your own case, when you were tempted and fell into drug abuse, how did you get a handle on it? Was it testing? Was it people saying that something was off? What was going on with you?
Dr Karcher: No one sets out to be an addict, particularly physicians who have worked so hard. They do not wake up one day and say, "I think I am going to pop some Percocet and become addicted" or "I am going to shoot up some fentanyl." They are often self-medicating and they become addicted.
Dr Caplan: Craig, what about the claim of the harms done? Let's look at this from the patient's point of view for a second. I do not want to be operated on by someone who has a drug abuse problem. I worry that this surgeon is not thinking straight, or that the surgeon is only thinking about "How do I get out of here so I can get my next whatever-it-is that I need." We are spending a lot of time in healthcare saying that we have to be safer, we want to get rid of errors, and we want to beef up handwashing. Is this not a safety issue?
Dr Klugman: We tend to test people who are involved in professions that have public safety in their hands—pilots and the military. There is no doubt that we do not want physicians who are actively high to be treating patients. But there are challenges with physicians. We are not sure that testing is the most effective way to prevent that from happening and whether it really makes a difference.
Dr Caplan: Somewhere between 1% and 15%[1,4] of physicians have some kind of problem going on. Do you believe that this is a tip-of-the-iceberg problem, just from your own experience?
Dr Karcher: I take part in a 12-step meeting for physicians. Maybe we will have eight or 10 people participating, out of all the hospitals in New York City. I know that physicians in certain fields get help quicker than others. Anesthesiologists get help because they are found passed out on the floor. Psychiatrists get help because maybe they have a little bit more insight. I do not know the statistics, but we have a lot of psychiatrists and anesthesiologists at the meeting. Do you think a surgeon is going to say, "I have a problem with alcohol; can you help me?" No, no. It is too risky for them.
Dr Caplan: It is a career-ender.
Dr Karcher: It is a career-ender. I do not know the answer for this. It is very possible as well that drug testing may not help. I don't know that anyone knows. I think that Mass General tests their anesthesiologists.
Dr Caplan: I think Mayo does, too.
Dr Karcher: And Cleveland Clinic tests their anesthesiologists. I personally do not know how that is going or what the answer is. But I have a lot of personal experience with physicians with issues, physician-addicts who are in recovery. What I do not have experience with are the physicians who do not get help. I only see the physicians who are getting help.
Must Substance Use Be a Career-Ender?
Dr. Klugman: The problem with the random testing, or even just testing people in very specific disciplines, is that we are making an assumption that everyone is a criminal, that they have done something wrong. That includes an assumption that drug use in itself is wrong, which we can spend another hour arguing.
Dr Caplan: If it is my surgeon, it is wrong.
Dr Klugman: Yes. Many states have physician health programs where, if you self-identify and tell the medical board that you have a problem, then they will provide you with counseling, a 12-step program, and mentoring. They will see you through this and help you recover, and it does not affect your license. If you are a surgeon and you self-identify, it is not a career-ender. In fact, if you admit it and ask for help, you save your career and hopefully save a patient's life because you will not be operating impaired. As Cheryl said, it is the people who do not self-identify.
Dr Karcher: That is a very, very good point. New York State has a great physician health program. The problem, as I see it, is that the stigma is so high. I did not report myself to our Committee for Physician Health. I did not self-identify because I was ashamed and I did not want to lose my practice or get involved in lawsuits. I did not know what was going to happen. I did not know whether they were going to say, "Here is this doctor who has been doing Percocet" and then contact the medical board, which would take my license away. I was so afraid that I went to lawyers who said, "Do not self-report."
Dr Caplan: Do you think physicians overprescribe addictive drugs to one another? We hear about the oxycodone problems and misuse of opioid-type drugs in the general population. Are physicians doing the same thing to one another?
Dr Karcher: Certainly not anymore, because the hammer has come down and there is this big computer in the sky to keep an eye on prescribing. It is so funny and also sad: I was at dinner the other night, and I overheard someone talking about her sister who came home crying because the physician would not give her any more pain pills for her back, and she was devastated. That is horrible.
Not everyone who takes Percocet is going to become addicted. Most people who take Percocet need it for pain. This is why I consider this such a complex issue. It is a travesty in my eyes that people are not being treated for pain because of something that someone like me or others have done. I am very sorry about that. People should have pain medication for their pain.
Dr Caplan: Craig, if a doctor has a bad back and perhaps is in a state where medical marijuana is legal or recreational marijuana is legal, and they use it for pain, are we going to come after them?
Dr Klugman: We are. If you are in a state that has legal medical marijuana and you have a condition that qualifies you to take it, it is still against federal law. The hospitals still do not allow it. If you show up to your clinic and you had been taking physician-prescribed or recommended medical marijuana, you could still be fired for being on an illicit substance.
Part of the issue is that we are taking a sweeping view of people who are using drugs during one part of their lives. Maybe you should be able to have medical marijuana after you are finished with your clinic for the day, knowing that you will no longer be high by the time you start seeing patients in the morning, or take your Percocet knowing that it will wear off by then. We need to look at this narrow piece of how it is affecting patient care. Is it a moral issue that is about character and "no one should be doing this," or do we simply not want people using while on the job? I believe that this is an important distinction.
Will Testing Reduce Harm?
Dr Caplan: Yes. There are issues around professionalism, but I believe that for most patients and peers in medicine, it is job performance. They worry about harm, they worry about what is going to happen to patients.
As I look at this challenge of tests that are not perfect, stigma, varying attitudes state to state about what drug is okay, what drug is not okay, I would like both of you to tell me whether, even if we did have testing, would we achieve reduction in harm? That is the goal, correct? Do we know that the programs we have work? You mentioned the sobriety success rates, but do the programs work? Do we have a lot of recidivism? Craig, what is your thought?
Dr Klugman: We have had some social experiments on this in other areas. Several states—Michigan and Utah, for example—have had mandatory random drug testing for people who have received public assistance. In 2014, Michigan tested 443 people who were receiving welfare and were suspected of drug abuse. They did not test everyone—only the people they suspected were on drugs. None of them tested positive. Utah screened and tested all welfare recipients. It cost them $30,000. They found 12 people positive for drugs.
There is a cost-benefit analysis that I think we need to consider. When we are looking at these populations in which we have done this blanket screening or even screening of populations that are suspected of using drugs, it has not improved safety and it has not suddenly led to people going out to get assistance in dealing with their problems. It has not done any of the things that we say this should do.
Dr Caplan: Cheryl, listening to Craig, those are heavy-duty efforts for low yields, but you often sit in a room with people who want help or know that you have struggled and beaten back addiction. If testing actually worked, if random testing did pick up a lot of folks who may not have recognized that they are getting into trouble, do we have enough resources to effectively help these people? What is your confidence level that we can help?
Dr Karcher: Physicians have access to drugs. That is what makes this a little different. Physicians have access to the whole pharmacopeia. In order to get help, I believe that a physician will only listen to another physician and an addict will only listen to another addict. I believe that you need a physician-addict to talk to another physician-addict.
Dr Caplan: Do we have that kind of expertise out there?
Dr Karcher: I would not say that we have expertise. We do have addiction psychiatrists now. And with the Internet, there is a whole international society of doctors who are in recovery.
But this is what I know: I do not want my surgeon to have any blood level of alcohol; I do not want my surgeon to have any level of opiates. Do you know how many physicians I have heard say, "I was a rock star when I was using"? They do not know that they are affected; they think they are rock stars. You cannot ask them whether they have an issue because they think they are great.
Dr Klugman: I would say yes—putting an emphasis on changing the culture, reducing the stigma, encouraging people to be more open about this, having more programs like the state physician health programs and support groups is definitely a great way to go. This avoids the stigma and treating everyone as if they are criminals.
Also consider that 5%-10% of drug tests are false positives and 10%-15% are false negatives. Someone could be using, and 15% of the time we will not know it because it will come up as a false negative. Also, in that 100 people, 10 who are not using will come up positive. Given the repercussions, the stigma, and the potential licensing issues, do we really want to subject people who have done nothing to that sort of situation?
Dr Caplan: This has been a great discussion. I have learned quite a bit from both of you about the complexity of this problem. What would you tell the person who says, "I think I have a problem"?
Dr Karcher: I would say that if you think you have a problem, you probably do. People who do not have problems do not think they have problems. Then, in the softest, gentlest, most loving way, I would say, "There are Caduceus meetings." The Caduceus meeting is a 12-step recovery meeting for physicians. The physician will say, "I do not want anyone to know." This is how I felt. I did not want anyone to know, but the fact is, in this meeting you are sitting with people who have exactly the same issue as you. If the person does not want to go to a Caduceus meeting, I would say, "Just try to stop drinking for 90 days and see what happens. See if you can."
Dr Caplan: When I started our discussion today, I was thinking, sure, random testing—why not? Let's begin tomorrow morning. But it is more complicated. It involves test accuracy, stigma, what is the most effective way, is it a deterrent? There are a lot of unknowns.
The issue deserves much more thought. I hope we have given our audience some tools and some things to think about through your excellent discussion and comments. Let me thank you both for being on Both Sides Now. I am Art Caplan.
Talking Points: Should Physicians Be Subject to Random Drug Testing?
Issues to consider:
Massachusetts General Hospital implemented a random drug-testing requirement for anesthesiology residents in 2004. A decade later, there were almost no residents who tested positive.
In 2010, a study showed that 17% of 2000 physicians surveyed said they personally knew an impaired or incompetent physician in the prior 3 years. Only 67% of the physicians who knew of a colleague's problems reported that person.
A 2008 study showed that only 65% of physicians who were in a drug treatment program for 5 years remained free of substance abuse.
Substance-induced mortality, including suicide, is higher among anesthesiologists.
An argument often cited against testing doctors is that it violates their civil liberties.
Many healthcare professionals worry that flawed testing may result in false positives, and doctors will be considered guilty, without proof.
California has had a Physician Diversion Program since January 1, 1980, treating physicians and surgeons so they may return to practice without endangering public health and safety.
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Cite this: Arthur L. Caplan, Cheryl Karcher, Craig M. Klugman. Should Physicians Be Subject to Random Drug Testing? - Medscape - Feb 28, 2017.