“The belief that there are such things as witches is so essential a part of the faith that obstinately to maintain the opposite opinion manifestly savors of heresy.”
So begins Malleus Maleficarum, a witch hunters manual published in 1486 that launched a new paradigm for all those concerned with the identification and extirpation of witches. Used as a judicial case-book the Malleus set forth definitions of witchcraft, rules of evidence, and the canonical procedures by which suspected witches were tortured and put to death. Written by Inquisitors for Inquisitors, the Malleus construct came to be regarded as irrefutable truth and contributed to the identification and execution of as many as 60,000 “witches”, predominantly women. The 29th and last edition was published in 1669.
Although there was a general belief in witches at the time the Malleus was published they were not regarded as evil or life threatening. Society did not fear them and Church and Political authority certainly did not feel the need to hunt them down. There were many scholars who publicly doubted the existence of witches at the time. That would soon change.
After being snubbed by secular and ecclesiastical authorities in his witch-hunting pursuits, the Dominican friar and German Inquisitor Heinrich Kramer told Pope Innocent VIII of a dangerous outbreak of witches that had occurred in the region. This diabolical conspiracy hell-bent on destroying humanity needed to be identified and destroyed for the public good, but church authorities were not cooperating.
On December 5th, 1484 Pope Innocent VIII issued the papal bull Summis Desiderantes affectibus giving full authority to proceed with “correcting, imprisoning, punishing, and chastising” such persons “according to their deserts,” and threatening to sanction or excommunicate those who hindered the pursuit.
From the late 15th century through the early 17th century a confederacy of “authorities” calling themselves demonologists assisted in identifying witches. Shaping ecclesiastical orthodoxy they set the standards that cooperating political authorities could follow in criminalizing, persecuting and punishing heretics.
Behavioral manifestations included living alone, cultivating strange herb and saying hello to a neighbors cat.Witches were blamed for everything—plague, crop failure, and erectile dysfunction.
Using the nebulous “witch label” anyone with a grudge or suspicion could accuse anyone of witchcraft .
Propaganda, threats, misinformation, guilt assumed from the start.
Physician oversight of witch persecution was standard.
During the European witch-hunts the legal notion of crimen exceptum (an exceptional and most dangerous crime] allowed for the suspension of normal rules of evidence to punish the guilty.
Because of the nature of the enemy the evidentiary bar was lowered and any witness, no matter what his credentials, could testify against the accused.
Belief in the seriousness of the situation rationalized cruelty.
The Devil’s mark (Stigmata diaboli) was taken as the mark of a witch entailing close inspection.
Professional witch-prickers used needles, pins and bodkins to poke the skin with lack of bleeding confirming the accusation. The accused did not bleed due to retractable needles and sleight of hand. False accusations, if exposed, were excused if they were a result of “zeal for the faith.”
The consequences of being branded a heretic by questioning the existence of witches essentially silenced any dissenting voices and the notion of crimen exceptum freed the consciences of those involved.
Sanctimony, feigned piety and hypocritical devoutness was used as justification. After all–Torture and torment are a small price to pay when it comes to protecting the public and saving souls.
Through the witch trials clerics, doctors, and lawyers used their expertise as witnesses to increase their prestige. Witch hunts developed into a means of economic profit. Some gained a lot of money from the witch trials. The witch or her relatives paid for the salaries of those who worked the witch trials including judges, court officials, torturers, physicians, clergymen, scribes, guards, attendants. Even the people who made the stakes and scaffolds for executions gained from the conviction and death of each witch.
“Witch hunting,” wrote the historian Rossell Hope Robbins, “was self-sustaining and became a major trade, employing many people, all battening on the savings of the victims.”
The costs of a witch trial were usually paid for by the estate of the accused or their family.
Far from the conventional image of a penniless hag, a significant proportion of accused witches, especially in Germany, were wealthy and male.
Their property was seized to pay the clergymen, judges, physicians, torturers, guards, scribes, and laborers who raked in increasingly large sums of money as well as other reliable assets.
With a single member accused, a moderately wealthy family could be ruined permanently.
Wretched creatures are compelled by the severity of the torture to confess things they have never done and so by cruel butchery innocent lives are taken; and by new alchemy, gold and silver are coined from human blood.
Context, characters and circumstances may differ but the mechanics do not.
The mosaic remains the same.
The Malleus shows how false constructs come to be regarded as irrefutable and the creation and chains of causation are timeless.
Forget what you see Some things they just change invisibly–Elliott Smith
Physician Impairment
The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence, published by the American Medical Association’s (AMA) Council on Mental Health in The Journal of the American Medical Association in 1973,1 recommended that physicians do a better job of helping colleagues impaired by mental illness, alcoholism or drug dependence. The AMA defined an “impaired physician” as “a physician who is unable to practice medicine with reasonable skill and safety to patients because of mental illness or excessive use or abuse of drugs, including alcohol.”
Recognition of physician impairment in the 1970s by both the medical community and the general public led to the development of “impaired physician” programs with the purpose of both helping impaired doctors and protecting the public from them.
The 1975 media coverage of the deaths of Drs. Stewart and Cyril Marcus brought the problem of impaired physicians into the public eye. Leading experts in the field of Infertility Medicine, the twin gynecologists were found dead in their Upper East Side apartment from drug withdrawal that New York Hospital was aware of but did nothing about. Performing surgery with trembling hands and barely able to stand, an investigation revealed that nothing had been done to help the Marcus brothers with their addiction or protect patients. They were 45 –years old.
Although the New York State Medical Society had set up its own voluntary program for impaired physicians three years earlier, the Marcus case prompted the state legislature to pass a law that doctors had to report any colleague suspected of misconduct to the state medical board and those who didn’t would face misconduct charges themselves.
Physician Health Programs
Physician health programs (PHPs) existed in almost every state by 1980. Often staffed by volunteer physicians and funded by State Medical Societies, these programs served the dual purpose of helping sick colleagues and protecting the public. Preferring rehabilitation to probation or license revocation so long as the public was protected from imminent danger, most medical boards accepted the concept with support and referral.
As an alternative to discipline the introduction of PHPs created a perception of medical boards as “enforcers” whose job was to sanction and discipline whereas PHPs were perceived as “rehabilitators” whose job was to help sick physicians recover. One of many false dichotomies this group uses and it is perhaps this perceived benevolence that created an absence of the need to guard.
Employee Assistance Programs for Doctors
Physician Health Programs (PHPs) are the equivalent of Employee Assistance Programs (EAPs) for other occupations. PHPs meet with, assess, and monitor doctors who have been referred to them for substance use or other mental or behavioral health problems.
Most EAPs, however, were developed with the collaboration of workers unions or some other group supporting the rights and best interests of the employees. PHPs were created and evolved without any oversight or regulation.
The American Society of Addiction Medicine can trace its roots to the 1954 founding of theNew York City Medical Society on Alcoholism (NYCMSA) by Ruth Fox, M.D whose husband died from alcoholism.
The society, numbering about 100 members, established itself as a national organization in1967, the American Medical Society on Alcoholism (AMSA).
By 1970 membership was nearly 500.
In 1973 AMSA became a component of the National Council on Alcoholism (NCA) in a medical advisory capacity until 1983.
But by the mid 1980’s ASAM’s membership became so large that they no longer needed to remain under the NCADD umbrella.
In 1985 ASAM’s first certification exam was announced. According to Dr. Bean-Bayog, chair of the Credentialing Committee, “a lot of people in the alcoholism field have long wanted physicians in the field to have a high level of skills and scientific credibility and for this body of knowledge to be accredited.”2 And in 1986 662 physicians took the first ASAM Certification Exam.
By 1988 membership was over 2,800 with 1,275 of these physicians “certified” as “having demonstrated knowledge and expertise in alcoholism and other drug dependencies commensurate with the standards set forth by the society.”3 “The formation of State Chapters began with California, Florida, Georgia, and Maryland submitting requests.4
In 1988 the AMA House of Delegates voted to admit ASAM to the House. According to ASAM News this “legitimizes the society within the halls of organized medicine.”2
By 1993 ASAM had a membership of 3,500 with a total of 2,619certifications in Addiction Medicine. The Membership Campaign Task Force sets a goal to double its membership of 3,500 to 7,000 by the year 2000 to assure “the future of treatment for patients with chemicals. It represents a blueprint for establishing addiction medicine as a viable entity.”5
Many of these physicians joined state PHPs and over time have taken over under the umbrella of the FSPHP.
The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA : the journal of the American Medical Association. Feb 5 1973;223(6):684-687.
Four Decades of ASAM. ASAM News. March-April 1994, 1994.
. American Medical Society on Alcoholism & Other Drug Dependencies Newsletter. Vol III. New York, NY: AMSAODD; 1988:12.
. AMSAODD News. Vol III. New York, NY: American Medical Society on Alcoholism & Other Drug Dependencies; 1988.
Membership Campaign Update. ASAM News. Vol VIII: American Society of Addiction Medicine; 1993:11.
The article below was recently published on “social media’s leading physician voice” KevinMD.com. A previous piece by the same author attempted to connect marijuana to heroin use. Interestingly, this type of archaic rigid paternalistic chatter is becoming more and more common in the articles and social media of healthcare. How, and more importantly why, is this type of tripe and rabble getting past editorial review? It is 2016 not 1958! Disappointingly, this absurd and sexist rant has generated a mere 20 comments thus far with the majority being negative. I do agree with the apt and accurate observations of “FEDUP MD” who states the following:
“The answer is not that cut and dried.
Do I want a surgeon who is clinically impaired from marijuana operating on me at the time, who just smoked a joint before entering the OR? No.
Do I care if a surgeon two weeks ago went to Aspen on vacation, smoked a perfectly legal joint at his hotel, and now is operating on me two weeks later? No.
Marijuana use today is not limited to the poor, the marginalized among us; nor is it kept in the inner city, as it pretty much was when I was a kid. Now it is widespread, even legal in some states. One might even make the argument it has become a substantial part of the life of the elite, the affluent of America. And when we think of elite and powerful individuals among us, do we rule out doctors? I think not.
So when I read a reader’s comment to a piece I wrote recently about marijuana and its possible connection to heroin, I was not surprised when one person rejected my ideas 100 percent. He went on to say why, and used the term “weed” once or twice in doing so. I said to myself, “Now here is a person who knows firsthand a bit about marijuana use. ” His use of the term, “weed,” told me this. He no doubt possesses more than a passing interest in the subject. Others who commented seemed to share his opinion — but not all.
My understanding of drugs and their impact on lives comes largely from my lifelong occupation as a social worker. Lots of years of doing social work in many settings including a couple of years working among the Sioux of South Dakota. In those mid-sixties, years alcohol abuse on the reservation was rampant, and hardly a new story. Drugs had not yet arrived. Drugs are there now big time and the situation is horrendous, awful, drugs and alcohol together. And I believed the conditions could not become worse than what I witnessed. Well, they could, and they have.
There is another side to my experience, however. As a much younger person, I dated, while living in Boston, a heavy user of marijuana. She also took LSD regularly, which tells you how long ago this happened. I didn’t meet the woman in the conventional way, a bar or some sort of social gathering (no Internet or on-line dating services then). No, I met the lady at an airport north of Boston: Plum Island Airport, quite near the ocean. I am a private pilot, and I had landed my two-seater Piper J3, and struck up a conversation with her, and offered her a ride, which she immediately accepted, and thereupon our romance began. Straightforward enough, I hope you agree.
The J3 is a wonderful airplane, old and slow, but lots of fun to fly. There is no starter. You have to get out and spin the prop to start the engine — very old school. Women seemed to love my J3, except that it wasn’t mine; it was a loaner.
Pilots incidentally are often a fairly conservative lot. Not a great deal of alcohol or drug abuse among us. Of course, there are glaring exceptions, but most pilots I know learned quickly that mistakes in aviation can and often are deadly. There are no dented fenders. I noticed too that doctors seem drawn to flying in considerable numbers. They often have the best equipment — I never saw a doctor in a J3 — which I gather they can well afford. And I should add that I never met a woman pilot/doctor, by the way.
They also were involved in many accidents. Why? It is complicated, I suppose, but doctors are busy fellows who might find a couple hours of free time, rush to the airport and were soon airborne. Not a lot of time to practice, as in practicing takeoffs and landings. No time for that, but in aviation as in medicine, practice makes perfect, or near perfect. Also, I think confidence is an issue. For doctors, at least the ones I was acquainted with, were seldom lacking in confidence, and were, therefore, capable of getting into flight situations they may have been completely unprepared for and untrained to deal with.
So my new friend, Ellen, and I dated. She was open and very upfront with me about her heavy marijuana use. She claimed she drove better when she was high, reminding me repeatedly of this as she weaved in and out of traffic on the Mystic River Bridge leading into Boston. I’d hold my breath, and occasionally recommended she slow down. She seldom did. But still, I enjoyed Ellen’s company, and went along for the ride for easily a year or more. I won’t say her drug use drove us apart, but it did not bring us closer together either, which leads me to this (likely unpopular) observation, and query: How many doctors entering the workplace these days have more than a casual connection to marijuana? I know the same question can be asked regarding alcohol, but I am not asking that question here, and it is, after all, my essay.
What if there were an admissions question upon entering medical school, and it went something like this: How would you describe your use of marijuana? Often, once in awhile, or never. Of course, answers to such a query would be totally unreliable, for obvious reasons. No one would admit to marijuana use when applying to medical school.
My friend and I parted after a time. She never said as much, but I suspected she found me a bit dull. She eventually moved back to Virginia, and last I heard, she had wed and had a family. Good for her. So no bad ending here. Maybe that’s what everybody was expecting — what I was leading up to — but you don’t get that.
But I will say this much. I continue to be a fussy pilot, and when I travel on an airliner, which these days happens less often — I always peek into the cockpit upon entering to see who is sitting in the left-hand seat. That’s where the pilot in command sits. I like to see an older man there, a bit stout and maybe balding or gray-haired. (Please don’t ask me about female pilots.) I know such a fellow is likely experienced. He has survived a long time, is my guess.
If I were to find a young Robert Redford-type in that left-hand seat, I would become uneasy and not fully sure of what I was getting myself into.
So the point I am making here is this: I am clearly discerning as to the skill and condition of an airline pilot, someone I seldom see, so why should I not be really picky when it comes to doctors I select, and whether or not they use marijuana regularly, or even at all?
To have striven, to have made an effort, to have been true to certain ideals — this alone is worth the struggle. We are here to add what we can to, not to get what we can from, life. – William Osler
Diagnostic Medicine
Diagnostic medicine is the process of identifying the condition or disease that a patient has and ruling out conditions or diseases the patient does not have through assessment of the patient’s signs, symptoms, and results of various diagnostic tests.
Diagnostic Test Accuracy
Diagnostic test accuracy is simply the ability of the test to discriminate among alternative states of health (Zweig and Campbell, 1993).
If a test’s results do not differ between alternative states of health, then the test has insignificant accuracy; if the results do not overlap with other states of health then the test has perfect accuracy. Most tests accuracies fall between these two extremes.
The intrinsic accuracy of a test is measured by comparing the test results to the “true condition status.”
‘True condition status” refers to one of two mutually exclusive states. Either acondition is present or it is absent.
We determine true condition status by means of a “gold standard” which is a source of information completely different from the test under evaluation which tells us the true condition status of the patient.
Say we want to develop a new rapid test for detecting strep throat. Strep throat is caused by the Streptococcus bacteria. Although more common in children and adolescents it can occur in people of all ages. Strep throat is one of many possible causes of sore throat and pharyngitis. It is contagious and can cause complications such as rheumatic and scarlet fever. Treatment with antibiotics can shorten the course of the disease and reduce the risk of complications.
A throat culture is obtained by swabbing the patient’s throat with a cotton swab. The sample is then sent to the lab where it is cultured. If strep is present it will grow on the culture and look as below. The bacteria either grows on the culture or it doesn’t. A throat culture is the “gold standard” for diagnosing strep throat. The problem is it may take two days to get back.
Sensitivity and Specificity
The two most important measures of diagnostic test accuracy are sensitivityand specificity.
The probability that a test will be positive in someone with the condition = Sensitivity
The Probability that a test will be negative in someone without the condition = Specificity
For diagnosing strep throat we want our test to be as close as possible to the gold standard in terms of both sensitivity and specificity.
Sensitivity and specificity can be illustrated by a table with two rows and two columns. This simple Decision Matrixwhere the rows summarize the data according to the true condition status of the patients and the columns summarize the test results. This table is called a “count table” because it indicates the numbers of patients in various categories. The total number of patients with and without the condition is, respectively n\ and n0; the total number of patients with the condition who test positive and negative is respectively s\ and s0; and the total number of patients without the condition who test positive and negative is respectively r\ and ro.
The total number of patients in the study group N, is equal to N = si+so+rx+ro, or N = n\ + no·
The true condition status is symbolized by the variable D, where D = 1 if the condition is present and D= 0 if the condition is absent.
Test results indicating the condition is present are called positive; those indicating the condition is absent are called negative.
Test results are symbolized by the variable T, where T =1 denotes positive test results and T= 0 denotes negative test results.
The sensitivity (Se) of a test is its ability to detect the condition when it is present.
We write sensitivity as Se = P(T = 1 | D = 1), which is read:
“sensitivity (Se) is the probability (P) that the test result is positive (T = 1), given that the condition is present (D = 1).”
Among the n\ patients with the condition, s\ test positive; thus, Se = s\/n\.
The specificity (Sp) of a test is its ability to exclude the condition in patients without the condition.
We write specificity as Sp — P(T = 0 | D — 0), which is read:
“specificity (Sp) is the probability (P) that the test result is negative (T = 0), given that the condition is absent (D = 0).”
Among no patients without the condition, ro test negative; thus, Sp — TQ/UQ
False Negative and False Positive Tests
There are consequences associated with all test results.
False Negative Tests: If a test falsely indicates the absence of a condition in someone who truly has it then treatment can be delayed or not provided.
The consequences of a false negative strep test depend on what we do with it. Serious consequences can arise if we use our new strep test as the sole basis for subsequent decision making. Putting complete trust in the negative test result would lead to no antibiotic treatment provided to a patient with Strep and can lead to continued illness, spread of the disease and complications that would not have occurred if antibiotics were provided. The patient could potentially get rheumatic or scarlet fever.
If the new test is negative but a culture was drawn the false results could delay treatment by a couple days or so but treatment is nevertheless provided. The consequences are likely to be minimal. It is highly unlikely a patient would get rheumatic or scarlet fever as, although a little later, they are still being treated with the proper antibiotics.
False Positive Tests: If a test falsely indicates the presence of a condition in someone who does not truly have it then unnecessary tests and treatments can occur. Incorrect treatment and false labeling of patients can also occur.
In the case of a false positive strep test, a patient may undergo a course of antibiotics when they do not need them. Although the patient may suffer side-effects from the antibiotics the severity and duration of any of these consequences are minimal.
The importance of a Diagnostic Accuracy in testing is directly proportional to the tests potential to cause patient consequences and harm.
Diagnostic Medicine uses a patient’s signs, symptoms and the results of various diagnostic tests to arrive at a diagnosis.
In diagnosing strep throat a good clinician will take into account a number of variables in consideration of a differential diagnosis and base testing and treatment on the preponderance of information supporting or opposing the diagnosis.
For strep throat using the new test in addition to a throat culture, history and careful physical exam and basing the decision to prescribe antibiotics on clinical acumen based on the overall picture is the best approach. The test can be considered a piece of the puzzle but does not define it. Therefore the risk of a false positive or false negative is minimal as it is just one data point.
Diagnostic accuracy is necessary if a test is being used as the basis for further tests and treatment. If a test is being used as the sole basis for further tests and treatment it needs to be accurate. If the results of a test can cause significant patient harm or death then it needs to be either 100% accurate or combined with other highly accurate tests to confirm the diagnosis.
The specificity of a test is particularly important as a false positive can result in unneeded interventions and treatment. Stand-alone tests used in diagnosis and treatment need to be both sensitive and specific. Diagnostic accuracy is a product of consequences of false-negative and false positive tests.
Diagnostic Research Methodology
Research to discover the accuracy of a diagnostic test should be straightforward; administer the test to a group of people and see if it works.
The test being tested is the “index test”. Results of the index test are compared with the results of a “gold standard” reference test.
The research question is, “How accurately do index test results predict the (true, gold standard) reference test results?”
Diagnostic test accuracy studies require a sample of subjects who have been given the test under evaluation, some form of scoring of the tests findings and a reference or “gold standard” to which the test findings are compared. Examples include autopsy reports, surgery findings and pathology results from biopsy findings.
The gold standard for a patient’s true disease status may not always be available. A brain biopsy could be considered a gold standard for diagnosing Alzheimer’s disease but is neither practical nor humane.
The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool is a set of fourteen questions that investigate the methodologic quality of scientific studies that quantify diagnostic test performance.
The questions identify research methodologies known to bias the accuracies research discovers.
Multiple factors need to be considered in evaluating the diagnostic accuracy of a test including diagnostic validation and verification. Is the test testing what it is supposed to be testing for and are we doing it correctly?
Diagnostic accuracy of a test necessitates a reference standard, The reference standard can be the best available method for establishing the presence or absence of a condition (such as the throat culture for strep throat) or a combination of methods (imaging, neuropsychological testing, clinical exam, etc. in Alzheimer’s disease.
Any test that is going to be used as a basis for decisions that impact other human beings needs to be validated before it is introduced on the market. The literature needs to be reviewed critically and trials must be designed using objective evidence that validates the test is testing for what it purports to be and verifies the correct methodology of the test. Verification that the test is being collected, handled, stored, transported and processed correctly is requisite.
Cutoff levels, , cross-reactivity and myriad other issues need to be worked out prior to bringing a diagnostic test to market.
The reliability, validity and accuracy of drug test results needs to be known prior to using a test. Specificity and sensitivity must be known prior to using a test on any population.
This should go without saying as to do anything else would be irresponsible and careless.
References
Evidence-based medicine, systematic reviews, and guidelines in interventional pain management: part 7: systematic reviews and meta-analyses of diagnostic accuracy studies Pain Physician 2009, 12(6):929-963. PubMed Abstract | Publisher Full Text
Jaeschke R, Guyatt G, Lijmer J: Diagnostic tests. In Users’ guides to the medical literature: a manual for evidence-based clinical practice. Edited by Guyatt G, Rennie D. AMA Press; 2002:121-140.
Streiner DL: Diagnosing tests: using and misusing diagnostic and screening tests.J Pers Assess 2003, 81(3):209-219. PubMed Abstract | Publisher Full Text
Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J: The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003., 3(25) http://www.biomedcentral.com/1471-2288/3/25webcite
GCP, good clinical practice; GCLP, good clinical laboratory practice; GLP, good laboratory practice; STARD, standards for reporting of diagnostic accuracy. See Section III, 2.13 From Nature Reviews Microbiology 4, S20–S32 (1 December 2006) | doi:10.1038/nrmicro1570
Under a dictatorship everything else becomes subordinated to the guiding philosophy of the dictatorship. Corresponding doctrine replaces professional guidelines, standards-of-care, and evidence based medicine. And unfortunately in the case of Addiction Medicine the guiding philosophy often trumps autonomy and ethics.
Inherent in the current chronic brain disease model of addiction is the importance of external control over individuals and political correctness and medicalization of addiction is allowing it. Demanding scientific literacy and discriminating good from bad science would prohibit what is occurring and in order to save American Medicine the problem needs to be clearly recognized or we will become a profession that is essentially defined by the impaired physicians movement.
The blue slides below are from a presentation at the 2014 FSPHP spring meeting in Denver, Colorado and can be seen here. The presentation was given by past FSPHP Presidents Gary Carr, MD and Warren Prendergast, MD, West Virginia PHP Director Brad Hall, MD and Montana PHP Director Mike Ramirez, MS.
This needs to be seen as a “to-do” list.
A.A. = ASAM = FSPHP
The quote is from Alcoholics Anonymous and the full passage is as follows:
“We are convinced that a spiritual mode of living is a most powerful health restorative. We, who have recovered from serious drinking, are miracles of mental health. But we have seen remarkable transformations in our bodies. Hardly one of our crowd now shows any mark of dissipation. But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”–Alcoholics Anonymous, 4th Edition, The Family Afterward
Federation of State Physician Health Program (FSPHP) physicians often quote A.A. because they are defined by A.A. in both mechanics and mentality. The “impaired physician” movement began with evangelical recovered addict and alcoholic physicians whose recovery was based on 12- step spirituality. As this group molded into the American Society of Addiction Medicine (ASAM) many of them found employment at 12-step rehabilitation facilities and others joined their state Physician Health Programs and organized under the FSPHP. Their ability to make authoritative pronouncements on physician impairment is based on their own claim to insiders knowledge of recovery as brandished in this A.A. passage which I find condescending toward the medical profession and oddly narcissistic.
This special knowledge, of course, was based on the chronic relapsing brain disease model with lifelong abstinence and participation in 12-step recovery.
These “miracles of mental health” joined their state PHPs and those who did not agree with their rigid inflexible views were removed. Those with access to special secret knowledge were eventually able to outvote those with intelligence and open minds as this groupthink infested and eventually monopolized PHPs.
It is important to understand that the ideology of A.A. is the ideology of the ASAM is the ideology of the FSPHP
Like all “front-groups” the ASAM purports to serve one agenda while in reality serving another. The ASAM claims to be a “physician society with a focus on addiction and its treatment” According to their website their mission is to
increase access to and improve the quality of addiction treatment;
to educate physicians (including medical and osteopathic students), other health care providers and the public;
to support research and prevention;
to promote the appropriate role of the physician in the care of patients with addiction;
and to establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public
In order to accomplish this the American Board of Addiction Medicine certifies doctors to “provide assurance to the American public that Addiction Medicine physicians have the knowledge and skills to prevent, recognize and treat addiction.”
Ostensibly these are laudable goals that are almost universally endorsed. The perceived organizational purpose and public persona are altruistic and humanitarian. Treating addiction not only saves individual lives but improves the community. It is for the common good.
Abuse Hidden Under Benevolence and Torture as Treatment
History reveals that all manner of abuse can lie underneath a patina of benevolence. In the past few months alone we have both Bill Cosby and the British Parliamentary pedophile ring as prototypical examples. Both cases reveal a decades long coverup of allegations in which the abusers escaped little or no investigation into their alleged crimes. Abuse of power with a large gap between the power of the abuser and the powerlessness of the abused is a common denominator. If the abuser endorses our own beliefs systems it creates a discord that promotes disbelief. It does not fit. Accusations are dismissed, deflected or otherwise suppressed. Power effectively extinguishes the truth. Disbelieved and delegitimized, information is suppressed, charges are not filed and law enforcement and the media turn a blinkered eye for decades. Indifference, disbelief, rationalization and cognitive dissonance prevent exposure and accountability. Hidden in plain site the truth was there and easy to find. The problem was no one was looking. Most did not want to look.
It does not take much sleuthing to uncover what is beneath the veil of the American Society of Addiction Medicine. The history, mentality and mechanics are well documented and reveal where they came from, how they evolved and what they have planned. It is a complicated web and hard to explain but once the pieces of the puzzle are fit together it is clear. But it involves assembling a complex puzzle by finding the individual pieces scattered in disparate areas including the regulatory, clinical, administrative and professional niches of the medical profession, Alcoholics Anonymous and 12-step related organization, public policy, all levels of the political arena and other areas. Once put together the portrait is clear.
In reality the ASAM is a political action group or special interest group that is designed to cement the chronic relapsing brain disease model with lifelong abstinence and spiritual recovery as the one and only treatment for addiction. A.A. is used as the energy source of the operation. By labeling addiction a “disease” requiring “treatment” in which someone is helpless they are able to dictate all aspects by coercion and control. But in my opinion the A.A. ideology is just used as a ruse to support the multi-billion dollar drug and alcohol testing, assessment and treatment industry. The zero-tolerance mindset of the “treaters” combined with the “helplessness” of the diseased enables them to erect a revolving door of testing, assessment and treatment that provides them with both control and a steady stream of money.
The FSPHP mandates 12-step ideology on all doctors in a zero-tolerance system of abuse and control while at the same time putting out misinformation that the PHP programs are the “new paradigm.” The page below is from the book Drug-Impaired Professionals by Robert Holman Coombs.
This is they type of propaganda these groups have propagated. What is described above is absurd and unrealistic but it is reported, reproduced and repeated to the point that it is accepted as the truth.
The majority of physicians referred to these programs are not even addicts. These programs of Zero-tolerance and 12-step indoctrination are based on coercion and control. They are causing many doctors to die by suicide as they are feeling hopeless, helpless and defeated. This portrayal of a group of blissful 12-stepping doctors over the moon because they found spirituality is nonsense.
But you will not find many doctors speaking out against them for fear of “contingency management.” Disagreeing or even questioning PHP practices including the validity of 12-step can literally cost you your license.
I have spoken to multiple physicians and nurses and have encouraged them to tell their stories here but they are afraid of retribution and “unintended consequences.” And who can blame them?
They can send you back to one of the “PHP-approved” facilities for “stinkin thinkin.”
Unfortunately the ASAM and FSPHP have successfully bamboozled others into believing they are true experts with noble intent. They have bamboozled the Federation of State Medical Boards (FSMB) to the point where they have gained autonomy and unrestrained managerial prerogative. They essentially use the state Boards to impose sanction on doctors who they report doctors for “noncompliance” which includes disagreeing with or questioning mandated A.A or refusing to admit you have a chronic relapsing brain disease when you in fact do not. They are in fact imposing A.A. on doctors and forcing them to accept their thinking under threat of loss of licensure. This violates the Establishment Clause and is a very serious problem that is being ignored. It is a slippery slope we are on.
The FSMB House of Delegates adopted an updated Policy on Physician Impairment at their 2011 annual meeting distinguishing “impairment” and “illness” stating that Regulatory Agencies should recognize the PHP as their expert in all matters relating to licensed professionals with “potentially impairing illness” that predates impairment often by many years.”
It also defines “relapse without use” as “behavior without chemical use that is suggestive of impending relapse.”
G. Douglas Talbott defines “relapse without use” as “emotional behavioral abnormalities” that often precede relapse or “in A. A. language –stinking thinking.”
The ASAM has monopolized addiction treatment in the United States. But what the FSPHP arm has done is far more sinister. A.A. has effectively taken over regulatory medicine and the private lives of doctors as a form of social control. A doctor can be referred to a PHP for virtually anything and if the PHP believes he or she is in need of an assessment it will be done by a “PHP-approved” facility which means it will be done by a 12-step facility. The PHP selects who will be monitored and dictates every aspect of what that entails and the entire process is done within the confines of A.A. ideology. It is a, in fact, a rigged game as the medical directors of the PHP approved facilities can all be seen on this list of like-minded docs who refer to theselves as “trusted servants” and “believe that evidence from extensive, well-designed studies demonstrates the great benefits of Twelve-Step recovery modalities including Twelve Step Facilitation in promoting long-term recovery.”
A.A. is imposed on doctors through the FSPHP. The FSPHP political apparatus exerts a monopoly of force. And the bottom line is that A.A. has taken over all aspects of “physician health” and is forcing doctors to accept doctrine that is perhaps helpful to a few, useless or unneeded for many, and harmful and sometimes lethal to others. This is unacceptable and it needs to be recognized.
“New Paradigm” of Zero-Tolerance and 12-step Spirituality Based on “success” of PHP to Move to Other Occupations and Kids.
To move this “new paradigm” to other populations they had to gain control of the doctors first. They have not only created a monopoly but buffered themselves from physicians who may disagree with what they are doing to others. This current system essentially stifles them.
The power, immunity and impunity this group yields over doctors was done silently and with no opposition. It was done by sequential public-policy steps. This is why anyone interested in civil liberties and human rights should recognize the menace this presents to society. The scaffold is in place and they are just adding more nooses. Just ask the airline pilots. They plan to impose similar systems on teachers, students and athletes.
And this is all spelled out in the ASAM White Paper on Drug Testing. What people need to realize is what is described therein is just a few public policy steps away from them. The only organization they have to convince is the organization that regulates any type of professional license, employment or benefit.
Gaining regulatory sway in the medical field and control over individual doctors was necessary to move this model to other populations. It is merely a stepping stone for things to come. It is only a few public policy steps from us to you.
This impacts us all. It enables control of research, public policy and public health. It is a system that suppresses dissent and shapes conformity. The FSPHP encourages the confidential referral of outliers.
The ASAM is pro-drug war and anti-medical marijuana. This essentially silences most doctors for fear of being recognized and being brought in. I know many doctors who will not even talk about it in public.
This is fixed doctrine and will not change.
That is why the ACLU and other groups who promote civil rights, those who are against the drug war and anyone involved in Medical Marijuana need to step in. These groups need to recognize the reality of who these people are, what they have planned and understand why they need to be stopped. They are currently not even in the public eye and by outward appearances they appear to be benign. In truth they are malignant and rapidly metastasizing without any symptoms.
In Order to Stop This the Following Must be Done
1) get a team of epidemiologists/statisticians to attack the “evidence-base” and “research” that the ASAM/FSPHP has used to support their claims (junk science, pseudoscience, success of 12-step, etc) and do a Cochrane type meta-analysis that will show there is little to no basis for it.
2) Demand accountability of the PHPs. Assign accountability to the Medical Societies and Departments of Public Health. Demand they be accountable for state-contractors with the Medical Boards (many of whom are complicit–in Massachusetts the Board of Registration in Medicine is simply an extension of the state PHP-i.e. Like-minds.
3) Demand that the criminal activity taking place within these PHPs be addressed by law enforcement.
4) Demand the Attorney General enforce the rampant Establishment Clause Violations occurring with mass 12-step coercion.
5) Identify and expose the backgrounds of many of the individuals involved including felons and double felons who reinvented themselves as “addiction medicine” doctors. Many of these individuals are repeat offenders with a history of manipulating the system who should have never had their licenses returned. In my opinion the ASAM/FSPHP/LMD rigged system is an example of corporate psychopathy. While corporate level psychopathy is estimated at around 3% the numbers here appear to be much higher if one looks at the moral disengagement, unethical decision making, lack of empathy and externalization of blame evident in their personal histories.
6) Correctly identify that this system of institutional injustice is responsible for the astronomical suicide rate in physicians. This is due to the fact that doctors who need help are not getting it for fear of being ensnared by the state PHP and those already ensnared are being subject to coercion, abuse, institutional injustice, degradation, dehumanization, delegitimization and civil and human rights abuses and that this is a public health emergency that needs to be addressed.
7) reveal the scam set up between the PHPs, rogue labs, and “PHP-preferred” assessment and treatment gulags.
8) show how this is only a few public policy steps from Doctors to Pilots to Teachers to students to kids. etc. etc.
This necessitates that we get the conversation going before it is too late.
AA and 12-step may be the best treatment for some individuals with addiction and substance use disorders. If it works for you, then more power to you. I have no problem with that.
What I do have a problem with is imposing and mandating 12-step treatment on others.
Under a dictatorship everything else becomes subordinated to the guiding philosophy of the dictatorship. Corresponding doctrine replaces professional guidelines, standards-of-care, and evidence based medicine. And unfortunately in the case of Addiction Medicine the guiding philosophy often trumps autonomy and ethics.
Inherent in the current chronic brain disease model of addiction is the importance of external control over individuals and political correctness and medicalization of addiction is allowing it. Demanding scientific literacy and discriminating good from bad science would prohibit what is occurring and In order to save American Medicine the problem needs to be clearly recognized or we will become a profession that is essentially defined by the impaired physicians movement.
Are Physician Health Programs (PHPs) above the law?
Unable to get law enforcement to take cognizance of reported abuse, many doctors I have spoken with believe that the actors involved are impervious to criminal liability. Complaints of fabrication and fraud involving PHPs and their affiliates to the police, the Attorney General and other law enforcement agencies have been given no credence, tabled or dismissed with little investigation.
Believing these agencies are deliberately ignoring credible complaints and the documentary evidence placed before them, some have concluded that state PHPs have been given the power to commit crimes with impunity and immunity.
PHPs are not above the law. It is by removing themselves from and blocking the usual routes of accountability and absolute operational control of the testing, assessment and treatment process that has enabled misconduct to remain hidden, unrecognized or excused. The crimes exist but they remain undetected, unnoticed and unpunished.
Removing Accountability
The essence of accountability is answerability which means having the obligation to answer questions regarding decisions and actions. This requires the transmission of information when it is requested. The accountable actor provides the information to the overseeing actors in a transparent manner.
Accountability also requires explanation and justification for the information provided. What was done and why? Standards, rules, regulations, codes, laws and other benchmarks are then applied by the overseeing actor to determine if the information provided was appropriate or inappropriate.
The availability and application of sanctions for illegal or inappropriate actions uncovered through answerability is also a necessary component of accountability. This is necessary to impose restraint on authority and power. Lack of enforcement of sanctions contribute to the creation of a culture of impunity.
The usual mechanisms that exist to impose restraint and create incentives for appropriate behavior and actions are absent. No outside oversight exists to limit their power or subject them to a set of rules. No regulation exists to curb abuse.
A Culture of Impunity
The authority accorded PHPs and the power they exercise exist in a culture of impunity.
No indications of abuse were found, a point brandished by the PHP as redeeming and proving no abuse was occurring. In actual fact it is an ominous finding that also relates to their apparent ability to violate the law.
The audit found no indications of abuse but that abuse could occur and not be detected because of an absence of due process for the complainant, excessive control of the complaint process by the PHP and absence of oversight by either the medical board or medical society. What this means is that a doctor with no power is making a complaint against an unsupervised agency with enough power to influence the investigation of a complaint against itself. The reason no indications of abuse were found is because the system is specifically designed to hide abuse. That is the intent.
Absence of transparency, regulation and oversight coupled with control of information enables both censorship and doctoring of records. Strict Confidentiality is enforced by HIPAA, peer review protection, and drug and alcohol confidentiality law.
PHPs are able to suppress and conceal criminal activity but they are also able to manufacture information designed to hide misconduct.
The North Carolina Audit found no objective selection criteria for the out of state assessment and treatment centers because none exist other than ideological mindset and monetary gain. The same facilities are used by most state PHPS. They are, in fact, mandated as they are the “PHP-preferred” facilities.
In 2011 The American Society of Addiction Medicine (ASAM) issued a public policy statement on coordination between PHPs, regulatory agencies, and treatment providers. recommending only “PHP-approved” treatment centers be used and the statement specifically excludes ‘non-PHP” recognized facilities.
What the Audit diid not discover is the medical directors of all of the “PHP-approved” facilities can all be seen on this list of Like-Minded Docs.It is a rigged game Every aspect of drug-testing, assessment and treatment is kept hidden and secret and within control of the PHP.
It is a rigged game in which they have removed themselves from all aspects of accountability. They have, in effect, manufactured a culture of impunity at our expense.
“PHP-Approved Attorneys”
My survey has revealed an additional factor stacking the deck and removing accountability from PHPs. The attorneys ostensibly representing doctors are also part of the racket.
A doctor referred to a PHP will be given a list of 3 or 4 attorneys by the PHP who are “experienced in working with the medical board.” What they do not tell you is that theses attorneys are hand-picked or cultivated to abide by the rules dictated by the PHP.
They will not “bite the hand that feeds” and any procedural, ethical or criminal misconduct by the PHP will not be addressed. Laboratory fraud, false diagnoses, and Establishment Clause violations are off limits.
The primary purpose of these attorneys is to enforce payment for laboratory fees and demand compliance with whatever the PHP demands. Their primary purpose is to keep doctors powerless under the PHP and prevent misconduct, including crimes, from being discovered.
The attorney pool is currently over-served by those serving two clients and most of those outside simply do not know enough about the “physician health” legal issues related to doctors. When they appear before the board it is as if they are a deer in the headlights. It is a new terrain where all due process and familiar protocol have been removed. Of course this was all facilitated by changes in administrative and medical practice acts orchestrated by the physician health movement “in the interests of protecting the public. This must be recognized and addressed.
Skilled negotiators and lawyers with administrative law experience would do well to consider representation for doctors before medical boards regarding “physician health” matters.
It is not that esoteric, complicated or difficult. As with the rest of the population, most have just not critically analyzed the issues behind the curtain.
Crooked Board Attorneys
Perhaps the lowest bottom feeders playing a role in this culture of impunity are those whose job is to ostensibly ensure that due process and fundamental fairness are followed. It is becoming quite clear that some of the state employed attorneys within medical boards control the flow of information by picking and choosing what is before the board for consideration. Many of these attorneys go on to represent doctors in cases before the board. If these attorneys acted as zealous advocates on behalf of their clients they would never get a referral again and because of this the system is plugged with an attorney pool unwilling to win but simply compromise.
From the late 15th century through the early 17th century a confederacy of “authorities” calling themselves demonologists assisted in identifying witches. Shaping ecclesiastical orthodoxy they set the standards that cooperating political authorities could follow in criminalizing, persecuting and punishing heretics.
Physician oversight of witch persecution was standard.
“Witch hunting,” wrote the historian Rossell Hope Robbins, “was self-sustaining and became a major trade, employing many people, all battening on the savings of the victims.”
Source: 
Disrupted Physician 