I was a staunch supporter of PHPs for physicians facing depression until 2016. See my 2006 EPM article "PHPs are in Your Corner" which was written after many Emergency Physicians responded to a survey I published in EPM (after a story I wrote about suicide prevention) that they would rather die than face the consequences of reporting to their MLB (medical licensure board). At the time, I felt I urgently needed to educate readers about a safer alternative.
Ten years later, EPM repeated the survey and results showed that not a lot had changed. Emergency Physicians still felt threatened by MLBs and now also have grave concerns about PHPs. My May 2016 article "PHPs: Still in Our Corner?" reflected my growing doubts and somewhat tempered advice about when and how to approach PHPs (VERY cautiously).
A 2017 study I coauthored with Katherine Gold MD confirmed that emergency physicians are not the only specialty concerned about reporting a mental illness to an MLB/PHP. While almost half of the surveyed physicians (all mothers) felt that they had suffered a mental illness at some time, only 6% had disclosed to an MLB. The reason? Dire consequences suffered by those they knew who had, some of them involving only the Boards (intrusive questioning, records production) and some involving PHPs ($1K evaluations taking place in coffee shops, monitoring requirements).
I have served for many years as a counselor to physicians both as chair of the Personal and Professional WellBeing Committee of ACEP and as the founder and principal of MDMentor.com, which deals with litigation stress and more recently also regulatory board stress. Because of a number of reports I have received from individuals with mental illness being diagnosed with substance abuse when diagnostic criteria are not met, it appears to me that currently the typical PHP philosophy, and many of their operating policies, may increasingly be influenced by things (such as the inducements of the $34B drug treatment industry) other than pure advocacy for their potential "deep pocket" physician patients. While I remain hopeful, at this time I urge you to read this section in its entirety, and consult knowledgeable colleagues in your state and consider engaging an attorney before making any decisions about engaging with a PHP.
Don't believe, as many do, that PHPs exist first and foremost to help you.
Here is a frightening recent case explaining why such caution may be advisable. This physician with a longstanding and stable history of treated depression was nearly railroaded into drug treatment by a PHP that is poorly managed and unsupervised by its MLB. Many other articles have appeared, confirming my fears. The only literature I have found that roundly supports PHPs seems to have been written by those from within the industry.
The BMJ on July 1 2016 published "Physician Health Programs Under Fire" by investigative journalist Jeanne Lenzer. The article asks disturbing questions about significant potential conflicts of interest emerging from some of these programs.
47 states and all Canadian provinces maintain some form of Physician Health Program (PHP). Suicide prevention is an avowed goal of PHPs. There have, however, been a number of suicides reported of physicians mandated into "selected" longterm residential rehab programs by PHPs. According to substance abuse experts with no ties to the rehabilitation or drug testing industry, there is absolutely NO evidence based justification for the claim made by PHPs that physicians require three times longer than the general public, in inpatient rehabilitation programs frequently far removed from home and social supports, in order to be "recovered" from SUD. Experts and even PHP directors have admitted that physicians are far more likely to readily recover from substance use disorders than nonphysicians, because of their educational level, their motivation to continue in practice and to protect their reputations. Such prolonged inpatient hospitalizations are almost certainly motivated by the deep pockets of physician clients, something that has been admitted under oath by one former PHP director.
Nor is there any scientific justification for the almost invariable requirement of five years of substance use monitoring following PHP enrolment of physicians for most conditions, even those that do not involve a diagnosis of substance use. A single 2008 study of PHP participants that was never subjected to rigorous statistical analysis, has been endlessly recycled, and its dataset mined for at least a dozen articles purportedly justifying the need for intensive and prolonged treatment and monitoring for physicians. Given the grossly deficient statistical analysis, and that the original study was sponsored by an individual who has profited for decades from drug testing and treatment programs, there can be little credence given to claims that this paradigm or blueprint is other than financially motivated.
The almost invariable pattern of referrals and monitoring being reported to me as promulgated by PHPs is worrisome. Especially since I have personally observed the fact that "selected" rehabilitation facilities that require cash up front from physician patients often sponsor retreats, receptions, dinners, and other inducements to PHPs individually or via the Federation of State Physician Health Programs. The NC auditor described this and other types of financial agreements between PHPs and "selected" facilities as representative of prohibited business arrangements.
Physician Health Programs have a variety of types of relationships with state licensing agencies. Some information about the existing relationships can be found here.
Most programs allow for self reporting of illness or suspected impairment by practitioners of medicine or by concerned colleagues or others (including anonymous complainants). If and only if no complaints or licensure actions have been initiated concerning a physician, the physician can in most states voluntarily enter into a confidential relationship with a PHP to secure evaluation and treatment for any impairment. However (and this is critically important to understand), in most if not all programs, such confidentiality can be broken and reports made to the MLB if the physician does not comply, in every respect, with any and all demands made by the PHP. Even if the demands are unreasonable, as for example requiring participation in AA meetings by individuals who have never had a criterion based diagnosis of alcoholism.
The Daily Beast on
March 23, 2015 featured a poignant article by Gabrielle Glaser telling the
story of Gregory Miday, a gifted young physician with an affective disorder and
substance use disorder, who completed suicide in the face of a relapse and
threats of punitive action by his PHP. The article is one of the few that
talks about the role of PHP's and their nearly exclusive adherence to a 12 Step
recovery model that is ill suited to the intellectual capacities of many
physicians, including apparently this young physician.
Medscape on August 19 2015 published a disturbing story by Pauline Anderson entitled Physician Health Programs: More Harm Than Good? which elaborates on some of the troubling issues hinted at in the Glaser article. It is well worth a read, as is the rebuttal from the FSPHP by current president Doris Gunderson, another by the ASAM (which organization was the progenitor for the FSPHP), and all the comments relating to these, many from physicians who have been through the PHP process.
The audit of the NC PHP that is referred to in the Anderson article and re-interpreted by Gunderson and others speaking for FSPHP/ASAM can be found here.
A subsequent video by Pamela Wible on Kevin MD asks whether PHPs could actually be responsible for some physician suicides, due to pressure on ill physicians to conform to faith based healing (12 Step programs) aimed at substance use disordered persons, which participation is mandated on order of most PHP's and must be undertaken ONLY at certain "selected" (based on unspecified criteria), expensive, inpatient rehab centers. Since there are only a few of these, for many physicians such mandatory hospitalization means travel, isolation from family and friends, and treatment in a state whose mental health laws may vary from their own. There are many, many reports of long-term (90 day) inpatient drug rehabilitation mandates being deemed by the PHPs to be absolutely necessary for physicians (when normal patients are "recovered" in only twenty eight days, or when their insurance runs out).
There are also reports that such referrals for mandatory inpatient treatment may be made by non-physicians (under the imprimatur of PHP directors who are usually--- but not always--- even physicians), sometimes without any medical examination being performed, without criteria being met for diagnoses justifying admission, or without even reasonable verification that there is in fact a currently impairing condition.
For example, physicians referred for a comprehensive 4 day evaluation ostensibly to determine the need for further treatment (when calling the facility to determine anticipated time of discharge on the fourth day or the type of clothing to bring) have reported that they have been told by rehab facility staff, that "ALL of our physicians stay 90 days".
Even more disturbing are verified reports that NON-physicians working for certain PHPs are countermanding the orders of personal physicians (with ongoing patient-physician relationships) for their physician clients for legally prescribed and sometimes life saving medications. The rationalization is that such medications as sleep apnea or asthma medications might interfere with PHP ordered drug testing. This disturbing pattern is also being seen in medical students who have been on ADHD medications since childhood.
Refusal to cooperate with such an illegitimate demand made by a non-physician (countermanding legitimate orders issued by a physician's personal physician) is then deemed, and subsequently reported to the MLB, as "substantial noncompliance with the terms and conditions of the PHP contract", and could result in discipline by the MLB.
It is also reported in legal documents from NC and MI that physicians are being told that their PHP-generated medical records and the credentials of the persons creating such records are not accessible by the physician who is the patient. This does not seem to be defensible. While all states guarantee the rights of patients to obtain records relating to their own medical care, several state PHPs claim that the evaluations they are conducting on physicians to determine the need for referral for treatment are not medical care, but rather "peer review". And then, incredulously (and flying in the face of both federal and state laws regarding peer review) that such records are still not available to the physician ostensibly undergoing "peer review".
At the suggestion of the state auditor, NC has revised its law referencing "peer review" in the context of the physician health program. It is not clear what NC is now calling the "evaluation" process which takes place in the offices of the PHP, under the auspices of the Clinical Director (currently a licensed professional counselor, NOT a physician), which process can result in a diagnosis that can lead to institutionalization. However, the hastily passed and poorly drafted law now offers immunity to PHP staff for such diagnostic evaluations that are performed "in good faith", without defining "good faith". The concept of "good faith in the practice of medicine" has never been legally defined anywhere, as it is always assumed to be the case. Ordinarily, good faith means that something is entered into with the intention to be fair, open and honest. Not divulging the results of an evaluation that can result in deprivation of liberty could never be considered fair, open, nor honest, and thus by definition any such practice is not being performed "in good faith".
Interestingly, the NCPHP is licensed and claims to be a nonprofit charitable educational organization. It is NOT a medical practice registered and licensed with the Medical Board, as would be required by the state Medical Practice Act, and state corporations law, in order for it to legally perform diagnostic activities of any kind.
Even if this unspecified "evaluation" is a sort of triage, if the person authorizing or performing the evaluation is or holds himself out to be a physician (which requires only the use of the designation "doctor" and undertaking to diagnose or treat in any way), it is, under NC law, the practice of medicine. If the evaluator is a psychologist, it is the practice of psychology. If the psychologist does not specify his or her doctoral credentials as being in psychology, but demands a change in a patient's medications, this is clearly the unauthorized practice of medicine, by a psychologist. There are verified reports that this is what is happening in North Carolina.
There should be accountability in negligence law, and also by the respective licensure boards, for any activity taking place in a PHP that involves assessing for, or making a diagnosis that can or does result in treatment decisions. Such accountability not seem to exist in NC, and probably in any other states that follow this model of management by a non-physician.
The disturbing Kevin
MD and subsequent videos by Pamela Wible, and feedback from readers seem to
corroborate the reports of some of the respondents to the Medscape
articles. The entire truth about PHPs is just beginning to emerge, and it
is quite difficult to know how to advise. There are substantial
state-to-state variabilities that may make a significant difference.
Medscape also has published an article by Sandra Levy "Why Do Depressed Doctors Suffer in Silence?" 6/26/17 based on reader response to a prior article, "Doctors and Depression: Suffering in Silence" by Pamela Wible. Wible's article was based on a survey of over 200 physicians who explained how they dealt with depression (not well). The responses to both articles were disturbing, and telling. Doctors do not reach out, because they (rather rationally it seems) fear regulatory consequences. Many such consequences, some dire, are detailed by physicians responding to the survey and to both articles, as well as to the Gold article.
I encourage anyone with experience with a PHP (positive or negative) to contact us so that we can continue to develop a clearer picture of what is currently happening in the PHP arena.
See also References page for useful new articles pertaining to this issue.
Emergency Medicine News published a piece entitled "Physician Health Programs: Coercive or Supportive?" in February 2016. The article unfortunately contained many questionable statements quoted from individuals, such as the authors of the original study on treatment of physicians, who benefit directly from profits generated by PHPs. My lengthy response citing the numerous half-truths and serious unacknowledged conflicts of interest by contributors to the article was rejected for space reasons, but a shorter letter entitled "The Truth about PHPs" was published in April. Suffice it to say that much education is needed to understand this complex issue, and those who have not studied it extensively should not ignore the advice of those who have.
J. Wesley Boyd, former director of the PHP in Massachusetts, published a thought provoking article in the AMA's Journal of Ethics Volume 17, Number 10: 885-1005 on October 1, 2015. Entitled "Deciding whether to Refer a Colleague to a PHP", this quite balanced article gave some very useful information about the ethics to be considered by anyone when making such a critically important decision. The article is open source, and can be found here.
A Philip Candiliss, who rather disingenuously did not identify himself as a former associate Director of a PHP, responded by a LTE (taking issue with the Boyd article) in January of 2016 in the same journal, claiming that Boyd (a former associate Director of the very same PHP, and therefore in all likelihood a professional colleague if not a co-worker) did not understand the "social contract" which, according to Candiliss, requires that PHPs function as they do. Candiliss asserted that "there is as yet no evidence that PHPs have a financial incentive to refer physicians to treatment programs" , which is a very strange way of arguing that no such financial incentives exist. Indeed, such potential conflict was strongly suggested in the NC PHP audit. To me Candiliss' claim is specious. Every statement in the audit is backed up by the auditor, every conclusion is straightforward, and the report reflects a careful year long investigation. Similar audits of PHPs are being undertaken or contemplated in several states, including Massachusetts and Nevada.
The North Carolina audit was quite extensive, well researched and referenced, and revealed the great potential for conflict of interest inherent in the system as it currently functions. The state auditor, Beth Wood, is well known to "pull no punches". And an auditor is beholden to no one. The NC Medical Society lobbied to change the state statutes in response to some of the audit's most notable revelations, such as the claim that PHP physician evaluations constitute "peer review" and thus are not subject to scrutiny by the individual physicians being "peer reviewed" by the PHP. The medical director, a psychologist counselor, is decidedly NOT a peer of physicians and thereby has no right to perform peer review of any physician. The audit had suggested that state laws should be expeditiously revised so as to provide more meaningful oversight of the PHP by the Medical Board.
However, the resulting legislation did not even address this issue, and both the attorney general and the NC governor’s office has tacitly admitted that no oversight is occurring even now.
In the AMA Journal of Ethics LTE detailed above, Candiliss argues that due process available during review by hospitals and other credentialling agencies such as medical boards is all that is required by a physician who is undergoing a PHP evaluation, and if that is not sufficient, then suing the PHP is always an option. He neglects to mention (as surely he cannot be ignorant of the fact) that PHPs typically are granted "state action immunity" from suit based on the (questionable, according to the NC audit) assumption that they are supervised by a state agency, the medical licensure board. Attorneys typically demand substantial retainers to take on such complicated regulatory cases. Many physicians who have paid $4-5,000 for evaluations mandated by a PHP and up to $150,000 for unnecessarily lengthy inpatient treatment do not have the financial ability to retain counsel in order to obtain due process, which due process should of course have been their right ab initio.
Candiliss also baldly asserts that physicians are not vulnerable populations (conveniently obfuscating the fact that physicians whose licenses are under threat are among the most vulnerable of all physicians), and therefore that any research that is conducted on them under the auspices of a PHP is not unethical. Participants have shared with me that a physician who answers "I have not recovered" when queried by a PHP about status in any unblinded "research study" knows that s/he will automatically be sentenced to more years of monitoring. I am told that often the PHP monitors will stand by observing as the data is being entered by the physician client into the ostensibly "voluntary survey". Candiliss also neglects to mention (or is unaware) that any research conducted on ANY population requires fully informed and voluntary consent under the Nurenberg code, well settled international law, and the Belmont report, codified in US law.
Boyd also created several audio seminars on QuantiaMD addressing this topic, which have evoked numerous comments that are well worth reading. To participate, you must join www.QuantiaMD, which is a free source of useful information and learning, viewed by about 25,000 physicians. His articles on Ethical Issues involving PHPs and Ethical Considerations regarding reporting a Colleague to a PHP are detailed on his website. These and most of the responses of his readers are chilling.
Some of the potential conflicts of interest inherent in recent PHP policies are also detailed in a presentation by Susan T. Haney MD which was given at the Organization of State Medical Association Presidents at the AMA in 2011. Not much has changed in the interim.
At present we don't know any safer alternatives for physicians to manage significant mental health issues than using physician health programs. Many physicians attribute their very survival to the intervention of a PHP, particularly in situations involving actual substance use disorders. Others feel decidedly differently, that their lives and careers have been ended by unfair and heavy handed tactics, undertaken in the name of patient safety but with far less lofty motives. And there have been well documented suicides of despairing physicians who have felt that their lives and futures were destroyed by the heavy handed tactics of regulatory agencies such as these.
It seems critical at this point in time for physicians with pure mental health issues (no significant substance use or illicit abuse whatsoever) to ABSOLUTELY resist any attempts to frame their disease process as having any related substance use issues. It is strongly advisable to engage legal counsel whenever approached regarding or and BEFORE being mandated into evaluation OR treatment by a PHP. And given the reported speed with which mandated interventions can occur, hiring knowledgeable counsel should probably be done prior to any interaction whatsoever (even a "friendly discussion") with the PHP.
When a physician entering into a PHP is required (as all will be) to submit to drug abuse testing, a physician should insist on witnessed, split samples, and pay to have them simultaneously analyzed in a different forensic lab, insisting on maintenance of chain of custody. This will require a bit of forethought, and representation by an attorney experienced in employment and discrimination law who can help to locate the required labs and procedures.
Steven H Miles, an acclaimed medical ethicist, was targeted by his MLB in 1998 while faculty after revealing to a class of medical students (who had recently lost a colleague to suicide), his own struggles with depression. His JAMA Piece of my Mind is poignant. Miles made a complaint of discrimination under the ADA to the Department of Justice without a lawyer, received a supportive opinion letter, and the MN licensure board (after ignoring the first letter) responded to a second by giving up its quest to demand Miles produce his psychiatric records and put Miles in longterm monitoring by the PHP. Miles' followup article from Minnesota Medicine is very difficult to find, but it tells the story of his wise and courageous battle with the state. Psychiatry News also covered the story. Many would do well to follow his example. Miles' story also appears as a case discussion on Medscape at http://bit.ly/SHMilesconsult
MN has prepared an extensive report on its PHP.
As of 2018, MI HPRP is the subject of a class action suit by healthcare providers alleging numerous due process and confidentiality violations.
The AMA Council on Science and Public Health published a report on Physician Health Programs in 2010. The AMA BOT is again considering the equitable treatment of physicians with alleged mental or physical health issues by MLBs.
AMA and the Federation of State Medical Boards have also revised model legislation regarding PHPs in the past several years.
The American College of Emergency Physicians (ACEP) has created Model
Medical Licensure Boards
It is impossible to discuss PHPs without mentioning the very close relationships they maintain with Medical Licensure Boards (MLB's). What you don't know about this relationship could really hurt you.
Some of the questions asked on many MLB applications are clearly impermissible forms of discrimination under the ADA (see Licensure Concerns), yet these continue to be asked, and honest answers can result in a referral to a PHP. See this case study (which is a verified personal account) as to what might happen.
Once a physician is enrolled in a PHP, any and all of their medical history can be revealed to the MLB on very tenuous grounds (such as the notorious "Level 1 Relapse"--- Behavior without chemical use that might suggest impending relapse), which may then make such private medical information public via their website in any disciplinary action. One state was at one time, reportedly enthusiastically tweeting disciplinary actions against physicians. Some are also known to monitor police blotters, for example swooping in on physicians named in minor fender benders in order to attempt to find disciplinary targets.
Clinical Psych News published a column by Dinah Merrill "What Stops Physicians from Getting Mental Health Care" in June 2017. The article explores various ways in which many MLBs discriminate against physicians who admit to a mental health diagnosis, the legal cases supporting the illegality of such discrimination under the ADA, and the AMA House of Delegates' recent effort to stop the practice. She also provides details about the Maryland programs, which do not discriminate.
North Carolina MLB has as of spring of 2017 changed its licensure renewal application questions so as to be in compliance with the ADA.
Some of the potential conflicts of interest between MLBs, PHPs and the drug treatment industry are detailed in a presentation by Susan T. Haney MD which was given at the Organization of State Medical Association Presidents at the AMA in 2011
For a frightening view of one way in which MLB investigations for NON health related issues can spill over into the health arena, see this and this posted on Medscape by an Emergency Physician. His transgression was to have settled a malpractice claim.
Medscape's Leigh Page has published an article (free subscription required) entitled the "Black Cloud of a Medical Licensure Board Investigation". The article is well researched and balanced, and the article as well as numerous comments by readers are enlightening. It is little wonder that so many physicians are unwilling to admit to known or suspected mental illness due to fears of professional, and particularly licensure consequences, as demonstrated in this 2016 article by Gold, myself and others.
Here is a 2015 article by Matt Freeman on a blog named "MedFly" that explains in great detail how MLB actions can affect the career and life of a physician. There are some inaccuracies in this posting, but a lot of it is true.
It is very clear that the effect of investigation by a licensing entity can be damaging emotionally, even to the point of suicide. Here is a frightening BMJ article by Bourne describing the phenomenon in the UK; it is no different in the US. Significant depression and anxiety, even to the point of suicide, and adverse effects on subsequent practice were experienced by most who had been recently investigated.
Here is an article written by a California attorney entitled "What to Do when the Licensing Board Comes Knocking". The advice is relevant to all Medical Boards although of course each will differ. Bottom Line: Do NOT go it alone, no matter how innocent you are. Your belief in the possibility of achieving justice in a fair system could potentially deprive you of your livelihood.
There is more information on MLBs in the section entitled Licensure Considerations and articles in References. Also, there is a Linked In Group (Physician Advocacy Exchange) with more information and resources. If you are a physician advocate, attorney or physician interested in these issues, please link with me on Linked In and ask to be admitted to the group.
I would welcome ALL comments and reactions to this article.
I am an observer, with no personal experience in the paradigms described other than as a licensee and counselor to some who have become enmeshed; however the sources referenced are deemed by me to be credible and, given my participation at both Federation of State Medical Boards and Federation of State Physician Health Program meetings, where I represented the American College of Emergency Physicians for many years as an observer, also to be plausible.