January 1st, 2013

Researchers: PHPs pose ethical issues, conflicts of interest

Two Harvard Medical School researchers say state Physician Health Programs (PHPs) pose ethical issues and potential conflicts of interest.

“We would like discussion about the nature and practice of PHPs by a broad spectrum of physicians who are not involved with the programs in any way, and even people outside of medicine,” says J. Wesley Boyd, MD, Ph.D., a psychiatrist at Cambridge Health Alliance and an assistant clinical professor at Harvard Medical School, who coauthored a commentary with John R. Knight, M.D., in December’s Journal of Addiction Medicine.

The pair previously served as PHP associate directors and are calling for national standards, a formal appeals process and a nation-wide system for licensing and periodic auditing.

“We do think there should be national standards that are debated and openly discussed and agreed upon, because otherwise you’ve got these little fiefdoms operating largely outside of the scrutiny of everybody,” Boyd says.

Most states have PHPs, which meet with, assess and monitor physicians referred for substance abuse or other mental and behavioral health problems.

Luis T. Sanchez, M.D., director of the Massachusetts Physician Health Services, a nonprofit subsidiary of the Massachusetts Medical Society, says he thinks the authors are misguided in seeking national standards.

“The reality is that every state has its own way of doing things,” Sanchez says, noting the individual medical boards and legislatures.

“Each state tries to comply with the state legislative practice act and whatever other pertinent rules and bylaws there are. There is no national body, so that would not work and doesn’t work, and is not needed from my point of view.”

“But we do adhere to guidelines,” Sanchez says, noting that the Federation of State Physician Health Programs, of which he was previously president, established guidelines, in addition to three other organizations in the past year. He is also on a task force to assist the American Medical Association in developing guidelines.

Boyd acknowledges that PHPs have a “drastically” higher success rate in treating substance abuse (with reported abstinence rates around 75-80 percent) than other forms of substance abuse treatment. However, the authors say the nature of the system is “coercive” because referred physicians have little choice but to cooperate if they wish to continue practicing medicine.

Sanchez says the hospital or organization where a physician works is obligated to report substance abuse issues to the licensing board, which can impose disciplinary action, suspensions, or take a physician out of practice. In Massachusetts, an exception to that reporting law is if there is no patient safety issue and no other laws violated, the physician can be referred to the PHP. “The reporting agency and licensing board have that authority,” Sanchez says. “What we try to do is reach out to physicians and get them involved before it becomes an impairment, before patients get affected.”

The threat of losing one’s license may contribute to the higher recovery rate among physicians, says Rick Barnett, Psy.D., LADC, president of the Vermont Psychological Association, who previously ran a training program on addiction for resident physicians.

Barnett says health care professional addiction rates are about the same as the general population, with the exception of some specialties where it may be higher. “I think that the treatment success rate is greater because they have their careers directly on the line a lot of the times, so they have way more incentive to try to stay sober and recover,” similar to airline pilots, Barnett says.

Barnett says PHPs are excellent programs. “But I suppose it can be a conflict of interest because on the one hand they are offered the benefit of protection from the respective medical board by following through with the program, so they don’t necessarily get their license suspended, but on the other hand, if they don’t follow through with their program – which for the most part is far more strenuous and rigorous than the general population, for obvious reasons – then they can be reported to the medical board.”

Still, Barnett said he believes working with a PHP rather than facing the medical board offers more protection for physicians. “Theoretically, (PHPs) are comprised of physicians or other health care providers who are quite familiar with addiction recovery and are sort of more willing to take the risk of helping the person to find a healthier way to live than the medical board might be.”

Sanchez says the Massachusetts PHP has a lot of peer involvement, including support meetings across the state.

Boyd and Knight say nationally, some PHPs refer physicians for outside evaluations that can be costly and not covered by insurance and raise the potential for financial incentives.

Boyd says “the conflict of interest issue between PHPs and the evaluation programs that they refer people to, that is huge and deep and complicated, because there is money going back and forth between them.” For example, the evaluation center may refer a physician for treatment at its own center, thus receiving thousands of dollars in treatment costs. Additionally, the authors say some evaluation and treatment centers sponsor or exhibit at PHP regional or national meetings, thereby supporting PHPs financially.

They also questioned the relationship between PHPs and state medical boards (which often authorize or provide funding for PHPs), suggesting programs may feel beholden to the board, and the practice by some PHPs of reporting “any and all” positive tests – even if they don’t indicate substance use or relapse.

According to Boyd, “if you have a program that is particularly bureaucratic and feels compelled to report every single thing to the board of medicine, that’s a travesty. That’s making life easy for the program and making life a living hell for the individual doctor.”

By Pamela Berard

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