Anonymous referrals to state PHPs can result in loss of careers, families and even lives. I have heard from doctors targeted due to age , religion, sexual preference , nationality, political stance and appearance. Referred to the state PHP with an anonymous complaint of “alcohol on breath” or “anger issues,” these good doctors were removed from practice under the guise of protecting the public. By claiming a doctor has a “potentially impairing illness” and falsely labelling him or her with a substance use or behavioral disorder they are able to remove due process and remove any doctor from practice. The system is designed to give the appearance of legitimacy. It is not. The stories I have heard and continue to hear from doctors and medical students are as horrific as they are heartbreaking. I have heard from female doctors who refused to go out on a date with, spurned sexual advances and even been raped by other doctors who then reported them to their state PHP for damage control. I have heard from many doctors who discovered misconduct such as insurance or Medicare fraud who were promptly reported to their PHP and doctors who were reported by competitors for patients. I have heard from doctors reported out of jealousy, anger, racism and bigotry. Some of these storied can be seen on who have thwarted sexual advances and even been raped who were reported to their state “letters from those abused and afraid
My work in physician health reform has resulted in some significant gains. For example the Medscape article Physician Health Programs- More Harm Than Good? by Pauline Anderson was the result of Medscape Editor taking an interest in my tweets about a year earlier and contacting me and taking an interest in my blog. Physician Health Programs- More Harm Than Good? broke new ground as it was the first mainstream medical article critical of PHPs. This was read by British Medical Journal Editor Jeanne Lenzer and this led to “Physician health programs under fire.” In this article published in the BMJ she takes on the financial conflicts of interest, abuse and fraud in PHPs and the FSPHP’s response to direct and specific questions revealed what an irrational and illegitimate authority they are. They cannot provide direct and simple answers to direct and simple questions and remain tongue tied to this day.
By all counts their days are numbered and the articles mentioned above and more to come are the direct result of bottom-up activism. So too is a forthcoming audit by Massachusetts state Auditor Suzanne Bump whose office has already interviewed enough abused doctors to warrant an investigation which will hopefully look into the misconduct and fraud being perpetrated by the Massachusetts PHP in collusion with a specific group of attorneys within the medical board that blocks due process and conceals evidence to protect the PHP and harm innocent doctors.
It took 25 years for the FSPHP to rise. Let’s hope their demise is much quicker. They need to be named as the enemy and addressed on a state by state basis. We have dealt some significant blows and I would like to keep throwing some direct punches to the enemy but at this point it is getting difficult due to financial matters and I urgently need funding and support.
The need for allies and funding is urgent as time is critical. We have to expose this group as an illegitimate and irrational authority, expose their fraud and scams and expose the backgrounds of some of the individuals involved. Physician health programs should not longer be considered the elephant in the room. All you have to do is look at documentary facts and evidence to see what is happening and any ignorance at this point would have to be deemed willful ignorance. You cannot continue to ignore the obvious. To those within the PHPs and their sympathizers and apologists your silence speaks volumes To save American Medicine it is essential this be exposed, investigated and the perps held accountable. Silence is no longer an option.
Doctors are hurting and they don’t have the time to reach out.
Melinda Hakim MD—CEO of DoctorCPR.com—a medical career site that reaches over 500,000 medical professionals looking for jobs and resources.
I grew up in the ‘80s in awe of my dad who was a talented general surgeon. As a kid, I used to make rounds with him at the local hospitals in Los Angeles and had the opportunity to witness the overwhelming appreciation his patients had for his work. Our home was inundated with dozens of homemade baked goods, knitted scarves, gift baskets, and colorful “thank you” cards carefully prepared by his patients. He never complained about his job. Even if he had to leave a family event or wake up in the middle of the night to do a trauma case ― he was never resentful. He felt invigorated by saving thousands of lives. He was grateful to be well compensated for his sacrifices. He worked extremely hard (sometimes putting in over one hundred twenty hours a week), but he was able to do his work the way he felt was best since he ran his own private practice. He was beloved, respected, and couldn’t imagine pursuing any other profession that offered greater rewards.
Unfortunately times have radically changed. The best and the brightest simply don’t want to become doctors anymore. Physicians are burning out. They are leaving the profession. They are going bankrupt. They are selling their private practices to big hospitals. They are retiring early. We are facing a growing doctor shortage. Doctors no longer want to be a part of a health care system that doesn’t value them after decades of sacrifice, debt, and brutal training. Physicians now have the highest suicide rate of all professions.
Doctors no longer want to be a part of a health care system that doesn’t value them after decades of sacrifice, debt, and brutal training.
As an undergraduate at Harvard University, I was fortunate to be surrounded by some of the country’s most talented students. Back then (in the ‘90s), many of the students were on the fence as to whether to apply to medical school or join the dozens of consulting and financial companies that aggressively recruited us. After speaking to the new generation of Harvard seniors at networking events — I realize that they are no longer on the fence. Our country’s brightest graduates are simply not choosing to become physicians anymore.
Of course, we cannot deny that we need to focus on curtailing health care costs. But we absolutely cannot cut health care at the expense of alienating physicians. Our talent pool is rapidly shrinking. Nearly every month now, another one of my most brilliant physician colleagues (from Stanford, Yale, Johns Hopkins, UCLA, and Harvard) leaves his medical practice. This is real. This is palpable. These talented physicians are quitting to join startup ventures, “concierge” practices for the ultra-wealthy, pharmaceutical companies, or the ranks of corporate America where they feel they are better compensated and respected for their brain power and sacrifice.
Let’s look at some of the facts to help explain why becoming a physician in America is rapidly losing its appeal.
1. Private practice medicine is increasingly unsustainable due to rising overhead costs and declining reimbursements
2. Doctors spend more than two-thirds of their time on paperwork rather than taking care of patients
3. Medicare reporting incentives do not reward over 99 percent of doctors
4. The average debt doctors face after medical school is $183,000
5. Many new doctors earn barely more than minimum wage when accounting for hours worked per week
6. State governments are passing laws to limit the compensation of “out of network” physicians
Doctors are hurting, and they don’t have the time to reach out. They don’t have the time to lobby Congress. They are far too busy trying to help their patients and keep their practices afloat.
Our country needs to figure out solutions to help preserve and encourage physician autonomy― not continually restrict it. With rapidly increasing government reporting regulations, new plans to move away from fee-for-service payments, growing patient complaints about high deductibles, Medicare audits, more complex documentation mandates, increasingly complicated coding requirements, payment denials, time-consuming prior authorizations, expensive Electronic Health Records mandates….why would our country’s top talent go through years of debt and brutal training to face over-regulation and exhaustion?
We also need to continue to compensate physicians at a fair level that matches their skills, high level of education, and sacrifice ― not figure out ways to “bundle away” what they make. Should health care dollars be shifted away from those who are waking up in the middle of the night to save lives, who are spending countless hours researching cases after work, who are neglecting their families to study for re-credentialing boards, who are saddled with inexorable debt, or who are spending thousands of dollars to attend meetings all over the world to find out the best way to care for patients? Contrary to popular belief, physician reimbursements comprise only a small proportion of our country’s total health care expenditures.
Short-changing the individuals who are sacrificing everything to save lives will lead to the biggest threat to our nation’s health care system.
Whether we like it or not, we will all be patients at some point in our lives. What will our country be like if we have to rely on health care professionals who are not high achievers and have little incentive to go the extra mile for our care? Will we be satisfied seeing our doctor for five minutes because he will face a pay cut should he spend 20 minutes with you? Won’t we get frustrated when we cannot get an appointment with a quality internist for two months because so many great doctors have left their practices?
America, this is serious. The brightest minds in this country are running away from careers in health care. Many of our best doctors are being forced out of business. We must start an open dialogue with doctors ― the individuals who are the most influential in advancing our health care system. The success of our health care system absolutely depends on the caliber of talent we attract to become and remain our nation’s physicians. Short-changing the individuals who are sacrificing everything to save lives will lead to the biggest threat to our nation’s health care system.
Want to make health care great again? We must all reach out to doctors and do everything in our power to demonstrate that we value our country’s physicians before it’s too late.
Although no reliable statistics exist, anecdotal reports suggest an alarming upsurge in physician suicide. This necessitates a reappraisal of known predisposing risk factors such as substance abuse and depression but also requires a critical examination of what external forces or vulnerabilities might be unique to doctors and how they might be involved in the descent from suicidal ideation to suicidal planning to completed suicide.
Depression and Substance Abuse Comparable to General Population
Depression and substance abuse are the two biggest risk factors for suicide. The prevalence of depression in physicians is close to that of the general population 1,2 and, if one looks critically at the evidence based literature, substance abuse in medical professionals approximates that of the general population. Controlled studies using DSM diagnostic criteria suggest that physicians have the same rates (8-14%) of substance abuse and dependence as the rest of the population 3 and slightly lower rates compared to other occupations.4,5 Epidemiological surveys reveal the same. Hughes, et al.6 found a lifetime prevalence of drug or alcohol abuse or dependence in physicians of 7.9%, markedly less than the 14.6% prevalence reported in the general population by Kessler.7
State Physician Health Programs
Perhaps it is how physicians are treated differently when they develop a substance abuse or mental health problem.
Physician Health Programs (PHP) can be considered an equivalent to 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. Originally developed as “impaired physician” programs, the PHPs were created to help doctors who developed problems with substance abuse or addiction an alternative to disciplinary action by State Medical Boards. These programs existed in almost every state by 1980. Often staffed by volunteer physicians and funded 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 referrals. Most EAPs were developed with the collaboration of workers unions or some other group supporting the rights and interests of the workers. As there is no such organization representing doctors, PHPs developed in the absence of regulation or oversight. As a consequence there is no meaningful accountability.
“Because PHP practices are unknown to most physicians before becoming a client of the PHP, many PHPs operate out- side the scrutiny of the medical community at large. Physicians referred to PHPs are often compromised to some degree, have very little power, and are, therefore, not in a position to voice what might be legitimate objections to a PHP’s practices.”8
Noting that “for most physicians, participation in a PHP evaluation is coercive, and once a PHP recommends monitoring, physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine,” Knight and Boyd raise serious ethical and managerial questions about current PHP policies and practice including conflicts of interest in referrals for evaluation and treatment, lack of adherence to standards of care for forensic testing of substances of abuse, violations of ethical guidelines in PHP research, and conflicts of interest with state licensing boards.
Knight and Boyd recommend “that the broader medical community begin to reassess PHP’s as a whole” and that “consideration be given toward the implementation of independent ethical oversight and establish and appeals process for PHP clients who feel they are being treated unfairly.” 8 They also recommend the relationship of PHP’s between the evaluation and treatment centers and licensing boards be transparent and that national organizations review PHP practices and recommend national standards “that can be debated by all physicians, not just those who work within PHPs.”8 Unfortunately this has not happened. Most physicians have no idea that the state physician health programs have been taken over by the “impaired physicians movement.”
In his Psychology Todayblog, Boyd again recommends oversight and regulation of PHPs. He cites the North Carolina Physicians Health Program Audit released in April of 2014 that reported the below key findings:
As with Knight and Boyd’s paper outlining the ethical and managerial problems in PHPs, the NC PHP audit finding that abuse could occur and not be detected generated little interest from either the medical community or the media.
Although state PHPs present themselves as confidential caring programs of benevolence they are essentially monitoring programs for physicians who can be referred to them for issues such as being behind on chart notes. If the PHP feels a doctor is in need of PHP “services” they must then abide by any and all demands of the PHP or be reported to their medical board under threat of loss of licensure.
LDTs bypass the FDA approval process and have no meaningful regulatory oversight. The LDT pathway was not designed for “forensic” tests but clinical tests with low risk. Some are arguing for regulation and oversight of LDTs due to questionable validity and risk of patient harm.13
These same physicians are claiming a high success rate for PH programs9 and suggesting that they be used for random testing of all physicians.14
As with LDTs, the state PHPs are unregulated, and without oversight. State medical societies and departments of health have no control over state PHPs.
Their opacity is bolstered by peer-review immunity, HIPPA, HCQIA, and confidentiality agreements. The monitored physician is forced to abide by any and all demands of the PHP no matter how unreasonable-all under the coloration of medical utility and without any evidentiary standard or right to appeal.
The ASAM has a certification process for physicians and claim to be “addiction” specialists. This“board certification” is not recognized by the American Board of Medical Specialties and is not a recognized medical specialty. The goal of the ASAM is to be recognized as the experts in addiction medicine with the consensus expert opinion based on the 12-step prohibitionist brain disease model. The ASAM has aligned itself with a number of inpatient drug treatment centers (Hazelden, Talbott, Marworth, Bradford,etc) and are heavily funded by the drug testing industry. It is in fact a “rigged game.”
State PHPs are non-profit non-governmental organizations and have been granted quasi-governmental immunity by most State legislatures from legal liability.
By infiltrating “impaired physician” programs they have established themselves in almost every state by joining, gaining power, and removing dissenters. Groupthink and 12-step indoctrination are the goals. By advertising as advocates for doctors who are “caring,” “confidential resources,” “giving help,” and advocating for “colleagues in need” the outward appearance is one of benevolence.
The biggest obstacle is that this system allows them to throw the normal rules of conduct under the imperative of a higher goal assumed to trump all other consideration. Those outside of programs either defend or ignore the reports of ethical and criminal violations, complacent in their trust of these “experts” claiming they are just helping sick doctors and protecting the public.
With no oversight or regulatory body involved this is all done with impunity, immunity, and undercover. They use the accusation of substance abuse as an indication to disregard the claims of the accused. The physician is left without rights, depersonalized, and dehumanized. The imposition of confinement, stigmatization, lack of oversight of the organizations, peer-review protected confidentiality, and lack of procedural protection is a one-way train to hopelessness and despair.
By establishing a system that of coercion, control, secrecy, and misinformation, the FSPHP is claiming an “80% success rate” 15and deeming the “PHP-blueprint” as “the new paradigm in addiction medicine treatment.
The ASAM/FSPHP had a major influence on the DSM-V where drug abuse and dependence are no longer separate entities. They are also working behind the scenes to get legislation to randomly drug test all physicians.
They are now after the “disruptive physician” and the evidentiary criteria are fairly low and red flags include “deviating from workplace norm in dress or conduct” and being tardy for meetings.
They have identified “the aging physician” as a potential problem because “as the population of physicians ages,””cognitive functioning” becomes “a more common threat to the quality of medical care.”
The majority of physicians are unaware that the Federation of State Medical Boards House of Delegates adopted an updated Policy on Physician Impairment in 2011 that uses addiction as an example of a “potentially impairing illness.” According to the Federation of State Physician Health Programs …”physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years. This is a critically important distinction. Illness is the existence of a disease. Impairment is a functional classification and implies the inability of the person affected by disease to perform specific activities.”
“Process addiction” was added as a potentially impairing illness including compulsive gambling, compulsive spending, compulsive video gaming, and “workaholism.” According to the FSPHP “the presence of a process addiction can be problematic or even impairing in itself, and it can contribute to relapse of a physician in recovery. As such, process addictions should be identified and treated.” They define three levels of relapse including the novel “relapse without use.”
Bullying, Helplessness, Hopelessness and Despair
Perceived helplessness is significantly associated with suicide.16 So too is hopelessness, and the feeling that no matter what you do there is simply no way out17,18 Bullying is known to be a predominant trigger for adolescent suicide19-21 One study found that adolescents in custody who were bullied were 9.22 times more likely to attempt suicide than those were not bullied.22
Heightened perceptions of defeat and entrapment are known to be powerful contributors to suicide.23,24 The “Cry of Pain” model 25,26 specifies that people are particularly prone to suicide when life experiences are interpreted as signaling defeat which is defined as a sense of “failed struggle” or loss of social position and resources.. The person is unable to identify an escape from or resolution to a defeating situation, a sense of entrapment proliferates with the perception of no way out, and this provides the central impetus for ending ones life.
There is also evidence that rescue factors such as social supports may play a role in preventing suicide. These rescue factors act buffers to protect against suicide in the face of varying degrees of life stress.27,28 The study of female physicians revealed meetings to discuss stressful work experiences as a potential protective factor, 29 and support at work when difficulties arose appeared to be a protective factor for the male physicians.30 Research involving Finnish physicians found that control over one’s work and organizational justice were the most important determinants of work-related wellbeing.31,32 Organizational justice is related to fairness and refers to an individuals perception of an organizations behaviors, decisions, and actions and how these influence one’s own attitudes and behaviors and has been identified as a psychosocial predictor of health and wellbeing3334 Low organizational justice has been identified as a notable risk factor for psychological distress and depression.35,36
A recent report indicates that job stress, coupled with inadequate treatment for mental illness may play a role in physician suicide..
Using data from the National Violent Death Reporting System the investigators compared 203 physicians who had committed suicide to more than 31,000 non-physicians and found that having a known mental health disorder or a job problem that contributed to the suicide significantly predicted being a physician.1
Physicians were 3.12 times more likely to have a job problem as a contributing factor. In addition, toxicology testing showed low rates of medication treatment. The authors concluded that inadequate treatment and increased problems related to job stress are potentially modifiable risk factors to reduce suicidal death among physicians.
They also warned that the database used likely underestimated physician suicides because of “underreporting and even deliberate miscoding because of the stigma attached.”
I can think of nothing more institutionally unjust than an unregulated zero-tolerance monitoring program with no oversight using unregulated drug and alcohol testing of unknown validity.
We have heard of numerous suicides due to these institutionally unjust programs. Three doctors died by suicide in Oklahoma in a one month period alone (August 2014). All three were being monitored by the Oklahoma PHP. I went to an all boys high-school of less than 350 students yet a classmate a couple years ahead of me died by suicide a few months ago. He was being monitored by the Washington PHP. His crime? A DUI in 2009–a one-off situational mistake that in all likelihood would never have recurred. But as is often the case with those ensnared by state PHPs he was forced to have a “re-assessment” as his five-year monitoring contract was coming to an end. These re-assessments are often precipitated by a positive Laboratory Developed Test (LDT) and state medical boards mandate these assessments can only be done at an out-of-state “PHP-approved” facility. Told he could no longer operate and was unsafe to practice medicine by the PHP and assessment center he then hanged himself. And at the conclusion of Dr. Pamela Wible’s haunting video below are listed just the known suicides of doctors; many were being monitored by their state PHPs–including the first name on the list– Dr. Gregory Miday.
None of these deaths were investigated. None were covered in the mainstream media. These are red flags that need to be acknowledged and addressed! This anecdotal evidence suggests the oft-used estimate of 400 suicides per year (an entire medical school class) is a vast underestimation of reality—extrapolating just the five deaths above to the entire population of US doctors suggests we are losing at least an entire medical school per year.
As physicians we need to demand transparency, oversight, regulation and auditing by outside groups. This is a public health emergency.
To wit:
They first came after the substance abusers and I did not speak out because I was not a substance abuser.
They then came for those with psychiatric diagnoses and I did not speak out because I was not diagnosed with a psychiatric disorder.
They then came after the “disruptive physician” and I did not speak out because I was not disruptive.
They then came after the aging physician and I did not speak out because I was young.
They then came after me and there was no one else to speak out for me.
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Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. The American journal of psychiatry. Dec 1999;156(12):1887-1894.
Brewster JM. Prevalence of alcohol and other drug problems among physicians. JAMA : the journal of the American Medical Association. Apr 11 1986;255(14):1913-1920.
Anthony J, Eaton W, Mandell W, al. e. Psychoactive Drug Dependence and abuse: More Common in Some Occupations than in Others? Journal of Employee Assistance Res.1992;1:148-186.
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Hughes PH, Brandenburg N, Baldwin DC, Jr., et al. Prevalence of substance use among US physicians. JAMA : the journal of the American Medical Association. May 6 1992;267(17):2333-2339.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry. Jun 2005;62(6):593-602.
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DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: Physicians’ Health Programs. Journal of Medical Regulation. Mar 2010;95(4):10-25.
Skipper GE, Weinmann W, Thierauf A, et al. Ethyl glucuronide: a biomarker to identify alcohol use by health professionals recovering from substance use disorders. Alcohol and alcoholism.Sep-Oct 2004;39(5):445-449.
Skipper GE, Thon N, Dupont RL, Baxter L, Wurst FM. Phosphatidylethanol: the potential role in further evaluating low positive urinary ethyl glucuronide and ethyl sulfate results.Alcoholism, clinical and experimental research. Sep 2013;37(9):1582-1586.
Skipper GE, Thon N, DuPont RL, Campbell MD, Weinmann W, Wurst FM. Cellular photo digital breathalyzer for monitoring alcohol use: a pilot study. European addiction research.2014;20(3):137-142.
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McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. Bmj. 2008;337:a2038.
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Disrupted Physician 