(MedEd)itorial: The Dark Side of Physician Health Programs
- Jan 31, 2017
I have a lot of great memories in my life graduating medical school, marrying the girl of my dreams, going on my first trip to Hawaii. Sitting in a cold, windowless room waiting to meet with a representative from my state’s physician health program (PHP) for the first time is not one of them. Nothing about the experience is. Looking back, all I remember was thinking what did I do to end up here? Since starting my internship, I had worked hard for my residency program. I covered extra shifts when colleagues were out sick, spent countless hours outside of work teaching medical students, and provided each of my patients with the type of dedicated care that had won me several awards thus far. Now, my entire medical career was in jeopardy because of an overblown reaction to a bad joke.
As mentioned in a previous post, PHPs exist to assist physicians that are struggling with ailments such as depression or substance abuse. The goal of these programs is to provide the physician with a safe place to seek treatment, a path back into medicine, and a safeguard for the community against physicians unfit for duty. When a doctor is referred to their PHP, it begins a process that can include lengthy psychiatric evaluations, inpatient rehabilitation admission, and several years of mandatory drug testing. Physicians that comply with the program and successfully work through it are often reinstated for duty; those that refuse can either voluntarily leave the profession or risk having their licenses revoked by the state medical board.
So how did I end up there? During my second year of residency, I suffered a meniscal tear that ultimately required surgical intervention. Given that I worked in a high volume residency program, I was given one week total of vacation for my procedure. After that, it was “highly encouraged” that I make it back to my rotation as soon as possible. So, despite still suffering from significant postoperative pain, I returned to work on a busy inpatient service six days after undergoing surgery. As expected, I was in a lot of pain. And, as is my right, at night I would come home and take some of my prescribed pain medication. Still, being a paranoid doctor, I set rules for myself: no more than 2 pills total and no narcotics fewer than twelve hours before my next shift.
One day in the residents lounge, a co-resident asked how I was making it through these shifts so soon after my surgery. I jokingly replied, “well the pain medications make it pretty easy.”
Unfortunately, this quick, innocent joke between colleagues was overheard by the wrong person and soon enough, it went through our chief residents all the way to our program director. The very next day, I was sitting in her office being told that I would need to undergo evaluation by our state’s PHP in order to continue the residency. I thought the whole thing was a prank until she informed me that I’d meet with my appointed PHP representative the following day. I was in shock. I didn’t even tell my wife.
As nervous as I was in that waiting room, I kept telling myself this was just a misunderstanding that would be clarified soon enough. Unfortunately, I was very wrong. Almost immediately, the representative informed me that I was required to attend a five day, nearly $9,000 inpatient evaluation at either CEDAR or Talbott Recovery. The reasoning was, “we don’t feel comfortable enough to evaluate you because it would be too easy to lie.”
Additionally, they required me to submit a urine sample that day. Though of course my sample was clean, they listed all the ways I could have cheated the system it didn’t take long for me to figure out that their mentality was “my way or the highway” and that the deck was stacked against me.
Still, I wasn’t giving up. I suggested that I could be evaluated by an outpatient psychiatrist first or try to find a cheaper place for inpatient evaluation, but each idea got shot down. When I left the office saying there was no way I would submit to an inpatient evaluation and the possibility of a three-month inpatient treatment program, they responded that in all likelihood I was ending my medical career.
As the weeks went by, my program director pressured me to attend the inpatient evaluation and said that it was the only way I could keep my job. The PHP required ongoing random drug tests (sometimes as often as three times in a week), none of which I ever failed. Finally, they allowed me to be evaluated by an outpatient psychiatrist of their choosing but when that psychiatrist cleared me for work after two sessions, the PHP informed me they were not comfortable with her results and still required inpatient evaluation. At this point, I was spending upwards of $150 per week on drug tests, paying out of pocket for psychiatry sessions, and attending regular AA meetings. But nothing was good enough. They told me every physician breaks down and does it their way eventually. I decided to be the exception.
With the support of my parents and wife, I hired a lawyer and threatened to take my case as high as the state medical board. As expected, this quickly hit a roadblock when the PHP notified us they were not required to turn over my records to me, my attorney, or any other medical professionals that I would choose for an independent evaluation. They could drag this process out for over a year and, in the meantime, my program would be permitted to replace my position.
In the meantime, somehow my co-residents found out that my leave of absence was for substance abuse â€“ that they were working extra shifts for me because I refused to get the treatment I need. Still, I wouldn’t back down. I threatened going to the news and fighting my battle publicly. I threatened to sue for damages once I was vindicated. And finally, after enough threats, the PHP allowed a compromise.
Despite having never failed a drug test and having never been diagnosed with substance abuse, I agreed to a random drug monitoring program for the rest of my residency program, regular attendance at the PHP-sponsored Caduceus meetings, and quarterly evaluations by the PHP. For the remainder of my residency, I was forced to combat the stigma of being a physician with substance abuse disorder and was surrounded by colleagues that refused to give me the benefit of doubt.
It has taken me a very long time to come out with this story. The fact that I publish this anonymously shows how much I fear our PHP. What I can’t show is how this experience left me embarrassed, humiliated, and depressed for several months. I can’t show how fearful I am of an organization whose purpose is to provide treatment and support for physicians in need.
Substance abuse in the medical field is a serious issue. Drug and alcohol addiction affects physicians at a rate often significantly above the general population. It’s estimated that 10-12% of doctors will develop drug or alcohol abuse issues during their career. This problem is further complicated by a physician’s ease of access to certain pharmacologic agents and the fact that an impaired physician can cause serious harm â€“ or even death to the patients entrusting them with their medical care. Healing the physicians that tirelessly work to heal us must be a priority. But there must be a better system.
Sadly, mine is far from the only horror story. Even for physicians legitimately diagnosed with substance dependence or abuse, the process can be a nightmare. I came to learn that PHPs have very little oversight and are frequently described as being coercive, controlling, and deceitful. They have complex, ethically-fraught financial ties to the designated facilities that they send physicians to for inpatient evaluation or treatment. The treatment programs themselves often place significant financial burden on the patient; some have reported costs exceeding $80,000. The PHPs by design leave physicians with little power to pursue second opinions, find less costly treatment programs, or appeal their case. At the end of the day, PHPs receive minimal state oversight and offer their patients minimal due process.
So ask yourself this: if you were a physician struggling with substance abuse, would you actually self-report to your state’s PHP? Would you feel safe knowing that you could be entrusting your medical career to an organization currently undergoing a class action lawsuit for a lack of due process? If you’re several hundreds of thousands in debt from college and medical school, would you sacrifice your autonomy and risk being subjected to a treatment plan that you do not agree with or cannot afford?
Imagine yourself as a patient going to see an orthopedist after you injured your knee. When you come into the office, he tells you that he will not be examining you himself but has decided that you have to undergo surgery on that knee. Furthermore, you have to undergo the surgery at a facility of his choosing and that it will cost you nearly three times what you might pay somewhere else. Moreover, the orthopedist actually has financial ties to the institution where he is requiring you to seek treatment.
When you ask for a second opinion, you’re told that he will refer you to another doctor of his choosing but that he will still make the final determination in how and where you receive treatment. If you refuse to comply with his plan, he will call your job and tell them that you’re unfit for duty. How long do you think this doctor would be in business? How many patients would be agreeable to that type of care?
Fortunately, a physician would never be allowed to treat their patients that way. So why are we allowed to be treated that way?