The Value of Physician Health Programs by Greg Skipper, MD

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The Value of Physician Health Programs by Greg Skipper, MD

The first national study of Physician Health Programs (PHPs) was recently conducted. It was carried out by an independent outside research team sponsored by a Robert Wood Johnson Foundation grant. The study sought to identify which states had PHPs, how they were structured and staffed, their scope and purpose, and finally in Phase II, to measure their outcomes by examining records from over 900 participating physicians who'd signed monitoring agreements 5 years or more previously. The key findings from the published results are summarized here along with editorial comments.1, 2, 3, 4, 5, 6

Forty-eight programs (including the one in the District of Columbia) existed at the time of the survey. The three states without PHPs were Georgia, North Dakota, and Nebraska. Forty-two PHPs participated in the survey (85%). All PHPs indicated that their primary goal was "early detection and clinical assistance for troubled physicians." Most PHPs are setup as independent non-profit foundations (54%) and the remainder are located within the state medical associations (35%) or are housed within the Medical Board itself (13%). No matter their location their funding primarily comes from regulatory boards (50%) with the remainder coming from participant fees (16%), state medical associations (10%), hospitals (9%), and malpractice companies (6%). The average PHP employs five full-time staff

Comments:

PHPs emerged in the late 1970's after the AMA published a paper entitled "The Sick Physician"7 recommending a proactive approach to assisting troubled physicians suffering from substance abuse or other mental health problems. Regulatory boards recognize the value of PHPs who offer a "confidential clinical approach" that encourages earlier referral of physicians with remedial problems associated with impairment. Regulatory boards subsequently sponsored and promoted PHPs.

Not only are PHPs good for patient safety, by encouraging early referral, but PHPs are cost effective by handling cases more expeditiously and by avoiding expensive legal battles. This is so because PHPs are more able to rapidly address cases, based on symptoms, often the very day of a referral, and can conduct an immediate intervention recommending discontinuation of practice and prompt entry into evaluation or treatment. Physicians agree to participate, for several reasons, not the least of which is to avoid being reported to the regulatory board.

This is in contrast to the regulatory board's approach, which is by its nature more constrained, usually requiring investigation to obtain evidence, followed by interviews, hearings and finally administrative law procedures, involving attorneys. This process can take months. The PHP thus helps boards decrease risk to patients (their primary mission), helps preserve physicians' careers (careers that can be ruined if a patient is harmed because of overt physician impairment) and simultaneously lowers costs.

It's of note that not everyone likes the idea of PHPs. Two states, California and Wisconsin, closed their PHPs over the past year since this study was conducted. The demise of the California PHP was widely publicized on cable news and other media venues. The California program (called the Diversion Program) came under attack by a Nader-esque Citizen's action group claiming that the "secret program" was "hiding bad doctors" and was not safe. The media took advantage of the public's bias against "drug addiction" and inflamed the issue, interviewing individuals who claimed they'd been harmed by addicted doctors. These allegations later proved to have nothing to do with physicians in the PHP but in the meantime the regulatory board, under political pressure, made the decision to close the California PHP.

Services offered by PHPs include: education regarding physician health and well-being (to encourage early referral), non-confrontational intervention, referral of participating doctors to competent providers for evaluation and/or treatment (most PHPs maintain a list of authorized providers who excel in evaluation and treatment of professionals), monitoring (conducted on the basis of a signed agreement between the PHP and physician including such things as drug testing, group therapy, reports from a worksite monitor, and others), and finally the PHP provides advocacy (to agencies such as medical boards, hospitals, and insurance companies) by documenting compliance to monitoring. PHPs accept referrals of physicians with remedial problems including substance abuse, psychiatric problems, disruptive behavior, dementia and physical disabilities.

Comment: PHPs have developed the world's most advanced expertise conducting monitoring. They utilize computerized random drug testing with sophisticated drug test panels and testing schemes and have developed innovative new alcohol markers (such as ethylglucuronide and ethylsulfate that can detect alcohol use for days rather than hours).8 Other problems, such as disruptive behavior are monitored by utilizing therapy reports and periodic 360 degree behavioral assessments.

In phase II of the study 904 consecutive records of physicians monitored for substance abuse for at least 5 years were examined. The most common substances of abuse by physicians included: alcohol (50%), opioids (36%), stimulants (8%), and other (6%). Fourteen percent of participants admitted IV drug use (more common than the general population (9%)). Seventeen percent of participants had been arrested at least once (most commonly for DUI) and 9% had been convicted. Some medical specialties were over-represented including anesthesiology (2.5 times more than would be expected), emergency medicine, psychiatry, and family practice. Some specialties were underrepresented including pediatrics and pathology. The most common sources of referral to PHPs included regulatory boards (22%), hospitals (18%), self w/ coercion (14%), colleague or partner (14%), self w/o coercion (11%) and treatment centers (7%). Almost all treatment of substance abusing physicians was abstinence based. In fact, only a few were treated with maintenance opioid therapy (i.e. methadone or buprenorphine) and those were not in active practice. Seventy-eight percent of treatment was inpatient and 22% outpatient.

Comments: PHPs were initially established with the primary focus on early detection and treatment of physicians with substance abuse problems. Most (85%) gradually expanded their role to address other remedial psychiatric problems, disruptive behavior, etc.. Regarding anesthesiologists, despite the fact that they have a much higher rate of problems with substance abuse and despite the fact that there is concern regarding their return to work following treatment, this study reports as good or better outcomes for anesthesiologists as other physicians.5

Outcomes for the 904 physicians were reported in several different ways. Regarding relapses, 79 percent of participants had no relapse to substance use after an average of 7.2 years follow-up. Of the 21 percent who had at least one relapse, 70 percent were outside the context of medical practice and 30 percent occurred within the context of practice. The survey asked if there was any evidence in the record that a patient was harmed because of relapse. There was only one case (.1 percent) where a patient was harmed, and it was secondary to inappropriate prescribing. As for program completion, 64 percent successfully completed five years of monitoring, 16 percent continued monitoring beyond five years under a new agreement (usually because of a relapse), 10 percent retired, 5 percent had their medical license revoked and 3 percent died (six from suicide). As for licensure, at the end of the monitoring period, 72 percent had an active license without restrictions, 3 percent had an inactive license, 2 percent were retired, 5 percent were active but had restrictions or probation, and only 5 percent had been revoked. Finally, from the perspective of drug tests, there were a total of 73,942 drug tests performed during the period of this study (an average of 94 tests per participant). There were 189 positive drug tests (0.26 percent). This is an extremely low rate of positive drug tests.

Comment: This national study was consistent with smaller studies of single states where 5-7 year outcomes for total abstinence have been approximately 80%. These findings are impressive in contrast to the abysmal rates of abstinence from treatment of the general population with substance abuse disorders. It is clear that doctors receive a different type and amount of treatment compared with the general population. Specifically, they receive better evaluations, better and more prolonged treatment, and most importantly they receive long-term monitoring with contingency management.

Physician health programs set a new standard of care and a high level of success for treatment of substance use disorders. These programs appear to be safe (there was only a single documented episode of overt patient harm from follow-up of the 904 physicians and that involved over-prescribing). The public is better served through confidential programs that provide early detection. The alternative of informing patients about their doctor’s prior problems may seem appealing to patient advocacy groups, but in the long run this would delay referral and lead to higher risk of patient harm. State regulatory boards with the vision to support PHPs have done the public a great service.


 

1 White, W.L., DuPont, R.L., Skipper, G.E. (2008). Physician health programs: What counselors can learn from these remarkable programs. Counselor Magazine, June 27, 2007, 44-51

2 McLellan AT, Skipper GE, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008 Nov 4;a2038, doi:10.1136.a2038

3 Skipper GE, DuPont RL. What About Physician Health Programs. The New Republic. January 18, 2009 (http://www.tnr.com/politics/story.html? id=2b230eae-edbb-4b38-951f-75529f5cb2c5)

4 DuPont RL, McLellan AT, Carr G, Gendel M, Skipper GE. How are addicted physicians treated? A national survey of physician health programs. JSAT 37 (2009) 1-7 5 Skipper GE, DuPont RL. Anesthesiologists Returning to Work after Substance Abuse Treatment. Anesthesiology, V110, No 6, June 2009 1423-24. 6 Skipper GE, Campbell MD, DuPont RL. Anesthesiologists with Substance Use Disorders: A

5- Year Outcome Study from 1

6 State Physician Health Programs. Anesth & Analg 109(3),Sept 2009, 891-896.

7 Anonymous: The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence. JAMA 1973: 223(6): 684-7.

8 Skipper GE, Weinmann W, Wurst FM. Ethylglucuronide (EtG): A New Marker to Detect Alcohol Use in Recovering Physicians. Journal of Medical Licensure and Discipline, 2004,90(2), 14-17.

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