Physician Health Programs (PHPs): The Ford Granada of Employee Assistance Programs (EAPs) and Stuntman Mike is at the wheel.

PHPs are essentially Employee Assistance Programs (EAPs)  for doctors, nurses and other health care professionals.    The vast majority of people know little or nothing about Physician Health Programs (PHPs) but they should. The grand plan is expansion to other occupations under what they are calling the “New Paradigm.”  Deemed “professional health programs”they don’t even have to change the acronym.

Physician Health Programs (PHPs) are being called  the “gold-standard” for EAPs.   Claims of unparalleled success are being used to promote PHPs to other populations as a “replicable model of recovery.”  Drs. Robert Dupont and Gregory Skipper are promoting PHPs as “A New Paradigm for Long-Term Recovery”  claiming an 80% success rate in doctors.   An article entitled “What Might Have Saved Philip Seymour Hoffman” claims the actor may still be alive today if he had access to one of these programs  and comments they “ought to be considered models for our citizenry” and the “best evidence-based addiction treatment system we have going.”

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Mercedes 450 SE

Such is not the case.  What is being touted as “gold standard” and “cream of the crop” is on closer inspection iron pyrite and curdled spit up.  I am reminded of the commercials comparing a Granada to a Mercedes when I was a kid.  I remember these commercials  well as I couldn’t wrap my head around them.  In one, as I remember it, two couples arrive at their parked adjacent cars with keys in hand. The Mercedes tries to open the door of the Granada and vice versa.  How is this scenario even possible I remember thinking. Was it a bar they just came out of  and they are drunk?     Is this related to “this is your brain on drugs?  Do they have some sort of memory problem like that old guy in the miracle ear commercial who looks confused when the waiter asks his preference for salad dressing and his companion yells “he said do you want Italian, thousand island or vinaigrette?”  How could anyone in a right state of mind  confuse a Ford Granada with a Mercedes 450SE?

 

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Granada


 

PHPs are not the Mercedes of EAPs but the jalopy with no breaks and broken steering of EAPs with Stuntman Mike from Quentin Tarantino’s Death Proof at the wheel.

Like smoke alarms and air bags,  EAPs are not in the forefront most peoples minds until they need them and like smoke alarms and air bags they usually work just fine for most people. Discerning and scrutinizing one’s EAP is not a common thing.  If your EAP was replaced by the PHP model you probably wouldn’t even know it. That is why this needs to be on your radar. Caveat emptor.  Forewarned is forearmed.

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Stuntman Mike

The dark underbelly of these programs are just beginning to be exposed in the general medical community.  See Pauline Anderson’s  Physician Health Programs- More Harm Than Good?  published on Medscape and  BMJ Editor Jeanne Lenzer’s “Physician health programs under fire” for an overview.  Look in the comments section for the horror stories.

Physician Health Programs  (PHPs) claimed “gold standard” for addiction treatment. “80% success rate” being used to promote “new paradigm” to other populations. 

1. National Physician Health Program Blueprint Study Publications List

2.  Setting the Standard for Recovery: Physicians’ Health Programs

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The claim of an 80% success rate is a 2009 study published in the Journal of Substance Abuse Treatment entitled  Setting the Standard for Recovery: Physicians’ Health Programs and authored by Robert Dupont,  A. Thomas McLellan,  William White, Lisa Merlo and Mark Gold.  This  study is the cornerstone of the “PHP-blueprint.” It is the very  foundation on which everything else is based, a Magnum opus used to lay claim to supremacy that has been endlessly repeated and rehashed in a plethora of self-promotion and treatment community blandishment.

To date there has been no academic analysis of the “PHP-Blueprint.”    There has been no Cochrane type analysis or critical review.    There has been no opposition to its findings or conclusions which are paraded as fact and truth without challenge or question and there is a general lack of concern from those both within and outside the medical profession.

One major problem with this claim of an 80% success rate is that close to 80% of those coercively enrolled in these programs do not fit the diagnostic criteria for substance use disorder or any other psychiatric diagnosis. In reality these programs cause far more harm and if we really looked at the impact of these programs and compared them to traditional EAPs the success rate would be abysmally low.


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Make Medicine Great Again!   Please Donate and Help Drain this Swamp!

https://www.gofundme.com/PHPReform


The Expansion of Physician Health Programs (PHPs) to Other Populations

1.  Although these programs claim to help doctors they may actually be harming many and contributing to suicide.

2.  The plan is to greatly expand these programs to other populations and you could be next.

In 2012 Robert Dupont delivered the keynote speech at the Drug and Alcohol Testing Industry Association annual conference and described a “new paradigm” for addiction and substance abuse treatment and proposed expansion of this paradigm to other populations including workplace, healthcare, and schools.

It is therefore critical that the “PHP-blueprint” be examined using critical reasoning and evidence base.   All of this needs to be assessed in terms of legitimacy and intent.

Lack of Evidence-Base and Conflicts of Interest

A  cursory  analysis of the study on which this success rate is based reveals very little evidence base.

The claim of 80% success rate in physicians is based on Setting the Standard for Recovery: Physicians’ Health Programs is unfounded.  The study is a poorly designed using a single data set (a sample of 904 physician patients consecutively admitted to 16 state PHP’s).

It  is non-randomized and non-blinded rendering the evidence for effectiveness of the PHP treatment model over any other treatment model (including no treatment) poor from a scientific perspective.  The study contains multiple flaws in both reasoning (type I and type II errors) and statistical analysis that render its conclusions invalid.

In addition the impact of undeclared but substantial financial conflicts-of-interest (including funding by drug testing and addiction treatment industries) and personal ideological biases (including personal 12-step recovery from addictions) in the authors of this study also needs to be considered.

Moreover the misdiagnosis and over-diagnosis of addiction in physicians in this paradigm  incentivized by lucrative self-referral dollars for expensive 90-day treatment programs is a significant factor.

False Endpoints and High Mortality Rate

The mean age of the 904 physicians was 44.1 years. They report that 24 of 102 physicians were transferred and lost to follow “left care with no apparent referral.”

What happened to them? These are physicians with multiple identifiers (state license, DEA, UPIN, etc) not transient drifters.

More importantly what happened to those 48 who were reported to the Medical Board for noncompliance and had their licenses revoked–that would be the critical time when this population would be at most risk for completing a suicide. That would be when hope was lost and the coerced physician, knowing that the fight was over, would take that step.

The outcomes they used were the last reported status of the PHP participant enrolled in the program.   Measuring success of program completion in doctors compared to the general population is meaningless as the short-term outcomes are quite different in terms of the external consequences imposed.   The consequence of not completing a PHP is the invariably career ending.    So what happened to the 24 of who “left care with no apparent referral,” the 85 who “voluntarily stopped or retired,” and the 48 who “involuntarily stopped or license revoked.”

Whether you leave a PHP voluntarily, involuntarily, or with no apparent referral it is the end game and your career is over.  Comparing this to other populations where the consequences of failing to complete the program are not so final is inappropriate.     Claiming superiority over programs with a 40% success rate is unfounded because for most of those people the consequences are not so final and may mean nothing more than an increase in testing frequency.

The big question is what happened to the 157 physicians who left or stopped?  How many of them killed themselves. With an average age of 44 there were  6 reported suicides 22 deaths, and another 157 no longer doctors.  I would venture to say the number of suicides is a lot higher than they claim.  But using the last recorded PHP status as the final outcome obfuscates this.

Due to the severity of the consequences a 20% failure rate is quite concerning. This is of particular concern because many doctors (if not most) monitored by PHPs are not addicts.

As noted above, PHPs are essentially Employee Assistance Programs (EAPs)  for doctors. Most EAPs, however, were developed in the presence of trade unions and other organizations working on behalf of the best interests of the employee. This collaborative effort led to EAPs that were more or less “organizationally just” with procedural fairness and transparency.

Imposed 12-step ideology and use of non-FDA Approved Drug and Alcohol Testing

No such organizations exist for doctors.   Due to the absence of oversight and accountability  PHPs have been able to use non-FDA approved laboratory developed tests of unknown validity on doctors without any opposition.

The distinction between professional and private life as a fundamental value of our society  and the importance of this boundary was also upheld by these groups.

In the PHP paradigm no procedural fairness or transparency exists and the boundary between professional and private life has eroded.

PHPs impose 12-step ideology on all doctors referred to these programs.   State Medical Boards  enforce this in violation of the Establishment Clause of the 1st Amendment yet there is little recourse for doctors as they are threatened with non-compliance and loss of licensure.

Selling the PHP Paradigm

The use of 12-step  is most likely not ideologically driven but profit driven.

Abstinence based 12-step programs justify the use of frequent drug and alcohol testing with ongoing lifelong assessment and treatment.    As with drug-courts,  PHPs provide a lucrative model to the drug and alcohol testing, assessment and treatment industry.

The plan to expand this to other populations is outlined in the ASAM White Paper.

Screen Shot 2017-03-08 at 7.29.21 PMThis concerns all of us.  The first step needs to be a critical appraisal of  Setting the Standard for Recovery: Physicians’ Health Programs,  the foundation of their claims of an 80% success rate and a conflict-of-interest analysis of its authors.  The legitimacy of the study and its claims needs to be questioned.

It does not take a Cochrane review to see that the emperor has no clothes.  This is not difficult. It is straightforward and simple.

As an illegitimate and irrational authority it is necessary that this opinion remain unchallenged. We need to challenge it.

Historical, political, economic and social analysis reveals that the “PHP-blueprint” is a false-construct built on circumnavigation and obfuscation.  An evidence-based scrutiny of the literature would reveal it to be invalid and of little probative value.

But if  nobody speaks up it is inevitable that they will expand the “PHP blueprint”  to other employee assistance programs and schools.

This is not just about doctors.  You too are at risk for coercion, control, conformity and forced adherence to a  lifetime of abstinence and 12-step indoctrination and if you do not speak up now it won’t be a risk but a certainty.


PHYSICIAN OR PROFESSIONAL HEALTH PROGRAM SURVEY

Professional Health Program (PHP) Survey

Please click on the link below and complete the following survey if you have been monitored or are being monitored by a PHP.

Professional Health Program (PHP) Survey

This is a confidential survey. If you have concerns about anonymity please create an alternative alias email address (this video shows you how to create an alias G-mail address), then use the alias email address as your “name” for future correlation.

scotty

MD Sues NC Medical Board/Physician Health Program-A Prototypical Case

A prototypical case involving PHP and Medical Board. PHPs’ integrity varies state by state depending on:

1. How entrenched the FSPHP is in the state PHP

2. Whether that state’s Medical Board has become a partner in PHP’s crimes.

It is very curious that states who have had a Medical Director who has also been President of the Federation of State Physician Health Programs seem to be the worst of the violators.

Based on over 200 responses I have received on my PHP survey [PHP Survey], North Carolina, Florida, Massachusetts and Washington State are physician career destroyers whereas West Virginia seems relatively unscathed (although I have learned that the FSPHP has been attempting to impose its “PHP-Bluprint” on the Board with some resistance.

What you see here is a classic case. Physicians and med schools urgently need to become aware and take a stance of resistance to these abuses. Wouldn’t you find this distressing – that only over the past [3 years], I have heard this same story from medical students to doctors in their 80s – through detailed and lengthy conversations – over and over again.

The identical same patterns of PHPs and medical boards acting in collusion emerge. As much as I don’t want to believe it, PHPs, acting in tight collusion with their sibling agencies, the medical licensing boards, have expanded their power and uniformly deprived physicians (and med students!) of their due process rights, against all understandings of appropriate powers with which they were originally vested.

No accountability exists as they have removed due process and freedom of choice.  The PHP controls every aspect of the assessment and monitoring process with absolutely no oversight.  As the North Carolina state PHP audit revealed, there is no oversight from the medical society or medical board.  In addition the assessment and treatment centers and drug-testing labs have no meaningful regulation.  No oversight or regulation of the multiple non-FDA approved laboratory developed tests (LDTs) of unknown validity exist.

As a power accountable to no one, PHPs have become predators who not only stalk and victimize doctors but harm the very public they were supposed to protect!

These PHPs, along with the cozy relationships with medical licensing boards, need to be confronted, as Dr.Manion has done, and dissembled and then rebuilt into accountable organizations state by state.

It seems apparent from my research that the FSPHP is not only an illegitimate but an irrational and opportunistic authority exclusively representing the interests of the medical board and the drug and alcohol testing, assessment and treatment industry.

PHPs are being promoted as a “gold standard”  and replicable model by the American Society of Addiction Medicine (ASASM), a “self designated practice specialty” not recognized by ABMS. The ASAM White Paper on Drug Testing  is recommending widespread application of the PHP model in other populations.  The FSPHP arose from ASAM state chapters and their intimate relationship with the Drug and Alcohol Testing Industry Association (DATIA) is as tight as thieves.

In addition the medical directors of every one of the “PHP-approved” assessment and treatment programs are not only ASAM doctor but belong to a self-described 12-step group called “like-minded docs.”

Like a treatment industry of the Taliban, they play on the dangers of alcohol use. To some of us, they are little more than prohibitionist profiteers and dimwitted “addiction addicts” who have “recovered (even in the sense of the word that would suggest that they have “recovered” [retrieved and had destroyed] and “re-covered” their felonious past) and are now in firm control of the gates to the rehab farm. As evidenced from previous articles, narcissistic and psychopathic personality disorders abound in this PHP movement. Physicians need to wake up and confront and dismantle this Frankenstein the state PHPs have become. PHPs urgently need accountability and answerability, not more immunity and secrecy. Here we are in a time of great physician scarcity and PHPs and Boards are eliminating physicians with utterly no accountability.

Link to complaint obtained via Pacer:  Manion v NC Medical Board and PHP

2016-02-09 DOC 2 Corrected Complaint and Demand for Jury Trial

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A lawsuit filed by a physician against the North Carolina Physicians Health Program (NCPHP) claims loss of significant and potential earnings as well as public humiliation, irreparable harm to his professional reputation, and severe emotional distress.

Kernan Manion, MD, a practicing psychiatrist for some 30 years, is suing the NCPHP as well as the North Carolina Medical Board (NCMB), the North Carolina Medical Society, several past and present medical board officials, and current NCPHP Chief Executive Officer Warren Pendergast, MD.
The suit alleges “arbitrary and unlawful application of summary suspension procedures” resulting from “intentionally and/or negligently abusive practices” and other common law, statutory, and constitutional violations.

In court documents, Dr Manion, who has never before been disciplined by any licensing entity in any state and has never been found liable for malpractice, said he was forced to inactivate his medical license in February 2013 after “wrongful and flawed” diagnoses conducted by the NCPHP and its agents.

He describes the experience with the PHP as “a Kafkaesque nightmare.”

According to events outlined in a statement of facts, Dr Manion, who maintains he has never suffered from mental or emotional health problems or from alcohol, drug, or any other form of substance abuse, was dismissed in September 2009 from his position as a civilian contracted psychiatrist with the Deployment Health Center at Naval Hospital Camp Lejeune.

He had raised concerns, which he described as “whistleblowing,” regarding what he felt was deficient care of active duty service members with posttraumatic stress disorder.
Dr Manion brought claims against his employers, alleging retaliatory discharge, after which he says he was harassed and followed, prompting him to contact local police.

Shortly thereafter, Dr Manion said he was notified by the NCMB that someone at the police department had expressed “concern” about his mental health and that the NCMB had opened an investigation.

Malice?

On his own initiative, Dr Manion obtained a comprehensive psychological evaluation, which, he said, concluded that he did not have a delusional disorder and that recommended that he be permitted to retain his unrestricted medical license. Despite this, says the statement, the NCMB ordered Dr Manion to undergo an assessment by the NCPHP, which he did.

That assessment, carried out by Dr Pendergast, concluded “wrongly and negligently or intentionally and with malice” that Dr Manion was mentally ill and in doing so, “relied upon only the unofficial information provided by the police office, reviewed no clinical records, and failed to interview any collateral sources as is required in such evaluations.”

Dr Pendergast apparently then recommended that Dr Manion complete a comprehensive psychological evaluation at an out-of-state mental facility. Such facilities, says the court document, often charge thousands of dollars and require that physicians incur costs for travel and spend multiple days, if not months, away from their medical practice.

According to the court document, PHPs have been criticized for “rampant fraud and abuse” and that the NCPHP and NCMB are “riddled with conflicts of interest.”

An audit carried out by the North Carolina state auditor, and reported by Medscape Medical News, found no abuse by the NCPHP but did state that there were “multiple conflicts of interest inherent in the relationships between NCPHP and its preferred assessment and treatment centers and an alarming potential for abuse and violations of the process rights by NCPHP.”

The filed court document also states that there was “no reasonable basis” for the NCMB and the NCPHP to conclude that Dr Manion was impaired and unfit to practice medicine, “conclusions that forced him into a Kafkaesque nightmare that ultimately concluded in the loss of his license and his livelihood.”

Dr Manion said he proposed an alternative in-state evaluation, but in January 2012, “based wholly” on its “intentionally flawed diagnosis and recommendation,” the NCPHP again voted to order Dr Manion to undergo evaluation and treatment at an out-of-state facility.

According to the court files, the NCMB brought formal charges against Dr Manion that alleging he failed to cooperate with the NCPHP. Dr Manion claims he submitted to yet another evaluation to assess his mental health status against his will.

This evaluation concluded that he was delusional “based chiefly on information…received from Dr Pendergast about Dr Manion and not based on medical evidence or corroborative fact checking,” according to the statement.

“Frightened and Threatened”

Told to inactivate his license and immediately resign from his position as medical director at a clinic or have felony charges brought against him for practicing without a license, Dr Manion said he was “frightened and threatened” into inactivating his license on February 9, 2013.

In trying to reactivate his license in December 2014, Dr Manion agreed to submit to another evaluation, which concluded that he “is not delusional, that he is fit to practice medicine, and that the prior evaluations conducted by or at the direction of NCPHP…are flawed and incorrect,” says the statement. It adds that the assessor believed that Dr Manion’s “display of anxiety, distress and intensity is proportionate to the circumstances which have occurred.”

Despite this, Dr Manion said the NCMB wanted him to submit to another NCPHP evaluation in order to activate his license, but he objected to undergoing another assessment.

As a result of these events, Dr Manion claims he has suffered, among other things, loss of significant earnings and potential earnings and the burden and cost of defense against unwarranted action, as well as “public humiliation, irreparable harm to professional reputation, and severe emotional distress.” The suit also claims one of his former patients committed suicide because of interruption of highly specialized care.

The broadly applied policies and practices of the NCPHP “draw unimpaired licensees into a Kafkaesque ‘damned if you do, damned if you don’t’ catch-22 scenario that almost always ends in severe and underserved harm,” says the statement.

The document estimates that Dr Manion has suffered and continues to suffer damages “in excess of $75,000.”

The suit was filed February 8 in the US District Court, Eastern District of North Carolina, Western Division.

“Unprofessional Conduct”

Medscape Medical News contacted the NCMB for comment, and spokesperson Jean Fisher Brinkley provided the following statement: “NCMB is aware of Dr Manion’s lawsuit but cannot discuss it as the matter is pending litigation.”

However, Brinkley provided a link to public documents on the NCMB website related to the disciplinary case at issue in the lawsuit, which includes “a detailed account of the Board’s concerns regarding Dr Manion.”

According to the October 10, 2012, Notice of Charges and Allegations, the NCMB outlined two charges against Dr Manion: “failure to respond reasonably to a Board inquiry” and “unprofessional conduct.”

On the first charge, the NCMB claims that in failing to undergo an assessment at Acumen Assessments Inc, which is the recommended out-of-state treatment facility, as required by a Board order issued February 27, 2012, Dr Manion’s conduct “constitutes a failure to respond, within a reasonable period of time and in a reasonable manner,” to inquiries from the Board concerning any matter affecting the license to practice medicine, within the meaning of the state’s general statutes.

On the second charge, the NCMB states that Dr Manion’s failure to undergo an assessment at Acumen, as required by the Board, “constitutes unprofessional conduct, including, but not limited to, departure from, or the failure to conform to, the ethics of the medical profession and is the commission of an act contrary to honesty, justice or good morals” within the meaning of the state’s general statutes.

According to the NCMB, for both charges, there are grounds under the general statutes for the Board “to annul, suspend, revoke, condition or limit Dr Manion’s license” to practice medicine.

In addition, the legal notice describes concerns about Dr Manion from a single police officer who reported them to the NCMB in 2010.

According to the NCMB, the police officer was subsequently interviewed by a Board investigator. According to an account of this interview, the officer alleged that Dr Manion spoke to the Wilmington Police Department chief of police in November 2010 and expressed concerns that he was being followed and that a tracking or listening device had been placed on his car.

According to the NCMB report, the officer outlined other instances that were cause for further concern.

Medscape Medical News contacted the NCPHP. However, Dr Pendergast declined to comment, noting that the “NCPHP cannot comment on this matter as it is pending litigation.”

 

Physician Health Programs: The Need for Transparency and Accountability

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Accountability, or answerability,  is necessary to prevent abuse and corruption.  This requires both the provision of information and justification for actions.  What was done and why?

Professional guidelines and standards of care, ethical codes of conduct and the law are all objective benchmarks that can be used to assess the actions and decisions of others.  In any free society this necessitates the existence of organizations of truly independent opinion capable of standing in this judgment.

State PHPs are Non-Governmental Organizations (NGOs) over which the state health department has no supervisory oversight.  There is no regulation, no transparency and no accountability.  There is no public scrutiny and they police themselves.

In Ethical and Managerial Considerations Regarding State Physician Health Programs Drs. John Knight and J. Wesley Boyd call for greater oversight and scrutiny of PHPs by the medical community at large.   They recommended periodic auditing, national standards and regulation.  They also attempted to convince the Massachusetts Medical Society to implement changes at PHS where they served as Associate Directors with over two decades of collective experience.

These efforts to promote transparency and accountability at both local and national levels, however,  fell on deaf ears.

State PHPs have systematically removed those not conforming to groupthink.  Threatening them with litigation if they breached “peer-review” statutes and confidentiality agreements has effectively silenced them from reporting any misconduct, abuse or even crimes they may have witnessed.

In Massachusetts John Knight was removed in 2009 and J. Wesley Boyd in 2010.  In Ethical and Managerial Considerations Regarding State Physician Health Programs  they comment “if a PHP highlights a physician as particularly problematic, the evaluation center might–whether consciously or otherwisetailor its diagnosis and recommendations in a way that will support the PHP’s impression of that physician.”  So too will the clinical laboratories.  

How is this any different from the case of Dr. Farid Fata, the Michigan oncologist who intentionally diagnosed healthy patients with cancer so he could charge them for unneeded chemotherapy?  The U.S. Attorney called it the “most egregious” case of health care fraud ever. His acts may have contributed to one patient death.   The institutional injustice of the PHP system is causing countless deaths of physicians.

To consciously “tailor” a diagnosis is fraud.  To tailor a diagnosis of substance use disorder or any other psychiatric diagnosis is the political abuse of psychiatry.  Misrepresentation, dishonesty, deception, and distortion play no role in the Profession and Guild of Medicine.  To do so violates the basic moral principles of Medical Ethics–Autonomy, Beneficence, Non-Maleficence and Justice.

The “PHP-approved” assessment and treatment centers are all staffed by doctors of “like-mind.”  It is a rigged game.

An audit of the North Carolina PHP found essentially no oversight from the Medical Board or Medical Society.  The audit found that “abuse could occur without being detected,” and this is by design.  By removing and blocking the provision of information necessary for accountability, restricting the liberties and freedoms of physicians, and increasing their power and control they have erected a framework of hidden abuse.

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The situation in North Carolina is standard operating procedure for PHPs under the Federation of State Physician Health Programs (FSPHP).  It is not the exception but the rule.

While outspoken in denouncing what they regard as unethical and unprofessional behavior by other doctors, they are resistant to apply even the most minimal standards to their own activities.

To whom are the PHPs accountable? Whom do they represent? These are legitimate concerns.


 

PHYSICIAN OR PROFESSIONAL HEALTH PROGRAM SURVEY

Professional Health Program (PHP) Survey

Please click on the link below and complete the following survey if you have been monitored or are being monitored by a PHP.

Professional Health Program (PHP) Survey

This is a confidential survey. If you have concerns about anonymity please create an alternative alias email address (this video shows you how to create an alias G-mail address), then use the alias email address as your “name” for future correlation.

scotty

Reefer Mad and Power Hungry

Link to article:https://digboston.com/reefer-mad-and-power-hungry/

Please comment on DigBoston website

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In 2013, Dr. Steven Adelman of Physician Health Services (PHS)—a powerful nonprofit founded by the Massachusetts Medical Society that provides help to residents and doctors struggling with substance abuse problems—published a now-infamous article on KevinMD titled, “Against the Medicalization of Marijuana,” in which he lambasted the 63 percent of voters who supported the Massachusetts initiative petition to eliminate criminal and civil penalties for marijuana by qualifying patients with diagnosed debilitating medical conditions. Blasting the mandate for the Department of Public Health to “operationalize the so-called medicinal use of cannabis in the Commonwealth,” Adelman wrote, “the community of physicians has been scratching its collective head and wondering, ‘What in the world are we going to do about patient requests to become certified to purchase, or grow, so-called medical marijuana?’”

In his report, Adelman noted the alleged perilousness of addiction, withdrawal, and cognitive impairment related to cannabis, and warned of the potential onslaught of underground entrepreneurs waiting to capitalize. Adelman, a so-called addiction expert at Harvard Vanguard, predicted a floodgate of unscrupulous profiteers diverting “massive” amounts of this “valuable” “addictive” “substance” to “non-patients,” and guessed that the health and well-being of the “greater public will be jeopardized for the relief of a few.”

As noted by many activists but ignored by all but niche marijuana media, in another instance, Adelmanblamed the bombing of the Boston Marathon on “marijuana withdrawal.” One of his cohorts, Dr. Robert Dupont of the Institute for Behavior and Health, rode a similar bandwagon, arguing that Dzhokhar Tsarnaev smoked his way to failure and, because of a disappointing report card, said, “Fuck it, I’ll become a terrorist.” DuPont also served as director for the  National Institute on Drug Abuse and currently runs one of the largest Employee Assistance Programs (EAP) in the U.S. with former DEA honcho Peter Bensinger. These guys are in the drug-testing business!

Most doctors don’t think like this. That includes most members of the Massachusetts Medical Society. But very few speak out about the fraud being carried out against the legalized medicinal use of cannabis. How does the same medical society that publishes the New England Journal of Medicine allow this type of tripe and rabble to evade editorial scrutiny? Why no backlash from dissenting doctors? Easy, no one has stood up to Adelman because as the head of an influential Physician Health Program (PHP) like PHS, he has power over the license of every doctor in Mass.

Such state operations have come under major scrutiny. A recent Medscape article titled “Physician Health Programs: More Harm Than Good?” reveals patterns of anonymous referrals, false diagnoses, and a lack of credible process. These state-based programs appear to have created a climate of fear in doctors, as all it takes is an anonymous referral to someone like Adelman to ruin a career. For these reasons, many doctors will not even talk about medical marijuana privately, let alone in public out of fear that they might get referred to their state PHP.

It’s hard to know who to hold accountable for these lies. PHS operates under the national Federation of State Physician Health Programs (FSPHP), which is located in Massachusetts. Meanwhile, the FSPHP is an arm of the American Society of Addiction Medicine (ASAM), which also pushes self-serving public policy under the guise of contributing to the greater good. That despite the Massachusetts Medical Society’s charge to “do all things as may be necessary and appropriate to advance medical knowledge, to develop and maintain the highest professional and ethical standards of medical practice and health care, and to promote medical institutions formed on liberal principles for the health, benefit and welfare of citizens of the commonwealth.”

Dr. Langan was an instructor in medicine at Harvard Medical School and an assistant professor of medicine at Massachusetts General Hospital for more than 15 years. He is a co-founder of a medical device startup and blogs at disruptedphysician.com.

DR. MICHAEL LANGAN

Deciding Whether To Refer a Colleague to a Physician Health Program, Oct 15 – AMA Journal of Ethics -J. Wesley Boyd, M.D., PhD

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Deciding Whether To Refer a Colleague to a Physician Health Program

J. Wesley Boyd, MD, PhD

Physicians should exercise caution in referring a possibly impaired colleague to a physician health program (PHP), given that PHPs work closely with their state medical societies or licensing boards but often receive little oversight. The AMA Journal of Ethics is a monthly bioethics journal published by the American Medical Association.

Source: Deciding Whether To Refer a Colleague to a Physician Health Program, Oct 15 – AMA Journal of Ethics (formerly Virtual Mentor)

Decision Making in Regulatory Medicine: A Framework to Identify the influence of Special Interest Groups and “Bent” Science

content-1In  Bending Science: How Special Interests Corrupt Public Health Research 1  Thomas McGarity and Wendy Wagner describe how special interest groups scheme to advance their own economic or ideological goals by using distorted or “bent” science to influence legal, regulatory and public health policy.

The authors describe a “separatist view” of science and policy that assumes scientific research is sufficiently reliable for public policy deliberations and legal proceedings when it reaches them.  This is illustrated as a pipeline in which it is presumed  the scientific community has properly vetted the information flow through rigorous peer-review and professional oversight.  The final product that exits the pipeline is understood to be unbiased and produced in accordance with the professional norms and procedures of science.   The reliability, integrity and validity of the final product is indubitably accepted.Screen Shot 2015-02-05 at 10.49.27 AMThe separatist  view does not consider the possibility that the scientific work exiting the pipeline could be intentionally shaped and contaminated by biasing influences as it flows through the pipeline.  When this occurs the final product exiting the pipeline is distorted or “bent” and bent science can result in bad decision making and bad policy.

Bent science starts with a pre-determined outcome and works backward from a desired result. It is not true science. Those orchestrating the deception (“benders”) use a variety of tactics and strategies to shape, package and spin science to support their own hidden agenda and suppress opposing science.

Benders attempt to hide, dismiss and debunk contrarian research and unsupportive science.  Benders will attack and harass the science and scientists that pose a threat to their interests. Using carefully crafted studies designed to confirm a desired outcome, the pre-determined conclusions are subsequently promoted and publicized to the relevant stakeholders who are often unable ( or sometimes unwilling) to discern real science from junk-science.

Misinformation, propaganda, and deception are disseminated in a variety of venues. Public relations firms are used to manipulate public perception and freelance writers are hired  brandish favorable consensus statements.  Authoritative reviews and critiques are ghostwritten under the names of  “outside experts” who profit both monetarily and by adding a high-profile publication to their resume.

Opinion is paraded as fact and with a dearth of professional oversight the charade usually goes unnoticed and unopposed.

Data-dredging, cherry picking, confirmatory bias, confirmatory distortion, fabrication, falsification, exaggeration, and a whole host of deceptive tactics are used to work backward from an already determined result.

Any information that contradicts the answer is manipulated, undermined, suppressed or downplayed; even if it is the result of real science and evidence-based research; even if it is the truth.  Professional procedure, protocol and ethics are off the table.  It is an underhanded free-for-all. Bare knuckle boxing. Trash your opponents work and label it junk-science. Undermine the integrity of your opponents.  Use ad hominem attacks to question the opponents motives. Claim the scientists are hacks on the take.  Start rumors about them.Screen Shot 2015-02-05 at 10.50.32 AMLoudly claim you are the one who is evidence based. Proclaim professionalism and authority.  Quibble. Move the goalpost.   Nit-pick and split hairs.  Proclaim over and over and over again you are the one who is evidence based.

And the problem is it usually works.  It is an unfair playing field.  When no meaningful barriers are in place to detect cheating and identify cheaters they usually win.

Bending science can have serious and sometimes horrific consequences and multiple examples including the Tobacco and pharmaceutical industry are given in the book.

Calling for immediate action  to reduce the role that bent science plays in regulatory and judicial decision making, the authors emphasize the assistance of the scientific community is necessary in designing and implementing reform.

“Shedding even a little light on how advocates bend policy -relevant science could go a long way toward remedying these problems.  Indeed, precisely because the advocates have overtaken the law in this area, heightened attention to the social costs of bending science could itself precipitate significant change.”

But there are difficulties in challenging bent science including a general lack of recognition of the problem. With an absence of counter-studies to oppose deliberately manufactured ends-oriented research this would be expected.

Bent science involves the deliberate manufacturing of a pool of  information designed to promote a specific agenda.  A level playing field would require a pool of opposing research specifically addressing that agenda.  In reality this requires both the incentive and the power to do so–an unlikely scenario short of an equally well funded competitor or sufficient public concern about the problem.

In fact counter-forces are often nonexistent. Investigatory techniques developed and promoted by the FBI crime lab (such as firearms identification and intoxication testing) is one example described in the book.  These techniques evolved with little meaningful oversight from the larger scientific community and could be badly bent but there is no meaningful pool of information to disprove them.  The authors aptly state that   “defendants in most criminal cases lack resources to mount effective challenges, much less undertake their own counter-research.”

And part of the “art” of bending involves swaying public opinion and the mainstream media is typically aligned with the benders so opposing viewpoints seldom make the headlines.

Additionally, there is no meaningful oversight or avenue to pursue accountability. No systems exist to prevent, catch and publicly expose bent-science or those who bend science.

The influence of special interest groups on the practice of medicine is unknown.  No one has examined the role of bent science in the rules, regulations, policies and decisions made by those who are in charge of the standards of medical practice and professional behavior of doctors but as a regulated profession governed by the  decisions and policies of regulators it is certainly possible.

Regulation of the Medical Profession

Alexis de Toqueville once observed that a key feature of American government was the decentralized character of administration. “Written laws exist in America,” he wrote, “and one sees the daily execution of them; but although everything moves regularly, the mover can nowhere be discovered. The hand which directs the social machine is invisible.”2

Administrative law is the body of law that allows for the creation of public regulatory agencies and contains all of the statutes, judicial decisions and regulations that govern them. Administrative agencies implement their powers in the form of rules, regulations, orders and decisions.   State medical boards are the regulatory agencies responsible for the licensure and discipline of physicians. They grant the right to practice medicine in the form of a medical license and each state has Medical Practice Act that governs and defines the practice of medicine. The medical board is empowered to take action against a doctor for substandard care, unprofessional behavior and other violations as defined by the state Medical Practice Act.

Administrative Code governs the licensure and disciplinary process and the State Administrative Procedure Act governs the legal process (due process, discovery, etc.). Regulatory changes are enacted through procedural, interpretive and legislative rules.

Both medical practice acts and administrative procedure acts are subject to change.  Changes in medical practice acts can redefine what is acceptable practice and what constitutes professional behavior. This can increase the power and control these agencies have over doctors both professionally and socially.

Changes in Administrative practice acts can decrease what rights a doctor has if this power and control is abused.  Changes in the wording of administrative code and administrative practice acts can have profound implications in these rights including due-process, timeliness of being heard, rights to appeal decisions and time-constraints for judicial review.

And when these changes occur they do so silently.  The hand that directs the machine is indeed invisible.  The consequences, however, are not.  These changes not only impact those touched by the hand but can have a systemic impact on the entire profession.

State medical practice acts as well as administrative practice acts and code are susceptible to change and therefore susceptible to the influence of special interest groups benefitting from such change.  Regulation of the medical profession is thus susceptible to bent science.

Bent Science and the Medical Profession

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The impact of bent science on the regulation of the medical profession has not been studied. As a profession governed by regulatory agencies medicine is certainly not immune to the influence of special interest groups who could in turn influence public policy and regulatory decisions, rules and regulations to benefit their own interests.

Making sound decisions about regulation calls for an understanding of the problem it is intended to solve. This demands methodologically sound science and evidence-based facts arrived at through rigorous peer review and professional oversight. The science on which policy decisions are made must be reliable and unbiased. Legitimate policy must be based on recognized and legitimate institutions and experts.

If the information regulatory agencies rely on to discipline doctors and protect the public is unreliable then serious consequences can occur.

It would be beneficial to look for changes in public policy, guidelines, rules and regulations involving the medical profession and examine the reasons behind them. When did the problem present? Who presented it? Was it based on methodologically sound and accurate data?  What organizations do the problem presenters represent?  What organizations or individuals aligned or associated with the presenters might benefit?  What are the consequences?  Who is harmed?

Howard Becker describes the role of “moral entrepreneurs,” who crusade for making and enforcing rules that benefit their own interests by bringing them to the attention of the public and those in positions of power and authority under the guise of righting a society evil.8   

The mechanics and mentality is similar to the science benders and, as discussed below,  they use some of the same techniques.

Moral entrepreneurs take the lead in labeling a particular behavior deviant and spreading this label throughout society.  They associate the behavior of some group with a society evil, affix an easily recognizable label to it and then express the conviction that the evil must be combated.  Labeled as being outside the central core values of consensual society, the deviants in the designated group are perceived as posing a threat to both the values of society and society itself.

Activities can rise to the level of ‘social problems” when harm or danger is attributed to those activities and governmental powers are called upon to put an end to those harms. Bent science requires convincing others of a viewpoint and the likelihood of this occurring increases when the activity that is identified as a problem resonates with underlying societal concerns and anxieties.  The problem is then endorsed by experts who give legitimacy to such claims.3,4 This legitimacy results attracts media attention which further enforces support from both the public and policy makers.5,6  

As a result any bent science directed at regulatory and public policy decision making should be clearly visible.

The sociologist Stanley Cohen used the term ”moral panic” to characterize the amplification of deviance by the media, the public, and agents of social control.7 According to cultural theorist Stuart Hall, the media obtain their information from the primary definers of social reality in authoritative positions and amplify the perceived threat to the existing social order. The authorities then act to eliminate the threat.9 The dominant ideas or ideologies are reproduced by relying on the opinions of the defining authority and then spread through the media.

An internet search of what labels have been affixed to doctors in association with a threat to society there are three.  A google search of “impaired physician” yields 20, 600 results; “disruptive physician” yields 17, 400 results; and “aging physician” yields 27, 800 results. A large number of these articles, opinion pieces and reviews associate impaired, disruptive and aging physicians with patient death and other adverse events, medical error, and malpractice.   The labels affixed to these physicians have been characterized as a major threat to public health and the rhetorical tools used in many of these articles seems aimed at increasing public anxiety.

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A PubMed search yields 154 results for the “impaired physician”; 47 results for the “disruptive physician”; and 19 results for the “aging physician.”  Many of these are opinion pieces written by the same group of physicians and aimed at hospital administrators, regulators and those involved in the legal or business aspects of medicine.

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There is, in fact, no evidence based research that associates the impaired, disruptive or aging physician with any adverse events. The “impaired,” “disruptive” and “aging” physician labels  as evinced by a quick google search seem escalated far beyond the level warranted by the existing evidence.

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The “impaired” and “disruptive” labels have taken on the status of moral panic and the “aging” label, which is being associated with cognitive impairment, seems to be heading in that direction. The number of articles being published and lectures being given on the dangers of cognitively impaired doctors is increasing.  It has not yet reached the level of public awareness the impaired and disruptive have.

To acknowledge that the current level of concern about these labels is exaggerated is not to suggest they do not exist. They do.  But the disparity between the evidence-base, or lack thereof, and the level of concern warrants further investigation.

To be clear,  doctors who are impaired by drug and alcohol abuse need to be removed from practice to protect the public and receive treatment;  doctors who are abusive to others or engage in behavior that threatens patient care need to be held accountable for their actions; and doctors who are cognitively impaired due to dementia need to be removed from practice and evaluated by the proper specialists.  If a diagnosis of dementia is confirmed then they need to be removed from practice.

What is the motivation behind the “impaired,” “disruptive” and “aging” physician labels and the multiple articles linking these labels to patient harm and medical error?  There is no data driven evidence so where does it come from?   Could moral entrepreneurs be behind it?  If so then there should be evidence  of bent science and to examine this we must look for evidence that these labels have been used to influence regulatory decisions, rules, regulations and policy.

And with the recently archived Journal of Medical Regulation this task can be easily accomplished.

The Journal of Medical Regulation as Timeline and Framework for Policy Evaluation

The Federation of State Medical Boards (FSMB) is a national not-for profit organization that gives guidance to state medical boards through public policy development and recommendations on issues pertinent to medical regulation. Shortly after its founding in 1912, the Federation of State Medical Boards began publishing a quarterly journal addressing issues relating to medical licensing and regulation of doctors. First published in 1913 as the Quarterly of the Federation of State Boards of the United States, the publication has undergone several name changes and publication schedules. From1921 to 1999 it was published monthly as the Federation Bulletin. In 1999 it was changed to the quarterly Journal of Medical Licensure and Discipline and in 2010 was revised to the Journal of Medical Regulation The Journal of Medical Regulation is in the process of archiving all issues dating back to 1913.

Presently every paper dating back to 1967 is available online and the archival organization and availability of full articles published sequentially over the past half-century is historically invaluable.   As the official journal of the national organization involved in the medical licensing and regulation of doctors, this archival organization allows for an unskewed and impartial examination in both historical and cultural context. We can identify when particular issues and problems were presented, who presented them and how.

The Journal of Medical Regulation archives provides a structured context to examine these issues in their historical and cultural context.  This facilitates a retrospective analysis.  As a timeline it allows identification of when the issues were presented.  It also allows us to look at the events preceding the problem, who benefited from them, and the consequences. Could these factors be involved in influencing the regulation of medicine and shaping the medical profession? Could bent science have been involved in regulatory and administrative changes that have significantly impacted the rights and well-being of doctors and how the profession of medicine is defined?  Could some of the current problems such as the marked increase in physician suicide, sham-peer review, and physician burnout be the result of bent science?  If bent science is contributing to bad policy and bad decision making then it need to be exposed and addressed.  Bent science is bad medicine and if it exists then we need to urgently shine a light on it.

  1. McGarity TO, Wagner WE. Bending Science: How Special Interests Corrupt Public Health Research. Cambridge, MA: Harvard University Press; 2008.
  2. de Toqueville A. Democracy in America. New York: Penguin Books; 1984.
  3. Blumer H. Social Problems as Collective Behavior. Social Problems. 1971;18:298-306.
  4. Stone DA. Causal Stories and the formation of policy agendas. Political Science Quarterly. 1989;104:280-300.
  5. Best J. Threatened Children, Rhetoric and Concern about Child Victims. Chicago University of Chicago Press; 1990.
  1. Gerbner G, Gross L. The scarey World of TV’s heavy viewer. Psychology Today. 1976;9(89):41-45.
  2. Cohen S. Folk Devils and Moral Panics: The Creation of the Mods and Rockers (New Edition). Oxford, U.K.: Martin Robertson; 1980.
  3. Becker H. Outsiders: Studies in the Sociology of Deviance. New York: Free Press; 1963.
  4. Hall SC, Critcher C, Jefferson T, Clark J, Roberts B. Policing the Crisis: Mugging, the State, and Law and Order. London: Macmillan; 1978.

 

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Do physician health programs increase physician suicides? —Pamela Wible, MD (Over 950 Comments Overwhelmingly Suggest they do!)

Source: Do physician health programs increase physician suicides? —Pamela Wible, MD

“Do Physician Health Programs Increase Physician Suicides?” 

“Do Physician Health Programs Increase Physician Suicides?” by Dr. Pamela Wible was published on Medscape August 28, 2015 and was subsequently posted on KevinMD on September 7 where it quickly became the #1 most popular article of the week and the #3 most popular article of the past six months. 323 comments have been left on Medscape thus far and 258 on KevinMD where comments are now closed.

Physician Health Programs: More harm Than Good?”  

Pauline Anderson’s article Physician Health Programs: More harm Than Good?” published August 19, 2015 on Medscape currently has 200 comments and the response from the President of their national organization the Federation of State Physician Health Programs (FSPHP) Doris Gunderson “FSPHP Response to ‘Physician Health Programs: More Harm than Good? published September 8 on Medscape has generated 172 comments.  

Conclusions based on comments = Increased suicide and harm by a landslide

What is the consensus so far regarding the questions raised by Anderson and Wible?    Judging by the comments thus far the overwhelming consensus is that Physician Health Programs are not only causing harm but large-scale, serious, far-reaching and grave harm and this is by a landslide.   Of the over 950 collective comments all but a handful have been extremely negative and critical.   These comments raise specific and serious questions that are not being answered by the FSPHP or their sympathizers and apologists.  

FSPHPs attempt at rebuttal with logical fallacy and authoritative opinion ineffective

Gunderson’s response to Anderson’s article deserves a point-by-point analysis at a later point, but to summarize, her rebuttal attempts to summarily dismiss the serious criticisms raised in Anderson’s article while completely avoiding the specific criticisms and dismissing key facts.  She does this by questioning the integrity and quality of the both the report itself and the sources used for the report.  

Calling it a “biased and unbalanced view of Physician Health Programs (PHPs)” Gunderson implies the piece falls short of the “journalistic excellence” expected of Medscape and that almost all of the information relies on “hearsay, including information from anonymous sources, allegations rather than facts, and a handful of anecdotes.”  She contrasts this to the “six pages of factual information and references to several peer-reviewed articles” that were summarily ignored by Medscape.  

 Quality of that information aside, Anderson’s article is investigative journalism not research.  It is designed to raise questions not compare outcomes.  It essentially expresses the concerns of tangential dissident voices that have previously been unheard  (or silenced) by the perceived authority in question and in doing so fulfills its purpose. Anderson’s paper is not a research based comparison of the literature but the exposure of criticisms involving an organization of alleged absolute power over doctors who have been stripped of due process and appeal; an organization allegedly bereft of accountability and oversight; a purported secretive unregulated system of coercion, disempowerment and control.

Most victims of this system lack the resources to even mount effective challenges, much less undertake their own counter research. Not sure what she was expecting but in situation like this allegations and anecdotes are the only ammunition available and articles such as this are the proper, and sole, means available to voice dissenting opinion and raise awareness and concern.

Gunderson predictably  goes on to present the usual appeals to authority, special knowledge and consequences and inevitably brandishes the “overwhelming success” of PHPs. She also references her own study concluding that PHPs reduce malpractice. She states:

“…research demonstrates that physicians who participate in PHP monitoring for any health issue have a lower malpractice risk compared to the physician population at large, underscoring the relationship between physician health and effective patient care.”

“Overwhelming success” is of course based on Setting the Standard for Recovery: Physicians’ Health Programs, a  poorly designed non-randomized non-blinded retrospective analysis of a single data set with multiple flaws in both reasoning (type I and type II errors) and statistical analysis that render its conclusions invalid. In addition the impact of undeclared but substantial financial conflicts-of-interest (including funding by drug testing and addiction treatment industries) and personal ideological biases (including personal 12-step recovery from addictions) in the authors make it nothing more than authoritative opinion.   Adding the alleged misdiagnosis and over-diagnosis of addiction in physicians by this group incentivized by lucrative self-referral dollars for expensive 90-day treatment programs renders it less than authoritative opinion.

As with the “PHP-blueprint” the claims of lower malpractice risk are based on a single retrospective cohort study (with Gunderson being one of the authors ) comparing malpractice risk prior to and after being enrolled in a state PHP that revealed a reduction in malpractice rates in those who participated in the PHP.    The 20% reduction they speculate:   

“…could be that participants learned skills during their treatment and recovery — skills to communicate better with colleagues, staff, and patients. It may be that experience with the PHP led participants to make use of other professional supports — that is, maybe to seek consultation earlier in their work. Or maybe they were more motivated to practice conservatively and adhere to standards of practice, given what they learned in the PHP program.”

This sounds great until you consider what impact being monitored by a PHP might have on the number of patient encounters a doctor might have before and after being enrolled in a PHP.  I speculate otherwise.

How many had practice restrictions, reduced hours, retired or were working in non-clinical positions after being enrolled in the PHP.  Being subject to PHP monitoring is not comparable to taking a daily dose of vitamin-D.  It has a very serious impact on one’s day to day activities and for a study looking at malpractice risk I would venture to guess that matching the NUMBER OF HOURS SEEING PATIENTS AND NUMBER OF PATIENT ENCOUNTERS  would be an essential part of the study design that should be explicitly and accurately matched especially in a group in which the average age enrolled was 50.   

This is akin to a pre-school claiming that participation in their program leads to a 20% reduction in wet diapers for children because of the skills those little fellers learned at their school.

Unfortunately this combination of logical fallacy and misrepresentation of seriously flawed studies usually sways the target.  Criticisms are dismissed and everyone walks away complacent in the belief these are just good people helping doctors and protecting the public, but that is not what is happening here.

Serious questions raised and silence of FSPHP deafening.

   The comments left here and on the other 3 articles have made it abundantly clear that not only is there a  problem with PHPs but a very serious problem. Allegations included fabricated diagnoses, “diagnosis rigging”, “treatment rigging,” total denial of due process, lab fraud and many other serious concerns.  Faced with these specific and serious criticisms and critical reasoning  the FSPHP has become tongue-tied as the individual horror stories mount.

Now  silence from authority is an acceptable stance when the criticisms are unreasoned and unfounded ad hominem attacks and generalizations based on bias and prejudice but that is not the case here.   The testimonials and criticisms are articulate, specific and remarkably similar.

Need for further exposure, awareness and investigation through mainstream media and others

Patterns are appearing that involve abuse of power and control of information in a system that manages all aspects of testing, assessment and treatment without oversight or regulation; an opaque and rigged game that dismisses all outside opinion with no transparency or apparent accountability (including the provision of information and justification for actions).  Due process has been removed and the  coercion, control and abuse of power are seen in these comments that are not only believable but plausible.  This is crystal clear.

These comments can be seen here:  FSPHP Response to ‘Physician Health Programs_ More Harm Than Good_’ and I urge others to read them, form their own opinions. investigate this area and help expose these issues.  If PHPs are causing this degree of harm and contributing to the suicide epidemic in doctors it needs to be exposed with dispatch and allies are urgently needed.

Do physician health programs increase physician suicides? —Pamela Wible, MD

Do physician health programs increase physician suicides?

How do we care for the people who care for us? As doctors, we’re immersed in pain and suffering — as a career. We cry when our patients die. We feel grief anxiety, depression — even suicidal — all occupational hazards of our profession.

A recent Medscape article on physician health programs suggests the people who are here to help us may actually be doing more harm than good. And they may even be increasing physician suicides.

 Both doctors I dated during medical school died by suicide. Eight physicians killed themselves in my town alone. I’ve become a specialist in physician suicide. My cell phone has turned into a suicide hotline. And I have a stack of physician suicide notes that I keep at home.

Here’s one of them:

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Dear Some, My family, I love you. To others who have been good friends, I love you too. This is just the end of the line for my particular train. Earth wasn’t a great place for me. We’ll see what else is out there. Will miss you all. I’m sorry for what it’s worth. Love Greg.

On June 22, 2012. Dr. Greg Miday killed himself — 12 hours after being told not to follow his psychiatrist’s safety plan by the physician health program that controlled his medical license.  Sober for years, he relapsed just before his death. A brilliant clinician, never impaired at work, Greg drank to cope with anxiety.

Afterwards, two interns jumped to their deaths from New York hospitals the same week (within three days of each other, I believe). Greg’s mother, a psychiatrist, sent this letter to the editor of the New York Times:

An unacknowledged predicament for physicians who identify their struggle with substance abuse and/or depression is that they are often placed under the supervision of their state medical board’s physician health program. My son, Greg, was being monitored by such a program. He took his own life at age 29, one week before he was to enter an esteemed oncology fellowship. His final phone calls were to the physician health program notifying them of his use of alcohol while on vacation, a disclosure he had previously described as a ‘career killer.’ These programs, which often offer no psychiatric oversight, serve as both treating and policing agencies, a serious conflict of interest. Threatened loss of licensure deters vulnerable physicians from seeking help and may even trigger a suicidal crisis. Medical Boards have the duty to safeguard the public, but the assumption that mental illness equals medical incompetence is an archaic notion. Medical Boards must stop participating in the stigmatization of mental illness. We cannot afford to lose another physician to shame.

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Greg Miday and his mother, Karen Miday

The facts: Our medical schools, hospitals, and clinics actually cause or exacerbate mental health conditions in physicians, then they blame us and force us to release our confidential medical records. And in the end, they take our license ..

Maybe that’s why my friend, an excellent psychiatrist, drives 200 miles out of town, pays cash, and uses a fake name to get mental health care.

And another physician friend who was deemed “too slow” (seeing patients) by her residency director, was sent to a psychiatrist who diagnosed her with mild OCD. (Don’t we all have some OCD if we are thorough physicians?) Well, she was actually then sent to medical board who referred her to a physician health program that mandated an AA-style substance abuse program — which makes no sense at all since she does not do substances, She doesn’t drink or smoke.

So who the hell is protecting us from being misdiagnosed, mistreated, and abused?

There are many who prey upon physicians. So who cares for doctors?

And how in the world can we give patients the care we’ve never received?

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears. Watch her TEDx talk, How to Get Naked with Your Doctor. She hosts the physician retreat, Live Your Dream, to help her colleagues heal from grief and reclaim their lives and careers.


“Do Physician Health Programs Increase Physician Suicides?” by Dr. Pamela Wible was published on Medscape August 28, 2015 and was subsequently posted on KevinMD on September 7, 2015 where it quickly became the #1 most popular article of the week and the #3 most popular article of the past six months. 323 comments have been left on Medscape thus far and 258 on KevinMD where comments are now closed.

Pauline Anderson’s article Physician Health Programs: More harm Than Good?” published August 19, 2015 on Medscape currently has 200 comments and the response from the President of their national organization the Federation of State Physician Health Programs (FSPHP) Doris Gunderson “FSPHP Response to ‘Physician Health Programs: More Harm than Good? published September 8, 2015 on Medscape has generated 172 comments.  

What is the consensus so far regarding the questions raised by Anderson and Wible?    Judging by the comments the consensus is that Physician Health Programs are not only causing harm but serious, far-reaching and grave harm on a large scale.  This is by a landslide.   Of the over 950 collective comments all but a few have been extremely negative toward PHPs. They raise specific and serious questions that are not being answered by the FSPHP, their sympathizers or apologists.  Gunderson’s response to Anderson’s article deserves a point-by-point analysis which will be done at a later date.  To summarize, her rebuttal attempts to summarily dismiss the serious criticisms raised in Anderson’s article by questioning the integrity and quality of the both the report itself and the sources used for the report.     Calling it a “biased and unbalanced view of Physician Health Programs (PHPs)” Gunderson implies the piece falls short of the “journalistic excellence” expected of Medscape and that almost all of the information relied primarily on “hearsay, including information from anonymous sources, allegations rather than facts, and a handful of anecdotes.”  This is in contrast to the “six pages of factual information and references to several peer-reviewed articles” that were ignored by Medscape.    Quality of that information aside, the point of Anderson’s article is to express the concerns of tangential dissident voices that often go unheard (or are silenced) by perceived authority not a research based comparison of the literature. The criticisms involve  lack of due process, accountability and oversight in a secretive and unregulated system of coercion, disempowerment and control.   Most victims of this system lack resources to mount effective challenges, much less undertake their own counter research.   She goes on to present the usual appeals to authority, special knowledge and consequences and brandishes the “overwhelming success” of PHPs and references her own study showing that PHPs reduce malpractice stating: 

“…research demonstrates that physicians who participate in PHP monitoring for any health issue have a lower malpractice risk compared to the physician population at large, underscoring the relationship between physician health and effective patient care.”

The “overwhelming success” is of course based on Setting the Standard for Recovery: Physicians’ Health Programs, a  poorly designed non-randomized non-blinded retrospective analysis of a single data set with multiple flaws in both reasoning (type I and type II errors) and statistical analysis that render its conclusions invalid. In addition the impact of undeclared but substantial financial conflicts-of-interest (including funding by drug testing and addiction treatment industries) and personal ideological biases (including personal 12-step recovery from addictions) in the authors make it nothing more than authoritative opinion.   Adding the alleged misdiagnosis and over-diagnosis of addiction in physicians by this group incentivized by lucrative self-referral dollars for expensive 90-day treatment programs renders it less than authoritative opinion.  As with the “PHP-blueprint” the claims of lower malpractice risk are based on a single retrospective cohort study (with Gunderson being one of the authors ) that compares malpractice risk prior to and after being enrolled in the Colorado PHP and showed a reduction in malpractice in those who participated in the PHP program.  The 20% reduction they speculate:   

“It could be that participants learned skills during their treatment and recovery — skills to communicate better with colleagues, staff, and patients. It may be that experience with the PHP led participants to make use of other professional supports — that is, maybe to seek consultation earlier in their work. Or maybe they were more motivated to practice conservatively and adhere to standards of practice, given what they learned in the PHP program.”

This sounds great until you consider what impact being monitored by a PHP might have on the number of patient encounters a doctor might have before and after being enrolled in a PHP.

How many had practice restrictions, reduced hours, retired or were working in non-clinical positions. For a study looking at malpractice risk I would venture to guess that matching the NUMBER OF HOURS SEEING PATIENTS AND NUMBER OF PATIENT ENCOUNTERS  would be an essential part of the study design.    In addition the average age enrolled in the PHP was 50 and the chances of reducing hours obviously increases with time as we age.   

This is like a pre-school claiming that participation in their program leads to a 20% reduction in wet diapers for children because of the skills those little fellers learned at the school.

Unfortunately this combination of logical fallacy and misrepresentation of seriously flawed studies usually sways the audience.  Criticisms are dismissed with everyone complacent in the belief that these are just good people helping doctors and protecting the public.  But that is not what has happened here.    The comments have made it abundantly clear that not only is there a  problem but a very serious problem and  allegations included fabricated diagnoses, “diagnosis rigging”, “treatment rigging,” total denial of due process, lab fraud and many other serious concerns.  Faced with these specific and serious criticisms and critical reason the FSPHP has become tongue-tied as the individual horror stories mount.

Now  silence from authority is an acceptable stance when the criticisms are unreasoned and unfounded ad hominem attacks and generalizations based on bias and prejudice but that is not the case here.   The testimonials and criticisms are articulate, specific and remarkably similar.

Patterns are appearing that involve abuse of power and control of information in a system that manages all aspects of testing, assessment and treatment without oversight or regulation; an opaque and rigged game that dismisses all outside opinion with no transparency or apparent accountability (including the provision of information and justification for actions).  Due process has been removed and the  coercion, control and abuse of power are seen in these comments that are not only believable but plausible.  This is crystal clear.

These comments can be seen here:  FSPHP Response to ‘Physician Health Programs_ More Harm Than Good_’ and I urge others to read them, form their own opinions. investigate this area and help expose these issues.

Comments (258)

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    Thanks, Pam.

    Now in my fourth decade, I can tell you that if I had mental illness, chemical dependency, or practically anything that could threaten my medical practice I would not tell anyone, including my one good physician friend who is my primary care doc. I don’t have any of those conditions mentioned, but I am very sensitive to those who do. In my mind, the most untrustworthy physicians are the ones on the state medical boards. They seem to have one and only one goal… protect the public at all costs and toss physicians who show any weakness. I never get any communications from them when they want me to shell out my yearly fee or remind me that I need to have a certain amount of CME hours.

    Our privacy is invaded by them even before we have a chance to declare it. Why is it that everyone in the world can know most everything about us as physicians from where we live to, but patient’s information is rabidly protected with the HIPPA maul?

    Thanks for your caring. Perhaps it is because a physician’s story would be safe with you? Ours is truly one of the lonliest professions. I don’t think we can trust anyone much, and am extremely careful about sharing myself as a person with anyone even though I have no mental illness or substance abuse issues.

    Now I’m in my 33rd year…my goal is maybe 45 years and I’m done.

    Warmest regards,

    Ron

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      I don’t tell m doctor that I’m a doctor or even in healthcare. I make a point of going further out of town to get any major treatment. The only time my doctor knew who I was is when I had to have some orhto surgery.

      I don’t trust any of them. Actually I don’t trust most doctors when it comes to these type of things. They will sell you out. They sell their own out for less.

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        Doctors have gone into hiding, Cruel “health care” system.

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        That is just so overwhelmingly sad — a doctor not being able to trust most other doctors. As a patient, I continue to struggle to try to understand why the same people who become doctors to help people can be so heartless and untrustworthy to each other. And yet, at the same time, a lot of doctors marry other doctors.

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          We are beaten up. We came into this profession with compassion and a desire to serve. Instead we have been bullied, hazed, victimized, and if we ask for mental health help . . . (just read the stories here to see what happens then). I couldn’t make this stuff up. Truth is stranger than fiction.

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      This is terrible. We need to bring more public awareness to these issues!

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        You’re absolutely right. Many very talented and compassionate physicians’ and nurses’ and PA’s careers are being destroyed by these self-righteous state-protected psychopaths. And this malignancy is soon to move to broader professional horizons – lawyers, counselors, teachers … just about anybody who needs a license to practice. All done under the virtuous banner of “protecting the public,” all the while depriving the professional of due process and operating without any oversight or accountability! And … all the while, these programs turn a handy profit by using their state-sanctioned authority to refer to their friends running “preferred programs.

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          Is there a way to protect due process by contract as well as by law? Web sites such as this can offer model contracts for doctors

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            Due process is in the NC law, and in the contract that NCPHP had with the NC Medical Board.
            It made no difference, as they just did not respect the law and offered no due process.

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            We are held to an inhuman standard and we have no safe accessible mental health care. It’s insane. No wonder we have such high rates of suicide. Again, I will ask, who is helping us?

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              Pamela,

              No one is helping us. No one will. We are the overpaid evil doctors who are just in it for the money. Didn’t you know that?

              The guy selling vitamins makes millions and he is a good businessman.

              The lawyer makes millions on BS lawsuits and he is a brilliant attorney.

              The doctor makes millions serving patients, doing a good job and saving lives or improving peoples live and he must be a crook or doing something wrong.

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                You must be referring to the specialist. No primary care docs making millions (that I know of).

                The media has certainly portrayed us poorly. And doctor bashing stories somehow get much more traction than others.

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                People don’t know or care about the difference. To them we are all the rich doctor. And so what if we make a good living.

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                  I’m a patient and part of the public and I don’t think doctors are all just rich and overpaid. I think you’re seriously underestimating how many of us patients do sincerely care about our doctors. You need to stop obsessing about the patients who do hate doctors and start building a coalition with those of us patients who do care about our docs. Just like in a political election, forget about trying to change the minds of people who will never vote for you and concentrate on engaging with and activating the patients who are on your side. I’ve said this many times here but I’ll say it again — We really need to start building a strong doctor-patient coalition.

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                  Divide and conquer. Us vs. them mentality. Really keeps us locked down in the status quo. Patients and docs should be on the same team. Weren’t we once?

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                Doctors don’t feel that way about other docs, do they? I don’t either, for what it’s worth. But even if that is the dominant image that the public has of doctors (and I’m not agreeing that it is), how does that explain how ruthless docs can be toward other docs?

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                  The PHP system is a funnel for psychopathy. Many of these doctors had a history of manipulating the system, got caught and had their licenses revoked. By claiming the salvation card, blaming their bad behavior on drugs and alcohol, and claiming they were redeemed through 12-step they got their licenses back. Unlike the doctors telling their stories here, many of these doctors were criminals who got caught doing something very bad. Many of these doctors joined their state PHPs and others found work in the drug and alcohol assessment, treatment and testing industry. It is these doctors who are involved in the culture of harm you see here. In my opinion what we are seeing is the result of corporate psychopathy and this system makes Enron look like a preschool picnic.

                  The final common pathway for many sociopaths is jail. This depends on them getting caught. The final common pathway for a sociopathic doctor who gets caught would likely be a PHP. And what do you think might happen when a group of these doctors find each other? Some of these individuals should never have had their licenses returned. Giving them power without any oversight or accountability probably wasn’t such a bright idea.

                  One of the common themes reported is the complete lack of empathy these people exhibit.

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                    The PHP system is the physician’s rabbit hole into the twilight zone. Don’t go near one. Voluntarily or otherwise.

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                      If a doc with a substance abuse and/or mental health problem opts to seek help from a direct pay private practice psychiatrist or other doc with no insurance records, are the helping docs required to report the docs with problems to anyone (medical board, doc’s employer, etc). Or are they both protected by doctor/patient confidentiality?

                        
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                          Speaking of MB position statements in re: reporting impairment, it is also important to note that MBs also have position statements re: reporting of unethical behavior. A number of physicians have reported the profoundly unethical behavior of the PHP clinician to the MB as unprofessional (and illegal) behavior (e.g. the violation of due process; coercive referral to preferred programs etc.). The MB has repeatedly declined to even consider the complaint. Appears they get to choose what is “unethical.” And apparently anything involving the illegal and abusive behavior of MBs and PHPs is immune from being considered “unethical.” Seems like they like a rigged game.

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                            Have most of the docs who have filed complaints with the MB about unethical behavior by the PHP been docs who were treated — or mistreated — at the PHP? I’m guessing that the MBs find it easy to blow off the opinions of docs who have a substance abuse problem as disgruntled resistant participants. Have any docs with no personal substance abuse problem and no need for a PHP filed any complaints about PHPs? Or are they reluctant to get involved with that can of snakes?

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                              MGH tried to remove me from PHS and the MGH attorneys, my Chief and his Chief had a conference with them to attempt this. When things got confrontational with one of the Chiefs they asked him how much he drank in a not so thinly veiled threat. The Boards have agreed not to second guess the PHPs and they are free to do what they want. Boards do not investigate PHP members–at least here in Massachusetts.

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                                Wow! to the way they threatened the Chief who tried to support you. I imagine there’s a certain amount of CYA going on here by everyone in case a patient gets hurt badly by a doctor down the line. Nobody wants to share the blame if that happens.. But, at heart, it sounds like PHPs are far too lucrative and that money train is what they’re protecting at all costs. Aren’t they supposed to be nonprofit organizations with the dual mission of protecting patients and helping doctors? How easy would it be to follow and document the money being made by PHPs and those who run them? Expose how lucrative they really are and you expose the motive. I’m really sorry that you’re having to go through this but I love how you’re fighting back!

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                            Wow.

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                            However, that said, it is also important to note that some / most states’ medicals boards have “position statements” that say that you must report an impaired colleague. My guess is that this pertains when you a) know an impairment exists; and b) have tried other means of intervention such as you or another colleague talking with the doc. Otherwise, this “duty to report” turns colleagues into undercover secret Stasi and creates distrust and further isolates and disrupts the necessary existence of a collegial community.
                            Now, if a physician with a run-of-the-mill illness like anxiety or depression or excessive use of alcohol or similar is in treatment with a private doc, my personal belief is that the private treating clinician’s 1st duty is to one’s patient. If there is a question about potential impact of that patient’s illness on others (e.g. their own patients) then I think it’s incumbent on the treating clinician to seek wise and confidential consultation with knowledgeable (non-PHP) colleagues.

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                        There is no duty to report anyone (i.e. mandated reporter) unless there is child abuse, elder abuse or intended harm. There is no duty to hospitalize unless the patient is a danger to oneself or others or incapable of self care. I would argue that if a therapist reported confidential information to anyone without explicit consent of the patient, they have violated their professional ethics and should a) be reported to their board and b) should be put on a “do not use” list.

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                        I’d like to know the answer to that too! Anyone know? Michael?

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                  As with most groups of people 95 + percent of doctors are honest and sincere individuals with moral compass and kind heart. They inherently “do the right thing.” The doctors who have erected this scaffold predominantly come from the same pool of like-minded addiction specialists.

                  In the 1980s some of these physicians realized they could make money by holding a doctors medical license hostage. The first step was the specialized facilities for doctors. It makes no sense on any level for doctors to spend 3-4 months in rehab. There is no difference between doctors and anyone else other than the specific education, training and experience they have. To claim doctors are “unique” and require different treatment is ludicrous. It is a dicto simpliciter argument that can be refuted just by pointing it out. It is an urban legend that exists to this day and one of many that must be addressed with critical reasoning, common sense and evidence-base.

                  And believe it or not it is this same group that has created the moral panics that has tarnished the image of doctors.

                  http://disruptedphysician.com/…

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                    Wow. This whole discussion about state PHPs has been a real eye opener to me, especially, assuming it’s true, that many of the people who run PHPs are doctors who lost their licenses for criminal reasons. it sounds like, to justify their jobs and maybe to retaliate for what happened to them, they go after other docs.

                    Even if 95% of docs are good people, I can see how the fact that any doc could be one of the 5% who might turn on you creates an atmosphere of threat and mistrust among doctors. This truly dark side of the healing profession is extremely disheartening. As a patient, I want there to be a way to keep dangerous doctors from practicing but there has to be a better way.

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                      Exactly why we are conversing publicly. There must be a better way. Curious what reform you would suggest?

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                        One more thought: Are there any countries that are handling the issue of treating doctors’ mental illness and substance abuse better? Or is this a worldwide issue for docs? If there are places that are handling it in a better, more fair/humane, less corrupt way, how are they doing it?

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                          Other Countries have PHPs but this model originated here and is also in Canada and has been put in place in the UK and some other countries facilitated by the countries equivalent of ASAM. Other countries PHPs are the same as the EAPs used by the rest of society. After all that’s how it should be. Specialized programs for doctors is not needed and there is no evidence for 3 months of treatment . This same group just made it up as a way to make money and bamboozled others into believing the lie. And they are still at it.

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                          What a great question! Just off the phone with a female doc in Canada with similar horror stories.

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                        Heh. I’ll let you know if/when I come up with any replacement ideas. To be honest, your OP and the comments here and on Medscape are making me aware of and educating me for the first time about PHPs. I knew nothing about them before this. But what I’m reading now is outrageous. You need to make more patients like me aware of this.

                        Clearly, replacing the current system is not going to happen overnight. But I would start with exposing the corruption of individual doctors in positions of power in these things. Systematically start to discredit the whole system, thereby creating a need for something new.. Find the docs who weren’t broken by the PHPs but instead emerged stronger, even if they are no longer practicing medicine. They are some of your potential leaders. I sure don’t have any instant solution. Just thinking out loud here. Brainstorming strategy was part of my former work.

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                      It is indeed the “dark side.” It’s eerily akin to “Shutter Island.” Once you go there, you’ll never escape. An if you try to visit just to investigate, whoa boy – they just don’t like snoops crashing their game.

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                        I didn’t think of Lehane’s (or Scorceses’s) Shutter Island while reading this thread. But now that you mention it. I did think of Kesey’s One Flew Over the Cukoo’s Nest while reading through this thread.

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                  It doesn’t. competition does. the threat of losing your practice or license due to a malpractice suit because some other as hole doctor said negative things about you does. Happens all the time.

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                    Fear really cause some strange behavior in humans.

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                      I agree.

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                      I agree. Living in a constant state of fear is a horrible way to live. I’ve lived that way a few times briefly but couldn’t take it so I had to just say “FU fear”, shake it off and refuse to live in fear of things that may never happen or that I have no way of stopping them if they do. I did this living in NYC after 9/11 as the smoke from the WTC blew by my apartment windows. I did this after my ovarian cancer dx. I did this after I had to be my own lawyer in housing court to keep a roof over my head. I still do this on a daily basis, living paycheck to paycheck when there is a paycheck, not being able to afford food everyday and still pay my bills. Maybe it’s easier for me than it is for docs to choose not to live in fear because I don’t have much to lose anymore except for my life. But still, docs should try to remember that they can’t use fear as a tactic against you if you refuse to live in fear.

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                        As an independent doc. let me tell you my fears.

                        malpractice
                        board certification
                        constant state of am I going to have enough cases and patient to keep clinic going and for how much longer
                        Can I do this for the rest of my career
                        I’m so stressed today and don’t know if I can continue this any longer
                        How am I going to pay the bills
                        Is there going to be some doc. my competition that is going to bad mouth me today. They have before.
                        The list is longer but I’ll spare you.

                        I know it’s like the refugees but it a different kind of fear.

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                          I’m truly sorry that you’re living with all of that. I certainly didn’t mean to minimize your fears. I really don’t believe in competitive pain or fear (as in whose is worse). I do think life is stressful for most of us, each in our own ways, and that we can’t really avoid stress in this world, only manage it. For me, swimming and laughing regularly are two of my best stress busters. I hope you find a way to manage yours and be happy. I guess there really is a kind of freedom in nothin’ left to lose. But let me tell you, even though I lost everything material and financial, in the past two years I did fight hard in deep uncharted waters (like our healthcare system) to live since my cancer dx. And now that I’m alive and kicking, I get to start over in my late fifties. I probably should be terrified. But I’m just happy to still be here.

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                      And doctors are human.

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                  People who are injured and afraid may act as irrational as an injured raccoon or squirrel. Have you ever tried to help an injured animal? They’ll bite you. Furthermore, a cycle of abuse perpetuates itself. Those who have been abused often become the abusers.

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                    Yes, I actually have helped and been bitten and clawed by injured animals. And I certainly understand, from the perspective of families with domestic violence and abuse, how some of the abused become abusers themselves. I also know several guys who I know were abused by their fathers as boys and who broke that cycle and, instead of becoming abusers themselves, grew into the least violent men I know — basically, they became the opposite of their fathers instead of becoming their fathers. This abusive dark side of medical culture is truly disturbing. Doctors are supposed to be healing and nurturing (as are families), not viscous and vindictive and sadistic.

                    Any time we try to change anything bad in this world, the first step is always awareness, shedding light on the darkness and spreading that awareness. Because of the nature of the problem, clearly, docs can’t fix this on their own. You’ll need to get others to work with you to change this. But you also need good activist leaders like you, Dr Wible. Keep kicking those doors down and shedding that light.

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      See whether any articles at www.aapsonline.org are useful.

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      Sad, as mental illnesses are biological as much as “physical” ones…actually, the term should be brain illnesses, but we are not to that point in our civilization yet to consider the brain (mind) an organ…though that makes no sense, logically.

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      Please don’t go. We need you to help bring our professional back to life. What are your plans for retirement? Don’t just hang out on the golf course Ron. Help heal our profession. I’m begging you.

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        Hi, Pam.

        Just recently I’ve dropped to three full days a week from four. Its nice in one way, but I think I get the hardest patients. Because I answer email, I get a fair amount of that, but the practice only fields about 6 or 7 phone calls a month and we see around 9 to 10 thousand patients visits a year. I have four nurse practitioners who work for me and we are a good team and the office has a very good community reputation.

        But I find myself getting tired more. I’m just 57 but I’ve been at this a long time and the intensity level is at the maximum throughout the day. My forty minute drive to and from work is relaxing because I don’t have to talk to anyone.

        After 200,000 to 250,000 patients visits in my career, I still find myself thinking mostly about my staff who need the work, my patients who need a graying doctor, and my grandchildren who remind me of all the other grandchildren. If I keep up this pace I could see another 40,000 visits or more. I get physicially tired.

        My wife Stacy and I have been married 38 years and we are stuck together for sure. But I can’t remember the last real good friend since undergrad in premed. I’m sure other docs feel isolated as well.

        I wish I could make a different with all these issues, but I don’t think the powers that be can listen because of their powers that are. I’ve never struggled with depression or addictions or any medical conditions, but there are a few doctors that I know who have. I don’t think they are bad people, but one strike in this game and you’re out according to those in power.

        I’ll keep going as long as I can.

        Warmest regards,

        Ron Smith, MD

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          Ron, You’re a real trooper and I bet it’d be a gift to have you as my doc. Hope you’ll stay involved with this PHP issue.

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          Medicine is all encompassing. It can be isolating for sure. So you never answered my question about your post-retirement activities. Have you given any thought to that?

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            Well, I haven’t gotten that far. We’ve just got our small, 115 yo farmhouse paid off, and I’ve talked to Stacy about maybe hiring a Pediatrician at the office and keeping it going so that my staff will continue to have jobs, and my patients/parents have the care they are used to. I thought too about doing some clinical teaching maybe at Mercer or one of the other schools in their resident’s clinic, since I like teaching.

            I don’t play golf, but I’ve got two grandsons and two granddaughters ages 2 to 6 that I want to spend as much time with as possible.

            I don’t know what to do about the PHP mess. Maybe if we physicians could spearhead a non-profit to compete with current PHPs where we could set the rules, more or less, and keep the physician’s confidences. Maybe it could be a membership thing…maybe there is already something like that.

            I have no confidence in state medical boards. They have a conflict of interest between their public image of patient protectors and what appears only at face value to be a friend to physicians. Maybe a physician advocate organization could wield some muscle in our behalf?

            Heck, that’s a steep climb…the public at large doesn’t have much sympathy I don’t think, even when they say their doctor is the best. Everybody else is questionably in their minds I think.

            I think I’m living out the end of medicines best years. No one starts solo much. That was really fun. I really liked the cutting edge of making critical primary care decisions…still do and I get my share of “I’ve never that before” patients.

            Ron Smith, MD

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              Solo docs are coming back! http://www.idealmedicalcare.or…

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                Looked at that link and its encouraging. But what I want to see it solo practice have at least an equal footing with freshly certified Pediatricians coming out of residency. Heck, I never ever considered working for a corporation or even a group when I started. Now, residents shy away from solo like it was the plague. I would really like to teach the business of solo practice to residents…they are missing out on the best that medicine has to offer I think.

                Ron Smith, MD

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                  Yes. You should teach because many students do not find suitable mentors during training. Need more inspired community docs teaching in med schools:

                  Is medical school an anti-mentorship program?

                  http://www.idealmedicalcare.or…

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                    The problem in the era of ACO’s is Indy’s can’t survive. Insurance company’s pay them peanuts compared with large university and private systems with their market share and army of administrators to feed. Frankly, I have found most university systems being “anti-mentor ship”, if those mentors are outside of the university system. Dr Sieberts thread about us being “whiners” is exactly what is wrong with an academic medicine today. There is a complete disconnect from those who are part time clinicians and the rest of us.

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    Pam in your own state the PHP program has been contracted out to a private company who have very little knowledge or caring about the job of physicians. It is 12 step based and frighteningly incompetent, but gee whiz, they got the contract. They treat physicians like street people and make demands on their time that are unrealistic. The medical board argued with me that care by a licensed board certified addictionologist was inappropriate so they sent a physician patient to Rush Medical Center. The result? Gee whiz, I actually knew what I was doing! I had been threatened qwith losing my own license for treating a fellow physician for his addiction. A system run by “Investigators” who again in your state are former police with no training in medicine.

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    Physician Health Programs are not the problem. The problem is the Frankenstein PHP’s have become over time. With no oversigjht, regulation or accountability the usual checks and balances that self-govern any group of individuals are not in place and Power without restraint follows an inevitable course. That is what we are seeing here. The historical precedents are many and we still fail to learn. Groupthink has poisoned the well and a Lord of the Flies free-for-all has evolved. Original intentions are lost. Those of decency and conscience are removed. Evidence-based science and critical reasoning are replaced with ideology and dogma. Empathy and moral compass give way to intolerance, injustice and fear to increase the grand scale of the hunt under the banner of “protecting the public'”

    Be it the “impaired,” “disruptive” or “aging” physician these witches are real, these witches are dangerous and we know how to find them.

    Wha remains in many state PHPs is a mix of self-appointed experts with personality disorders ((narcissism, sociopathy), bullies collectively mobbing ( previously insecure doctors of low to mediocre reputations fueled by first time Power who derive pleasure at wielding it – this ranges from bystander indifference to outright cruelty), and lastly 12-step recovery zealots blinkered by black and white thinking who believe their ability to make authoritative pronouncements over others is a divine grant bestowed on their own “recovery” and consider any use of substances “addiction” in need of lifelong abstinence and fundamentalist devotion to their creed. From the point of view of these “like minded docs” drinking a beer is a spiritual malady commensurate with an IV heroin addiction. Any resistance to AA is deemed “relapse without use” or in AA parlance “Stinkin thinkin,”. As with standards of care, professional ethics and the law, the Establishment Clause of the 1st Amendment does not apply to them.

    The biggest problem here is that the PHPs are diagnosing doctors with problems they do not have and mandating unneeded treatment and monitoring. This is taking place because no one oversees them. They have been given carte Blanche authority and power and when the animals are running the zoo that’s a big problem.

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      Some of these self-appointed experts need to be profiled — their medical careers previous to working at a PHP, their personalities, their lavish lifestyles, their connections, their intimidation tactics, their conflicts of interest. Every bit of dirt you can dig up on them and document and expose. Heh. Is my background in investigative research showing? But seriously. Find the worst offenders and expose them. But of course document everything to CYA before going public with it.

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        Let’s take a look at a typical scenario.

        In 2000 when this doctor who had a revoked license requested it be reinstated two board members were opposed due to his long term history of manipulating the system.

        http://www.ct.gov/dph/lib/dph/…

        These include the following statements: “The twice weekly random, observed urine screens imposed upon petitioner by the 1992 and 1994 Consent Agreements were insufficient to detect his then on-going substance abuse. Petitioner WAS QUITE ADEPT AT MANIPULATING The SYSTEM TO AVOID DETECTION.” (my emphasis).

        How did he get it back?

        Advocacy of his state PHP of course.

        Many in the current abusive PHP system got their licenses back using the 12-step salvation card and reinvented themselves as specialists in “addiction medicine.” They are given a “clean slate.”

        This doctor is now running the entire Health Professionals Program in Florida–nurses, doctors, and any licensed medical practitioners from acupuncturists to veterinarians are referred to this program.

        Brilliant! Let’s not just give him his license back but how about we put him in a leadership position with no transparency, regulation or accountability and put all the medical professionals careers and lives in his hands. You can read some of the reviews on the vitals.com website for examples. They are very similar to what are being reported here. Of course the majority of the comments are probably true but in this sick system are considered the bellyaching of sick doctors and ignored.

        Here is a recent comment that tells it all:

        “Every single available website has years of overwhelmingly negative reviews, accompanied by similar stories of abuse, coercion, and damage, all for this physician. Enough. Please join us in our promotion of public awareness and help end the injustice at stopscottteitelbaum.com.”

        Even with a petition out no one is listening as they consider the whole chorus of doctors condemned here for trivial issues a bunch of bellyaching dangers to the public.

        It is this same route that felons, double-felons, Doctors who stole IV pain medication and replaced it with saline from dying cancer patients, pedophiles, and a guy who got caught selling industrial quantities of the date-rape drug to undercover cops are now practicing medicine while those who got a single DUI, borrowed their husbands ativan to help them sleep, had a little too much at the christmas party or sometimes nothing at all are losing their licenses and some are dying.

        Label the accused as deviant to disregard the claims of the accused. It is hard to wrap ones head around the thinking here.

        How about we just apply Occam’s razor or a little bit of common sense? It’s time to WTFU.

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      I agree completely

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      you have elucidated the problems very well, very succinctly. Yes, those drawn to positions of authority in PHP programs probably come from those backgrounds along with some naïve doctors who are chronic do-gooders (except in this case, they harm and kill).

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        If you want to march in front of your PHP, I will join you…that is what I want to do here in Tx.
        PHYSICIAN’S LIVES MATTER.
        PHPs=DEAD DOCs
        etc.

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          Gail, I really like the “Physicians Lives Matter” slogan.

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          I’m not a doctor but I am a veteran of political and social justice campaigns, including building coalitions. I am also a patient who is on your side on this issue. But with all due respect, if you want to start reaching out to the public for support on this, I really think it’s a bad idea at this point in time to try to co-opt the phrase “Black Lives Matter” into “Physicians Lives Matter”. Honestly, that’s bound to push some buttons and alienate some who would be on your side. Docs need their own slogan. Surely we can think of something else. If it annoys me, I can only imagine how the black community might take it as docs equating their issues with young black men who get shot in the back or strangled by police officers.

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            Ok well, I never thought of it that way. I was thinking of it very concretely. I think the black population had a great idea in bringing forth that slogan, and it is effective, to the point. Of course I borrowed it, because it was so great! I believed I was honoring the black population which has been decimated in the same way, by authorities run amuck without oversight. I completely support blacks in their marches and believe we should march, too. Want to join me?

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              but I see your point in believing I was usurping this motto, though I wasn’t sensitive to that idea…ok will not use it…will think up another. Thanks for your constructive voice.

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                It’s just my humble opinion. You’re, of course, free to use any slogan you want to use. My background is not in medicine but I have friends and familiy who work in healthcare. My professional background is decades of experience in strategic research, analysis, campaigning and coalition building. And I sincerely think that the public would not react well to the Physicians Lives Matter slogan and it’s seeming to equate racist violence with what addicted doctors go through. It’s not that I’m not sympathetic to what PHPs do to docs. I am.

                But I think this slogan might backfire on you. I wouldn’t march with you under it and I’m already with you on this issue. As for marching in the streets, I’ve been doing that for years for numerous social justice issues. I live in Brooklyn a few miles from where Eric Garner was killed by police on Staten Island.

                Please don’t take any of what I’ve said as hostile to your cause. We’re on the same side here.

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                  No, I don’t! I saw it as cautionary and something I didn’t think of. You are right about this! I would rather you tell me I have spinach between my teeth than let it keep hanging there!
                  As one who enjoys smiling…
                  I will come up with something else. Thanks.

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                    Something else I thought of to share is that I learned that we aren’t necessarily speaking of addicted physicians, though a program harming one suffering already from that illness is bad enough, but we are reading here and on other websites about any physician getting involved with PHPs for any reason, including being “reported” to them anonymously having no recourses to the draconian measures dealt to them by PHPs under the guise of providing for their “health”.

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            I agree with you Kit. I think an original slogan is better 🙂

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    “At times to be silent is to lie. You will win because you have enough brute force. But you will not convince. For to convince you need to persuade. And in order to persuade you would need what you lack: Reason and Right”
    ― Miguel de Unamuno

    The first “step into the breach” is to question and challenge authoritative opinion and that is being done here and on Medscape. The FSPHP is used to making authoritative pronouncements without opposition or scrutiny. When challenged directly with specific questions and facts they simply do not answer the questions.

    It is clear there is a big problem with PHPs as currently being managed by the FSPHP. What is being described is abuse of power not unlike the political abuse of psychiatry seen in the Soviet Union. Doctors are being diagnosed with illnesses they don’t have while those who do need help are getting improper treatment in a rigged system of friends referring to friends. Others are afraid to get help for fear of being ensnared by the PHP. How many good doctors are we losing every year unnecessarily? How many suicides?

    Although the comments here are alarming it is just the tip of the iceberg. Even under guaranteed anonymity and not having to provide any identifying information the majority of doctors I talked to who are being monitored by the MA PHP would not call the state auditor to tell their stories. They were too afraid of the PHP finding out. A 3-month stay in an out-of-state “PHP-approved” facility for “relapse prevention” keeps most doctors silent. The PHPs use the accusation of substance abuse or behavioral problems as a means to delegitimize doctors and remove their power and this is a hole hard to crawl out of when an outside facility confirms a problem. It is a rigged system and the ideological and financial conflicts-of-interest are significant. The FSPHP is both illegitimate and irrational authority.

    An evidence-based scrutiny of the literature would reveal their research to be invalid and of little probative value.

    A public policy analysis would reveal the logical fallacies involved in trumpeting their positions including exaggerated rhetoric and fear monitoring strategies designed to inspire moral panics and exploit fears to further an underlying political agenda

    A critical analysis of authoritative opinion would reveal cherry picking. proof by anecdote, deceptive propaganda, double talk, contradictory, illogical and incomprehensible jabber, unprovable and un-disprovable statements and a panoply of logical fallacy.

    These groups misrepresent, censor and suppress. They nit pick and split hairs. The concept of denial is not just used to force people into treatment and justify abuse during treatment but to suppress specific questions and deliberately avoid key facts.

    The next step needs to be exposing the Emperor has no clothes. Once this is acknowledged it would not take long to address directly the specific problems and erroneous assumptions of this paradigm through the lenses of science, critical reasoning, ethics and common sense. If this were to be done the entire Potemkin village would fall like a house of cards.

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    I’m an early career doctor. I got mixed up with a PHP due to an error. PHP tried their best to label be dependent on alcohol. It didn’t work because I don’t drink and I had strong supporters and testimonies.

    The PHP director gave me a choice: spend all my money or ruin my career. I have no reason to be involved with the PHP. I have wonderful documentation of everything. I would love to see a few PHP directors in jail.

    I had committed lawyers, great documentation, and powerful supporters, and I am lucky to be out of PHP’s reach now. I can get back to my patients now. I can easily see how another doctor in my position could be murdered by coercion from the PHP.

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      This is unusual as the PHPs have taken a Machiavellian and “stand your ground” approach to their decisions. They usually do not negotiate or back down unless they have their backs to the door. As I am sure they did not reconsider the facts or have a change of heart. Something must have threatened them. Could you tell us what it was that caused them to retreat?

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      Sad. So how did you prevail when others do not?

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      Orwellian Napoleonic law with no due process. Do you think lawyers would put up with this for one second?

      WWJDD?

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        No.

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          And what is the fundamental difference in character between lawyers and doctors?

          Lawyers FIGHT, they are not only willing to do so, some REALLY DIG IT. Doctors consider is “unprofessional” to fight. Even though lawyers are professionals too.

          Doctors are like British generals who sent columns into machine gun fire at the Battle of the Somme in WWII cause that was the honorable thing to do in the Boer War or whatever. The honor strategy is obsolete and it is getting our troops killed.

          I don’t expect this to change anytime soon. Moses waited forty years in the desert so that the servant mentality would disappear. I’m just appealing to the minority of doctors who get it or who are starting to come around.

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            Disagree. Lawyers may fight when their own ass is on the line (and they generally don’t have malignant Bars or Legal Assistance Programs), but in terms of defense of docs, most have been pretty lazy and even deferential to the Boards. After all, a lot of them are chums. Why disrupt the gravy train? I can’t get over the fact that no lawyer has ever challenged forced out of state evaluation, inappropriate extended in-pt treatment, the shaky corporate and legal basis of PHPs, the medical liability of PHPs, the use of polygraph experts, use of explicitly contraindicated lab tests, violation of confidentiality under both HIPAA and 42 CFR Part 2, violation of HCQIA …. As bad as the PHP scourge has been, the performance of legal representation has been abysmal. One can only conclude 3 causes: incompetence / laziness of counsel; deferential bias (pre-existing relationship with Boards legal staff); or “law-for-profit only,” i.e. run out of money, you done run out of justice.

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      Congratulations to you and your lawyers! Amazing what it takes to extract oneself! Care to say what strategy your lawyers used to make the predators back away? And over what period of time and at what $$ cost?

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      I am glad you escaped! I didn’t think escape possible.

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    State Physician Health Programs (PHPs) were originally developed by competent and caring physicians to both protect the public and help sick colleagues who developed problems with addiction or substance abuse. The current system does neither. These programs have been taken over by a group that does not represent the best interests of doctors or the patient public. Physician health programs are not the problem. We need PHPs. What needs to be addressed is the current management of them under the FSPHP. This group has created a culture of impunity and harm.while effectively removing due process from doctors while removing answerability and accountability from themselves. There is no oversight, regulation or accountability. They are a power unto themselves with carte blanche managerial control. The horror stories are real and mounting. They are also consistent. Egregious ethical violations, forensic-fraud, diagnosis rigging, and other crimes are being reported. It is a system of institutional injustice and organizational sham-peer review. They have also convinced medical boards to give them complete autonomy when it comes to physician assessments. There is absolutely no oversight.

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      So PHPs were well run until recently? When did the “current management” and institutional injustice begin? Do you have a timeline?

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        In 1973 the AMA Council on Mental Health published The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence in JAMA. recommending 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.” This led to the development of state “impaired physicians programs” 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. 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.

        At this same time specialized treatment centers for doctors were being developed by members of the “impaired physician movement” such as G. Douglas Talbot who claimed physicians are unique because of what he called the “four MDs.” “M-Deity”, “Massive Denial” “Militant Defensiveness” and “More Drugs.” This was used to justify the thrice lengthy stay of doctors compared to the rest of the population.

        Doctors admitted to these programs complained of false diagnoses, coercion and abuse all under threat of loss of their licenses and in 1987 the Atlanta Journal constitution did a series of reports after five inpatients died by suicide during a four-year period at one of Talbott’s facilities (Ridgeview) and at least 20 more did so after being discharged.

        Critics of these boot-camp like programs included ASAM President LeClair Bissell and former Assistant Surgeon General John C. Duffy.

        But in 1995 The Federal Bulletin: The Journal of Medical Licensure and Discipline, published by the Federation of State Medical Boards published articles reporting the 90% success rates of PHP programs directed by ASAM physicians in 8 separate states. This formed an alliance between the FSPHP and the FSMB. This is when they gained a seat at the table of power and the FSMB accepted their offer of “rehabilitation” as an alternative to “discipline.” Since that time the FSPHP has duped the FSMB (as well as others) into accepting public policy and changing medical practice law to gain power and immunity. They also pushed for changes that removed due process and rights of doctors. To see how far this has gone one only has to look at the 2011 FSMB Public Policy Statement on Physician Impairment. The FSMB accepted “potentially impairing illness: and “relapse without use” as definitions and agreed not to second guess the PHPs. Medial Boards have agreed not to question their decisions. They have also introduced non-FDA approved drug and alcohol testing (LDTs) and these are being used by the PHPs. The conflicts-of-interest are immense both financially and ideologically.

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          You are a walking encyclopedia on this topic. Amazing.

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            Thanks. If I can clarify anything for anyone I am happy to do so. And unlike the group we are talking about I can reference sources, facts and documentary evidence.

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              Just curious Michael. How long have been at this? When did you first start researching PHPs?

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                Since July 1, 2011 when I was minding my own business and the Massachusetts PHP asked me to submit a blood test for alcohol and requested I have an evaluation at a “PHP-approved” assessment center. Since that time I have obtained documentary proof that the MA PHP is colluding with both the drug testing and assessment centers to fabricate false positive tests and the assessment and treatment centers to intentionally report normal tests as abnormal to support unneeded treatment. This will eventually be recognized as political abuse of psychiatry against the medical profession and those behind it are affiliated with the drug and alcohol testing, assessment and treatment industries.

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          I agree completely.

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          EAPs especially need to be cautious about signing a contract with these “specialized programs.” They will have not only sold their souls to the devil, they will have contributed to the derailment of good physicians’ careers. It is VITAL that they understand the malignancy and profit motive of these predators.

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            I actually don’t trust EAPs. And I was represented by a union for 18 years before my layoff and was an active member, serving on the negotiating committee for our contract. Nope. I don’t trust EAPs.

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            The “PHP-blueprint” iis merely a template for the “Nrw Paradigm” and that is the plan that has been in place all along as envisioned by Robert DuPont. In fact Gunderson alludes to it in her response to Pamela’s paper. If you do an Internet search with “new paradigm” “PHP blueprint” and DuPont you will find a lot of information relating to this and see how they are laying the foundation for exanding this to as many people as he can.

            The FSPHP do not represent the best interests of doctors but serving the interests of a business plan.

            Doctors are afraid to speak out of fear and intimidation because iit serves a purpose. The “recovery racket” ASAM and FSPHP are singing the praises of PHPs with no opposition. To sell this model to other EAPs as the next best thing you can’t have a bunch of doctors telling the truth about them. Who would want them? But by creating a culture of fear and intimidation and keeping doctors silent they can continue to claim “gold standard”

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              Well, they’ve laid the groundwork pretty effectively. “Preferred programs,” “preferred labs;” “PHPs really don’t do evaluations;” state sanction authority; complete immunity; no malpractice worries; denial of due process; no pesky oversight; complete control over career if non-compliant – and even if compliant; shaming of the victim and reporting to their employer. And now, the masterpiece – congressional endorsement and guaranteed insurance parity for extended hospitalization for oh-so-necessary treatment at the facilities we’ve set up especially designed for professionals.
              Wow! Sort of like insider trading, though that, even in great magnitude, doesn’t hurt people so directly.
              Wonder how many “in-the-know” docs who are members of the medical societies which proudly proclaim ownership of these PHPs have hopped on the bandwagon to own a piece of this action!
              It’s easy! It’s franchisable!
              All you gotta do is open a shabby facility, hire questionably-recovered drunks and druggies with a high school education and with a penchant for bullying and a delusional zeal about their being God’s angel here to rescue you from your illness to do the counseling; make friends with the right people at FSPHP (a little donation can’t hurt); and get yourself designated as a “preferred program.”
              And you’re guaranteed an endless stream of high-paying referrals who dare not balk because you now are powerful like the PHP you’re in bed with and you too can take away their license – just label them as “disruptive” and “non-compliant.” What a rush!
              And who’s going to believe THEM anyway – they’re just disturbed docs, officially stamped with the PHP imprimatur of infallibility. Docs now with zero credibility. And now no money to hire a lawyer! What a dream! What a golden goose investment opportunity for economically squeezed docs and morally depraved lawyers looking for a good income stream. It’s a virtual annuity! Do you realize how much you could make on mandatory testing alone?! 5 years of guaranteed monitoring! Even if they’re not diagnosed with alcohol or drub abuse issues! Wowzer!
              Before he blueprint goes public, you really want to get in on this!

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              It sounds like a big chunk of the problem is that PHPs have apparently been allowed to become, first and foremost, a lucrative, profit-driven business when they should be nonprofit organizations with the central mission of helping and healing docs, not making as much money as possible. Frankly though, this doesn’t surprise me since I think our entire healthcare system has been allowed to become a profit-driven big business in which making money is the main goal. In the profit-driven business of healthcare in the US, why would PHPs be any different? The people who are deeply vested in, at all costs, keeping it this way are the ones who are making the money. It’s hard to attack PHPs for making tons of money off of some doctos’ misery when our entire healthcare system is making tons of money off of patients’ misery. That kind of money and corruption come hand-in-hand.

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            The grand plan of these criminals is expanding the PHP model to the rest of the population. What is happening to doctors

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      It would seem that a system that has no oversight would also have no enforceability. If the source of their power is the legislature, then we need to reverse that legislation. I recognize that’s a long-term solution (and to necessarily even accomplishable). Then next step it would seem is to make it clear that certain states are to be avoided at all costs. Effectively, a physician embargo.

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      I am in total agreement.

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    I would like to hear from supporters of PHPs please. Recent articles on Medscape are filled with tragedies from those who have been injured by PHPs: http://www.medscape.com/viewar… and http://www.medscape.com/viewar…

    It is my objective to hear from both sides. If you are a doctor, please comment if PHPs have helped you with your mental health. As a physician who is extremely concerned about all these physician suicides (just off the phone with another doc who lost her colleague) and I need to know what we are doing (or not doing) as a profession to help or harm our vulnerable colleagues.

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    This is sad, and not limited to the healing professions. Aspiring lawyers must go through a bar admission process that in many jurisdictions still requires disclosure of any past mental health issues. I’ve known cautious law students who have discontinued seeing psychiatrists and stopped taking medication so that they could honestly answer “No” to these types of invasive inquiries. Regulators might say that this is an unwarranted over-reaction, but try explaining that to risk-averse-by-nature law students who are spending more than $100,000 for a professional education that will be useless in the absence of a license to practice. These types of mental health inquiries by licensing boards (which have no particular expertise or competence in these areas) are useless and counter-productive, and should be prohibited by law, in my opinion.

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    The following is a quote from an article on physician suicide by W. Clay Jackson, MD featured on the PsychCongress Network this morning:

    “Clinicians’ risks for suicide mirror those of general society in many ways, but differ in one critical area: the
    intense sense of personal identity tied to the professional role,” said Dr. Jackson. “When that identity is threatened, physicians are at high risk of depression and self-harm.”

    Need I say more?

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    Hello all. I am so grateful for this posting. This is SUCH an important issue. I certainly felt more despairing when, due to a history of depression alone (no other significant illness, no substance abuse, no malpractice, excellent reviews by supervisors and colleagues during residency etc.) I was required to enroll in a 2-year PHP contract in order to get my license to practice following residency. The program required monthly visits with a case manager who asked me the same questions each time: had I abused substances, had I gotten in trouble with the law, had I complied with my psychiatrist’s suggestions, etc. – even though none of these had been the issue to begin with. They were asking the wrong questions. It also required reports every 3 months from a “workplace monitor” (a colleague), my therapist, my family members, and my psychiatrist, on my “behavior.” I was being treated as though I had committed a crime, when all I had done was voluntarily disclose on my licence application that I suffered from depression and had VOLUNTARILY chosen to take medical leave twice for a few months during residency, for more intensive treatment. I had an impeccable professional record and still do. This was extremely humiliating and the restrictions I had on my license (the fact that I had to comply with this monitoring program) have followed me every time I have had to apply for hospital privileges, or a license in a new place. Certainly the demoralization of this process exacerbates/exacerbated my depression, and exhaustion. I think we certainly do need programs specifically designed for physician mental health, but that these programs need to be there for the purpose of helping physicians – NOT for the purpose of policing them. I realize some physicians with mental health issues can at times be a risk to patients, but most are not. PHP’s need to match the services they provide to each individual physician based on individual issues/risks/needs.

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      Given your experience, what program would you wish that you had available to you? What would you suggest that we offer to support (rather than punish or police) med students and docs. Thanks.

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    I find it interesting that the FSPHP continues to compare doctors to pilots. Also interesting that, on the whole, it is likely that both pilots and doctors routinely perform their tasks with a serious lack of sleep. No cause for concern here? Frankly, I would rather have my surgeon or pilot drink a beer before work than reporting for work after only 2 or 3 hours sleep. Interesting that the house of medicine, at least during training years, has actually been designed to keep doctors awake all night and all day and then expect them to perform well. This is institutionalized impairment. What about protecting the public from this? Where’s the outcry?

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      They often use the nuclear power, airline and railway industry as examples of “safety sensitive” occupations that use drug testing in their push to randomly test all physicians. The big difference is that these three agencies follow strict Federal Workplace Drug Testing Guidelines and use only certified labs and FDA approved tests. These industries follow strict procedure and protocol using strict chain-of-custody procedures and MRO review. There is accountability and oversight. In addition, these industries have unions or other groups looking out for the best interests of their employees. Doctors do not. This is how non-FDA approved laboratory testing with no FDA oversight has been introduced into these programs. There are no safeguards. While government drug testing uses only certified labs the PHP system uses commercial labs using these “Laboratory Developed Tests” (LDTs) that they themselves pitched to the labs. The conflicts-of-interest are unimaginable and it is unconscionable that the medical profession has allowed their own to be tested with what is essentially junk-science. Just look at the history of the EtG introduced by Greg Skipper who was director of the Alabama PHP at the time. He claimed 100% specificity at an arbitrary cutoff level of 100, then raised it to 250, 500, 1000, 2000 to unknown as the test was shown to be unreliable and with no evidence base. Any rational authority would have taken it off the market but the PHPs just kept raising the cutoff leaving a wake of ruined lives behind them as they arbitrarily changed the cutoff and claimed it to be valid. This is not science but snake-oil carney hucksterism.

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        The Airline Pilots Association has been complicit in all of this. They are not a union, but an association, that frequently, if not always, works against the interest of the pilots they purport to serve. ALPA is a paper tiger; a political behemoth, if you will.

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    “Greg’s mother, a psychiatrist”

    This does not surprise me one bit. And while this article is about “physician health programs” doing more harm than good, I would also argue that psychiatrists are also guilty. Partly by self-selection and partly by virtue of psychiatry training, they have this desire to “fix” people. They pick up on verbal and non-verbal queues to figure out what people are “really thinking”, and they know how to influence people and change behaviors. One can not stop being a psychiatrist when they go home, it’s part of who they are. This weighs on people and may cause irreversible harm to those who spend a significant amount of time around psychiatrists. Anecdotally, out of all of my friends who I grew up with, only 1 has ever had a significant physiological problem, this actually required hospitalization during high school. Not surprisingly, one of his parents is a psychiatrist.

    On the other hand, short 15 min appointments every few months are beneficial for many people with mental health problems, I will always refer these patients to the experts if needed.

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    Please post directly to Doris Gundersen, FSPHP response, Medscape. She needs to hear from all of you.

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      One gets the sense that she and her affiliates don’t particularly want to hear critical feedback. Interrupts their firmly held notion that anyone who objected was just in denial or a defiant troublemaker who hadn’t done their 12 steps of submission. It’s very difficult for people like this who live in an insular world of magical thinking to accept information that challenges their fundamental assumptions. It literally blows their mind.
      It’s best they adapt quickly, because what truly is going to blow their mind and their pocketbook are the suits for intentional misdiagnosis, operating without a medical license, involuntary detention, denial of due process, deprivation of civil liberties, physician patient endangerment, and patient endangerment (patients of victim physicians of these gulags). Every state that has let these programs run under state authority and immunity will face incomprehensibly huge punitive damages.

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        Let’s get started! Please advise what is best to do right now…Gail

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          Assuming Dr Langan wants it, doctors could start massively supporting him in his case to highlight what the MA PHP is doing and make an example of MA as just the tip of the iceberg of what many state PHPs are doing. Get tens of thousands of docs to sign a petition in support of Dr Langan. Buttons, t-shirts, bumper stickers asking “Where is Dr Langan?” or “Free Dr Langan” or “Who is Dr Langan?” or “What have they done to Dr Langan?”. He could become the Karen Silkwood of the reform PHPs movement.

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            I’m willing to do whatever it takes to expose this. I have documentary evidence of how they are colluding with both the laboratories and the “PHP-approved” facilities. Both of these are verified by outside groups and they were forced to correct the intentionally fraudulent interpretation. In addition I have proof of the Establishment Clause violations confirmed by outside groups.

            http://americanhumanist.org/ne…

            Not sure if you are aware of the Like-minded docs and their involvement in all of this.

            Both the 2011 ASAM Policy on Coordination Between PHPs, Treatment Centers and Regulatory Agencies and the updated FSMB Policy on Physician Impairment state that assessment and treatment must be at a “PHP-approved” facility. It is assumed that FSMB “approval” is based on some sort of objective qualitative criteria and quantitative measurements but this is not the case.

            The NC PHP Audit found that no objective criteria exists in choosing the out-of-state treatment centers they used. Warren Pendergast, FSPHP President at the time could not provide the State Auditor with what criteria went into selecting the places he sent doctors to for evaluation. His best response was “reputation” and “word of mouth.”

            This would be akin to the FDA being asked what criteria went into the FDA approval process and replying “word on the street” but no one has awakened to the significance of this disparity between rhetoric and reality. The “PHP-approved” facilities have a single selection criteria–ideological. All of the medical directors of these facilities are not only all ASAM “addiction medicine” doctors but members of a conservative fundamentalist group of doctors called “Like-minded docs.”

            The list can be seen here: http://www.likemindeddocs.com/…

            PHPs mandate evaluations only at “PHP-approved” facilities and the states enforce it. We have no choice. They give a false-choice by offering 3 or 4 options but they are all on this list.

            Therefore the state is mandating treatment at 12-step ASAM facilities only and this is an Establishment Clause violation. The fact that this is a hard-core 12-step group makes it even more pronounced.

            And look at all the other conflicts of interest. Greg Skipper introduced all the junk-science tests (EtG., PEth, Soberlink) and is behind the push to randomly test all doctors with his witch-pricking non FDA approved tests, Former Drug Czar Robert Dupont who owns the 6th largest EAP and is calling PHPs the “new paradigm.” He and Skipper are also authors of the PHP blueprint for which they claim an 80% success rate. ASAM President Stuart Gitlow is on there.

            So too is Paul Earley, the Medical Director at Talbott where the neuropsychologist reported a normal MMPI as abnormal to show “denial” and shaved points off My IQ test to show “cognitive impairment”in 2008. The GA Psychological association confirmed the MMPI fraud and forced him to correct it.

            Oh and Wayne Gavryck the MRO for PHS is on the list. After Luis Sanchez and Linda Bresnahan conspired with USDTL to add my ID # and a “chain-of-custody” to an already positive sample he was the one who was supposed to reject it. Like a firefighter arsonist he did the opposite. The MRO declared not only an invalid test valid but an intentionally invalid test valid. Based on that they sent me for an evaluation and gave me 3 choices and the medical directors of all three of them are on this list.

            http://www.likemindeddocs.com/…

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    While the title of the article borders on the sensational, some states’ physician health programs (PHPs) do drive some health professionals crazy! I agree with the sentiment of the article – PHPs need to evolve. They seem to be very good when a person has an addiction problem (e.g daily reporting online and via phone) and provide major legal cover so a health practitioner can keep his/her job… they may be addicted to pain meds and be stellar ER physicians, but they still need to work.

    Like some of the comments here already mentioned – read through your state medical board’s “monthly newsletter” about whose licensed got yanked or suspended. Nearly all of them have been relapses in egregious moral (and/or criminal) behavior, such as signing pain meds like candy (with inadequate record keeping), being drunk AND causing harm (car accidents, showing up drunk to hospital).

    For mental health conditions (that can indeed drive someone to drink, use drugs, gamble, etc) such as anxiety, depression, adult ADD, I recommend getting a thoughtful mental health team and keeping your “game face” on. Do not let anyone except your boss know, and only if he has to. Your colleagues will use it against you and if you DID NOT REPORT the “impairment”, you’re dead meat. That ADHD may sound minor but he’s not gonna like it when you have 55 patients in the office and you’re getting behind, or risk being called “moody”, “chronically late”, “disorganized”, or “dysfunctional”. INVEST TIME in your kids, family, exercise and relaxation time, and tell your family (esp parents and siblings, if alive) that even the strongest need to be held and pampered. A confidant in the same profession is a godsend…just make sure to keep this private.

    I have a med license in 2 states. What did they do for me (adult with longstanding history of depression, ADD and associated anxiety)? Nothing. I asked for a psychologist referral and told me to ask “my” health provider. The PHP of one state does nothing (unless you REALLY screw up more than once) and the other does nothing, but charges an arm and a leg, and threatens the physician with license restrictions and/or an investigation, which will stay in your records.

    And for the one who asked if a psychiatrist has to report a health professional to a state’s PHP. The answer is “it depends”. From my own experience – if you are showing signs of impairment and that has, or is causing harm to patients, he does have a responsibility to do something (urge you to get help, medical and legal, speak to your boss and HR staff and maybe take a leave, etc). In other words, he should serve as an advocate for your care, especially if he/she is finally seeking care. This is usually substance use/abuse. At least two academic physicians (one a psychiatrist) have told me “depression, anxiety, ADHD – those are OK to keep private or not disclose if someone has been in treatment for a long time and is medically/mentally stable”. However, if you have schizophrenia and bipolar disease, you should probably disclose as it may affect your decision-making process if you relapse.

    Lastly, I’m sorry about Greg Miday. His psychiatrist may have been more forceful and specifically tell him to forget about the PHP – he is the mental health provider and HAS to report the admission to the state PHP. However, Greg had a history of alcoholism dating back to his college years, and at several times was “enabled” by his friends and even his family at one point or another. You all know the individual – popular at med school, good looking, high grades, well-liked by everyone and seemingly unable to get into any real trouble. The guy’s designated friend/mentor to keep him sober committed suicide – a BIG red herring. Alcoholism and depression can co-exist, but are VERY different things. I have a history of depression, but not alcoholism. “Going out for drinks” is great to “smooth things out” after a hard day’s work. This guy rarely gets reported. The one with a history of depression that is showing signs of overwork, fatigue, and emotional lability? He’s the one with the problem. I would counsel doc with a mental health problem or chemical dependency problem to take their time when going “up the ladder” academically. Literally take 6-12 months and work as locum tenems or at the max 3/4 employed. Being a resident is a lot harder than being a med student, and being a fellow even tougher than a resident. Just my two cents guys. Now, gonna ride my bike with the kiddos.

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    Thank you, Dr. Wible, for bringing awareness to this problem. It is clear that our healers are in crisis and need help. I’m surprised the media, is being so quiet. Physician suicide should be brought out into the open and addressed. I think the silence surrounding this issue is making physicians feel even more isolated. Let’s continue to discuss, tweet and share this information online–so that it gets the attention it deserves!

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    Once again, I don’t believe the working conditions for residents and med students are any worse now then they were 30 years ago. What has changed is how uncertain are the goals and potential rewards for tolerating the abuse. Military recruits are willing to undergo the rigors of boot camp if the rewards are clear. If one wants to avoid potential drug abuse, depression or even suicide while undergoing medical training then one needs to be honest with themselves about the potential risks and benefits.
    Personally if I had to do it again today given what I know and where I started I would never do it. Motivation alone is often times not enough and one has to be realistic or face the consequences.

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    Thank you Dr. Wible for your continuing efforts to care for doctors. Anecdotally, I have many close friends who have been treated for anxiety or depression throughout their medical careers, or have seen a mental health provider at some point. Luckily, it’s never gotten to the point of substance abuse in their cases.

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      Have they had involvement with PHP programs? If so, was the experience a positive or a negative one?

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      Actually, it worked out okay. I saw a psychologist briefly in medical school and just talked to my PCP. My wife and several friends have seen a psychologist for depression that was provided by the residency program (the campus mental health program i think). I don’t think that these were true physician health programs, and the medical board was never involved.

      It’s actually been a good experience for me and my wife (who’s also a doctor). If our close friends have issues we tell them about our experience and have recommended they see psychologists (sometimes the same one). I’ve never heard of any negative repercussions from them.

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        So your care was handled locally by a therapist you trusted? That makes all the difference. I think that is all many docs wish they had the opportunity to experience for themselves. A safe place to go.

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          Doc Joe’s wife and friends got the help they needed for their depression through the med school campus/residency mental health program. It’s good to hear that this is being done without repercussions to the doc who sought their help.

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          It kind of raises a different issue why there is so much anxiety and depression in the medical field, but these were positive experiences for the most part. Currently, applying for another job is doing wonders for my outlook!

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            Watching people die. Telling parents there child died in the car accident. Amputating people’s limbs. Giving a dad a cancer diagnosis. This is no cake walk. Ya think docs don’t feel this stuff? What? Just go home and play with the kids and have sex with your spouse and bury the stillborn you delivered to the devastated mother. Really? Just kinda pretend this stuff doesn’t bother you. . . .

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              It bothers me sometimes, but it comes with the territory. I think it’s a privilege to care for people when they are at their most vulnerable, and consider it an honor. Other doctors have said it far better than I can, but the loss of autonomy and individualty/creativity are what bother me the most, along with all the data entry. I’ve said it in other posts, but we have new “interdisciplinary rounds” at the bedside that consist of hearing the nurse read a script, and we are given our own script/template to follow. That part is bad enough, but having our boss follow us around to make sure we are following the script is absolutely the final straw.

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        It’s good to hear from a doc who was able to get the help you needed with depression without having a negative impact on your career. And that your wife and several friends were able to do so too. It’s also good to hear that this help was available through your university/med school/residency program. It can be done. I hope you’re all doing well now.

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      Same question as Gail. Where did they get treated?

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    I understand comments are closing soon. Hopefully this will be a stepping stone to a larger discussion as the comments seen here show that the current management of the PHP system is causiing grave, far reaching and sometimes permanent consequences. No more doctors should die from this institutional injustice and organizational fraud. Naom Chomsky said “I think it only makes sense to seek out and identify structures of authority, hierarchy, and domination in every aspect of life, and to challenge them; unless a justification for them can be given, they are illegitimate, and should be dismantled, to increase the scope of human freedom.”

    Doctors need to stand up and challenge the current paradigm. As seen here these challenges will be met with silence because they cannot justify their actions. As an illegitimate authoity it is necessary we dismantle them and replace them with a transparent, just, accountable and fair system that actually does help doctors and protect the public. If we don’t do this decisively and urgently then darker clouds lie ahead for the medical profession and all of us.

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    To be clear: I am certainly no expert on PHPs. My video raises a question based on conversations I’ve had with suicidal docs. Many developed suicidal thoughts during their PHP treatment. I had no idea about any of this until hearing about Greg Miday’s death.

    Just raising the question. I am not one to demonize anyone. I do feel medical students and physicians are not receiving the mental health care they need in training (unrelated to PHPs). My focus is humanizing medical education and preventing physician and medical student suicides.

    I thank all of you who have participated in this heated conversation. I hope this will be the first of many conversations. We certainly need to heal as a profession. And I will echo Karen Miday that “we cannot afford to lose another physician to shame.”

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    I am lucky that I am not one of these statistics! After a left knee replacement, I had severe chronic pain, which turned out to be caused by a Staph infection, requiring a repeat knee replacement and a central line for IV Vancomycin. After all these facts came to light, the BOM and my attorney required me to join the PHP, which caused me to lose my Board Certification, and eventually my medical license. I considered suicide MANY times, but due to the love of family and friends, I had the courage to live. In spite of being clean and sober for 7 yrs., I will never be a physician again!

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    One of the architects of the current system, Dr. Robert Walzer, M.D., J.D. who was instrumental in tinkering with administrative and medical practice laws to remove the due process and appeal rights of doctors surrendered his license in 2001 due to inappropriate sexual relationships with patients. He was the co-author of the current physician health program paradigm. It is important to look at some of the backgrounds of those involved in this system as a number of them have histories of manipulating the system. Many were doctors who had their licenses revoked and got them back through the support of their state PHP. Many are felons and some are even double felons who had been convicted of criminal acts. This system often returns doctors to practice who should not be practicing medicine yet ends the careers and ruins the lives of many good doctors for little reason and without justification. It is as if the animals have been put in charge of the zoo.

    http://mss.fsmb.org/FSMBJourna…

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      How did your interview go Michael? Love to know!

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        They are currently reading through all of my blogposts and looking at the more than 700 comments here and on Medscape that make it crystal clear the current system is causing damage to doctors on a large scale. The comments raise specific and serious questions that are not being answered.

        Silence from authority is an acceptable stance when the criticisms are unreasoned and unfounded ad hominem attacks and generalizations based on bias and prejudice. But that is not the case here. The testimonials and criticisms are articulate, specific and remarkably similar. I’ll let you know as soon as I hear back.

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    You know, I feel like I’m walking in the same sort of Wicked Wonderland I had to survive as a child, growing up with two brilliant but flawed parents, who had obvious personality disorders and alcoholism. Maybe that’s why I am trying to do some good…to repair the damage.
    Still, Helen Keller said that one person alone can’t do that much, but together we can do a lot! I surely hope so.

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    Misinformation and propaganda have been used to treat doctors differently. Look at this quote from Marv Sepala who has close ties to the PHP and is medical director of “PHP-approved” assessment and treatment center Hazelden.

    “Few, no matter how desperate, seek help of their own accord.” “Physicians are intelligent and skilled at hiding their addictions.”

    “They’re often described as the best workers in the hospital,” he says. “They’ll overwork to compensate for other ways in which they may be falling short, and to protect their supply. They’ll sign up for extra call and show up for rounds they don’t have to do.”

    This is just another example of authoritative opinion with no substantive value. It is moral entrepreneurship at its finest; the fallacy of appeal to authority and secret knowledge.

    If Seppala were asked to provide the evidence-base and rationality of these statements he would be hard pressed to do so.

    It is this type of misinformation and propaganda that allows the “impaired physician movement” to drag away the “best worker in the hospital” and deem him “in denial.”

    “We were so surprised. We didn’t even know he had a problem” say the nurses, patients and colleagues left behind.

    Well the truth is he probably didn’t!

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      Dr. Langan,

      I love your website and your spirit…I would also direct readers of this blog to a very important photo on your website:

      https://mllangan1.files.wordpr…

      WWJDD? (What would juris doctor do?) Not put up with this for one second.

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      You say succinctly here much of the conclusions I had drawn when I had a critical look at what is happening. It is deadly and very sad.
      PHPs must undergo major revisions or be abolished, since MB’s are the disciplinary authority (and that is a whole ‘nuther issue!)…If they aren’t going to act to identify scientifically who has a problem and who does not need their “help”, then work to heal that practitioner with state of the art methodologies, then they need go.
      As in good-bye/good riddance

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        Reclaiming sanity and civility in medicine requires swift and certain action. We need allies and activists.5

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          Agreed, Dr. Langan. Here is a glimpse of some of the logic being used by this group to identify a potentially impaired pilot:

          “An alcoholic pilot grows up, sobers up, gets locked up, or covered up.”

          “Heavy use of aftershave, difficulty during a recurrent event, and talking about marital or relationship problems in cruise. (see EtG)”

          “The time that presents the greatest risk for relapse in a pilot’s recovery is ‘release from monitoring’
          (see EtG)”

          “There is speculation that pilots have massive egos”

          I have noted that the HIMS page, on the alpa.org, website is now suspiciously absent though.

          Exiting your sandbox now. Thanks for allowing me to participate.

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    I encourage all of you to also join the discussion following the FSPHPs response to Dr. Wible’s articles on Medscape. The PHPs boast a very high success rate. This success is measured by clean urines. That measure counts my now deceased son as a success. He never dropped a dirty urine. So, as the saying goes, “the treatment was a success, but the patient died.” Let’s suppose we have a treatment with a 90% success rate, but also a very high fatality rate. Wouldn’t we want to take a closer look? Unfortunately, the PHPs do not want to discuss the outcome of the remaining 10%.

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      Will get on it

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      I’m doing so, but Dr. Gaither is really getting under my skin.

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      An 80% success rate is being claimed to parade the “PHP-Blueprint” and promote the “new paradigm” One of the first orders of business needs to be critical appraisal of the validity of this study and a conflict-of-interest analysis of its authors.

      They are pitching the PHP model to other EAPs as the “gold standard” for addiction treatment. It is also used to deflect criticism ( ASAM President Stuart Gitlow responded to Knight and Boyd’s critical PHP article with an editorial “Who can argue with an 80% recovery rate?) Doris Gunderson refers to it in her response to Medscapes criticisms.

      Articles such as “What Might Have Saved Philip Seymour Hoffman,” claims PHPs “ought to be considered models for our citizenry” and the “best evidence-based addiction treatment system we have going.” The author repeats the 80% success rate for doctors and claims Philip Seymour Hoffman might still be alive if he had been treated using the PHP model.

      The basis for these claims is a 2009 study published in the Journal of Substance Abuse Treatment entitled Setting the Standard for Recovery: Physicians’ Health Programs and authored by Robert Dupont, A. Thomas McLellan, William White, Lisa Merlo and Mark Gold.

      This study is the cornerstone of the “PHP-blueprint.” It is the very foundation on which everything else is based, a Magnum opus used to lay claim to supremacy that has been endlessly repeated and rehashed in a plethora of self-promotion and treatment community blandishment.

      To date there has been no academic analysis of the “PHP-Blueprint.” There has been no Cochrane type analysis or critical review. There has been no opposition to its findings or conclusions which are paraded as fact and truth without challenge or question and there is a general lack of concern from those both within and outside the medical profession.

      The study is a poorly designed using a single data set (a sample of 904 physician patients consecutively admitted to 16 state PHP’s).

      It is non-randomized and non-blinded rendering the evidence for effectiveness of the PHP treatment model over any other treatment model (including no treatment) poor from a scientific perspective. The study contains multiple flaws in both reasoning (type I and type II errors) and statistical analysis that render its conclusions invalid.

      In addition the impact of undeclared but substantial financial conflicts-of-interest (including funding by drug testing and addiction treatment industries) and personal ideological biases (including personal 12-step recovery from addictions) in the authors of this study also needs to be considered.

      Moreover the misdiagnosis and over-diagnosis of addiction in physicians in this paradigm incentivized by lucrative self-referral dollars for expensive 90-day treatment programs is a significant factor.

      The mean age of the 904 physicians was 44.1 years. They report that 24 of 102 physicians were transferred and lost to follow “left care with no apparent referral.”

      What happened to them? These are physicians with multiple identifiers (state license, DEA, UPIN, etc) not transient drifters.

      Of the 802 left in the program they report 155 failed to complete the contract. Of these, 48 involuntarily stopped or had their license revoked and 22 died with 6 of those being suicides.
This study is looking at defined endpoints while being monitored so 6 killed themselves while being actively monitored by the program. But what about the 24 that left with no apparent referral? It is unlikely the just left on a whim. There must have been some precipitant event.

      More importantly what happened to those 48 who were reported to the Medical Board for noncompliance and had their licenses revoked–that would be the critical time when this population would be at most risk for completing a suicide. That would be when hope was lost and the coerced physician, knowing that the fight was over, would take that step.

      It does not take a Cochrane review to see that the emperor has no clothes. This is not difficult. It is straightforward and simple.

      see more

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        Thanks for presenting this and your analysis of the flawed and unscientific study…the SINGLE study that all this BS is based upon. Much of the treatment of brain problems is based upon consensus, not well-designed studies that follow scientific methodology. Our poor patients! The diagnostic nomenclature is archaic and prejudices and persists even in DSM5! the axis thing is patently silly…and I can go on. Who asserts “personality disorders”. Is this based on solid science? It is all BS. My son told me this one—“spot it and you got it”…uncover the BS and understand it for what it is—all psychobabble, which destroys many, many lives, not just the lives of physicians.

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        Wonderfully researched and written, Dr. Langen. As a physican myself, and the mother of a young physician who died of suicide while under the supervision of his state (MO) PHP, I commend your effort to effect change. After my son’s death, the clinical director told my husband that Greg was “a model patient.” Gives one some idea as to how success is measured. Even if the 80% were true, wouldn’t we want to consider adverse events? Certainly no drug with that high a completed suicide association would ever be approved without a Black Box warning. No Black Box warning here.

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          Karen Miday @GGail Hirschfield Fitzgerald Yes we would. More concerning is what is the actual mortality rate here? What happened to those doctors who left voluntarily, involuntarily, or with no apparent referral and under what circumstances does this occur?

          Due to the severity of the consequences a 20% failure rate is alarming. 20% lost their careers that’s for sure and if you look at EAPs across the country for other occupations I would bet most people who completed them are still working in those jobs and most of those people had real illness.

          The 20% failure rate is most concerning because many doctors (if not most) monitored by PHPs are not true addicts.

          The problem is no one questions these studies.

          The FSMB, hospital administrators, insurers, and everyone else has accepted them as expert authority and their authoritative opinion as fact. It is this acceptance of faith without objective assessment that has allowed them to get whatever they want by claiming it is in the interest of public safety.

          By confusing ideological opinion with professional knowledge, the medical boards and others have acted as willing gulls each step of the way. No counter-forces existed and they still don’t.

          Junk science and unvalidated neuropsychological testing is used by these groups unconstrained and willfully. There is no regulation, oversight, or accountability.

          They are using polygraph testing (despite the AMA’s previous public policy statement deeming it junk) to both condemn “disruptive” surgeons and deem convicted pedophiles fit to return to work.

          They have introduced junk-science in drug and alcohol testing and unvalidated “neuropsychological” testing to detect “character-defects.”

          Their next step is to get rid of the strict procedural protocols used for drug and alcohol testing that protect the donor. They are claiming MRO review is unnecessary.”

          see more

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            An “innovative”program like a PHP ought to be held to rigorous evaluation with thoroughly measured parameters, such as “patient entry criteria,” “double-blinded assessment” etc. It is highly unlikely that any such study has even been done on any PHP program.
            In effect, a PHP program, aka “the Program,” is really like a medical device or pharmaceutical. These of course must go through rigorous testing before being put on the market. And if they’re found to be dangerous in “post marketing surveillance,” and have untoward effects that weren’t picked up earlier, for the public’s safety, they’re immediately removed from the market, independent of how many patients they allege benefitted.
            FSPHP’s fallacious “throwing the baby out with the bathwater” argument ignores this very principle. The “Program” is dangerous – it is killing patients and harming others’ careers and upending their lives. Yes, some bona fide substance abusing / dependent physicians have benefitted. And there’s another group for whom”the Program” is working quite well and who would really prefer that we go to all this bother: the inner circle of doctors, lawyers, path labs and recovered addicts who run this scam.

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    My hope is that everyone who has posted commentary will visit the FSPHP response on Medscape and post a comment directly to Dr. Gunderson. She needs to hear from as many people as possible. Has been too easy to dismiss the PHP “dissenters” as a “vocal few.”

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    To see how they are colluding with labs to fabricate drug and alcohol tests see my post below. “”Forensic” testing is tightly controlled with strict chain-of-custody procedures and MRO review to prevent false-positives. A single positive test can result in grave consequences so need to be rare. Most EAPs use only FDA approved tests and follow the Federal Employee Drug Testing Guidelines with strict procedure and protocol.

    Physicians Health Programs on the other hand use a variety of non-FDA approved tests of unknown validity on doctors. In fact a PHP director, Greg Skipper, MD, FSPHP of the Alabama PHP, introduced the first one when he pitched it to NMS labs as a laboratory developed test and then started using it on doctors to market it. It is junk-science testing of unknown validity and it is incomprehensible that the medical profession has allowed this to happen. But they are not only using junk science they are abusing junk-science. See below how they collude with the labs marketing these tests to intentionally give positive results.

    http://disruptedphysician.com/…

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      Yes, these tests are not standard, not scientific, and you have shown us all how they are “gamed”. The Emperor Has No Clothes…

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        The Emperor really does have no clothes. This is a Potemkin village built on misinformation, moral panics, logical fallacies and outright lies. The group that has erected this scaffold has somehow been exempt from the standards of care, professional ethics and evidence-base obligations of the rest of medicine. If you look behind the door it is an accumulation of authoritative opinion, junk-science and research designed to make the data fit they hypothesis. If a doctor has a drug or alcohol problem they should be diagnosed and treated the same way as anyone else. So why are they treated for 3 months or longer?

        Because G. Douglas Talbott put forth the urban legend that doctors are unique and have have incredible denial because of what he called the “four MDs.” “M-Deity”, “Massive Denial” “Militant Defensiveness” and “More Drugs.”

        He states that “Impaired doctors must first acknowledge their addiction and overcome their ‘terminal uniqueness’ before they can deal with a drug or alcohol problem.”

        Now some doctors are arrogant undisciplined egotists but narcissistic personalities exist in any profession and expanding traits that may apply to a small percentage of doctors to include all doctors as a universal truth contradicts reality. Applying a stereotypical paternalistic length of treatment in doctors three times as long as non-doctors to force a “one-size” fits all treatment on them has no evidence base.

        I would guess only three “M”s are involved. Medical Licence–as leverage to extort 2.More Money

        That is why we need to call B.S. from the get-go. Had someone called B.S. on this when he said it we wouldn’t be in the mess we are in today.”

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          Michael L. Langan Most people are afraid to “call BS” – it’s just an inborn trait. And in a healthy system, the BS eventually gets exposed and flushed out. But predators and bullies know how to manipulate that trusting docility and up the ante by assaulting dissenters. You’re right, if docs and their lawyers had confronted this menace in its early stages, we wouldn’t be here. But here we are, and the menace has become a well-embedded brutal tyrant and nothing less than overpowering force and a unified voice from those adversely affected is going to drive out this tyrant.

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          Word!

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        or “Often we have heard it told,
        All that glitters is not gold”—Merchant of Venice

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    PHPs have essentially been taken over by bad people over time. Doctors with integrity and moral compass who were not part of the groupthink were removed as the bad apples organized and gained power and control. What we are now seeing is the result of “corporate psychopathy.” For example in Massachusetts the PHP, PHS, inc. removed John Knight in 2009 and Wes Boyd in 2010. In 2011 PHS became a member of the Federation of State Physician Health Programs (FSPHP). In the past month alone I have heard from both a medical student and a a resident who were referred to PHS for minor issues unrelated to substance abuse or mental health. Both were told they had a problem and were in need of an assessment at one of the “PHP-approved” assessment centers and threatened with non-advocacy if they did not do so. This is extortion. It is a criminal enterprise using medical licenses and future careers as leverage all hiding under a veil of protecting the public.

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      Let me emphasize that is both unethical and immoral for one physician to disrupt the life of another so profoundly, but since the PHP will stop at nothing, their actions are criminal.
      Both criminal AND civil action must be taken against individuals and the group in these runaway PHPs.

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      This is extortion, fraud, racketeering, exploitation and other terms I don’t know the meaning of but some good lawyer would.
      Your last sentence says it all…but how to see that we all, especially those who have died at their hands, get the justice we deserve, we “good docs”?

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    Today (9/10/15) is World Suicide Prevention Day. What are we specifically doing to prevent physician suicides? And to prevent physician suicides within PHPs? I just got another letter from a PHP doc who intends to die by suicide.

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    After reading this article and responses what came to mind was some words of advice that Q gave in one of the James Bond movies. First, never let them see you bleed and second, always have an escape plan. For physicians the first has become painfully obvious leaving the second as our only controllable option. Our drive, compassion and intelligence has unfortunately not become enough to sustain us in an increasingly hostile world but if we have a good and viable escape plan it may just give us enough strength to go on.

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    The PHPs are colluding with labs (Quest, USDTL) to fabricate positive drug and alcohol tests. To see how easily this is done take a look at my post below. The records show how Linda Bresnahan from the MA PHP faxes a request to USDTL labs requesting my ID number be added to an already positive alcohol test and the chain-of-custody be updated. USDTL complies with the request without hesitation and provides PHS with a positive test identifying me as the donor. The docs are crystal clear and show deliberate, indefensible and unconscionable fraud. This misconduct (and subsequent cover-up) involves former FSPHP President Luis Sanchez and USDTL V.P. of Lab Operations Joseph Jones and appears to be standard operating procedure.

    These documents need to be made public and the significance of what this shows needs to be recognized and addressed. Some of the suicides that have been reported to me involve purportedly falsified tests that were used to extend PHP contracts. Joseph Jones seems to have no problem giving positive tests to people by faxed request and he knows that the consequences of such tests can be grave, far reaching and permanent. How many have killed themselves over deliberate misconduct like this. If that is the case these are more murders than suicides.

    http://disruptedphysician.com/…

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      The stuff you’re documenting needs some widespread exposure. This is 20/20 or 60 Minutes material. Have you tried to approach any mainstream media? Since you’ve been through this PHP system personally, do you think you’d have a hard time being taken seriously as a credible source? It’s a tricky subject to approach the public with since we do want to be protected from dangerous doctors. But I think the truth about PHPs needs to be exposed. Since docs risk retaliation by these PHPs and are therefore controlled by fear, it seems to me that there is more safety/less risk in numbers. One possibility is a petition exposing the abuse and corruptions of these PHPs, published only with many thousands of docs signatures (as many as possible) so nobody’s neck is out there alone.

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      Criminal—contact the FBI about it. Turn in a report.

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      This is the worst thing I have ever heard in my long career in medicine.

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      Unreal.

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        But it doesn’t end there. Once a test is fabricated on a targeted doctor the PHP mandates an assessment at a “PHP-approved” assessment center where they are willing to “tailor the diagnosis to fit the PHPs impression” of that doctor. They in partdo this by falsifying MMPI and IQ tests. I have heard from multiple doctors who report the same results I received on both. The MMPI interpretation shows a “naive and unsophisticated attempt to present himself in a positive light” and “unwilling to admit to even common faults” consistent with an elevated L (Lie) scale. To show cognitive impairment they shave a handful of IQ points off specific subsets of the Wechsler IQ test.

        I noticed the diagnosis rigging immediately in my report. The assessment was a combination of confirmatory distortion, fraud and cherry picking but it is difficult ot prove because 1. Most of the assessment is non-disprovable. and 2. They withhold records.

        As the MMPI was an objective test with standardized cutoffs and the report was false I thought if I could prove this part it would invalidate the rest (fruit of the same poison tree). I asked a neuropsychologist at MGH to obtain just my MMPI under the guise of continuity of care and requested the original scoring sheet, raw data and interpretation. They sent her the records which revealed the MMPI interpretation was made up out of whole cloth. This was no close call or ambiguous interpretation but a clear deliberate act to show normal test results as abnormal. I filed a complaint with the Georgia Psychological Association Ethics Board and they agreed. They were forced to correct the test. This was done only with their backs to the wall. Attorneys should be aware that I have heard from multiple doctors who received the same interpretation (which would be unusual in doctors as the L-scale usually does not work unless the person is naive and unsophisticated). This is a template to support denial and is part of the diagnosis rigging.

        http://disruptedphysician.com/…

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          The MMPI is little more than an expensive symptom self-check list dispersing disguised individual symptom criteria for most DSM diagnoses throughout the instrument. We were forced to take it in college and I thought it was a piece of s$#* that only served to treat the slimeball psychologist administering it as the supreme know-it-all (and he was one very odd case) and then again a few years ago as a well trained mental health clinician and my attitude is unchanged. In fact, it’s worse. I now think the MMPI is not only a worthless p.o.s. as a psychological instrument, it’s actually a harmful instrument and ought to be removed from the shelf. Same for that ancient p.o.s. the Rorschach.

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            YEP!

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            My L-scale T score was 49 and as its SD measurements from the mean that define abnormal and the cutoff for an elevated L-scale is 65 this was no close call. He made it up. Once the MGH neuropsychologist got the raw data and scoring sheet she wrote a letter documenting there was no basis for his diagnosis and I requested he correct it. He ignored these requests. I then got opinion letters from Multiple neuropsychologists st MGH and Harvard as well as the inventor of the L-scale and reported him to the Georgia Psychological Board thinking he would be held accountable. The Board’s “cognizant”reviewer deemed it a “difference of opinion” and blocked it. From going to full review even though the interpretation is a result of a specific cutoff . The “cognizant” reviewer just snubbed the opinion
            Of the originator of the test.

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          I have knowledge of very similar things happening at the diagnostic/treatment facilities, such as the physical examination reported in the record not being done, according to the physician patient. The record clearly shows on the physical exam “no marks or scars” when in fact the patient has had a total hip replacement and abdominal surgery with scars. The patient maintains he was seen in a room with no examination table, that he removed no clothing, and that a NP listened to his heart and lungs thru his shirt and undershirt. That was the physical examination but the record shows abdominal examination, neurological exam, etc. Clear case of fraud in my opinion, but I am sure it would be dismissed as “the wrong computer button was pushed.” And on and on it goes.

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          Yes, they will stop at nothing. You are a number, and an income source, nothing more/nothing less. They think, “hey! don’t take this personal, uh…” these thugs!
          Please take legal action, criminal or personal…they defamed you, that much is clear. With false information. Don’t you think you would win a civil case at least? I think a jury would see to it…and make sure press are at your trial.

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    The ocd story hit home to me. I was told I was slow handwriting vitals. Program director felt maybe I had a disability. My disability was I wanted to make sure I hand wrote accurate info and computer system was slow and disorganized. Eventually I just decided to do it faster and sacrific accuracy and no one knew the difference writing vital ranges.

    It was frustrating but senseless. Of course I had no disability. I cried and was sad for weeks. The only thing they came up with was that I should work to copy my numbers faster…. This remains a skill I have not used post residency… Copying sets of numbers from a computer repository of data for an hour and half a morning. I ended up calculating how much time I spent in tasks that most hospitals have a computer do and put it in a pie chart with things like seeing patients, synthesizing plans. I showed my pd that we all spent 80 percent of our day copying numbers from the computer to notes then the notes to sign out notes etc and he was kind of appalled we spent so much time doing dumb shit he let me go. He said it would be fixed in like three years when they replaced the shirty emr.

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      How sad. Hope you weren’t sent to a PHP with a r/o dx of “slow data entry disorder.” And then sent to a “preferred program” where they teach you how to enter data faster, and then put on a 5 year monitoring program where you have to use all of your strength to call on your higher power not to go into a homicidal rage.

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    @Dr Pamela Wible

    Pamela this is a culture of harm that operates on coercion, control, fear and intimidation. As you know I have been trying to expose the criminal activity at the Massachusetts PHP for some time. I am happy to say that it looks as if state Auditor Suzanne Bump is going to proceed with an investigation.

    I have been told that they now have enough statements from doctors and are going to proceed but this took some time as doctors who reported abuse were afraid to talk to a state agent even with guaranteed anonymity. Over 50% refused to make an anonymous call to the investigator even after being told they could withhold their names, hospital and any other identifying information. They were too afraid that the PHP would find out and punish them. One doctor I have known for 20 years who was Chief of his Department told me he just could not bring himself to do it because it could be a set-up. “I only have one year to go and don’t want to blow it.” This is the type of fear they have instilled in their victims. Most have developed a learned helplessness. There is no lifeline. Many probably have PTSD. This is understandable because they are used to no one listening to their truth.

    Doctors have been reporting misconduct and obvious crimes to medical boards, departments of public health, medical societies, law enforcement, the media and the ACLU only to be turned away. These agencies don’t believe the reports once they hear they have substance use or behavioral issues.

    In addition PHPs utilize “point people’ who are “like-minded” friends positioned at state agencies, ethics committees, boards and other places. These people block, dismiss and otherwise bury complaints. Physician Health and Compliance Committees on state medical boards are simply extensions of the PHP. Although they give an appearance of legitimacy they are simply lackeys of the PHP directed by the PHP. Board proceedings are simply sham peer-review.

    The policy of many states Attorney Generals Office is to blindly support the position of he Medical Board without consideration of the facts. They also will not investigate complaints of Boards and this apparently extends to PHPs as contractors of the boards. I am unsure how this has been established but complaints to AGO’s are invariably rejected without investigation no matter how serious or obvious the accusations. Complaints are simply ignored. Reports to the DOJ have also been unsuccessful. Political abuse of psychiatry, diagnosis rigging, lab fraud and Establishment Clause violations are simply ignored.

    Those who should and should be investigating are not and we need to find out why. It is most likely not an agency issue in most cases (with the exception of some medical boards) but a bottom up blockade specifically intended to bury complaints and prevent exposure. The usual channels are simply blocked. We need to circumvent the usual channels and make those of conscience and integrity cognizant of this public health emergency.

    see more

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      I’ve been studying physician psychology for nearly 50 years (both my parents are docs) and I now believe that doctors (with the exception of a few like my mom) are the most fearful group of people I have ever met in my life. Absolutely petrified to stand out, speak out, stray from the group. I implore you all to come forward and share your stories (even anonymously) here. Silence will not save us.

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        I agree at least in the developed world.

        The therapeutic state tempts the citizen with compassion then stabs him in the back.

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        You are absolutely right. Neither conciliation nor silence worked in dealing with Hitler. The malignant Hitlerian philosophy that’s infected PHPs needs to be treated aggressively. These programs are killing our fellow physicians. Of that, there is no doubt.

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          From the number of phone calls I am receiving from suicidal docs in PHPs I am concerned.

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            I agree – I think we’re at a crisis point. And opening this dialog is obviously going to make audible the swell of pain that has been so effective silenced. All have been discounted as either disgruntled whiners who deserve whatever diagnostic designation the infallible PHP assigned, or drunks and druggies in denial and clearly not in recovery because if we were truly in recovery, we wouldn’t be so angry.
            It’s like finally confronting the horror of intrafamilial abuse and captivity.

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      It will be great if the Auditor will do an audit. In NC we found that to be a tool to get the ball rolling.

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      That’s extraordinary that MA State Auditor is investigating. It would be in every state’s best interest to conduct a comprehensive audit as these programs, operating under the power of state sanction and immunity are exposing each state to immense liability once the due process and civil rights violations are exposed. And, as seen by the widespread case reports here and on Medscape as well as on Dr. Wes Boyd’s blog, these horrendous abuses will be exposed.

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      Good for you! I hope , hope, hope, you make some substantial inroads and other PHP authority figures will quake in their boots! (well, here in Texas). Look, PHP programs should not CAUSE PTSD! which leads to suicides. That is crazy in and of itself! MBs are bad enough—hostile, cause lots of death and destruction, and they resort to lies and deceit as well, criminal activities.
      This is as bad as the Mafiosa….they have all been reading “The Prince” or even “Mein Kampf” (well, I read the former, but not the latter) or Mao’s Red Book…

      but they are behaving as badly as the KGB and other terrifying organizations, and WE MUST STOP THEM! to save lives.
      PHYSICIAN’S LIVES MATTER
      The folks at FSHPH have plenty of blood on their hands, causing mayhem and devastation in physicians’ lives.

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    Reporting for work on 2 or 3 hours is routine Dr. Miday. This very much was and still is a culture of abuse, particularly at regional airlines. I often drank to get legal rest as schedules were not aligned, in the least, with healthy circadian rhythms.

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    there was a time when a trusted my doctor with whatever. Nix, no more.

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      Could you please elaborate? I hope my patients can trust my, my complete and total confidentiality, and I trust theirs as well. I really would like to know more of your thoughts here. Gail

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        I don’t know what to say really. But let me try: 1: Doctors works for huge cooperations these days. They are under pressure to create surplus. 2: Doctors make quick assumptions about patients. Kind of “know the type” based. Instant profiling, in other words.They don’t have the time to get to know you. 3: One doctor makes a mistake profiling you, it will still be all over, and follow you for the rest of your life. I always thought whatever I tell my doc. is between me and my doc. No more. Patients have no priv. 4: Docs fire patients if the are not obedient. 5: When I grew up, Docs had special number on the plate on their cars. Like 007 or something. If you heard some hysterically beeping the horn, it was probably a Dr. bringing someone to the hospital. some kid who had broken limbs because falling from a tree or something. Doctors worked real hard. Earned good money. They never had to feel smarter than anybody else. Because they were. Readers, intellectuals, knew the world. Conclusion: Patients private info is floating is floating around for thousands of “hospitalists” to read, and it might not even be true. I few of them will be my neighbors.

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    Coming up with a newer motto:
    PHP=Physicians Harming Physicians
    so far, that’s all I got. Any ideas? that don’t involve expletives?

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    I encourage all of you to also join the discussion following the FSPHPs response to Dr. Wible’s articles on Medscape. The PHPs boast a very high success rate. This success is measured by clean urines. That measure counts my now deceased son as a success. He never dropped a dirty urine. So, as the saying goes, “the treatment was a success, but the patient died.” Let’s suppose we have a treatment with a 90% success rate, but also a very high fatality rate. Wouldn’t we want to take a closer look? Unfortunately, the PHPs do not want to discuss the outcome of the remaining 10%.

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    I came across your this article and reading it was like looking in a mirror. The only difference is that I am a nurse, not a physician. We however, have programs that are the same thing. Due to a single dumb move, I reported myself to this thing because I was under the impression that it was the right thing to do. Little did I know that it would start me on the roller coaster of horror that involves yes, ethics violations, forensic-fraud, diagnosis rigging, questionable informed consent and so forth. For a single bad choice, I was consigned to the in and outpatient treatment in a drug/alcohol recovery place that was totally inappropriate, based on nonexistent/inappropriate diagnoses, a multi year contract, with stipulations that make it near impossible to find a job. I am basically under the same obligations as a person who stole narcotics from their patients. These programs pretty much have a one size fits all template. I have had the 12 step stuff crammed at me by the aforementioned zealots, coerced into signing a contract that was/is wholly inappropriate with requirements that are laughable at best (AA meetings? I don’t drink or smoke and never have) had heinously expensive at worst. Then, in spite of the advertised confidentiality one supposedly gets by having self-reported, this is now painted all over my professional license for any and every one to see. Due to the incredible lack of the least bit of empathy and the infiltration of “groupthink, etc” stated by a commenter above, I have had the worst possible experience. In a nutshell, I will have to discuss my mental health with every potential employer for the rest of my career.
    Having experienced this nightmare, I feel I can speak accurately, when I say that this “Frankenstein’s monster” of a program that is supposed to “advocate” for me (at least that what part of their supposed mission statement) has done me no favors, been of absolutely no help and honestly feels like punishment. Were there anything besides nursing that I could both love like I do and make a livable income with, I would do. Wholesale destruction of my career and reputation as well the immense expense on unnecessary treatments is not what I call advocacy.

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      And you self-referred? Criminals who turn themselves in get better treatment than health professionals I’ve talked to who have self-referred seeking mental health care.

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        Yup! Not a day goes by, that I don’t have to do something required of this program. It could be an AA meeting (which I truly loathe), a drug test (at my personal expense), their support group (which is all people with chemical dependency issues) or the restrictions at work (amazingly I found a job) rearing their ugly head. I realize I did a dumb thing and regardless of why, there are still consequences. I understand that, but this has become so very Monty Python-esque. I have to try and keep something of a sense of humor about it, because otherwise, well, let’s just call it a coping mechanism. My mental health issue is depression. Why, if treatment was in order, was I not in a setting that focused on that? How is being treated like an alcoholic/drug addict is supposed to help this? It is truly frightening what these programs are doing to our health professionals. I certainly had no idea what I was in for and I fear it is only going to get worse.

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          Sadly, one can only conclude from your and so many others’ stories (see also Medscape) that no physician should EVER go to a PHP, whether voluntarily, sent by their hospital or group, or even ordered by the Board. We’re going to have to disempower this psychopathic predators by active resistance and demanding of the PHP and Board proof that whatever diagnosis is postulated and whatever “treatment” is recommended has been shown to be justified. And to demand a self-chosen 2nd opinion.

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    As a patient it’s very hard to read that doctors abuse other doctors. What kind of position does that put us patients in?

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      The trickle down effect of an abusive medical system is not good for patients. For the record.

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      I think you can draw your own conclusions…we lose fine docs and who takes their places? I am not sure…less fine? less competent or experienced? I imagine so. I am getting older and am more and more a patient. I wonder who will care for me in the coming years, especially when it is obvious with Obamacare that my life will become less and less valuable “to society” as time goes by. We are in a Soylent Green culture right now, so it shouldn;’t surprise us too much that abominations such as we read on this site are happening.
      Dr. Wible, I think you have more optimism about the ability for us to speak out and make solid changes in the entrenched bureaucracies which will do anything they can to remain in power.

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        I’m a perpetual optimist. Can’t help it.

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          I’m definitely optimistic about us confronting and overthrowing this band of predatory psychopaths that have infiltrated and then overthrown the PHP movement and infected medical boards with their “our way or death” philosophy.

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          Me too. Sometimes I think I’m a pathologic optimist and you sound like you could be one too, Dr Wible. But some of us have to believe “it” can be done. As I’ve gotten older, I think I’ve somehow managed to retain a big chunk of my youthful idealism. But now I can be a pretty pragmatic idealist. I’m no purist but I’m probably a hopeless romantic.

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    I was never subject to these programs, but I did get a chance as a medical student to attend a special AA meeting called the Caduceus society at the Betty Ford clinic which was designed for such health professionals. Leaving aside the arguments about incorrect greek symbols, it was pretty inspiring to see so many doctors, pharmacists, dentists, and others working to manage their addictions and get better. And many people there did seem grateful for the program, including some who kept returning for years after they achieved sobriety.

    We hear about those who were negatively affected by the programs, but we don’t hear from the ones who went through it successfully, passed the five years of monitoring, and then never got in trouble again.

    That said, the entire field of addiction medicine isn’t very evidence-based. There is a lot of reliance upon AA, which has never been proven to work more than just leaving people to their own devices, and which has a spiritual component which may be offensive to some atheist/agnostic physicians.

    There is also the reality that we as a profession have a responsibility to the public. Patients have no idea if their surgeon is secretly alcoholic or otherwise impaired. It is up to the medical boards to decide what constitutes impairment and to try to protect the public. Perhaps they should be more understanding. But suppose that Dr. Miday was a surgeon whose patient died. If it came out afterwards that he was under monitoring by the medical board which allowed him to keep practicing after he relapsed into alcoholism, and may have had alcohol in his system when he operated? Could you imagine the public feeling of betrayal? Instead of the medical board trying to monitor and treat doctors, we would have District Attorneys demanding random drug tests and pursuing murder charges for any physician with a substance abuse disorder.

    Above all else, I have no desire to be on a medical board, charged with making these decisions…

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      Well, to begin with, my son was not a surgeon. He was, however, a hospitalist who covered the entire internal medicine section of Barnes Hospital, primarily overnight, with one other “nocturnalist.” Like most doctors, and especially those in a hospital setting, he did not work alone. He worked with many nurses and other professionals. He also had contact with many attending physicians via phone during his overnight shifts.
      None of these fellow professionals ever saw him impaired in any way. He was actually admired by most of his colleagues for his medical acumen and dedication to his work. He did not drink when he was working. Substance Use Disorder occurs on a spectrum. The assumption that a heavy after-hours drinker will always progress to drink when working is absurd. There is no one size fits all prognosis. There is no one size fits all treatment. This is the mentality that is propagated by AA and twelve-steppers who have become zealots. It is not evidence-based, and, in fact, is completely irrational. Please understand that I am in no way suggesting that my son was not in need of treatment. He was. In fact, he was planning to go the Harris House, a public recovery center in St. Louis. It was his hope that he might be evaluated and treated in a less restrictive, and local setting. His PHP appeared to have other plans for him.
      But speaking of surgeons, I hope you are aware that Halsted, one of the founders of modern day surgery, was addicted to cocaine for much of his career. We should all be grateful that PHPs weren’t around when he was practicing.
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        Ma’am,
        I’m so sorry for your loss.

        I am indeed aware of Halsted. He was treated according to the best practices of the time, which converted his addiction to cocaine into one for morphine. He had many great achievements, but his failures are rarely cataloged or mentioned. One wonders just how many patients were mangled and died when he operated on them during his “off” days. I think it is a good thing that medicine is no longer quite in the old days, when a code of silence kept exposing patients to doctors like him.

        I don’t know if you’ve seen this story:
        http://www.texasobserver.org/a…

        I think it shows why I am ambivalent on the issue. Someone still needs to protect patients from impaired doctors. Have these programs gone too far? Perhaps in some states, but clearly in states like Texas, they have not gone far enough. It is a very, very nuanced and complicated issue.

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          Halsted became addicted to cocaine in 1884 and was subsequently sent to Butler Sanatorium in Providence RI where he was converted from cocaine to morphine and discharged in 1886.
          Unbeknownst to most, he remained a morphine addict until his death in 1922. Observations of Halsted during this time period are well recorded and by all counts he was careful, methodical and precise. I am unaware of any mangled or dead patients on his “off days” which surely would have been mentioned in the written observations and reflections of his colleagues, many of whom kept personal daily records as was common at that time. All observations of Halsted reveal quite the opposite. He was noted to become reserved and withdrawn after returning from Butler but nothing suggesting “off days” is recorded to my knowledge.

          You state his “failures are rarely cataloged or mentioned” implying a large number exist that you are aware of. The only failure I can think of is a poorly written manuscript he sent to a medical journal for publication while cocaine addled. I am curious if you could specify some of these failures?

          Or are you just assuming mangled and dead patients based on the fact that Halsted was addicted to morphine? There is no evidence-base to conclude Halsted mangled or killed patients. There is also no evidence-base that “impaired physicians” are contributing to patient morbidity or mortality as far as I know. Could you tell us what evidence exists to suggest “impaired physicians” are causing patient harm? Certainly we don’t want doctors under the influence seeing patients but the alarmist message that denizens of drug-addled doctors causing mayhem in our hospitals seems to have no factual basis and the “culture of silence” is based on one small study done by the ASAM/FSPHP.

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            Are you implying that a surgeon, a known opioid addict, who actively testing positive, should be allowed to keep operating while intoxicated on morphine if his colleagues think he is fine?

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              Please point out where I said that. I asked you specific questions and you respond with a “straw man” argument. This and your and your use of other logical fallacy commonly used by those promoting these programs ( “appeal to consequences,” “appeal to common practices,” etc.), proof by anecdote, and use of misinformation with no evidence base is all part of the canned spiel pathognomonic of those involved. What is your affiliation with PHPs or the drug and alcohol testing, assessment and treatment industry? I would like to redirect you back to my original questions.

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                When you spend 3/4 of your response talking about how Halsted didn’t hurt anyone despite operating while intoxicated with morphine, the implication is that you are okay with a surgeon’s friends and colleagues turning a blind eye to active substance abuse, so long as they don’t “hurt anyone”.

                Let me put it this way. Do you believe what Halsted did should be acceptable in today’s medical practice? If not, why are you defending him?

                And while we are making ad hominem arguments, what drug did you or a “friend” test positive for that has you so passionate about the issue? If you read my original post, I MENTION THE LACK OF EVIDENCE AND MY HESITANCY OVER THE PROGRAMS. I am not some rabid inquisitor. I just think this issue is complicated with arguments on both sides.

                There is no evidence. We can’t even tell what makes a good doctor, or when a complication is a surgeon’s fault. How can we possibly know what the intoxication rates in the profession are or their implications? But as anecdotes like the Texas neurosurgeon illustrate, there must be a balance between treatment/help and coercion/enforcement.

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                  Halsted’s contributions to medicine are incalculable and vast. He not only revolutionized surgery and introduced many of the procodures we use today he shaped modern medicine. Halted is credited with changing the approach of medicine and surgery from its previously unrefined reputation to a more calculated manner. He is the father of careful, slow methodological surgery. He also happened to be addicted to morphine.at the time.

                  You stated he was mutilating and killing patients and there was a catalog size list of “failures” seldom mentioned. I merely asked you to support your statements.

                  I am in no way defending Halsted’s drug use but I’m defending Halsted. You portray him as a drug addled reckless surgeon maiming and killing patients is reckless and ironic as you are accusing the man who changed the entire profession of one of the very things he changed.

                  Hallsted may have had a “potentially impairing illness” but his achievements are real and immeasurable. Linking him to patient harm is not justifiable.

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                    Dangers of black or white thinking.

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                      Yes. the “impaired physicians movement” often uses Halsted as an example of how doctors can continue practicing medicine while impaired and how the “code of silence” allows it.
                      Multiple sources document his behavior when he was addicted to cocaine including his behavior in the OR. This is what led him to treatment at Butler in Providence where Morphine replaced cocaine.and to which he was addicted to until he died. No evidence of impairment was reported during those years but his achievements are prolific and numerous.

                      In all likelihood Halsted’s morphine intake was a constant measured dose that allowed him to function on a daily basis– s maintenance dose that was consistent. Whatever the case may be it is absurd to interpret the situation a century later in our current social, cultural and intellectual context.

                      Halsted changed medicine forever and made this world a better place. His contributions to public health and aseptic infection control alone saved untold lives. He is a hero and a legend..

                      But from the point of view of some people he was just an addict with a “disease” and noting else matters.

                      Black and white thinking, false dichotomies and either or thinking abound in this groupthink.

                      Thank God this group wasn’t around when Halsted was. But the question is how many Halsted’s are we losing today—snuffed out by zealots and self-appointed experts

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                        This brings to mind Winston Churchill, who was by most accounts a raging alcoholic. He still managed to save the entire western world. And, so yes, I would agree that not every substance using person is impaired. I am not suggesting that doctors who are clearly impaired should continue to see patients. However, this idea of “preventing harm” due to “potential” future happenings seems completely irrational and more likely to place more people – patients as well as physicians – at serious risk. Doctors are under constant scrutiny by both patients and colleagues. It is not rational to remove a physician until there is at least a suggestion of impairment (generally impairment occurs over some period of time, and does not typically happen acutely). I fear that if we continue on this course, the aging physician is certain to be next, because, of course, advanced age is a “potentially impairing” condition.

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                  Well, just to add to discussion about Halsted, I suspect that had he lived in today’s world, he would be most competent to perform as a physician if he were treated with MAT (Medication Assisted Treatment) using Suboxone. I wonder how many opioid addicted surgeons are given this option. This is current state of the art in addictionology. However, since it is not 12 step based, I suspect that most PHP’s do not endorse this approach. If I am incorrect, please let me know. And, thank you for your ambivalence on this issue. We are grateful for your dialogue. And, thank you for your note of condolence.

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                    My son did have a “potentially impairing illness” but so do physicians with insomnia, or too many sequential nights on-call. “Potentially?” “Really?” 90 days to treat a “potentially impairing” illness?
                    What ever happened to reasoned medical assessment and treatment? As a psychiatrist, I am well aware of the concept of treatment in the “least restrictive” environment. Let’s save the 90 day inpatient treatment (actually 28 days would likely suffice but would be far less lucrative) for those who are actually impaired.

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                      Exactly! Let’s treat the physicians in humane ways which are the most effective and the least costly, like we do with other patient the best that we are able to. Right?

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                      Part of the failure of one-sized-fits-all thinking. Humans are complex and deserve very individual and well-thought out treatment plans by a physician they trust. The therapeutic relationship is essential to compliance and healing. Why treat patients as criminals or guilty until proven otherwise? Many docs I have spoken to have turned themselves in to get help. They are actively seeking help, yet they are met with distrust and it seems an adversarial relationship rather than a therapeutic one.

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                    Nonetheless, Suboxone IS a street drug.

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                      Yes, true, but it is typically diverted to treat withdrawal sx. In light of the huge surge in deaths by accidental heroin overdose, it is certainly the lesser of many evils. It would be very sad, and in my opinion inconscienable, if it is not considered as a treatment option for opioid addicted physicians.

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                        I am not implying that it has no proper use, but the street thugs want anything and everything. They don’t think that deeply as to what it could be used for. However, why shouldn’t it be used to treat physicians addicted to opioids? if it is effective (I am an FP so don’t really know that much about this medication and its best uses!).
                        The treatment of addicted physicians is horrible, by the PHPs, that is…it isn’t treatment, it is a death sentence.
                        PHYSICIAN’S LIVES MATTER so let’s get on with the task of BEST PRACTICES!!! in the treatment of such medically ill physicians, and it there is oversight needed, let it be SANE and RESPONSIBLE!

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                    Which raises the question – who gave PHPs the right to dictate what is the correct treatment approach? Would we allow one group to dictate the treatment of Lyme disease? Depression? angina?

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                    Also appreciate this heated dialogue. Enjoy looking at this from all angles. I’m learning a lot!

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                    That’s an interesting idea. I am not familiar with suboxone. Is it addictive in any way? Can we ethically perform an experiment taking surgeons and looking at their performance on simulated tasks before and after suboxone administration? If it is proven, that might provide some ammunition to get PHPs and Medical Boards to start offering it to physicians.

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                      Suboxone is an opioid that is a partial agonist. It stimulates opioid recepters, but has limtied analgesic effect and no euphoric effect. It does, however, bind very tightly to opioid recepters, so that once in place, it is impossible to get high using opioids of abuse. And so, yes, it is addicting, but not imparing. It is a major advancement in the treatment of opioid addiction and has saved many lives. I really do not know if physicians are allowed to take it. I do know, however, that rigid 12 steppers see it as “replacing one addiction for another,” and so I suspect that PHPs do not allow it. Would love to have some real data on this, but, again, that is what we are missing, and the PHPs, via the FSPHP, certainly seem unwilling to provide us with any.

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                  No, there is nothing to substantiate that this was an impaired physician vs being a bad and careless one.

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          Was this fellow impaired and under a PHP program? No one is arguing that ill physicians shouldn’t have treatment and medical care, as a condition of practice IF NEED BE, or certainly that bad physicians who write their names on women’s uteri that they remove don’t need to be disciplined. That is not what is at stake here.
          What IS at stake is that what is going on is as Dr. Langdon described, a bureaucracy gone way out of hand and running on its own hidden agendas, not patient welfare, much less physician welfare.

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          The article you cite is interesting. Apparently, the neurosurgeon in question did not suffer from a mental illness or substance abuse. If he had, the PHPs would have quickly removed him. He was, however, completely incompetent. Interesting that we have no real system in place to remove incompetent docs – just ones who are perfectly competent (like my son) who have “potentially impairing” illnesses. Maybe the PHPs should be going after the docs who are really doing harm.

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            Excellent point.

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            There is another article which talked about the neurosurgeon’s cocaine and alcohol abuse- as reported by a roommate. I must have linked to a different one.

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              This quote is from the article you linked about Dr Christopher Duntsch. It makes clear that impairment from drugs and alcohol was an issue:
              “….After his license was suspended, Duntsch disappeared. At his home and office, my calls rang and rang before going to voicemail boxes that were full. It’s not clear how such a well-trained surgeon could have performed so disastrously, but the June 26 Medical Board report offers a hint: “Respondent is unable to practice medicine with reasonable skill and safety due to impairment from drugs or alcohol….”

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          Did I miss it? Was this neurosurgeon signed up with a PHP program? in Tx?

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            The point is that the Medical Board in Texas wasn’t powerful enough to MAKE him go into a PHP program and place him under monitoring and restrictions.

            Some states have PHPs and Medical Boards that are apparently far too aggressive. Others (like Texas) clearly aren’t powerful enough.

            My point is that it is a complicated issue, with positives and negatives on both sides.

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              Really? No, the TMB doesn’t make physicians sign up with a PHP, but if one doesn’t then the Board takes action. This could happen quickly.
              You have made your decision concerning the weaknesses of the TxPHP from one article, even though you say here he didn’t sign up for the it. I guess. So how could you then conclude it is not powerful enough? Did he have a mental illness or substance abuse problem? because if he was just a bad actor, then he is not qualified to go into this program, as poorly run as it is.
              Your logic escapes me. And it is off the topic of whether or not PHPs are so vile as to actually cause physician suicides and other deep harms. Is that something you care at al about?
              Remember—-
              PHYSICIAN’S LIVES MATTER

        • Avatar

          The fact that Dr Christopher Duntsch was allowed to keep peforming surgery is horrifying and terrifying. Clearly, nobody protected patients from this doctor.

          • Avatar

            Yes, but it has nothing to do with this particular topic.

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              I think it’s relevant. The article that VA linked said that Dr Duntsch had an alcohol and substance abuse problem. So what happened in TX that allowed him to keep performing surgery until he killed and paralyzed numerous patients? You can’t talk about eliminating/reforming PHPs without talking about the problem they supposedly address and what happens without them and what should replace them.

              In general, I’m on docs’ side here. But if you want to just stick to your talking points about how PHPs are horrible and inhumane to docs without addressing what happens to patients when docs go untreated, you’re going to lose me. The Dr Duntsch case isn’t exactly an unrelated tangent.

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      I think that medical providers should be identified IF they are affected by their illness enough to affect their medical care, IF that is done carefully, non-punitively, and effectively by an alternate program other than the clearly punitive or disciplinary mandate of the MB’s. I doubt anyone would disagree with me, that ill doctors should get treatment and that treatment should have proper oversight to ensure effectiveness.
      But I submit that is not what is happening now. Doctor, if you are one, you would do great on one of these PHPs as one of its “Board Members”, as it is obvious that you have an agenda.
      400 doctors a year, or two medical school classes, kill themselves. Often the last straw is when they have been duped into thinking they actually might get some understanding and help.
      Look, doctor, do you believe this?
      PHYSICIAN’S LIVES MATTER!
      or would you put some sort of qualifier on that? like, “well, yes but only if…”

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        We lose an ENTIRE MED SCHOOL. Not 2 medical school classes. The average medical school is 126 per class or approx 500 per school. 400 physician suicides is considered an underestimate due to miscoded death certificates and “accidental” deaths as noted here: http://www.idealmedicalcare.or…Also nobody is tracking medical student suicides which is likely 150+ per year in USA.

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        ” IF they are affected by their illness enough to affect their medical care”

        So… how exactly would you determine this? If someone is reported to the medical board because they were observed diverting drugs, and then tested positive, are you saying that nothing should be done until there is a clear incident in which that doctor kills someone?

        Performing surgery on someone while intoxicated to any degree is a violation of the Hippocratic Oath barring an extraordinary circumstance, and I mean MacGuyvering a chest tube in somebody on a plane extraordinary. Outpatient medicine, I’ve heard of some concierge doctors who have one and only one beer at lunch before going back to work, but they are few and far between. Most don’t think it’s okay to drink or do anything before that kind of work either.

        You can’t attribute 400 suicides a year to Physician Health Programs. Yes, some can be. How many? I have no idea- but neither do you. I’m not saying some of these programs aren’t behaving badly- but this is not a straightforward issue.

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          No one here would say that it is ok for impaired physicians to be able to harm their patients. However, the remedies in place are lethal.
          Did you even read the lead article? Doctors already dealing with mental illness including substance abuse are not helped, as the name suggests. They are put in a robotic system which feeds various organizations, are dehumanized and crippled by the process til they get out of it or are released in a few years, or are crushed and killed. THAT, my friend, is what is happening.
          If you, as a physician, think this inhumanity is ok, then I simply shake my head and hope never to meet you.
          Where is the AMA, the TMA? Why haven’t we physicians unionized? Who wants to join me in a letter to the ADA ?
          PHYSICIAN LIVES MATTER.

        • Avatar

          Of course one cannot attribute 400 suicides annually to PHPs. I don’t believe anyone is suggesting that. Regarding this concept of “potentially impairing illness,” I suspect that lack of sleep is the condition that impairs physicians most often. It is very interesting that this “potentially impairing” condition is not only overlooked by the medical establishment, but is actually seen as a way to prove oneself as a physician.

        • Avatar

          I don’t think she is suggesting all 400 are related to PHPs.

    • Avatar

      Docs who I have spoken with have told me they do not have a family history of alcoholism and began to drink to deal with occupationally-induced mental health distress. Where does a doctor turn for mental health support without repercussion? Physician Health Programs would imply by name that physicians could seek help with mental health, but their focus is substance abuse (which may be the end result of unmanaged mental health issues of our profession). My questions:

      1) Why wait for physicians to be in such a state of chronic mental distress before intervening? Why not help folks as a normal part of their workday? We are immersed in pain and suffering as a career. We need a place to go for support rather than drinking at night to numb the pain.

      2) Where do docs go for help with OCD, anxiety, and other distress (unrelated to substance use) that would not go on their record and negatively impact their ability to get credentialed and licensed?

      3) For those who are involved in PHPs are we certain that they are getting the care they need? Who runs these programs? What kind of education is required? What does prayer and giving up a medical condition to a higher power have to do with evidence-based medicine and science?

      I have more questions. I would like to hear from others. I find the ins and outs of PHPs and what happens to my colleagues a bit baffling and hard to understand. Is there a standard algorithm used for those who are in PHPs?

      • Avatar

        I’m a nurse practitioner who crashed and burned after 10 1/2 years in family practice. My last few years in family practice were a slow nose dive into hell. The grind was soul crushing.

        I loved my patients and they loved and appreciated me but the dysfunctional medical system did me in.
        As a sensitive soul called to a career to help people, I was doomed to fail in the current medical system that is focused on production while giving lip service to quality and patient centered care.

        I have no experience with PHPs but the concept alone raises warning bells. Just thinking about having to participate in a PHP back when I was struggling, depressed, unable to sleep, and having terrible anxiety is enough to give me a panic attack. We need a better way.

        We need to continue bringing our concerns up. We need to talk to each other. We need to refuse to be abused.

        I currently do short locums assignments and as I travel and meet other providers I find a great deal of stress and discontent in the medical profession everywhere I go. I love to take a moment out of my day and ask another provider how they’re doing. Unfortunately, many are too busy to even lift their head up for even a moment to talk. It’s a sad and tragic situation.

        Lets keep talking. Lets be compassionate to each other and to ourselves. We’ll figure this out someday.

      • Avatar

        It’s basically Soviet psychiatry for physicians with problems.

      • Avatar

        I think you will find another, positive perspective in Atul Gawande’s writings:
        http://www.newyorker.com/magaz…
        I don’t have access to the archive, but a version of it also appears in his second book, “Better”, if I recall correctly.

        It describes how a physician health program intervened in the career of a “Dr. Goodman”, an orthopaedic surgeon who suffered from gross depression and harmed dozens of patients. He almost committed suicide, until a program diagnosed him with depression, and saved his career (and possibly his life).

        • Avatar

          There is nothing wrong with a physician program as such. A program which helps physicians get better is great! Who would argue? But this doesn’t refer to a state program, and it is now somehow defunct—don’t you wonder why? I certainly do! I think that can bolster my argument, as I see graft and corruption, coercion implied here. Don’t you? At any rate, as this is referring to a private healing program, it is off-topic.
          but the state programs are not that…they are killers, not healers.
          PHYSICIAN’S LIVES MATTER

        • Avatar

          That is very reassuring. Thank you for sharing that.

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Physician Health Programs: More Harm Than Good? State-Based Programs Under Fire- Pauline Anderson

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Physician Health Programs:  More Harm Than Good?

State-Based Programs Under Fire

Pauline Anderson

|August 19, 2015

There is growing scrutiny of US physician health programs (PHPs), which are state-based plans for doctors with substance abuse or other mental health problems.

Detractors of the PHP system claim physicians who voluntarily disclose they have mental health or drug problems can be forced into treatment without recourse, face expensive contracts, and are frequently sent out of their home state to receive the prescribed therapy. Some physicians allege that during their interaction with the treatment centers, large amounts of money were demanded up front before any assessment was even conducted.

In addition, critics assert that there is no real oversight and regulation of these programs.

Called by turns coercive, controlling, and secretive, with possible conflicts of interest, some say the PHP experience has led vulnerable physicians to contemplate suicide.

Two states ― North Carolina and Michigan ― have already been asked to step in and investigate many of the issues raised by PHP critics. In North Carolina, the state agreed with many of the concerns raised and recommended “better oversight” by its medical board and society. And in Michigan, litigation in the form of a class action lawsuit has been launched against the Health Professional Recovery Program (HPRP), a program similar to PHPs.

Michael Langan, MD, an internal medicine specialist in Boston, has first-hand experience with a PHP.

Dr Langan was at Massachusetts General and Harvard University in Boston when he approached the Massachusetts state PHP to help him get off an opioid analgesic. He had begun taking the drug to help him sleep after developing shingles and said he spent several months in prescribed PHP treatment after “signing on the dotted line.”

On his first day at the assessment center, Dr Langan said he was asked how he was going to pay $80,000 cash. “This was before they even evaluated me,” he told Medscape Medical News. Subsequently, Dr Langan said he underwent an independent hair and fingernail analysis that turned out to be negative “for all substances of abuse.”

Since then, he has been documenting possible cases of negative interaction with these organizations. The system, he says, leaves physicians “without rights, depersonalized and dehumanized.”

He fears that the role of PHPs has expanded well beyond its original scope, becoming monitoring programs that have the power to refer physicians for evaluation and treatment even on the basis of administrative failings, such as being behind on chart notes, he said.

He has heard reports of “disruptive physicians” being diagnosed with “character defects.” The monitored physician, he added, “is forced to abide by any and all demands of the PHP ― no matter how unreasonable ― under the coloration of medical utility and without any evidentiary standard or right to appeal. Once in, it’s a nightmare.”

Disempowered, Without Recourse

It is estimated that 10% to 12% of physicians will develop a drug or alcohol problem at some point during their careers.

PHPs were initially established to help physicians grappling with a substance abuse or mental health problem and to provide them with access to confidential treatment while avoiding professional investigation and potential disciplinary action.

Often staffed by volunteer physicians and funded by state medical societies, the original intent of these programs was to help health professionals recover while protecting the public from potentially unsafe practitioners.

PHPs assess and monitor the physicians referred to them. In most states, physicians who comply with PHP recommendations can continue to work, provided they undergo regular drug testing and other testing to ensure sobriety.

Some PHPs are run by independent nonprofit corporations, others by state medical societies. Still others receive support from state medical licensing boards. The relationship of each PHP to the state medical board varies. The scope of services offered through PHPs also differs.

Today, such programs exist in every state except California, Nebraska, and Wisconsin and are represented by an umbrella organization known as the Federation of State Physician Health Programs (FSPHP).

According to its mission statement, the FSPHP’s mandate is to “support physician health programs in improving the health of medical professionals, thereby contributing to quality patient care.”

Coercive Process

Concerns about the PHP system have been percolating for a number of years. In 2012, an editorial by J. Wesley Boyd, MD, PhD, Cambridge Health Alliance and Harvard Medical School, and John R Knight, MD, Boston Children’s Hospital and Harvard Medical School, published in the Journal of Addiction Medicine brought many of the issues to the profession’s attention.

In their editorial, Dr Boyd and Dr Knight alleged that once a mental health issue has been disclosed, doctors are “compelled” to enter a PHP and are instructed to comply with any PHP recommendations or face disciplinary action.

“Thus, 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.”

In an interview with Medscape Medical News, Dr Boyd, who was associate director of the Massachusetts PHP for 6 years, elaborated on what he sees as the lack of due process afforded physicians by such programs.

“In general, these programs are given a free pass because it’s doctors helping doctors, and the feeling is that they wouldn’t be doing that if they weren’t generally nice people concerned about the well-being of others.”

Although many PHPs and the individuals running them are well intentioned, “there are generally few avenues for meaningful appeal” for doctors wishing to dispute PHP treatment recommendations, said Dr Boyd.

Approached on this question, the FSPHP’s director of program operations, Linda Bresnahan, maintains in a written response to Medscape Medical News that “options exist for a physician to seek an additional independent evaluation” and to appeal to the medical board or workplace.

Not so, said Dr Boyd, who counters that physicians have been made to feel “disempowered” and without recourse. “People tend to think that if you raise complaints, you’re just bellyaching and your complaint can’t be legitimate.”

Dr Boyd also said he has heard anecdotal reports of a number of doctors whose interactions with a PHP were so difficult they became suicidal.

“It’s not surprising that if you have your licensing board crawling up your rear end, rates of depression go up and rates of suicide go up,” he said.

Regular Audits in Order?

More and more physicians, even those involved in a PHP, feel that regular monitoring of such programs is in order. For example, Dr Boyd said there should be routine audits “to ensure that rampant abuses of power are not happening.”

Asked whether she believes random audits for state PHPs are warranted, the FSPHP’s Bresnahansaid that the federation “supports quality assurance processes, utilizing both internal and external approaches, and is working to develop guidelines for PHPs to promote accountability, consistency, and excellence.”

Michael Myers, MD, professor of clinical psychiatry, Department of Psychiatry and Behavioral Sciences, SUNY Downstate Medical Center, in New York City, who is on the advisory board of the New York PHP, also favors audits.

Dr Myers has been in practice for 35 years, the last 20 of which have been devoted to caring for physicians and their families. There is no doubt, he told Medscape Medical News, that his state’s PHP program has been “absolutely lifesaving” for some doctors.

However, he acknowledged that there have also been “a lot of unhappy campers” who took issue with the program’s process. At the same time, though, he can recall only one physician who made a formal complaint. Dr Myers noted that the PHP program was initiated on the premise, “if we don’t govern ourselves, then someone else will do it for us.”

“We are trying to have some autonomy, but if a person is unhappy, there isn’t the same mechanism that would exist, say, at a university, where there’s a whole protocol that a professor with a grievance can follow.”

This lack of mechanism for due process was at issue in a recent Michigan class action lawsuit launched by three health care professionals (two registered nurses and one physician assistant), who claim in the statement of complaint to represent the “hundreds, and potentially thousands of licensed health professionals injured by the arbitrary application of summary suspension procedures.”

Although the state program was originally designed to simply monitor the treatment of health professionals recommended by providers, the HPRP has recently “unilaterally expanded its role to include making treatment decisions,” according to the complaints.

They state that “the mandatory requirements of HPRP, coupled with the threat of summary suspension, make involvement in HPRP an involuntary program circumventing the due process rights of licensees referred to the program.”

They also claim the “involuntary” nature of HPRP policies and procedures and the unanimous application of suspension procedures upon HPRP case closure “are clear violations of procedural due process under the Fourteenth Amendment,” the plaintiffs claim.

Initially, the three plaintiffs had their licenses arbitrarily suspended. But in each case, the suspension was promptly overturned by a judge.

For some who have been watching these events, this lawsuit just might be the catalyst to make much needed changes to physician health programs across the country.

“Kafkaesque Nightmare”

Jesse Cavenar, Jr, MD, vice chairman and professor emeritus, Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina, calls the PHP experience a “Kafkaesque nightmare.” Although he himself has not been referred to a PHP, he said a psychiatrist colleague of his, who was anonymously accused of smelling like alcohol, was evaluated and subsequently diagnosed with alcohol abuse.

According to Dr Cavenar, there was nothing to support the diagnosis. The doctor also claimed that the “thorough” physical examination noted in his record was never conducted. In the end, said Dr Cavenar, the psychiatrist was in treatment for 13 months. His medical and legal bills topped $90,000.

Dr Cavenar, who obtained power of attorney in this case, tried but failed to communicate with the treatment facility on behalf of his colleague. He also failed to obtain the medical record.

“When you have a facility that has made a diagnosis and they refuse to talk to anybody about how they made that diagnosis, you say, ‘Something is wrong here.’ ”

During his brush with the PHP system, Dr Cavenar also discovered that at least one evaluation facility has an “understanding” with the referring PHP that a physician will be diagnosed and spend a minimum 90-day interaction period in the treatment facility.

Medscape Medical News spoke to another knowledgeable, highly placed source, who asked not to be identified. He supported Dr Cavenar’s assertion of a mandatory 90-day assessment period, saying he had heard from two other physicians who had undergone treatment in the PHP system that there was in fact such a mandatory period proscribed for them in advance even of an evaluation to determine their level of need.

“I’m no bleeding heart; if you do the crime, you do the time,” said Dr Cavenar. “That’s not what we’re seeing here. We’re seeing people who didn’t do the crime but who are getting tapped with time.”

Bresnahan told Medscape Medical News via email that FSPHP is not aware of a blanket “90-day minimum interaction period” with treatment centers. Rather, among the many treatment centers familiar to PHPs, there are a variety of “programs” within the treatment centers that vary in length, and a variety of programs such as outpatient, intensive outpatient to residential treatment, and variations of residential treatment.

“Treatment centers often offer a 1- to 5-day multidisciplinary evaluation to determine treatment needs, including length of stay and outpatient vs inpatient treatment options. In general, residential treatment centers offer different programming that vary in length of stay from 30-day treatment programs to 45-day treatment programs to 90-day treatment programs.

“Along with these options, PHPs do utilize treatment centers that will provide clients with a variable number of days of treatment. In these examples, the treatment center determines the recommended length of stay during the course of treatment based on clinical needs,” she notes.

Asked about treatment costs to physicians, Bresnahan responded that she is unaware of reports of large lump sums expected on admission.

“FSPHP is unaware of excessive up-front fees in the $80,000 range,” she writes. “It is our understanding that a treatment phase can range from $5000 to $50,000 depending upon the days and the type of programs.

“A number of healthcare professional programs are now having progress with insurance reimbursement to offset portions of the cost,” she adds. “Some offer financial assistance based on a needs assessments, and some may also offer payment plans,” Bresnahan told Medscape Medical News.

Dr Cavenar felt so strongly about his colleague not having due process that he lobbied for an audit of North Carolina’s PHP.

His initial efforts were ignored by the state medical board, he said, so he approached the state governor’s office. Finally, Dr Cavenar said he and three other concerned psychiatrists successfully secured a state audit of North Carolina’s PHP system, the results of which were released in April 2014.

PHP Originator Speaks Out

According to psychiatrist Nicholas Stratas, MD, one of the problems with the North Caroline PHP is that decisions regarding a referred physician are vetted by a legal team.

Dr Stratas has a unique vantage point. He was the originator of the North Carolina PHP, was the first-ever psychiatrist and president of the North Carolina Medical Board, and still holds numerous affiliations with both Duke University and the University of North Carolina.

“In our state, the PHP has turned into something that was never intended…. [It] has become bureaucratized and legalized,” he told Medscape Medical News. “When I was on the board, we had one attorney; now, they must have six or seven attorneys, and the whole job of triaging physicians is left to the legal department.”

Dr Stratas said that at least until the state audit, the North Carolina PHP left physicians with no legal recourse once they were referred to a treatment facility.

“They have taken the position that because they are a peer review mechanism, they don’t have to comply with the nationally recognized condition that everybody should have access to their own records; they will not provide records to the physician.”

Dr Stratas related the case of a psychiatrist who after a detailed assessment was determined to have no addiction or mental health problems. This psychiatrist got caught up in the PHP system after an anonymous caller complained about “weird” behavior, according to Dr Stratas.

On questionable advice from his attorney, the psychiatrist voluntarily suspended his medical licence, thinking it was temporary and would help sort the situation out, but now he cannot get it back until he undergoes “treatment,” said Dr Stratas. After almost 2 years, said Dr Stratas, this psychiatrist is still without his medical licence.

Auditor’s Report: Potential for Undetected Abuse

The state auditor’s report found no abuse by North Carolina’s PHP. However, there was a caveat ― the report determined that abuse could occur and potentially go undetected.

It also found that the North Carolina PHP created the appearance of conflicts of interest by allowing the centers to provide both patient evaluation and treatments and that procedures did not ensure that physicians receive quality evaluations and treatment because the PHP had no documented criteria for selecting treatment centers and did not adequately monitor them.

“Abuse could occur and not be detected…because physicians were not allowed to effectively represent themselves when disputing evaluations… [and because] the North Carolina Medical Board did not periodically evaluate the Program and the North Carolina Medical Society did not provide adequate oversight,” the auditor’s report noted.

The North Carolina PHP “did not use documented criteria to select treatment centers” and “did not conduct periodic evaluation of the treatment centers to ensure compliance with established operating criteria.”

The auditor added that the program’s “predominant” use of out-of-state treatment centers placed an undue burden on physicians.

Furthermore, according to the report, the North Carolina PHP “created the appearance of conflicts of interest by allowing treatment centers that receive Program referrals to fund its retreats, paying scholarships for physicians who could not afford treatment directly to treatment centers, and allowing the center to provide both patient evaluations and treatments.”

The report recommended that physicians have access to “objective independent due process procedures” developed by the state medical board and medical society and that plans be implemented for “better oversight” of the program.

The report also stated that North Carolina’s PHP was required to make it clear that physicians “may choose separate evaluation and treatment providers” and that the PHP undertake efforts to identify qualified in-state treatment centers for physicians.

Since its release almost a year ago, many of these recommendations have been addressed by the North Carolina Medical Board.

“We absolutely embrace the auditor’s recommendations and are working really hard to implement them,” Thom Mansfield, the board’s chief legal counsel, told Medscape Medical News.

North Carolina’s PHP has undertaken to provide periodic reports to the medical board, and an independent audit of the program will be carried out every 3 years, Mansfield added.

Physicians who disagree with their assessment or treatment can now have their case reviewed by a committee independent of the PHP compliance committee and of the medical board, he said.

Mansfield also noted that the state PHP has established criteria for identifying suitable centers to conduct assessments and offer treatment, with an emphasis on developing more in-state resources. “I know the PHP is now referring people to at least two in-state centers,” he said.

In taking these actions, said Mansfield, the North Carolina Medical Board hopes it is “showing leadership” for other states.