“To the Editor:
I am writing in response to Physician Health Programs: More Harm Than Good? (August 19).
While Medscape consistently offers journalistic excellence to physician readers, this report in my view and those of my colleagues provided a biased and unbalanced view of Physician Health Programs (PHPs).
In assisting the reporter with the story, the Federation of State Physician Health Programs (FSPHP) provided six pages of factual information and references to several peer-reviewed articles, yet almost all of this information was excluded from the report. The report relies primarily on hearsay, including information from anonymous sources, allegations rather than facts, and a handful of anecdotes.
I recognize this response is lengthy, but as the President of the Federation, I am compelled to point out the report’s many failings.
Regarding the North Carolina PHP, it is misleading to focus on ‘the appearance of conflicts of interest’ when none were found and ‘abuse (that) could occur and not be detected’ when no abuse was demonstrated through an extended, external audit. Two auditors from the North Carolina Office of the State Auditors randomly interviewed numerous PHP participants and no abuse was reported. The same experts reviewed physician participant files, extending over a ten-year period, and each file contained ‘sufficient and appropriate evidence to support the referral to a treatment center.’
The report also lodged many criticisms against treatment programs, but based on allegations and second-hand anecdotes. It appears that not a single treatment facility was invited to counter these criticisms with factual information about the operation of their programs.
An unnamed source included in the article ‘heard from two other physicians’ that a mandatory period of treatment is prescribed in advance of any clinical evaluation. This is patently false. Treatment decisions are made on a case-by-case basis and only after a comprehensive clinical evaluation has been completed.
The FSPHP encourages the utilization of an evidence-based approach, whenever possible, to promote high-quality treatment experiences for physicians. We have developed guidelines and follow standards of practice produced by the medical profession and made available through organizations such as the American Medical Association, the American Psychiatric Association, the Federation of State Medical Boards, the American Society of Addiction Medicine, and the American Academy of Addiction Psychiatrists, to name a few.
Treatment and monitoring for physicians with serious illnesses is generally intensive and extensive, just as it is for other professionals, like pilots, who are employed in safety sensitive positions. It is too great a risk to put a pilot behind the controls of a plane or send a surgeon into the operating room with a minimal amount of treatment for a potentially impairing condition. Doing so jeopardizes the safety of the public. There is also potential for discipline, up to and including loss of licensure for the undertreated professional.
Some individuals interviewed for the article provided anecdotes of physician experiences with PHPs. Our obligation to maintain confidentiality for PHP participants prevents an opportunity to address certain factual errors or challenge information taken out of context by those individuals.
Physician health research may be in its infancy, but we do have evidence-based, peer-reviewed studies that demonstrate recovery rates for addicted physicians who undergo residential treatment, coupled with PHP monitoring, exceed recovery rates observed in the general population by a very large margin. This model of care is so successful that there is movement to design similar protocols for the general public to better manage chronic illnesses such as diabetes, hypertension, and obesity. Additionally, research demonstrates that physicians who participate in PHP monitoring for any health issue have a lower malpractice risk compared to the physician population at large, underscoring the relationship between physician health and effective patient care.
The detractors of PHPs interviewed for the article maintain that PHPs are coercive. Yet the report fails to mention that PHPs have no authority to mandate treatment and monitoring, suspend or revoke licensure, or otherwise discipline physicians. Most PHPs utilize contingency contracts, which are supported by a large research base of proven methodologies. Such agreements spell out specifically and clearly the steps a physician must take to comply with a treatment plan and in return, maintain the privilege to practice medicine.
Early in the course of recovery from illness, these contracts tend to be more rigid to protect patients and the recovering physician alike. Over time, and with demonstrated improvement in health and functioning, the contracts are relaxed. Several PHPs afford full confidentiality to their participants and have no medical board involvement whatsoever. In these states, a majority of physicians voluntarily connect with their PHP. Mandatory involvement has declined. In this context, illness is generally identified early, before impairment or death occurs and importantly, before patient safety is compromised.
Similarly, detractors maintain that PHPs have no oversight. In fact, we operate under a microscope, answering to individual practitioners, medical boards, malpractice carriers, defense attorneys, state attorneys, medical societies, hospitals, medical schools and residency training programs. We are also accountable to patient safety entities and a Board of Directors. PHP participants routinely provide feedback, and we consider their feedback in creating policies and procedures. Quality assurance processes, including audits and performance reviews, have been pursued proactively by many state PHPs. The FSPHP has also convened a task force to further our efforts toward accountability, consistency, and excellence, acknowledging that there is always room for improvement.
Lastly, and perhaps most disturbing, the reporter writes that ‘some say the PHP experience has led vulnerable physicians to contemplate suicide,’ again using anecdotes and absent reliable science. Such an explosive charge should be supported by nothing less than incontrovertible facts, and in their absence, borders on the irresponsible.
Tragically, approximately 400 physicians take their own lives each year in this country. Of significance, the incidence of physician suicide has remained steady for decades, even before the advent of the physician health movement and the development of PHPs. Several FSPHP members as well as other constituents committed to improving the health and well-being of physicians are involved in research efforts to better delineate risk factors unique to physicians so that we can begin to improve how we identify and support vulnerable colleagues and prevent such heartbreaking losses.
Physician Health Programs around the country are dedicated to promoting and improving the health of medical professionals, with the goals of maintaining patient safety and quality care and providing the best possible opportunity for the recovery of the physician. To paint the kind of picture of PHPs as presented by this report and to imply they do more harm than good fails to acknowledge the overwhelming success of PHPs. It does a disservice not only to our colleagues working in the field, but also to those thousands of physicians who have overcome their impairing conditions and have returned successfully and safely to the practice of medicine. “More harm than good” is likely to occur when physicians needing assistance are discouraged from seeking help after reading misleading information on an otherwise reputable online resource.”
Doris C. Gundersen, MD
President, Federation of State Physician Health Programs
Medical Director, Colorado Physician Health Program
Assistant Clinical Professor, University of Colorado
Hat tip: Dr. Michael L. Langan.