“EtG” stands for ethyl glucuronide, a metabolite of alcohol, and was reported by Gregory Skipper, M.D. and Friedrich Wurst, M.D., in November 2002 at an international meeting of the American Medical Society, to provide proof of alcohol consumption as much as 5 days after drinking an alcoholic beverage, well after the alcohol itself had been eliminated from the body.
Almost 98% of ingested alcohol is eliminated through the liver in an oxidation process that involves its conversion to acetaldehyde and acetic acid, but the remaining 2% is eliminated through the urine, sweat, or breath.1
In 2003, because of these and other reportedly remarkable results (e.g., positive findings, confirmed by admissions by the tested individuals, after traditional urine tests had registered negative)
EtG testing began in the United States after Dr. Skipper pitched it to National Medical Services, Inc. (NMS Labs) and it was developed as a Laboratory Developed Test (LDT).
The relevance to the article below is the fact that the EtG paved the way for the hair tests described. The EtG is the index case and prototype for an array of unproven forensic tests introduced to the market as LDTs.
The LDT pathway was basically developed for laboratory tests that would not otherwise come to market due to the prohibitive costs of FDA approval (for example a test for a rare disease). Bringing an LDT to market does not require testing in humans (in vivo). Nor does it require that it be shown the test is testing for what it is purportedly testing for (validity). It is essentially an honor system. It was not designed for “forensic” testing but for simple testing with low risk.
None of this testing is approved by the FDA. It is essentially an unregulated industry.
NMS became a leading proponent of EtG testing and, starting in 2003, began publishing claims promoting the absolute validity and reliability of the EtG in detecting alcohol. Akin to the vitamin and supplement industry those promoting and selling the tests could say anything they want—and they did.
NMS initially established a reporting limit or cutoff of 250ng/ml at or over which EtG test results would be reported as “positive” for drinking alcohol. This was later upped to 500ng/ml, then 1000 ng/ml.
NMS reported it as the “Gold Standard” claiming any value above 250 ng/ml indicated “ethanol consumption.”
It was subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash4,5, hand sanitizer gel6, nonalcoholic beer7, and nonalcoholic wine.8
As the cutoff value got higher they added another minor metabolite of alcohol, EtS, as a “confirmatory” LDT.
The authors of a 2011 study demonstrating that hand sanitizer alone could result in EtG and EtS concentrations of 1998 and 94 mug/g creatinine concluded that:
“in patients being monitored for ethanol use by urinary EtG concentrations, currently accepted EtG cutoffs do not distinguish between ethanol consumption and incidental exposures, particularly when uine specimens are obtained shortly after sustained use of ethanol containing hand sanitizer.”9
Sauerkraut and bananas have even recently been shown to cause positive EtG levels.10
A 2010 study found that consumption of baker’s yeast with sugar and water11 led to the formation of elevated EtG and EtS above the standard cutoff. EtG can originate from post-collection synthesis if bacteria is present in the urine.12 Collection and handling routines can result in false-positive samples.13
EtG varies among individuals.14 Factors that may underlie this variability include gender, age, ethnic group, and genetic polymorphisms.
“Exposure to ethanol-containing medications, of which there are many, is another potential source of “false” positives.15
On August 12, 2006, The Wall Street Journal published a front-page article, titled “A Test for Alcohol – And Its Flaws.”.16
Quoting Dr. Skipper, among others, the article includes:
“Little advertised, though, is that EtG can detect alcohol even in people who didn’t drink. Any trace of alcohol may register, even that ingested or inhaled through food, medicine, personal-care products or hand sanitizer.”
“The test ‘can’t distinguish between beer and Purell’ hand sanitizer, says H. Westley Clark, director of the Federal Substance Abuse and Mental Health Services Administration. . . ‘When you’re looking at loss of job, loss of child, loss of privileges, you want to make sure the test is right”, he says…”
“Use of this screen has gotten ahead of the science,’ says Gregory Skipper…”
Methinks Dr. Skipper might have realized this when he initially proposed it as an accurate test after a pilot study done on only a handful of subjects. Or perhaps when he used the LDT pathway to bypass FDA approval and oversight.
On September 28, 2006, SAMHSA, a federal agency that is part of the U.S. Department of Health and Human Resources, issued an Advisory, which on the first page contained a “grey box” warning, as follows:
“Currently, the use of an EtG test in determining abstinence lacks sufficient proven specificity for use as primary or sole evidence that an individual prohibited from drinking, in a criminal justice or a regulatory compliance context, has truly been drinking. Legal or disciplinary action based solely on a positive EtG, or other test discussed in this Advisory is inappropriate and scientifically unsupportable at this time. These tests should currently be considered as potential valuable clinical tools, but their use in forensic settings is premature.”17
Bias has been identified as a large problem with drug trials.18 Industry-sponsored research is nearly four times as likely to be favorable to the company’s product as NIH-sponsored research.19 As an example, one survey of seventy articles about the safety of Norvasc (amlodipine) found that 96% of the authors who were supportive of the drugs had financial ties to the companies that made them.20
But what about the multi billion dollar drug-testing industry and the financial ties here?
Imagine if this was a drug and not a drug-test.
Essentially Greg Skipper and the FSPHP arm of ASAM launched a very lucrative joint business venture with a commercial drug-testing lab. They introduced the test via a loophole as a laboratory developed test. An LDT has no FDA regulation so the lab was able to promote, market and sell these tests with no meaningful oversight or accountability.
The lab then contracted with state licensing boards and their state PHPs (who designed, implemented and managed drug and alcohol testing programs for nurses and doctors). A mutually beneficial scheme for the labs (who collect the samples) and the PHPs (who utilize, interpret and report the results.
The PHPs develop the arbitrary cutoff levels based on alleged “scientific” research and the labs promote whatever they say. “Gold-Standard,” “accurate” and “reliable.”
How many lives were ruined by this test? How many careers were lost, families shattered and futures erased. I would venture to say a lot. Just look through all of the legal cases as I have. It is unconscionable. Sociopathic profiteering.
How many committed suicide feeling helpless, hopeless and entrapped?
And the labs have taken a “stand your ground” approach. Never admit wrongdoing. Never settle.
In a February 2007 article in the magazine “New Scientist,” Dr. Skipper is quoted
“…there is not yet an agreed threshold concentration that can be used to separate people who have been drinking from those exposed to alcohol from other sources. Below 1000 nanograms of EtG per millilitre of urine is probably ‘innocent’, and above 5000 booze is almost certainly to blame. In between there is a “question zone…”
No Dr. Skipper—it is you who is most certainly to blame and you alone. Every time you upped the threshold you claimed it was reliable and accurate starting with a level of 100.
And what of all the people whose lives you ruined by introducing junk science with no evidence base via a regulatory loophole. “probably innocent?” Shame on you Dr. Skipper…. Shame..shame..shame.
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 otherwise—tailor 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.
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.
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.
Link to article:https://digboston.com/reefer-mad-and-power-hungry/
Please comment on DigBoston website
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.
In 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.The 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.Loudly 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
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.
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.
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.
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.
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.
Here’s one of them:
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.
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.
RenegadeRN — I have rarely heard of a doctor even givingthat as a choice. We, as a society, are so hung up andfearful of death that we fail to see it as the natural part of …
QQQ — You want doctors to improve the quality of theirwork? Maybe if the powers that be who often partakewould BACK OFF, doctors could start reading and …
Carleton Foxx — Dr. Treadway you raise an excellent point.People learn all sorts of things from TV even when they’renot trying, so why not correct CPR form? I’m sure the …
ebrose — Either the authors have drunk the Kool-Aid orthey have been hitting the samples closet in the office. As aretired physician (internist/pulmonologist) who …
Dictatorships can be indeed defined as systems in which there is a prevalence of thinking in destructive rather than in ameliorative terms in dealing with social problems. The ease with which destruction of life is advocated for those considered either socially useless or socially disturbing instead of educational or ameliorative measures may be the first danger sign of loss of creative liberty in thinking, which is the hallmark of democratic society. All destructiveness ultimately leads to self-destruction—Leo Alexander
“Let it be considered, too, that the present inquiry is not concerning a matter of right, if I may say so, but concerning a matter of fact.”–Adam Smith
“Most men endure the sacrifice of the intellect more easily than the sacrifice of their daydreams. They cannot bear that their utopias should run aground on the unalterable necessities of human existence” -Ludwig von Mises
The importance of a recent article published in Medscape critical of state Physician Health Programs (PHPs) cannot be overemphasized. Physician Health Programs- More Harm Than Good? by Pauline Anderson breaks new ground as it is the first mainstream medical publication to address the serious concerns so many of us are aware of but can do nothing about. Physician Health Programs (PHPs) were Originally funded by medical societies and staffed by volunteers and existed in every state by 1980., The equivalent of Employee Assistance Programs (EAPs) for other occupations. Their purpose was to help sick doctors and protect the public from harm. Over time, however, these programs have been subverted by special interest groups representing the drug and alcohol testing, assessment and treatment industries whose primary agenda is to sell the “PHP-Blueprint” to other occupations and groups. This is being done by falsely claiming unparalleled success for doctors treated by PHPs and they are touting it as , the “new paradigm” when in reality this model. subjects doctors to all manner of abuse in a system of institutional injustice and a culture of harm. Many of these horror stories are now being told in the comments section of the Medscape article and a subsequent article by Dr. Pamela Wible, MD entitled Do Physician Health Programs Increase Physician Suicides?
Yes they most assuredly do and the stories we are hearing are articulate, consistent, believable and very sad. T Those who were previously silent out of fear and due to threats are now coming forward. It can no longer be ignored or deflected. The Federation of State Physician Health Programs (FSPHP), however, has remained silent. We are hoping this will make the mainstream media as the FSPHP needs to be held accountable for their actions and that requires answerability and justification. The silence of the FSPHP speaks volumes.
“Science under dictatorship becomes subordinated to the guiding philosophy of the dictatorship.” So begins Medical Science Under Dictatorship1 written in 1949 by Leo Alexander and published in the New England Journal of Medicine. Alexander acted as consultant to the Secretary of war and the Chief Counsel for the Nuremberg trials.
The guiding philosophic principle is Hegelian or “rational utility” and “corresponding doctrine and planning”, Alexander said “replaced moral, ethical and religious values” and Nazi propaganda was highly effective in perverting public opinion and public conscience. He explains how this expressed itself in a rapid decline in standards of professional ethics in the medical profession. This all “started from small beginnings” with subtle shifts in the attitudes of physicians to accept the belief that there is such a thing as “a life not worthy to be lived.”
In 1985 the British Sociologist G.V. Stimson wrote of a new form of professional control in the United States that had emerged in the preceding decade whose “success rests on the ability to take certain areas of conduct such as alcoholism and drug abuse (which are formally disciplinary issues) and handle them as diseases.”2
“The impaired physician movement is characterized by a number of evangelical recovered alcoholic and addict physicians, whose recovery has been accompanied by an involvement in medical society and treatment programs. Their ability to make authoritative pronouncements on physician impairment is based on their own claim to insider’s knowledge.”2
Among these authoritative pronouncements was the use of specialized treatment centers. Many professionals were critical of these programs including Assistant Surgeon General John C. Duffy who criticized the “boot-camp mentality”4 toward doctors and American Society of Addiction Medicine President Leclair Bissel who when asked in a 1997 interview when the field began to see physicians as a specialized treatment population replied “when they started making money..” .” 5
Amid reports of abuse, coercion and control in facilities using a doctor’s medical license as “leverage,” the Atlanta Journal Constitution ran a series of reports in 1987 documenting the multiple suicides of health care practitioners at one of these programs (5 while in the facility and at least 20 after discharge).6 Neither these suicides nor a large settlement against the same facility (finding a non-alcoholic doctor was intentionally misdiagnosed as an alcoholic and forced into months of treatment) for fraud, malpractice, and false imprisonment involving intentional misdiagnosis7 generated any interest among the medical community at large.
And by 1995 the door had closed as the Federation of State Physician Health Programs ( FSPHP ) relationship with the Federation of State Medical Boards (FSMB), the national organization responsible for the licensing and discipline of doctors, was forged. A 1995 issue of The Federal Bulletin: The Journal of Medical Licensure and Discipline, contains articles outlining the high success rates of these programs in 8 states with an editorial comment from the FSMB that concludes:
“cooperation and communication between the medical boards and the physician health programs must occur in an effort to protect the public while assisting impaired physicians in their recovery.”8
The Federation of State Medical Boards (FSMB) has approved any and all policy and regulation put forth by the impaired physician movement then organized under the Federation of State Physician Health Programs (FSPHP) with no apparent inquiry or opposition.
In 2003 Dr. Gregory Skipper, one of the key players of the impaired physician movement partnered with NMS labs to develop the alcohol metabolite ethyl-glucuronide (EtG) as a laboratory developed test13 14 he proposed be used as a monitoring tool for covert alcohol use in physicians after a pilot study involving just 14 psychiatric inpatients.15
The policy entrepreneurship this group so effectively uses to advance their goals can be seen in the August 25, 2004 Journal of Medical Licensure and Discipline which contains articles both presenting the problem 11 and providing the solution.11 The EtG was then introduced as an accurate and reliable indicator of covert alcohol use and the impact of this cannot be underestimated as it introduce to the market not only unregulated non FDA approved tests for forensic use but tests reaching further back into history then those used by workplace drug-testing programs.
The limitations of any test needs to be understood both in the forensic and clinical context but there is a lot less flexibility in the forensic context when people’s liberties, freedoms or property rights ( as with a medical license) are in jeopardy.
Sensitivity and specificity need to be carefully considered. The positive predictive value of a test is the true positives over the true positives plus false positives. If you are going to sanction somebody as a result of a single test that test needs to have 100% sensitivity.
When workplace drug testing was introduced debates over both the accuracy and scope of tests occurred. The employees right to privacy and the employers right to have a drug-free workplace were discussed with the general consensus being testing for impairment was a legitimate concern but preservation of private life should remain.
What was done here dissolves both.
PHP programs require abstinence from all substances including alcohol and strict adherence to 12-step doctrine9 yet many of the physicians monitored by them are neither addicts nor alcoholics. Requiring abstinence from drugs and alcohol while using non-FDA approved Laboratory Developed Tests in monitoring programs is a dangerous combination. The suicides reported by the Atlanta Journal Constitution in 1987 were prior to the introduction of these tests. Adding these tests of unknown validity to an already abusive program of coercion and control would only worsen the situation.
I have been hearing of multiple suicides involving both the fear of results and false results. I have also been hearing of doctors who have killed themselves because they were suffering from depression but did not seek help as their fear of being ensnared into the PHP outweighed the need to get help.
Three decades after G.V. Stimson so accurately defined the impaired physician movement the impaired physician movement defines the professional control of medicine.. Their involvement in medical society physician health programs (PHPs) and treatment programs has evolved into absolute control of both. Pronouncements on physician impairment have evolved from insider’s claims to written edict. And their reach has extended from impairment due to drugs and alcohol to “potential impairment” and “relapse without use.” Their reach has extended from drug and alcohol impairment to all other aspects of medicine and the impact has been profound. Medicine has been subordinated to the guiding philosophy of the impaired physician movement and doctors are dying in droves du to institutional injustice.
How does the profession of medicine reconcile the fact that we have allowed an as yet non ABMS recognized “self-certification” specialty full reign over those who are ABMS recognized? How is it that we allow non-FDA approved Laboratory Developed Tests (LDTs) of unknown validity on doctors coerced into state Physician Health Programs (PHPs)? A recent debate in Washington calling for regulation of “clinical” LDTs just took place and the fact that they are being used for “forensic” purposes in doctors is incomprehensible. Has anyone noticed it is the same people introducing the tests who are claiming PHPs are the “gold standard,” trying to push them on other EAPs and calling for more widespread use of these tests?
The use of non-FDA approved Laboratory Developed Tests (LDTs) for drug and alcohol testing is currently limited to PHPs and the criminal justice system. (i.e. monitoring programs in which those doing the testing have power and those being tested have no power). That may soon change. See Drug Testing and the Future of American Drug Policy and The American Society of Addiction Medicine White Paper on Drug Testing describing the plans for widespread expansion of this drug testing to other groups including kids.
Those involved in the Massachusetts General Hospital Laboratory Medicine, Toxicology and addiction medicine departments looked critically at these tests and decided hands down against using them. Why? Because no evidence base exists and the potential harm far outweighs any perceived benefit. “Research” has been done on those being monitored by PHPs and the criminal justice system and Drs. J Wesley Boyd, M.D., PhD, and John Knight, M.D. of Harvard Medical School who collectively have over two decades of experience as Associate Directors with the Massachusetts PHP, Physician Health Services, Inc. addressed this research in a 2012 article published in the Journal of the American Society of Addiction Medicine entitle Ethical and Managerial Considerations Regarding State Physician Health Programs. The allegations that PHPs are engaging in research in violation of the Nuremberg code ( that was a direct result of the Nuremberg trials for which Dr. Alexander acted as consultant ) should have raised some eyebrows. It hasn’t.
If the ASAM becomes recognized by the ABMS “addiction medicine” specialists will inevitably join hospital formulary, clinical laboratory and ethics committees to erect the same scaffold seen in the PHPs and those with hidden agenda will be able to outvote those of good conscience and critical reasoning. Patient care will then be subordinated to the guiding philosophy of the impaired physicians movement.
This system of institutional injustice is killing doctors by suicide as the medical societies and Departments of Public Health have given PHPs full autonomy and authority and it is poised to impact patient care.
I challenge you to name any other company, organization, group or agency within or related to the profession of medicine and the field of science that is bereft of absolutely all transparency, regulation or oversight? It does not exist.
The PHP scaffold has deliberately removed themselves from all aspects of accountability including answerability, justification of actions and the ability of outside actors to hold them in judgment of any information provided by answerability. Heads I win, tails you lose. That is a big red flag in itself. and those not currently being held accountable they may very well be after you next as their plans include expansion to other groups includes EAPs, the Department of Transportation, athletes, students and even kids!
Doctors have been afraid to talk about this for fear of being ensnared themselves. Those already in these programs have remained silent out of fear, threats and punishment. It is my hope that the articles published by Paula Anderson and Pamela Wible will open the door to mainstream media coverage and result in the outrage this deserves. As Leo Alexander states in the closing words of this paper–“Yes, we are our brother’s keepers.
In The Argument of Fascism Ludwig von Mises wrote:
It cannot be denied that Fascism and similar movements aiming at the establishment of dictatorships are full of the best intentions and that their intervention has, for the moment, saved European civilization. The merit that Fascism has thereby won for itself will live on eternally in history. But though its policy has brought salvation for the moment, it is not of the kind which could promise continued success. Fascism was an emergency makeshift. To view it as something more would be a fatal error.
Medscape Medical News > Psychiatry
Physician Health Programs: More Harm Than Good?
State-Based Programs Under Fire
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.”
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.
Jesse Cavenar, Jr, MD, vice chairman and professor emeritus, Department of Psychiatry, Duke University School of Medicine, Durham, Northcarolina, 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.
I was heartened to read Doug Brunk’s recent article on the need to address the problem of physician suicide within the medical profession (“Medicine grapples with physician suicide,” February 2015, p. 1). As a physician who knows of many suicides of good doctors, I have been working with Dr. Pamela Wible to expose this phenomenon gradually (as it is difficult to get one’s head around if presented all at once) and have been making some gains.
Another issue tied to the incredible stresses endured by physicians is rooted in the groupthink within state physician health programs (PHPs).
Dr. John R. Knight and Dr. J. Wesley Boyd (who collectively have more than 25 years’ experience with the Massachusetts PHP) have been trying to expose the ethical and managerial issues tied to the “diversion” or “safe haven” programs for physicians with alcohol or drug problems (J. Addict. Med. 2012;6:243-6). My posts on disruptedphysician.com also examine these issues.
Meanwhile, a 2014 performance audit of the North Carolina Physicians Health Program found that “abuse could occur but not be detected” and revealed conflicts of interest between the state’s PHP programs and “PHP-approved” assessment centers. Another key finding is the PHP “created the appearance of conflicts of interest” by allowing treatment centers that receive referrals to fund its retreats and scholarships for physicians who could not afford treatment directly to treatment centers. The audit also uncovered other disturbing practices that lead to undue pressure on North Carolina’s physicians. For details, check out the report here.
More recently, several health professionals have filed a class action suit in the Eastern District of Michigan against several entities, including the state’s Health Professional Recovery Program. The lawsuit alleges, among other things, that the involuntary program has become a “highly punitive” one in which “health professionals are forced into extensive and unnecessary substance abuse/dependence treatment.”
Getting the word out about the impact of PHPs on physicians (and other health care professionals) has proven difficult for many reasons, but we must remain vigilant. The health of our fellow physicians and the medical profession depends on it.
Michael Lawrence Langan, M.D.
Title: PHPs: part of the problem.(Letter to the editor)
Author: Michael Lawrence Langan
Publication: Clinical Psychiatry News (Magazine/Journal)
Date: April 1, 2015
Publisher: International Medical News Group
Volume: 43 Issue: 4 Page: 14(1)
The bad science, bad medicine, bad policy and bad actors are easy to identify. It would be like shooting fish in a barrel.
So what are the barriers?
Why has this not been done?
The answer to that is complex but involves a confluence of factors including psychological, political and cultural. “Feel good fallacy,” “political correctness, and moral and policy entrepreneurship have effectively swayed the targets intended. The well-funded misinformation and propaganda was cast with a large net using the same techniques others have successfully used throughout history to accomplish the same. Moral panics, moral crusades, and a plethora of logical fallacy have been used and used with considerable resources and skill.
So what can we do about it?
The first “step into the breach” is to identify the problem with the first one being 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.
But the very first and simplest step is to use your voice to question this authority. Neutrality is not an option. Either support what these groups are doing or question them with your voice and the written word.
The bad science, medicine, policy and actors are obvious. It would be like shooting fish in a barrel and the first target needs to be the “PHP-Blueprint.” It would be so easy to take down this “research” they are using to promote PHPs as a “gold-standard” and replicable model. Shooting fish in a barrel requires someone take aim and at this point hardly anyone is even willing to pick up the gun.
Drug Companies and Doctors: A Story of Corruption.
What we need is a Marcia Angell to take on the multi-billion dollar drug and alcohol testing, assessment and treatment industry.
While all eyes were focused on the drug companies these multi-billion dollar industries erected a scaffold of immunity and profit by removing (and blocking) themselves from essentially all aspects of accountability; answerability, justification for actions and the ability to be punished by outside actors. The 2009 quote in reference to “big pharma” is just as applicable to the drug and alcohol testing industry,” the inpatient assessment and treatment centers and the “authorities” pushing public policy and swaying public opinion to accept irrational and illegitimate authoritative opinion as truth.
And unlike the pharmaceutical industries carefully constructed “bent science” which requires a keen eye and critical analysis , the evidence-base supporting the testing, assessment and treatment industry rests on a foundation that can…
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