“Physician Health”

Beyond the Schoolyard: Workplace Bullying

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This infographic on workplace bullying was created by International Business Degree Guide to convey the message that workplace bullies not only hurt people, they can also hurt business–driving away good employees in their quest for control.

Adept at dissimulation, those in authority often see what the bully expressly feigns and pretends to be. Under observation by authority the bully hides his true self and often cultivates an image designed to please and impress.  Veiling truth to those in power protects the bully.  Reports of abuse are disbelieved or ignored; dismissed or minimized as exaggeration; deemed a product of bellyachers and whiners.

In addition to hiding his true self the bully will often tell superiors what they want to hear. The workplace bully promotes an image of loyalty, dedication and hard work to superiors and may even feign common ideals and goals.   This  impression management often works.

When bullying ends in tragedy it is often revealed that those who could and should have done something about it knew about it and did nothing.  This failure to act may be the result of blinkered apathy, willful ignorance and even malicious complicity.  This is especially true when the  political and ideological views of the bully align closely with those in charge and the victim of bullying is remotely aligned.

Moral superiority, bigotry, racism and other biases all too often factor into the equation.

Perhaps those without sufficient empathy of others to take action when reports of abuse and harassment are reported to them will do their jobs if they realize workplace bullying might harm them personally or what they value most.

via Beyond the Schoolyard: Workplace Bullying.

Source: Beyond the Schoolyard: Workplace Bullying

Beyond the Schoolyard: Workplace Bullying

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WorkplaceBullies

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Beyond the Schoolyard: Workplace Bullying

Not only do workplace bullies hurt people, they can also hurt business – driving away good employees in their quest for control. What can you do if you find yourself having to face a bully every day?

Share this infographic on your site!

Beyond the Schoolyard: Workplace Bullying

Not only do workplace bullies hurt people, they can also hurt business – driving away good employees in their quest for control. What can you do if you find yourself having to face a bully every day?

Not All That Different …

Schoolyard bullies vs. workplace bullies
Both share a need for control – exercising power through humiliation of a target. If reinforced by cheering kids, fearful teachers or ignoring administrators, there is no reason to change and it often continues into adulthood. (1)

What Is a Workplace Bully?

Characteristics of a workplace bully: (2)

  • Tormenters
  • Tattlers
  • Finger pointers
  • Publicly pick on people
  • CC the whole world in emails
  • Point out your mistakes and tell everyone

Narcissism and self-orientation

What workplace bullies usually score high on in personality tests (3)

Bullying Victims

How many workers are dealing with bullies?
50%
Workers who say they’re treated rudely at least once a week (in 2011); up from 25% in 1998 (4)
66%

Bullying victims who had to lose or give up their jobs to make the bullying stop (1)
40% of workplace bullies are women, picking on other women more than 70% of the time. (5)

How Bullying Can Hurt Your Business

Work is stressful enough on its own, but adding a bully to the mix can make it unbearable.
9% of people say they’re happy at the office. (3)
Less than 1/3
Employees who say they’re engaged at work (3)

Workplace bullying can have serious negative effects on employees, such as: (6)

  • Stress
  • Absenteeism and low productivity
  • Lowered self-esteem and depression
  • Anxiety
  • Digestive upset
  • High blood pressure
  • Insomnia
  • Trouble with relationships due to stress over work

All of this can hit the company’s bottom line, causing: (6)

  • High turnover
  • Low productivity
  • Lost innovations
  • Difficulty hiring quality employees due a “hostile work environment” reputation

Got a Bully? Here’s How to Deal

Avoid the workplace in the first place (1)

  • Ask why the job is open and how long the predecessor was there (turnover is a bullying sign)
  • Ask about the attitude toward “workaholics.” If it’s expected, then you can know what you’re getting into
  • Ask about policies and codes that help ensure a respectful workplace

Once you encounter a bully (5)

  • Don’t get emotional (bullies like that)
  • Don’t blame yourself (the problem is the bully, not you)
  • Do your best work
  • Build a support network
  • Document everything
  • Seek help
  • Get counseling
  • Stay healthy
  • Educate yourself about policies
  • Don’t expect to change the bully
  • Start a new job search

25% of workplace bullying deals with discrimination. If that’s the case, you can talk to an attorney. (7)

Don’t hire a bully
Recognize certain traits in an interview process: They usually interview well due to a desire to control the situation. Invite them to an informal lunch and see if they’re empathetic (good) or brag about “cracking the whip” (bad). (8)

Sources:

1. http://www.workplacebullying.org
2. http://www.forbes.com
3. http://www.usatoday.com
4. http://hbr.org
5. http://www.huffingtonpost.com
6. http://www.bullyingstatistics.org
7. http://www.ivillage.com
8. http://www.ere.net

I am Offering Over $25,000 in cool prizes to anyone who can prove fewer than 3 felonies were committed by past FSPHP President Sanchez as shown by documentary evidence alone! I claim I can detect multiple very serious crimes in these documents–prove me wrong and the whole lot is yours!

mllangan1 6 Comments

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Federation of State Physician Health Programs (FSPHP) removed from accountability with low risk of suffering consequences for misconduct

According to Erich Fromm rational authority is based on competence, experience, and mutual respect.  Irrational authority is often disguised as benevolent paternalism and is designed to perpetuate or intensify conditions of inequality through the use or threat of force, deceptiveness, and secretiveness.

The Federation of State Physician Health Programs (FSPHP) has has operated as an unexamined authority for the past 25-years .  They have pushed practice and policy unquestioned and without opposition that has gravely harmed individual doctors, the medical profession itself and the public at large.  Everything they have done has been done to benefit themselves and their drug and alcohol assessment, testing and treatment affiliates in the provision of protections, power and profits.

Examining the specific practice and policy pushed reveals a body of false-claims making designed to facilitate the systemic use of coercion and threats, remove all due process protections and fundamental rights from physicians and prevent, block and eliminate the evidence.  This practice and policy collective has created a culture of impunity, immunity and deference that is able to successfully conceal ethical violations and crimes.  Uncovering their wrongdoing is a nearly impenetrable gauntlet. It is a system of institutional injustice that is undoubtedly a major contributor to the suicide epidemic in the profession.  They have been able to conceal the truth, avoid investigation and prevent punishment for years by removing themselves from all accountability and outside inquiry. Direct and specific questioning appears to be their Achille’s heel as the recent spat of articles critical of these programs is showing just how much of an illegitimate authority they really are.

In her rebuttal to Pauline Anderson’s article “Physician Health Programs: More Harm Than Good?” FSPHP President Doris Gunderson dismissed the accusations of fraud and abuse in one fell swoop as  “allegations rather than facts” and second hand anecdotes.  Countering allegations of an absence of oversight and regulation she states:

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“In fact, we operate under a microscope, answering to individual practitioners, medical boards, malpractice carriers, defense attorneys, state attorneys, medical societies, hospitals, medical schools and residency training programs. We are also accountable to patient safety entities and a Board of Directors.”

Untrue. Accountability demands both provision of information and justification for actions to outside entities capable of punishing misconduct. . What was done and why?  No such entity exists and no pathway for appeal or grievance redressal exists either. Zero accountability.  Ditto for the “PHP-approved” assessment and treatment centers. As cash only out-of-pocket facility they remove themselves from the prying eyes of insurers.

screen-shot-2016-01-13-at-9-55-47-amThe North Carolina PHP Audit  found the past FSPHP President and NC PHP director Warren Pendergast could not identify the qualitative or quantitative indicators used for “approving”  PHP-approved facilities. The best he could come up with is “reputation” and “word of mouth” yet state medical boards mandate evaluations of doctors at these  facilities and specifically exclude  non-“PHP-approved” facilities.This is enforced by the Federation of State Medical Boards Policy on Physician Impairment.  Each state managed by the FSPHP utilizes the same dozen or so facilities and each state medical board mandates it under threat of disciplinary action.  It is in fact a rigged gam

Denying accusations of coercion Gunderson states in her rebuttal to Anderson’s article:

“The detractors of PHPs interviewed for the article maintain that PHPs are coercive. Yet the report fails to mention that PHPs have no authority to mandate treatment and monitoring, suspend or revoke licensure, or otherwise discipline physicians.”

screen-shot-2015-10-07-at-7-11-18-pmThe report fails to mention it because it is more either/or logical fallacy based on the false dichotomy between “treatment” and “punishment” that is often used to promote the FSPHP mythology.  Although PHPs do not have the legal authority to mandate, suspend or revoke a license they have the functional authority to do so.   This is also dictated by public policy.  (ASAM Policy on Coordination Between Treatment Providers,  Professionals Health Programs, and Regulatory Agencies).

Legitimate authority articulates ethical, evidence-based, or internally consistent arguments when challenged.  Legitimate authority does not simply delegitimize one’s opponent and use logical fallacy and obfuscation to avoid addressing the substance of an argument. In her rebuttal Gunderson claims the NC Audit was favorable to them because no evidence of abuse was found.  This is akin to a serial killer claiming victory because no bodies were found in his dungeon replete with torture devices and restraints. State auditor Beth Woods set this straight when she told the BMJ in  Physician Health Programs Under Fire  that the holes were big enough in the program “you could drive a truck through them” and it would be “difficult, if not impossible, to defend” oneself against an incorrect assessment” as no ability to “appeal a diagnosis or assessment” existed.

screen-shot-2016-01-13-at-9-52-11-am“Compounding the problem, said Wood, was that “the chief executive and medical director were in total control of entire process.” They assessed allegedly impaired doctors, but when those assessments were contested, they were responsible for presenting complaints to the state medical board. The doctors concerned were not allowed to be present and were not allowed to see the programs’ medical reports on them.”

Multiple Barriers Removing Accountability at Multiple Levels

The  inability to obtain one’s own medical records or lab reports is the first obstacle one must overcome. The second barrier is that even if documents are obtained there is no one to give them to.  The third is the existence of “point people” who deflect, block and otherwise dismiss valid complaints.  The only oversight provided to the involved labs is an an accreditation agency, the  College of American Pathologists (CAP) They can investigate and correct but do not have the ability to sanction.

screen-shot-2016-12-09-at-1-13-29-pmOf the many hundreds of doctors I have spoken to and who have taken my survey not one has been able to obtain evidence of abuse.  It was either refused, censored or doctored.   I have obtained documentary evidence that is specific, detailed and unequivocal.

It is therefore critical it be recognized for what it shows and it is morally imperative that those involved be held to account as the documents illustrate clearly and undeniably a collusion between a state PHP and its drug testing lab to fabricate evidence.  The corruption is top-down as it involves another former FSPHP President Luis Sanchez and the VP of Laboratory operations at USDTL Joseph Jones.  As explicit and detailed as it is in revealing unequivocal  black and white crimes it has been ignored by the usual channels.

Research on street criminals suggests the certainty of punishment has the strongest deterrent effect (basically will I be caught) and the more people think they will be arrested for a crime the less likely they are to commit it. Criminals weigh their actions against possible gains and consequences and the risk of consequences in this system have been essentially zero.  Diagnosis rigging, coercion, threats and abuse are rampant because they have no fear of punishment.  The Chairman of the commission that examined the  causes of the 2008 financial collapse compared the  relatively small fines paid by corporations to “someone who robs a 7-Eleven, takes $1,000 and being able to settle for $25 and no admission of wrongdoing.” He added,“Will they do it again? Absolutely, because it pays.” This is like someone who robs a 7-Eleven, takes $1,000 and never gets caught so he goes to the next 7-Eleven and takes $2000 then hits as many 7-Elevens as he can for as much as he can.

Multiple Crimes, Multiple Felonies and Egregious Misconduct.  Fabrication, Falsification, Concealment and Perjured Evidence. Color-of-Law Abuse, Civil Rights Violations 

In June of 2011 I signed a patent-license agreement with a company to bring an epinephrine auto-injector to FDA approval  within three years.  It was recently mentioned in an NBC news article in the wake of Mylan’s Epipen price hike and the patent  documents can be seen here and a slideshare overview here.  This was successfully derailed the following month when I was asked by the state PHP to have an alcohol test.  This was for no apparent reason. I have never been accused of having an alcohol problem and my work performance at MGH was reported as “impeccable.” There were no issues in any arena.  The events are described in detail here, here, and here.

The blood test was reported positive to the medical board on July 19, 2011 as seen here:   positive-peth-july-19-2011    I requested records but PHS refused but relented in December 2011 and I obtained the   USDTL Litigation Packet  which contained a faxed request from PHS to the lab requesting my unique  identification number and a “chain-of-custody” be added to an already positive report See key docs here.:12:3:2011 Litigation Packet (Selected)

The records showed falsely created and fabricated evidence. Clear fraud. I filed a complaint with the College of American Pathologists CAPLetter.  They investigated and forced USDTL to correct the test as reported in an  October 4, 2012 letter from the lab to Sanchez. Instead of revealing the correction the two concealed the revision and reported “non-compliance”  two weeks later  and board took disciplinary action against my license.  In December 2012 CAP contacted me to followup on the outcome of the revised test which I was unaware of.   I informed them they did not tell me and confronted  PHS but they claimed no knowledge of it.. On December 11, 2012 Sanchez reports to the board that he just found out that the test was revised but it had nothing to do with the disciplinary action taken by the board..  Sanchez and Jones deny there was any correction 67-days earlier and stand by their guns.

In August of 2014 I was able to obtain the complete USDTL documents under new HIPPA-Privacy Rule for labs which removed PHS approval.  Full docs can be seen here:  August 6, 2014 to Langan with health materials.   The  October 4, 2012 correction from USDTL to Sanchez  contradicting Sanchez claim of not finding out about the correction until December is included.Note the language used in the  Letter claiming Sanchez was informed of the revised  test 67-days after he actually was.

Recently obtained documents under records reform act –  Langan PDF copy  They show documents entered as evidence date-stamped and entered into the administrative record after the hearings at which they were to be heard.   Multiple others missing and never addressed.   It is now clear that Stoller concealed all documents relating to PHS misconduct since December of 2011.

Specific and detailed evidence of criminal activity was provided to Board Attorney Deb Stoller over the course of more than five-years. This showed clear collusion between the state physician health program and one of their preferred national drug testing labs.  It is important to recognize the gravity of what this means.   I provided a state officer with evidence of crimes similar to Annie Dookhan–clear fabrication and collusion to fabricate evidence. She suppressed it.     This is much much worse than Annie Dookhan as the lab is used by state physician health programs across the country and over the past five-years their have been multiple suicides of doctors who have allegedly been given fabricated drug and alcohol tests just like mine.    Many of these doctors were given positive tests right before they were to complete a 5-year contract and this is a pattern that seems to be occurring as the rule rather than the exception.   Facing five more years of abuse some doctors have chosen to end their lives rather than continue with the PHP.

Specific and detailed evidence of the fraud was given to Deb Stoller over the course of five-years and she did nothing about it to protect Sanchez.   The impact of this is much greater and the consequences much more severe than what occurred with Dookhan.  As The documents clearly showed felony crimes this is egregious and indefensible.

screen-shot-2016-12-09-at-1-14-00-pmWhat is chilling is that this request to falsify evidence was done by fax and the lab complied with full knowledge that the positive-test would result in grave and possibly permanent consequences for someone.  The moral detachment of Jones is incomprehensible to me.  If I was offered a  million dollars at this moment to fabricate a drug test on some stranger I would not do it. I would not for any amount of money and I don not believe the majority of my friends would either.I also contacted Jones (  August 6, 2014 to Langan with health materials ) and told him of the severe consequences this was having for my family but he did not respond.   Had it not been for the new HIPAA -Privacy rule I would never have obtained these documents and without the record reforms act I would never have obtained the evidence implicating Stoller ( Langan PDF copy )

screen-shot-2016-12-09-at-1-13-52-pmIt is now time to enter phase two of exposing the corruption of PHPs. It is now necessary to necessary to relentlessly contradict the lies and falsehoods and and present the evidence with logic and clarity.    It is necessary to name names, point fingers and demand that direct and specific answers to direct and specific questions.  It is time to shine a bright light on the specific  unethical and illegal acts detailed here. They are the rule not the exception and the diagnostic rigging and forensic fraud make these more murders than suicides. This is a public health emergency.   By my estimates over 80% of those being monitored by PHPs do not even meet the diagnostic criteria for substance use disorder or any other psychiatric disorder.  It is political abuse of psychiatry.

screen-shot-2016-04-26-at-10-58-19-pmLegitimate authority has a responsibility to be truthful to one’s words and deeds and policies need to be enforced in a consistent manner.  State PHPs are engaging in fraud in collusion with their preferred drug and alcohol assessment, testing and treatment centers.   They are giving diagnoses to individuals who do not meet the diagnostic criteria for a given diagnosis to provided unneeded treatment. They are financially exploiting doctors under threat of disciplinary action against there medical licenses.

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The Board claims no crimes were committed because no one has been charged with any crimes.  No, Dr. Sanchez has committed very serious crimes including multiple felonies. This can no longer be ignored. These crimes can be determined by the documentary evidence alone. They are self-evident.

To settle the matter once and for all I am offering over $25,000.00 in cool prizes to the first person who can disprove my claim that Dr. Sanchez committed multiple felonies.    My claim is that by simply looking at the dates and documents multiple felonies are clear.  They are not equivocal.  The first person to disprove this assertion may collect each and every item pictured below.  You can even write up a legally binding contract and I will sign it. There is something for everyone and if anyone has any questions about any of it feel free to ask.screen-shot-2016-09-09-at-7-26-42-pm

To summarize,  I can find multiple clear  felonies in the documents that need no further inquiry. They are black letter law and involve fraud, concealment, perjury and other crimes.  Policies and laws need to be enforced equally.   The Board cannot play favorites and give allowances to its friends when it comes to criminal activity.  Sanchez is licensed by the medical board just as I am and the screen-shot-2016-09-09-at-9-08-18-pmboard’s position on the fraudulent practice of medicine is quite clear.

One felony would be demand the board address what is seen here.  Multiple felonies make it inexcusable to ignore and if it is ignored it will be relentlessly addressed again and again and again.   As it is so difficult to obtain evidence it is necessary that this be addressed with full measure as a precedent.  People just like this are harming good doctors across the country and unless you are profiting from the drug and alcohol testing and treatment racket you should be disgusted at what is seen here.   The fact that Sanchez pontificates on the behavior of others makes this particularly egregious.  Moreover, Jones also tests newborns and other groups with these same tests.  If he is this unethical who knows what amount of damage has occurred.  Anyone of integrity and conscience should be outraged by what is seen here.  As it is one of the clearest and most specific examples of laboratory fraud I am going to be asking for help getting this out–it should be used to show how this type of drug and alcohol testing can be abused.

Direct and specific questions deserve direct and specific answers. This will need to be addressed directly as it is not going away and neither am I.   If cannot disprove fewer than three felonies than they need to be addressed.   Suspect similar point-people in other agencies protecting them.

If multiple felonies were not committed then  you would think at this very moment there should be people knocking on the door trying to get my attention so they can collect these prizes.    I don’t hear anybody knocking, do you?

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Prizes as Below

Medical Students and Physician Health Programs–A Modest Proposal to Medical School Administrators to Prevent a Potentially Impairing Catastrophe

mllangan1 14 Comments

screen-shot-2016-03-10-at-10-17-17-pmIt is hard to imagine a more stupid or more dangerous way of making decisions than by putting those decisions in the hands of people who pay no price for being wrong. 
-Thomas Sowell

I have been contacted by multiple medical students since my post concerning state physician health programs (PHPs) targeting medical students. These students have reported similar stories of coercion into unneeded treatment under the threat of being pulled from medical school.  They were told either comply with the demands of the PHP or you will not be coming back next semester.

Potentially Impairing Diagnosis

One concerning pattern that is emerging in these reports are students that are being referred to these programs not because of any specific concern or precipitant event, but because of a past diagnosis or existing long-term diagnosis that has been stable under treatment by qualified professionals.  Two students who contacted me have had ADHD since high school under control with legitimately prescribed Adderall , two had histories of depression long resolved and another  was being treated for depression with a legitimately prescribed anti-depressant.   These students were in the dark as to why they were being referred to the PHP, knew nothing about PHPs and had no idea any adverse consequences were a possibility.  They initially thought this was some sort of student health type wellness “check-in” where they would just touch base for reassurances regarding proper diagnosis and treatment and that would be the end of it.   Such  was not the case as things took a nasty left-turn for them once they met with the PHP.  Each was referred for out-of-state evaluations. Each was given a diagnosis with recommendations for inpatient treatment.   Each was told by their medical schools that if they did not comply with recommended inpatient treatment they would be pulled out of school the following semester and not be coming back.  Each has met a dead end negotiating with their schools. Only one student is capable of getting the money to complete the recommended treatment  which is out-of-pocket and not covered by insurance (60-80 thousand dollars on average).screen-shot-2015-04-03-at-2-48-33-am

How did this occur?  The inpatient evaluation centers justified their treatment recommendations by questioning the stability of their diagnoses and expressed concerns about possible underlying issues potentially precipitating future impairment. The conclusions were that they would “benefit from treatment” and that the evaluators “could not advocate” it would be safe for them to continue medical school because of their “potentially impairing illness” and the possibility of future patient harm. Of course substance abuse issues were also raised as both students with ADHD were given diagnoses of “Amphetamine Use Disorder” and two others were given a diagnosis of possible “Alcohol Use Disorder.” The latter was based entirely on a positive PEth (Phosphatidyl-ethanol) biomarker (a test introduced and promoted by physicians involved in state physician health programs.

What boggles the mind is that these students all provided letters from their treatment providers and obtained independent and comprehensive evaluations from outside experts contradicting the diagnoses and disavowing inpatient treatment as well as collateral support letters.  None of it was acknowledged let alone addressed.  Two students asked why they needed inpatient treatment when they had expert opinions deeming it unneeded and they were fine.

“Because they are the experts.”

Now the assumption of omniscience,  blind faith and the spirit of authoritarianism are unacceptable mindsets in academic medicine.  The validity and reliability of opinions lie in their underlying methodology and evidence base. Reliance on the personal authority of any expert or group of experts is the fallacy of appeal to authority.  Social and academic responsibility demand investigation and questioning when contradictory evidence is presented especially when the consequences can be permanent.  The American philosopher and feminist theorist Marilyn Frye defined oppression as “a system of interrelated forces and barriers which reduce, immobilize and mold people who belong to a certain group, and effect their subordination to another group.”  Individuals in academia should play not be willing participants in a system of institutional injustice and the role of detached bystander giving full deference and allowances to these pious wolves is no different than being a willing henchman.  The result is the same. screen-shot-2015-03-25-at-9-01-24-pm

It appears the  Federation of State Physician Health Programs (FSPHP) has used the same tactics with academic administrators as they have with regulatory and hospital administrators. They have convinced them to not question their methods or motives lest it “undermine a culture of professionalism.” They have done this by claiming.

  1. We are the experts. We are benevolent. We are here to help.
  2. Leave it all up to us.  No worries. Referral  is the first step so do not burden yourselves with preliminary investigations of board disciplinary meetings.  We will do all the work and take the burden off of the administration.  No more in-house review.
  3. By the way questioning our authority undermines our authority.  We are the experts and we are doing all the work. We should make this official by written policy and procedure. No questioning our diagnoses.

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.

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Unexamined, Illegitimate and Irrational Authority

It is important to recognize that the Federation of State Physician Health Programs (FSPHP)  has been making authoritative pronouncements on physician health issues as unexamined authority since 1990. Over the past 25-years they have influenced a large body of practice and policy with no meaningful opposition. It only takes a modicum of investigative research to reveal each specific practice, each legal, regulatory and healthcare policy the pushed and each position they took on the issues.  It is simple to identify the what, when and why on all of it.  One invaluable resource is the The Journal of Medical Regulation  archives which is the official publication of the Federation of State Medical Boards.  It has been fully archived online with every issue in chronological order containing full articles.  An index related to all practice and policy pushed by the FSPHP is easily generated by putting in keywords related to physician impairment.

screen-shot-2016-12-08-at-3-34-23-pmOnce practice and policy is identified a risk/benefit type analysis can be done on each and this is a rather simple matter as the issues are fairly black and white.  Statistics is not needed-just common sense and logic.   What one will find is that the practice and policy promoted by the FSPHP has not in the best interests of doctors or society but in the best interests of the FSPHP and the drug and alcohol testing and treatment industry .  In short, the individual practices and policies have provided physician health programs with more power and protection while incrementally removing the fundamental rights and due process protections of doctors with the end result being not only control of their professional behavior but their private lives.  To benefit the drug and alcohol testing and treatment and treatment industry they have pushed a plethora of bad ideas including introducing junk-science for forensic drug testing and limiting physician evaluations to only “PHP-approved” assessment and treatment centers.   A public policy analysis is long overdue.   So too is a conflict of interest analysis and a critical analysis of the”research” which consists of two categories; 1. Research showing that shows the high success rates and benefits of PHPs 2. Research on laboratory developed tests (LDTs) and other dubious testing methodology they have introduced (such as non-validated neuropsychological testing for diagnosing disruptive physicians) and promoted    (including polygraphs which is unbelievable since AMA policy discounts them as a game of chance.).   All practice and policy that has been pushed by the FSPHP was accepted by the FSMB (and others) without question or concern.   It has all  been done with no meaningful opposition.

It was not until 2012 that anyone stood up and challenged their policy and practice.  In 2012 John Knight, M.D. and J. Wesley Boyd, M.D., PhD published a Journal of Addiction Medicine article entitled Ethical and Managerial Considerations Regarding State Physician Health Programs and they state:

“Because PHP practices are unknown to most physicians before becoming a client of the PHP, many PHPs operate out- side the scrutiny of the medical community at large. Physicians referred to PHPs are often compromised to some degree, have very little power, and are, therefore, not in a position to voice what might be legitimate objections to a PHP’s practices.”

screen-shot-2015-11-17-at-11-00-44-pmHighlighting the  significant financial conflicts-of-interest between PHPs and their preferred assessment the authors add:

“..if the PHP highlights a physician as particularly problematic, the evaluation center might—whether consciously or otherwise— tailor its diagnoses and recommendations in a way that will support the PHP’s impression of that physician.”

As any first-year  medical student knows a “diagnosis” is derived from signs and symptoms. It is something that is arrived at. It cannot be “tailored” like a suit.  It represents diagnosis rigging and fraud. And as the “recommendations” inevitably amount to inpatient treatment this equates with the political abuse of psychiatry.   This paper generated little interest.  Just as facts, evidence and reason are drowned out under the all encompassing misappropriation of the term “denial” the serious allegations of Knight and Boyd were drowned out under the bogus claim of the successful outcomes of these programs.

Emerging and Emergent Concerns of Diagnosis Rigging and Fraud

 Pauline Anderson’s  Physician Health Programs: More Harm Than Good? has recently opened the door to exposing the financial exploitation and abuse of doctors by state physician health programs (PHPs) and their preferred drug and alcohol testing and treatment facilities. The August 2015 Medscape News article was the first mainstream medical publication to specifically address the coercive tactics of these programs and the dearth of oversight and accountability.

screen-shot-2016-09-30-at-1-31-17-pmIn her  rebuttal  to Medscape Medical News  FSPHP President Doris Gunderson claims that PHPs do indeed have oversight. She states:

 In fact, we operate under a microscope, answering to individual practitioners, medical boards, malpractice carriers, defense attorneys, state attorneys, medical societies, hospitals, medical schools and residency training programs. We are also accountable to patient safety entities and a Board of Directors. 

This statement is untrue.  Accountability requires both the provision of information and justification for actions to a a truly independent outside agent capable of providing sanctions for misconduct. This requires an outside independent organization with both investigatory and disciplinary authority. No such agency exists for these programs. Multiple articles questioning these programs integrity and intent have come out since this time such as “Physician health programs under fire”  published in the British Medical Journal (BMJ) and written by  BMJ editor Jeanne Lenzer.  None received any meaningful response.  The fact that the President of the FSPHP responded to the BMJ with logical fallacy and half-truths is concerning.  Another past president of the FSPHP who was the medical director of the North Carolina PHP was unable to identify what qualitative indicators and quantitative measurements went into “approving” the “PHP-approved” facilities.  The only response he could give was reputation and word of mouth.  He could not provide any criteria. and did not plausibly answer the question.The audit of the NC PHP can be found here.  Documentation that another past president of the FSPHP is involved in forensic fraud and fabrication of evidence is precise and clear.  It is indefensible.  These are all past presidents of the FSPHP and their inability to provide direct and simple answers to direct and simple questions is inexcusable.

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Removal of Due Process Through “Medicalization”

Physician health programs (PHPs) are viewed as facilitating “treatment” not “punishment” and are analogous to criminal justice system policy aimed at solving social problems by obtaining individual compliance to a given social structure.  Given the assumption that these programs are providing help to those suffering from a substance use or psychiatric disorder provides great political leverage with decision makers. Given that these same organizations have actively stoked the politics of fear by creating the mythology of  a hidden cadre of drug addled and disruptive doctors posing a danger to patients removes any possible thread of lifeline for the accused.  The mere accusation of substance abuse or behavioral deviance is used to disregard the claims of the accused. 

images-31-copyMedicalization removes the constitutional safeguards of due process.   The potential for abuse is especially the case in the absence of clearly articulated and openly established program policies and procedures.

The Urgent Need for a “Counterpower”

It is critical to create some type of  due process or redress for putative impaired medical students who are the objects of state physician health program therapeutic interventions. At present there is no “counterpower” to PHP control.  This could take the form of an advocacy group or intervention review organization with the goal of ensuring the veracity of both the claims and purported diagnosis and make certain that individual rights were not circumvented in the name of “help.” Although it is difficult to stand up to”authority” and not “make waves” it is essential to do so as soon as possible.

Students monitored under the current paradigm find themselves straining at a dual leash. The obstacles that are  thrown in their paths by the physician health rabble are as onerous as they are unnecessary. It is essential that some sort of appeals and support process be implemented as this situation is corrected.   Social and academic responsibilities always demand the scholarly search for truth and the correction of error.  Give some allowances while this sorts itself out.

Mark Twain said that it is “easier to fool people then to convince them that they have been fooled.”  The ease of this task is undoubtedly inversely proportional to the complexity and scope of the bamboozle. The current physician health paradigm rests on a  “Big Lie” which can be defined as something repeated loud enough and often enough that it drowns out all opposing viewpoints.  The “Big Lie” here was the proposition that doctors are different and doctors are dangerous.  A scaffold of false claims creating a false -construct has been built upon the “Big Lie” –it is a constructed reality that is false.  It is a house of cards that is easily debunked.   All it will take to do this is the interest and the will to do so.

A Modest Proposal-Facts Matter and a Diagnosis is Derived from Signs and Symptoms-It Cannot be “Tailored”

screen-shot-2016-09-30-at-1-30-53-pm In the interim I propose the following.  It would not be that difficult to set up a second opinion through medical schools involving an anonymous group of their own experts.  The reason for this  anonymity is self-evident. The primary reason other doctors do not speak up against these programs is the fear of being targeted themselves.  Allowing physician health programs carte blanche authority is bad policy and being bamboozled into accepting this group as unquestioned expert authority is a fools game.  Providing independent evaluation is a simple task and if the independent evaluation concludes there is no problem then rest assured there is no problem.

One of the saddest aspects of this is the damage done to society by the injury inflicted on otherwise capable and brilliant students whose careers are being snuffed out by charlatans and fools.

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The Alienation Of America’s Best Doctors | Melinda Hakim MD

mllangan1 5 Comments

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The Alienation Of America’s Best Doctors | The Huffington Post

 Doctors are hurting and they don’t have the time to reach out.

Melinda Hakim MD—CEO of DoctorCPR.com—a medical career site that reaches over 500,000 medical professionals looking for jobs and resources.

I grew up in the ‘80s in awe of my dad who was a talented general surgeon. As a kid, I used to make rounds with him at the local hospitals in Los Angeles and had the opportunity to witness the overwhelming appreciation his patients had for his work. Our home was inundated with dozens of homemade baked goods, knitted scarves, gift baskets, and colorful “thank you” cards carefully prepared by his patients. He never complained about his job. Even if he had to leave a family event or wake up in the middle of the night to do a trauma case ― he was never resentful. He felt invigorated by saving thousands of lives. He was grateful to be well compensated for his sacrifices. He worked extremely hard (sometimes putting in over one hundred twenty hours a week), but he was able to do his work the way he felt was best since he ran his own private practice. He was beloved, respected, and couldn’t imagine pursuing any other profession that offered greater rewards.

Unfortunately times have radically changed. The best and the brightest simply don’t want to become doctors anymore. Physicians are burning out. They are leaving the profession. They are going bankrupt. They are selling their private practices to big hospitals. They are retiring early. We are facing a growing doctor shortage. Doctors no longer want to be a part of a health care system that doesn’t value them after decades of sacrifice, debt, and brutal training. Physicians now have the highest suicide rate of all professions.

Doctors no longer want to be a part of a health care system that doesn’t value them after decades of sacrifice, debt, and brutal training.

As an undergraduate at Harvard University, I was fortunate to be surrounded by some of the country’s most talented students. Back then (in the ‘90s), many of the students were on the fence as to whether to apply to medical school or join the dozens of consulting and financial companies that aggressively recruited us. After speaking to the new generation of Harvard seniors at networking events — I realize that they are no longer on the fence. Our country’s brightest graduates are simply not choosing to become physicians anymore.

Of course, we cannot deny that we need to focus on curtailing health care costs. But we absolutely cannot cut health care at the expense of alienating physicians. Our talent pool is rapidly shrinking. Nearly every month now, another one of my most brilliant physician colleagues (from Stanford, Yale, Johns Hopkins, UCLA, and Harvard) leaves his medical practice. This is real. This is palpable. These talented physicians are quitting to join startup ventures, “concierge” practices for the ultra-wealthy, pharmaceutical companies, or the ranks of corporate America where they feel they are better compensated and respected for their brain power and sacrifice.

Let’s look at some of the facts to help explain why becoming a physician in America is rapidly losing its appeal.

1. Private practice medicine is increasingly unsustainable due to rising overhead costs and declining reimbursements

2. Doctors spend more than two-thirds of their time on paperwork rather than taking care of patients

3. Medicare reporting incentives do not reward over 99 percent of doctors

4. The average debt doctors face after medical school is $183,000

5. Many new doctors earn barely more than minimum wage when accounting for hours worked per week

6. State governments are passing laws to limit the compensation of “out of network” physicians

Doctors are hurting, and they don’t have the time to reach out. They don’t have the time to lobby Congress. They are far too busy trying to help their patients and keep their practices afloat.

Our country needs to figure out solutions to help preserve and encourage physician autonomy― not continually restrict it. With rapidly increasing government reporting regulations, new plans to move away from fee-for-service payments, growing patient complaints about high deductibles, Medicare audits, more complex documentation mandates, increasingly complicated coding requirements, payment denials, time-consuming prior authorizations, expensive Electronic Health Records mandates….why would our country’s top talent go through years of debt and brutal training to face over-regulation and exhaustion?

We also need to continue to compensate physicians at a fair level that matches their skills, high level of education, and sacrifice ― not figure out ways to “bundle away” what they make. Should health care dollars be shifted away from those who are waking up in the middle of the night to save lives, who are spending countless hours researching cases after work, who are neglecting their families to study for re-credentialing boards, who are saddled with inexorable debt, or who are spending thousands of dollars to attend meetings all over the world to find out the best way to care for patients? Contrary to popular belief, physician reimbursements comprise only a small proportion of our country’s total health care expenditures.

 

Short-changing the individuals who are sacrificing everything to save lives will lead to the biggest threat to our nation’s health care system.

Whether we like it or not, we will all be patients at some point in our lives. What will our country be like if we have to rely on health care professionals who are not high achievers and have little incentive to go the extra mile for our care? Will we be satisfied seeing our doctor for five minutes because he will face a pay cut should he spend 20 minutes with you? Won’t we get frustrated when we cannot get an appointment with a quality internist for two months because so many great doctors have left their practices?

America, this is serious. The brightest minds in this country are running away from careers in health care. Many of our best doctors are being forced out of business. We must start an open dialogue with doctors ― the individuals who are the most influential in advancing our health care system. The success of our health care system absolutely depends on the caliber of talent we attract to become and remain our nation’s physicians. Short-changing the individuals who are sacrificing everything to save lives will lead to the biggest threat to our nation’s health care system.

Want to make health care great again? We must all reach out to doctors and do everything in our power to demonstrate that we value our country’s physicians before it’s too late.

If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources.

The Regulatory Capture of American Medicine by the Drug and Alcohol Testing, Assessment and Treatment Industry

mllangan1 14 Comments

But in this Court, what Diff’rence does appear!
For every one’s both Judge and Jury here;
Nay, and what’s worse, an Executioner.

William Congreve, The Double-dealer

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Regulatory capture is a form of government failure that occurs when a regulatory agency created to act in the public interest, instead advances the commercial or political concerns of special interest groups that dominate the industry or sector it is charged with regulating and introduced in an article by George J. Stigler in 1971 entitled The Theory of Economic Regulation. The main idea of the article can be summarized in Stigler’s (1971: 3) affirmation that:

“…as a rule, regulation is acquired by the industry and is designed and operated primarily for its benefits.”

The basic hypothesis of Stigler is that an industry may use—or rather abuse—the coercive public power of the State to establish and enforce rules in order to obtain private gain.

Historians will at some point recognize 1995 as the “regulatory capture” inception point of American medicine when the  Federation of State Physician Health Programs ( FSPHP ) forged a relationship with the Federation of State Medical Boards (FSMB), the national organization responsible for the licensing and discipline of doctors and memorialized in a 1995 Journal of Medical Licensure and Discipline(Vol82N3)with articles claiming high success rates in eight state PHPs.

An accompanying Editorial written by past President of the FSMB Barbara S. Schneidman, MD, MPH concluded that:

“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.”

Roger A. Goetz of the the Florida Impaired Practitioners Program, for example reported that 84% of all referrals to the PRN “Occur prior to any violation of the Medical Practice Act or any evidence of patient harm.” Journal of Medical Licensure and Discipline(Vol82N3)  As protecting the public from patient harm is the primary directive of medical boards those statistics seem pretty impressive!   That the PRN prevented inevitable spirals of drug addled and besotted doctors from mayhem is questionable as how many were just like Leonard Masters?  After being accused of overprescribing Goetz told Masters he could either relinquish his license or have an evaluation. Masters chose the evaluation thinking he would be returning in 4-days but was diagnosed as an alcoholic and spent 4-months.  He didn’t even have a drinking problem.  He successfully sued G. Douglas Talbott and the facility for false imprisonment, malpractice and fraud.

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Goetz was also instrumental in promoting the chronic-relapsing brain disease model as a pathway to return revoked medical licenses.  No matter how abhorrent their  behavior,  by misplacing blame on the “disease” doctors who should have hung up their smocks forever quickly returned to practice as they didn’t do it the drugs or alcohol did.    In this manner serial sex-offenders, pedophiles,  date-rapists using roofies and fiends who replaced dying cancer patients narcotics with saline and let them die in agony were quickly returned to the fold.    The error in this thinking is that for the most part drugs and alcohol may induce good people to do disinhibited things or stupid things but they do not make good people do bad bad things. Empathy and moral compass are innate and the majority of doctors would not roofie drinks or take away dying patients pain meds under any influence. Unfortunately no test exists for psychopathy.

Many found employment as medical directors of these specialized programs and others became active in their states PHPs.

Since that time the FSPHP has duped the FSMB easier easier than a carney dupes a rube.

They asked the FSMB to approve public-policy to request state medical boards provide absolute deference to their state PHPs as their experts in all things related to physician health and to agree to never ever question their decision making skills regarding monitored doctors lest it “undermine a culture of professionalism” and this was agreed to.

Deference is acceptable but agreeing to blind deference and accepting the delusion of infallibility is unwise.  A culture of deference is unacceptable.  Lord Acton noted in a letter to a friend that the main point he was trying to get across when he wrote “Power tends to corrupt, and absolute power corrupts absolutely”was not that power corrupts powerful people but that power corrupts other people.  This dynamic certainly holds here. They make allowances.

Since that time they have expanded from ‘impaired physicians” to “disruptive physicians” to the “aging physician.”  They have gained power and autonomy without regulation or oversight and by removing transparency and absolutely zero accountability they have essentially run amuck.

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In 1995 this was a simple but growing shakedown scheme using a medical license to extract money under the threat of its loss. The PHP refers doctor X to “PHP-approved facility” for an evaluation and the “PHP-approved” facility tells doctor X you will stay here until I say so or I tell the PHP you ain’t gettin your license back.  Doctor X  stays because he knows the PHP can do it as the PHP is not going to be questioned by the medical board.They refer to it as “contingency-management” but it essentially meets the criminal definition of extortion.

Business has boomed since 1995 as they introduced non-FDA approved drug and alcohol tests into the market even though they are unvalidated with very low specificity. Junk-gadgets such as the SCRAM alcohol monitoring bracelet and the Soberlink cellular photo breathalyzer have been promoted as accurate and valid.  None of this has any oversight but their linkages with the drug and alcohol testing, assessment and treatment industry has become an enormous gold mine.  Both the drug-testing and assessment and treatment industry are multi-billion dollar enterprises.

The FSMB even made it public policy for medical boards to provide deference to PHPs and consider them experts in all things  physician health.   In this manner they have introduced a panoply of junk science, brought legions of polygraph examiners out of their basements and rebranded the 360 degree personal development employee assistance tool as a bona fide diagnostic instrument used for disruptive physician evaluations.  The FSMB has also accepted concocted and imaginary concepts such as “potentially impairing illness” and “relapse without use” as not only nonfictional but medically scientific truth.   If they proposed tiddlywinks for assessment of the “aging” physician the FSMB would probably buy it.  Is potentially potentially impairing illness next.?   There has been no apparent inquiry or opposition to this.

Accountability requires both the provision of information and justification for actions and they have minimized both.  Prohibiting doctors from obtaining their own assessments, medical records and drug-testing records markedly reduces risk of exposure as does prohibiting release of those records to third parties.   Cash only prevents inquiry from insurers. The PHPs have no oversight or regulation.  The drugscreen-shot-2016-02-09-at-3-39-27-am and alcohol testing labs have no FDA oversight as the tests are non-FDA approved. Other than accreditation agencies such as the College of American Pathologists there is no agency to investigates error or misconduct. CAP cannot sanction.  The assessment and treatment centers have little oversight or regulation.   In sum this system refuses to provide information and even if they did provide information they do not have to justify it to anyone and no agency exists to punish them even if they could not justify it.  Zero accountability.

And with zero accountability corruption not only thrives but is inevitable.   The simple extortion scheme from 1995 has now grown to around two dozen “PHP-approved” assessment and treatment centers and state boards require that only “PHP-approved” facilities be used and specifically excludes non “PHP-approved” facilities.   The preferred facilities engage in “diagnosis rigging” and false diagnoses to warrant unneeded treatment.  The labs such as USDTL and Quest engage in laboratory misconduct and will create a falsely positive test at client request.    It is a closed system where everything is kept within the PHP circle.

And complete regulatory capture has been achieved through autonomous units within Boards that essentially serve as PHP protection units and hired guns.  They protect the PHP and their friends and also act as an assassin squad to do whatever the PHP wants them to do to suspend, revoke and interfere with the medical licenses of doctors any which way they want.

In Massachusetts Policy 94-002 created Physician Health and Compliance Unit (PHCU) Board counsel as an independent unit outside the enforcement division of the Massachusetts Board of Registration in Medicine by design.

These units were created at the request of state physician health programs ostensibly to monitor the compliance of doctors under monitoring their monitoring contracts.   The MA PHCU Board counsel is run by attorney Deb Stoller and also includes attorneys Robert Harvey and Tracy Ottina.

Screen Shot 2016-08-06 at 2.22.27 PMPHCU Board counsel were additionally afforded the  power to act as both “hearing-officers” on cases and present these same cases to the Board and recommend disciplinary action. This was by design also.  They were set up to hold all the cards and it is a stacked deck.

This additional circle around the closed-loop system provides an additional layer of protection to prevent the fraud and abuse from being discovered.  That the  Massachusetts Board is not under any active supervision from the executive branch has been confirmed in writing to the Massachusetts Legislature by Governor Charles Baker in a letter accompanying his Bill (H.4188) which aimed to finally establish a framework for active supervision and oversight over the Board.

These units enforce PHP policy and requirements including the restriction of assessments to the out of state (“PHP-approved”) assessment and treatment centers and forbid any outside assessments.    Any doctor in Massachusetts will be forced to go to Georgia, Alabama, Arkansas, Kansas  or some other remote venue for an evaluation under the guise of special knowledge.   Any doctor reported to the PHCU as “non-compliant” is summarily suspended. Truth and evidence are irrelevant. The opinions of all outside experts no matter how qualified or how many are not only dismissed they are patently ignored  with eyes wide shut.   They simply do not register anything outside the racket.  They abuse administrative law procedure to dismiss, deflect and delay.   Having the power to act as both a  hearing-officer to accept or exclude evidence and present cases to the Board and make disciplinary recommendations provides them with absolute power to render judgment.   It means they are in charge of every decision made, and they have the power to be rid of whomever they choose as judge, jury and executioner.  The Board’s simply defer to PHCU Board counsel and give little thought or time to what was presented and ratify whatever is asked. They are uninformed and disengaged.

The system is almost foolproof.   It is a culture of impunity and deference.  To make matters worse states Attorney Generals defer to the medical-board and their physician health experts.  The AGO represents the state agency and its expert in legal challenges and crimes reported by doctors are dismissed at the outset.  The agency responsible for investigating rackets and laboratory and healthcare fraud as well as civil rights violations and color of law abuse is the states AGO. No one is minding the minders.

The assistant AGOs representing boards appear to use the same tactics as the PHCU Board counsel and a similar moral disengagement mentality but it is unclear what the interface is with the PHP/medical board and states AGOs.  If anyone has any insight please advise as I have not figured it out.  Perhaps they agreed to deference to the medical board/PHP just as the medical board agreed to deference to the PHP.  Perhaps they have specific administrative attorneys who they use or even a cadre within but it is implausible that the entire AGO would be supporting the rehab racket.

But in the final analysis this has resulted in is a complete systems failure where corruption and abuse is occurring as a product of bad apples in plain view and within the walls of regulatory medicine with each agency deferring to the integrity and honesty of its predecessor. This is not good governance.

Historians will someday look back at the fall of American medicine and wonder how it was allowed to happen and link systemic as well as specific problems pervasively plaguing the profession with regulatory capture by the drug and alcohol testing, assessment and treatment industry.

 

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Why are we tolerating the use of junk science against those in the medical profession? A direct question that begs for a direct answer.

mllangan1 7 Comments
 “That everyone shall exert himself in that state of life in which he is placed, to practice true humanity towards his fellow men, on that depends the future of mankind.” – Albert Schweitzer 
“By and by never comes” –St Augustine

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“A day’s impact is better than a month of dead pull”-Justice Oliver Wendell Holmes, Jr.

 I am looking for a few honest and credible statisticians, biostatisticians or epidemiologists who want to make a difference in the spirit  of service and helping others.  I can’t pay you but you would be combating injustice, corruption and dishonesty.   You would be doing your part in helping the Medical Profession, honest and decent doctors, our country and  perhaps our future.  

It is only a few public policy steps and minor changes in state regulatory statutes before what is described in the ASAM White Paper on Drug Testing comes to fruition.  Before we know it the Drug and Alcohol Testing Industries “New Paradigm” as described here by Robert Dupont will be ushered in as it did with doctors; not with a bang but a whimper.  From the ASAM white Paper:

“THIS WHITE PAPER ENCOURAGES WIDER AND “SMARTER” USE OF DRUG TESTING WITHIN THE PRACTICE OF MEDICINE AND, BEYOND THAT,BROADLY WITHIN AMERICAN SOCIETY. SMARTER DRUG TESTING MEANS INCREASED USE OF RANDOM TESTING* RATHER THAN THE MORE COMMON SCHEDULED TESTING,* AND IT MEANS TESTING NOT ONLY URINE BUT ALSO OTHER MATRICES SUCH AS BLOOD, ORAL FLUID (SALIVA), HAIR, NAILS, SWEAT AND BREATH WHEN THOSE MATRICES MATCH THE INTENDED ASSESSMENT PROCESS. IN ADDITION, SMARTER TESTING MEANS TESTING BASED UPON CLINICAL INDICATION FOR A BROAD AND ROTATING PANEL OF DRUGS RATHER THAN ONLY TESTING FOR THE TRADITIONAL FIVE-DRUG PANEL.”

To prevent this future drug testing dystopia, that includes testing schoolchildren, we need to take a step back and analyze the reliability and credibility of the “evidence-base” behind these multiple non-FDA approved forensic drug and alcohol tests and testing devices the ASAM proposes be used on the population at large utilizing the Medical Profession as a urine collection agency and bypassing forensic drug testing protocol by calling this “evaluation” and treatment rather than “monitoring” and punishment. New definitions, loopholes, secrecy and subterfuge are the bread and butter of these prohibitionist profiteers.

Amazingly, there has been no Academic review of these tests, let alone a Cochrane type critical analysis.  It is essentially untapped territory.  In addition there has been no Institute of Medicine type Conflict of Interest Analysis.  And that is why I am asking for help from statisticians, biostatisticians and epidemiologists.  The task would entail a review of the literature prior to the introduction of these tests for evidence base of forensic applicability (there essentially is none) and a review of the literature peri-and post marketing of these devices to assess the reliability and credibility of the underlying methodology and ascertain the evidence-base.  The goal would be publication in both academic journals and presentation to the general public through media publication with the assistance of investigative journalists and other writers. The goal is to get the truth out about these tests and allow both the medial profession and public at large to awaken to the menace this presents to medicine, our society and our future.

 Lack of Evidence-Base, Bias and Conflicts of Interest:  Making the Data Fit the Hypothesis

I am no epidemiologist or statistician but as with pornography I know junk-science when I see it.  Almost all of these tests were introduced with little or no evidence-base and, as with most of their endeavors, they did it below board via loopholes and cutting corners.

The overwhelming majority of papers are small, methodologically flawed, non-randomized, non-blinded  retrospective studies in that appear to make the data fit the hypothesis.   The authors can invariably be linked to those profiting from the tests of the testing process ( the patent holder, doctors associated with the drug testing labs, ASAM or FSPHP, Robert Dupont, Greg Skipper, etc.)

 

Ethyl Glucuronide (EtG) was introduced in 1999 as a biomarker for alcohol consumption,1 and was subsequently suggested as a tool to monitor health professionals by Dr. Gregory Skipper because of its high sensitivity to ethanol ingestion.2   

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Described as the  “innovator of EtG as an alcohol biomarker,” Skipper and  Friedrich Wurst,  “convinced” NMS labs in Pennsylvania “to start performing EtG testing in 2002.

The study most often cited as 100% proof that there is 100% accuracy in EtG testing proving alcohol consumption involved a mere 35 forensic psychiatric inpatients in Germany that was published in 2003.3  

Shortly thereafter the Physician Health Programs began using it in monitoring doctors and other professional monitoring programs soon followed.

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Up until the birth of the EtG tests used for forensic drug and alcohol monitoring had to go through the arduous, expensive and necessary FDA approval process.   The LDT pathway was designed to develop simple tests with little risk that have  low market potential (i;e. the cost of the normal FDA approval process would prohibit them from coming to market).  The LDT pathway was designed to improve patient care and help improve diagnosis and treatment. It was not designed for forensic tests.  LDT approval does not require in vivo testing.  It is essentially an honor system and to develop an LDT it is not even necessary to prove that the test is actually testing what it is purportedly testing for (validity).

So with little to no evidence base they introduced the EtG, had it developed and marketed as a LDT in collusion with unscrupulous labs, and then began using it on physicians being monitored by State PHPs. This then spread to other monitoring organizations in which there was a large power-differential between those ordering the tests and those being tested (criminal-justice, other professional monitoring programs).  These biomarkers have never been used in Federal Drug Testing, SAMHSA approved, DOT, and other organizations where unions or other organizations are present and looking out for the best interests of those being tested.

Another example of how this group removes accountability.  There has been essentially no oversight or regulation of LDTs.  Although there was a recent push for regulation of these tests the Drug and Alcohol Testing Industry Association lobby made sure that forensic tests would be exempt.

They then began publishing “research” on the EtG using the physicians being monitored as subjects. Many of the studies promoting the EtG and other biomarkers can be found  in  Journals that are linked to organizations that are linked to AA and were organized to educate the medical community.

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These small, methodologically flawed studies amount to little more than opinion pieces but   This “evidence-base” is predominantly in biased journals published by biased medical “societies.  
The EtG 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  Sauerkraut and bananas have even been shown to cause positive EtG levels.9
The United States Substance Abuse and Mental Health Services Administration warned against using a positive EtG as primary or sole evidence of drinking for disciplinary or legal action.10  The Wall Street Journal in 2006 reported the problems with the EtG to the general public.11   
Screen Shot 2014-03-23 at 10.45.36 PMAs any rational authority would do, the majority of monitoring agencies abandoned the EtG after these flaws were revealed. The PHPs did not.  They continued to use the EtG on doctors uninterruptedly by telling them to avoid any products that could potentially contain alcohol; a ubiquitous substance in the environment. Since that time they have justified and rationalized (EtG)2,12 13  use by sequentially raising cutoff levels from 100 to 250 to 500 to 1000 to 2000 to now unknown and adding other LDTs as “confirmation tests such as Ethyl Sulfate (EtS)14,15 Phosphatidyl-Ethanol ( Peth)16 17 and other devices such as the Subcutaneous Remote Alcohol Monitoring Bracelet (SCRAM) and, their newest device the Cellular Photo Digital Breathalyzer (CPDB) that has recently been launched, just like the EtG Screen Shot 2014-02-23 at 10.00.22 PMwith little to no evidence base other than a pilot study done by Greg Skipper and Robert Dupont.18 
A  2013 article published in an ASAM incubated journal Alcoholism: Clinical and Experimental Research promotes the Phosphatidyl-ethanol (PEth ) test to confirm drinking.16  The study was done on physicians being monitored by the Alabama Physician Health Program who tested positive for EtG/EtS alcohol biomarkers. It is co-authored by Robert Dupont, Greg Skipper, and Friedrich Wurst and involved 18 subjects who tested positive for EtG/EtS of whom 7 claimed they did not drink.  After finding that 5 of the 7 tested negative for PEth they concluded that “positive PEth testing following positive EtG/EtS results confirms recent drinking.  Hard to wrap your head around the science in that one.Screen Shot 2014-04-30 at 1.06.53 PMSkipper is also using both Scram ankle bracelets and the CPDB monitoring in pilots in the Human Interventional Motivational Study (HIMS) Program that was developed in 2009 to “identify, treat and, eventually, re-certify airline pilots with substance abuse problems. 
 
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The Cochrane Collaboration does systematic reviews of the literature using conscientious, explicit, and judicious criteria to in order to produce and disseminate only high quality and evidenced based health care, exclude bias, and enhance transparency. The Cochrane database is a current and evolving database that includes the accuracy of diagnostic tests and is internationally recognized as the standard in evidence based health care.  This benchmark for evidence based health care and systematic reviews, records just 5 controlled trials under the topic ethyl glucuronide.8,19-21 These 5 studies represent the only high-quality evidence regarding EtG applying to EtG. Information provided by the five studies suggests the following, and only the following:

  1. EtG and EtS measurements increase with alcohol ingestion.
  2. The window of detection is shorter than what is commonly proposed (80 hours).
  3. Individual values are variable both within and between subjects.
  4. Non alcoholic wine can cause positive levels.

Notably, there are no studies that fit Cochrane Criteria, other than non-alcoholic wine, that look at the pharmacokinetics of EtG or EtS in terms of dose-response curves, cut-off levels, specificity drug and food interactions, or modes of ingestion.

SAMHSA notes that there is little research on PEth and that EtG, EtS, and PEth “do not have a strong research base,” and that “it is not known at this time how the test results might be affected by the presence of physical diseases, ethnicity, gender, time, or the use of other drugs. Until considerable more research has occurred, use of these markers should be considered experimental.”

Phosphatidylethanol (PEth), SCRAM, and the  yields no data as a test in the Cochrane library.

SAMHSA notes that there is little research on PEth and that EtG, EtS, and PEth “do not have a strong research base,” and that “it is not known at this time how the test results might be affected by the presence of physical diseases, ethnicity, gender, time, or the use of other drugs. Until considerable more research has occurred, use of these markers should be considered experimental.”

Evidence based medicine (EBM) can be defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.22

Medical progress and scientific advancement is occurring so fast that the volume of medical literature is expanding at a rate of greater than 7% per year.23

Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.22  

Expert opinion is the lowest level of evidence available in the EBM paradigm.24,25

Fortunately, the scientific method is a tool to help people progress toward the truth despite their susceptibilities to confirmation bias and other errors.26

Unfortunately, due to a confluence of factors (including political) this has not been done.  But, unless we want a  future as envisioned by Robert Dupont and explained in the the ASAM White Paper on Drug Testing we need to act now.  This is not a “New Paradigm” but a “New Inquisition.”

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  1. Wurst FM, Kempter C, Seidl S, Alt A. Ethyl glucuronide–a marker of alcohol consumption and a relapse marker with clinical and forensic implications. Alcohol Alcohol. Jan-Feb 1999;34(1):71-77.
  2. Skipper GE, Weinmann W, Thierauf A, et al. Ethyl glucuronide: a biomarker to identify alcohol use by health professionals recovering from substance use disorders. Alcohol Alcohol. Sep-Oct 2004;39(5):445-449.
  3. Wurst FM, Vogel R, Jachau K, et al. Ethyl glucuronide discloses recent covert alcohol use not detected by standard testing in forensic psychiatric inpatients. Alcohol Clin Exp Res. Mar 2003;27(3):471-476.
  4. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. J Anal Toxicol. Nov-Dec 2006;30(9):659-662.
  5. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. J Anal Toxicol. Jun 2011;35(5):264-268.
  6. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. J Anal Toxicol. Oct 2008;32(8):594-600.
  7. Thierauf A, Gnann H, Wohlfarth A, et al. Urine tested positive for ethyl glucuronide and ethyl sulphate after the consumption of “non-alcoholic” beer. Forensic Sci Int. Oct 10 2010;202(1-3):82-85.
  8. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  9. Musshoff F, Albermann E, Madea B. Ethyl glucuronide and ethyl sulfate in urine after consumption of various beverages and foods–misleading results? Int J Legal Med. Nov 2010;124(6):623-630.
  10. Administration SAaMHS. The role of biomarkers in the treatment of alcohol use disorders. In: Advisory SAT, ed2006:1-7.
  11. Helliker K. A test for alcohol–and its flaws. The Wall Street Journal2006.
  12. Wurst FM, Skipper GE, Weinmann W. Ethyl glucuronide–the direct ethanol metabolite on the threshold from science to routine use. Addiction. Dec 2003;98 Suppl 2:51-61.
  13. Wurst FM, Alling C, Aradottir S, et al. Emerging biomarkers: new directions and clinical applications. Alcoholism, clinical and experimental research. Mar 2005;29(3):465-473.
  14. Anton RF. Commentary on: ethyl glucuronide and ethyl sulfate assays in clinical trials, interpretation, and limitations: results of a dose ranging alcohol challenge study and 2 clinical trials. Alcoholism, clinical and experimental research. Jul 2014;38(7):1826-1828.
  15. Hernandez Redondo A, Schroeck A, Kneubuehl B, Weinmann W. Determination of ethyl glucuronide and ethyl sulfate from dried blood spots. International journal of legal medicine. Jul 2013;127(4):769-775.
  16. Skipper GE, Thon N, Dupont RL, Baxter L, Wurst FM. Phosphatidylethanol: the potential role in further evaluating low positive urinary ethyl glucuronide and ethyl sulfate results. Alcoholism, clinical and experimental research. Sep 2013;37(9):1582-1586.
  17. Hahn JA, Dobkin LM, Mayanja B, et al. Phosphatidylethanol (PEth) as a biomarker of alcohol consumption in HIV-positive patients in sub-Saharan Africa. Alcoholism, clinical and experimental research. May 2012;36(5):854-862.
  18. Skipper GE, Thon N, DuPont RL, Campbell MD, Weinmann W, Wurst FM. Cellular photo digital breathalyzer for monitoring alcohol use: a pilot study. European addiction research. 2014;20(3):137-142.
  19. Hoiseth G, Bernard JP, Stephanson N, et al. Comparison between the urinary alcohol markers EtG, EtS, and GTOL/5-HIAA in a controlled drinking experiment. Alcohol Alcohol. Mar-Apr 2008;43(2):187-191.
  20. Wojcik MH, Hawthorne JS. Sensitivity of commercial ethyl glucuronide (ETG) testing in screening for alcohol abstinence. Alcohol Alcohol. Jul-Aug 2007;42(4):317-320.
  21. Sarkola T, Dahl H, Eriksson CJ, Helander A. Urinary ethyl glucuronide and 5-hydroxytryptophol levels during repeated ethanol ingestion in healthy human subjects. Alcohol Alcohol. Jul-Aug 2003;38(4):347-351.
  22. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. Jan 13 1996;312(7023):71-72.
  23. Norwitz ER, Greenberg JA. Promoting evidence-based medicine. Rev Obstet Gynecol. Summer 2008;1(3):93-94.
  24. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA. Feb 25 2009;301(8):868-869.
  25. Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ. Oct 30 2004;329(7473):1029-1032.

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Guest Post: Dr. Daniel Vande Lune, MD discusses how HCQIA provided immunity is misused by hospitals for sham peer-review

mllangan1 7 Comments

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The Ability for Hospitals to Hide behind the Immunity of HCQIA and the Abuse and Coercion by the PHP: my story and caveats.

I have been asked to write a guest blog and whole heartedly agreed. I am not afraid to tell my story and indeed, I feel that physicians need to know my story, so they don’t become yet another victim. This story really isn’t any different that a lot of other physician’s experiences. I want to be certain it is understood that my story is two-fold; violation of due process, breach of contract, and a sham peer review on the hospital’s part and a myriad of violations including roughshod disregard for civil liberties, committed by the North Carolina Physicians’ Health Program. Unfortunately, most physicians have no idea about many of the legal aspects that surround our careers, nor do they have any idea the power a hospital or PHP can wield.

In 1986, HCQIA (Health Care Quality Improvement Act) passed into law. On the outside, this act looked like a good thing because it tried to reign in escalating medical malpractice cases, and to protect people from those physicians. Quite generally, it allows physicians to be reviewed by their peers without the threat of civil litigation by the physician being reviewed. There are many points that have to be met in order for a peer review organization to stand behind HCQIA and earn its immunity. Again, unfortunately, because of this immunity, doctors can become the victim of a Sham Peer Review.

Lawyer, Gregory Piché, who has experience representing not only physicians but also hospitals in these matters, has written an excellent book, Sham Peer Review: The Power of Immunity and Abuse of Trust. While the book duly notes that it is very hard for physicians to fight back against a perceived sham peer review, it is not impossible. There are a multitude of reasons why a doctor might be targeted, for example, professional jealousy or competition. In the second chapter of his book he outlines 12 signs that you may be a victim of a sham peer review. I won’t enumerate those here but, they are eye opening. In my story, I was able to check off 10 of the 12 warning signs.

So enough background for now, let’s get on with my personal example. In November 2013, I was accused of misbehavior at the outpatient surgery center associated with Johnston Medical Center (Smithfield, North Carolina). Four staff members, who were kept anonymous from me, accused me of throwing an instrument and later that same day, striking a patient. Heinous behavior. I didn’t recall anything special from the day in question, I still stand by my side of the events. The instrument I was accused of throwing was a retractor. We were doing an arthroscopic case and thus no retractors were being used. All I can guess is that when we converted to an open procedure, I may have gently tossed the arthroscopic cannula onto the back table. The second accusation, again most heinous, was in a large man who was having hand surgery under a Bier block with sedation. He repeatedly moved and fidgeted, at one point sitting bolt upright on the operating table. I forcibly grabbed his wrist, still attached to a lead hand, and placed it firmly on the operating table, making a thudding sound. I certainly did not strike this patient, that violates my personal rules of honor and integrity. Skipping way ahead for a moment, I eventually had a Fair Hearing through the hospital’s administrative remedies, at which time only one of the accusers showed up. She was not a credible witness and in the end stated that the others hadn’t witnessed anything visually.

Mind you, these events supposedly took place in November of 2013. I was not made aware of it until December and didn’t go before the MEC until January. This is where it is very important to know the bylaws or to review them should you find yourself in a similar position. Under the bylaws I was to have been notified in writing and provided with details concerning the accusastion. Yet, I received only a phone call and then was not told any details of the accusations. Additionally, as a first time report, this should have gone to the head of the surgery department, not directly to the MEC. It should have been handled internally.  This was the first violation of their bylaws. In North Carolina, failure to follow your bylaws is considered a breach of contract.  From this point on they were violating my rights of due process. Because of the violations of their bylaws, due process, and their breach of contract, they have no right to stand behind the immunity of HCQIA. I wish I knew then what I know now. I should have looked at my bylaws and hired counsel before attending a meeting with the MEC. However, I figured that my explanation would ring true with my “peers.” Another mistake. I did ask about having a lawyer present but I was told that would not be allowed, which is probably true under the bylaws, but certainly is another personal violation of representation.

I presented myself to the MEC and gave my side of the story but I was rebuffed.   They investigated and told me they believed my accusers, the same accusers that DID NOT show up to my fair hearing eight months later. I was told that I would be “voluntarily required,” an oxymoron, to go the North Carolina Physicians’ Health Program to be evaluated. The oxymoron was explained as such: if they made it required, they would have to immediately report me to the NPDB. However, it was not voluntary in that my privileges were threatened if I didn’t attend. As I was planning to move out of North Carolina within six months, I agreed simply to keep the peace and move on without issue. I was given assurances by the Vice President of Medical Affairs that the evaluation would be kept confidential and that if anything came of the visit, it would be recommendations only. I, like many others, had never heard of the PHP before.

Due to scheduling issues, I was unable to be evaluated until late February, meanwhile still practicing and working out of this hospital; I was covering their ER, performing consults, and bringing them surgical cases (revenue). I presented for my evaluation, confirmatory email in hand, only to be told that I didn’t have an appointment that day and would need to reschedule. Fine, although I was convinced that was a test of my patience something that has been confirmed by others. Again, due to scheduling issues, (travel for interviews, death of a friend, and on call requirements), I didn’t get seen until early April. I was eventually accused, by the hospital, that I was purposefully delaying my evaluation. Much to my amazement, upon presenting, I was told that I would have to have a urine drug screen and that I would have to pay for it! This was not mentioned ahead of time, although the receptionist who had erred with my initial appointment, commented that I had been told.  I was also told, by the psychiatrist, that there was no doctor-patient relationship and he could report me to any authorities he saw fit. Despite me signing a release, I feel that without a doctor-patient relationship, he never had the authority to see my subsequent test results. Certainly, an argument can me made about a HIPAA violation on his part. To this point I have had my 5th and 14th Amendment rights violated by the hospital. NCPHP is probably guilty of illegal search and seizure as well as invasion of privacy.

We haven’t even started the evaluation. We began our talk. Not more than 15 minutes into the evaluation, he was trying to strong-arm me in to a contract with the PHP which would follow me to any future state where I might work. I refused, as I had been guaranteed that I was there for recommendations only. I answered all questions voluntarily, wanting to present myself as open and willing, not an “angry person.” I never refused a question, answering some of the most intimate questions possible. During this evaluation, I was never asked the 20 Questions of Johns Hopkins nor the CAGE questions. I was simply asked about consumption of alcohol which I didn’t deny. I have never been accused of coming to work impaired nor have I had any legal issues related to the social use of alcohol.

As the evaluation ended, I was escorted to and joined in the restroom by the psychiatrist, who was present as I provided a sample. Humiliating and violating. I then asked what drugs it tested for; I was told 12 drugs and alcohol. I balked as I had told him that I used alcohol socially. The urine was in his possession and I was told “not to worry about it.” Of course, the test came back positive for ethanol metabolites. As my evaluation was on Friday, the test result was communicated to me on Monday. At this point, the NCPHP recommended to the hospital that I undergo an evaluation for anger management as well as substance abuse. Remember, I had never been accused of impairment and this was a single isolated test. The courses were expensive and out-of-state. I refused anything to do with substance abuse evaluation or monitoring – which required the out-of-state evaluation or six months of draconian monitoring. I was especially concerned about travel restrictions under the monitoring contract as my daughter was getting married back in the Midwest. I was told they couldn’t guarantee that I could travel for her wedding. Obviously, that was a deal breaker.

At this point, I appealed to the hospital, offering to attend local anger counseling for which I would pay and I even offered to undergo urine testing at the hospital. The hospital continued to rebuff my concessions and attempts at coming to an amicable middle-of-the-road solution. I finally hired a lawyer who made it plain that signing a contract with the NCPHP was not a good thing. It was roughly at this time that the State Auditor in North Carolina released her report on the NCPHP. With all of the stories I know, it’s hard to believe that they didn’t find more evidence of malfeasance in reviewing 100 charts. They did find conflict of interest issues and recommended that physicians be allowed to seek their own care. Despite this recommendation, I was not afforded that opportunity. I presented this information to the MEC along with position statements from SAMHSA (they are against use of an isolated positive test and don’t believe the EtG test should be used as the sole forensic test especially when dealing the career of a professional), as well as reports condemning the EtG test (it is not approved by the FDA). Again, I was rebuffed.

In early May, after failing to sign the contract, I was summarily suspended from the hospital. Again, the bylaws were violated as I did not meet any of the definitions for a summary suspension. Why after six months was I suspended summarily? If they were so concerned, I should have been suspended the previous November.   After 30 days, by federal mandate, I was reported to the NPDB and subsequently investigated by the NCMB. I was released from my contract at Duke University. Although my license was never suspended, revoked, or restricted, I have been unable to get even a locums job. I have been rejected by at least three hospitals in Iowa. I’m working towards a Texas license but I’m finding that to be quite difficult. The hospital and PHP have continued to hide behind the veil of immunity. The violations of due process and breach of contract cannot be questioned which eliminates that immunity. The bigger concern is violation of civil liberties committed by both institutions.

Interestingly, the NCMB investigated and asked that I seek another evaluation, for anger management, with a counselor. They gave me a short list of providers in Iowa City, where I had relocated with my family. I went to one visit and she found no issues, other than an adjustment disorder stemming from the way I had been treated. I thought one visit rang hollow, so I pretty much begged the counselor to give me some recommendation. She said I could possibly benefit from a course in communication. Again, from a list of their choosing (the NCMB), I completed an at home course that dealt with communication and anger management.

Meanwhile, the hospital continued to hide behind the recommendations of the NCPHP. They would not back down from that. I eventually was given a Fair Hearing. After three nights of testimony in August and September of 2014, I was vindicated. The panel said that there was not enough evidence to have sent me for an evaluation in the first place, making everything following that moot. One of them has called it a witch hunt; a sham peer review. This decision was remanded by the MEC back to the panel who stuck to their initial decision. However, the MEC refused to overturn my suspension, which is allowed according to the bylaws. An appellate review also fell on deaf ears.

I think this story has many take home points. It never hurts to get a lawyer involved, the earlier the better. I firmly believe that had I involved a lawyer in January of 2014, I may never have had to go for an evaluation at the PHP. Know or review your hospital bylaws if you are ever in any situation with a hospital. Although I was given assurances that only recommendations would be made, the hospital hid behind their HCQIA immunity and the PHP, both entities holding my license/privileges over my head. Get everything in writing. Avoid any PHP, unless you feel you truly need their help, voluntarily. Even then, consider an evaluation by a trusted community colleague. The NCPHP is very typical of these organizations throughout the country, its modus operandi is addiction medicine. They base all of their recommendations on the spiritual 12-step program of alcoholics anonymous and the disproven belief that physicians need more intense treatment, junk science as most people call it. Like most of these institutions, they do not treat patients. They evaluate and refer you to an expensive out-of-state course, where you will most likely be entrapped in a prolonged, never ending contract with the PHP. It has been well documented that if you attend a substance abuse evaluation, you will most likely be labeled an abuser, ending up with 90 days of inpatient treatment. Lastly, be aware of the warning signs of a sham peer review, especially if you are just starting in a new position. Physicians are proud and territorial and they are not always “their brother’s keeper.”

I continue to fight for my professional career but the road blocks are enormous. Finding a lawyer to file suit, on a contingency basis, has also been impossible. As physicians, we need to stand up to these inequities. We need to support each other and contemplate the future when we may need to band together in a class action lawsuit. Maybe it’s time the ACLU becomes truly involved and excited about this opportunity.

Daniel Vande Lune, M.D.

 

The “Impaired Physician Movement” Takeover of State Physician Health Programs (PHPs)

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Forget what you see
Some things they just change invisibly–Elliott Smith

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Physician Impairment

The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence, published by the American Medical Association’s (AMA) Council on Mental Health in The Journal of the American Medical Association in 1973,1 recommended that physicians do a better job of helping colleagues impaired by mental illness, alcoholism or drug dependence. The AMA defined an “impaired physician” as “a physician who is unable to practice medicine with reasonable skill and safety to patients because of mental illness or excessive use or abuse of drugs, including alcohol.”

Recognition of physician impairment in the 1970s by both the medical community and the general public led to the development of “impaired physician” programs with the purpose of both helping impaired doctors and protecting the public from them.

IMG_1010The 1975 media coverage of the deaths of Drs. Stewart and Cyril Marcus brought the problem of impaired physicians into the public eye. IMG_0940Leading experts in the field of Infertility Medicine, the twin gynecologists were found dead in their Upper East Side apartment from drug withdrawal that New York Hospital was aware of but did nothing about. Performing surgery with trembling hands and barely able to stand, an investigation revealed that nothing had been done to help the Marcus brothers with their addiction or protect patients. They were 45 –years old.

Top: Twin Gynecologists Stewart and Cyril Marcus Bottom: The Movie

Although the New York State Medical Society had set up its own voluntary program for impaired physicians three years earlier, the Marcus case prompted the state legislature to pass a law that doctors had to report any colleague suspected of misconduct to the state medical board and those who didn’t would face misconduct charges themselves.

Physician Health Programs

Physician health programs (PHPs)  existed in almost every state by 1980. Often staffed by volunteer physicians and funded by State Medical Societies, these programs served the dual purpose of helping sick colleagues and protecting the public. Preferring rehabilitation to probation or license revocation so long as the public was protected from imminent danger, most medical boards accepted the concept with support and referral.

As an alternative to discipline the introduction of PHPs created a perception of medical boards as “enforcers” whose job was to sanction and discipline whereas PHPs were perceived as “rehabilitators” whose job was to help sick physicians recover. One of many false dichotomies this group uses and it is perhaps this perceived benevolence that created an absence of the need to guard.

Employee Assistance Programs for Doctors

Physician Health Programs (PHPs) are the equivalent of Employee Assistance Programs (EAPs) for other occupations. PHPs meet with, assess, and monitor doctors who have been referred to them for substance use or other mental or behavioral health problems.

Most EAPs, however, were developed with the collaboration of workers unions or some other group supporting the rights and best interests of the employees. PHPs were created and evolved without any oversight or regulation.

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The American Society of Addiction Medicine can trace its roots to the 1954 founding of theNew York City Medical Society on Alcoholism (NYCMSA) by Ruth Fox, M.D whose husband died from alcoholism.

The society, numbering about 100 members, established itself as a national organization in1967, the American Medical Society on Alcoholism (AMSA).

By 1970 membership was nearly 500.

In 1973 AMSA became a component of the National Council on Alcoholism (NCA) in a medical advisory capacity until 1983.

But by the mid 1980’s ASAM’s membership became so large that they no longer needed to remain under the NCADD umbrella.

In 1985 ASAM’s first certification exam was announced. According to Dr. Bean-Bayog, chair of the Credentialing Committee, “a lot of people in the alcoholism field have long wanted physicians in the field to have a high level of skills and scientific credibility and for this body of knowledge to be accredited.”2 And in 1986 662 physicians took the first ASAM Certification Exam.

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By 1988 membership was over 2,800 with 1,275 of these physicians “certified” as “having demonstrated knowledge and expertise in alcoholism and other drug dependencies commensurate with the standards set forth by the society.”3 “The formation of State Chapters began with California, Florida, Georgia, and Maryland submitting requests.4

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In 1988 the AMA House of Delegates voted to admit ASAM to the House. According to ASAM News this “legitimizes the society within the halls of organized medicine.”2

By 1993 ASAM had a membership of 3,500 with a total of 2,619IMG_8919certifications in Addiction Medicine. The Membership Campaign Task Force sets a goal to double its membership of 3,500 to 7,000 by the year 2000 to assure “the future of treatment for patients with chemicals. It represents a blueprint for establishing addiction medicine as a viable entity.”5

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Many of these physicians joined state PHPs and over time have taken over under the umbrella of the FSPHP.

Others became medical directors of treatment centers such as Hazelden, Marworth and Talbott.

  1. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA : the journal of the American Medical Association. Feb 5 1973;223(6):684-687.
  2. Four Decades of ASAM. ASAM News. March-April 1994, 1994.
  3. . American Medical Society on Alcoholism & Other Drug Dependencies Newsletter. Vol III. New York, NY: AMSAODD; 1988:12.
  4. . AMSAODD News. Vol III. New York, NY: American Medical Society on Alcoholism & Other Drug Dependencies; 1988.
  5. Membership Campaign Update. ASAM News. Vol VIII: American Society of Addiction Medicine; 1993:11.

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johnnyLawrence

Abuse Hidden Under a Veil of Benevolence: Bill Cosby, Physician Health Programs and Cognitive Dissonance

mllangan1 9 Comments

The blue slides below are from a  presentation at the 2014 FSPHP spring meeting in Denver, Colorado and can be seen here.   The presentation was given by past FSPHP Presidents Gary Carr, MD and Warren Prendergast, MD, West Virginia PHP Director Brad Hall, MD and Montana PHP Director Mike Ramirez, MS.

This needs to be seen as a "to-do" list.

This needs to be seen as a “to-do” list.

A.A. = ASAM = FSPHP 

The quote is from Alcoholics Anonymous and the full passage is as follows:

“We are convinced that a spiritual mode of living is a most powerful health restorative. We, who have recovered from serious drinking, are miracles of mental health. But we have seen remarkable transformations in our bodies. Hardly one of our crowd now shows any mark of dissipation.
      But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”–Alcoholics Anonymous, 4th Edition,  The Family Afterward

Federation of State Physician Health Program (FSPHP) physicians often quote A.A. because they are defined by A.A. in both mechanics and mentality.  The “impaired physician” movement began with evangelical recovered addict and alcoholic physicians whose recovery was based on 12- step spirituality.  As this group molded into the American Society of Addiction Medicine (ASAM) many of them found employment at 12-step rehabilitation facilities and others joined their state Physician Health Programs and organized under the FSPHP.   Their ability to make authoritative pronouncements on physician impairment is  based on their own claim to insiders knowledge of recovery as brandished in this A.A. passage which I find condescending toward the medical profession and oddly narcissistic.

This special knowledge, of course, was based on the chronic relapsing brain disease model with lifelong abstinence and participation in 12-step recovery.

These “miracles of mental health” joined their state PHPs and those who did not agree with their rigid inflexible views were removed.   Those with access to special secret knowledge were eventually able to outvote those with intelligence and open minds as this groupthink infested and eventually monopolized  PHPs.

It is important to understand that the ideology of  A.A. is the ideology of the ASAM is the ideology of the FSPHP 

Like all “front-groups” the ASAM purports to serve one agenda while in reality serving another.  The ASAM claims to be a “physician society with a focus on addiction and its treatment” According to their website their mission is to

  • increase access to and improve the quality of addiction treatment;
  • to educate physicians (including medical and osteopathic students), other health care providers and the public;
  • to support research and prevention;
  • to promote the appropriate role of the physician in the care of patients with addiction;
  • and to establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public

In order to accomplish this the  American Board of Addiction Medicine certifies doctors  to “provide assurance to the American public that Addiction Medicine physicians have the knowledge and skills to prevent, recognize and treat addiction.”

Ostensibly these are laudable goals that are almost universally endorsed.   The perceived organizational purpose and public persona are altruistic and humanitarian.  Treating addiction not only saves individual lives but improves the community.  It is for the common good.

Abuse Hidden Under Benevolence and Torture as Treatment

History reveals that all manner of abuse can lie underneath a patina of benevolence.   In the past few months alone we have both Bill Cosby and the  British Parliamentary pedophile ring as prototypical examples.  Both cases reveal a decades long coverup of allegations in which the abusers escaped little or no investigation into their alleged crimes. Abuse of power with a large gap between the power of the abuser and the powerlessness of the abused is a common denominator.  If the abuser endorses our own beliefs systems it creates a discord that promotes disbelief.  It does not fit.   Accusations are dismissed, deflected or otherwise suppressed.   Power effectively extinguishes the truth.  Disbelieved and delegitimized, information is suppressed, charges are not filed and law enforcement and the media turn a blinkered eye for decades. Indifference, disbelief, rationalization and cognitive dissonance prevent exposure and accountability. Hidden in plain site the truth was there and easy to find.  The problem was no one was looking. Most did not want to look.

It does not take much sleuthing to uncover what is beneath the veil of the American Society of Addiction Medicine.  The history, mentality and mechanics are well documented and reveal where they came from,  how they evolved and what they have planned.    It is a complicated web and hard to explain but once the pieces of the puzzle are fit together it is clear.  But it involves assembling a complex puzzle by finding the individual pieces scattered in disparate areas including the regulatory, clinical, administrative and professional niches of the medical profession,  Alcoholics Anonymous and 12-step related organization, public policy, all levels of the political arena and other areas. Once put together the portrait is clear.

In reality the ASAM is a political action group or special interest group that is designed to cement the chronic relapsing brain disease model with lifelong abstinence and spiritual recovery as the one and only treatment for addiction.   A.A. is used as the energy source of the operation.  By labeling addiction a “disease” requiring “treatment” in which someone is helpless they are able to dictate all aspects by coercion and control.  But in my opinion the A.A. ideology is just used as a ruse to support the multi-billion dollar drug and alcohol testing, assessment and treatment industry.  The zero-tolerance mindset of the “treaters” combined with the “helplessness” of the diseased enables them to erect a revolving door of testing, assessment and treatment that provides them with both control and a steady stream of money.

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The FSPHP mandates 12-step ideology on all doctors in a zero-tolerance system of abuse and control while at the same time putting out misinformation that the PHP programs are the “new paradigm.”  The page below is from the book Drug-Impaired Professionals by Robert Holman Coombs.

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This is they type of propaganda these groups have propagated.   What is described above is absurd and unrealistic but it is reported, reproduced and repeated to the point that it is accepted as the truth.

The majority of physicians referred to these programs are not even addicts. These programs of Zero-tolerance and 12-step indoctrination are based on coercion and control.  They are causing many doctors to die by suicide as they are feeling hopeless, helpless and defeated.    This portrayal of a group of blissful 12-stepping doctors over the moon because they found spirituality is nonsense.

But you will not find many doctors speaking out against them for fear of “contingency management.”  Disagreeing or even questioning PHP practices including the validity of 12-step can literally cost you your license.

I have spoken to multiple physicians and nurses and have encouraged them to tell their stories here but they are afraid of retribution and “unintended consequences.”  And who can blame them?

They can send you back to one of the “PHP-approved” facilities for “stinkin thinkin.”

Unfortunately the ASAM and FSPHP have successfully bamboozled others into believing they are true experts with noble intent.  They have bamboozled the Federation of State Medical Boards (FSMB) to the point where they have gained autonomy and unrestrained managerial prerogative.    They essentially use the state Boards to impose sanction on doctors who they report doctors for “noncompliance” which includes disagreeing with or questioning mandated A.A  or refusing to admit you have a chronic relapsing brain disease when you in fact do not.    They are in fact imposing A.A. on doctors and forcing them to accept their thinking under threat of loss of licensure.  This  violates the Establishment Clause and is a very serious problem that is being ignored.  It is a slippery slope we are on.

The FSMB House of Delegates adopted an updated Policy on Physician Impairment at their 2011 annual meeting distinguishing “impairment” and “illness”  stating that Regulatory Agencies should recognize the PHP as their expert in all matters relating to licensed professionals with “potentially impairing illness” that predates impairment often by many years.”  

It also defines “relapse without use” as “behavior without chemical use that is suggestive of impending relapse.”Screen shot 2013-05-13 at 1.30.29 PM

G. Douglas Talbott defines  “relapse without use”  as  “emotional behavioral abnormalities” that often precede relapse or “in A. A. language –stinking thinking.”

The ASAM has  monopolized addiction treatment in the United States.  But what the FSPHP arm has done is far more sinister.   A.A. has effectively taken over regulatory medicine and the private lives of doctors as a form of social control.  A doctor can be referred to a PHP for virtually anything and if the PHP believes he or she is in need of an assessment it will be done by a “PHP-approved” facility which means it will be done by a 12-step facility.  The PHP selects who will be monitored and dictates every aspect of what that entails and the entire process is done within the confines of A.A. ideology.  It is a, in fact, a  rigged game as the medical directors of the PHP approved facilities can all be seen on this list of like-minded docs who refer to theselves as “trusted servants” and “believe that evidence from extensive, well-designed studies demonstrates the great benefits of Twelve-Step recovery modalities including Twelve Step Facilitation in promoting long-term recovery.”

A.A. is imposed  on doctors through the FSPHP.  The FSPHP political apparatus exerts a monopoly of force.    And the bottom line is that A.A. has taken over all aspects of “physician health” and is forcing doctors to accept doctrine that is perhaps helpful to a few, useless or unneeded for many, and harmful and sometimes lethal to others.  This is unacceptable and it needs to be recognized.

“New Paradigm” of Zero-Tolerance and 12-step Spirituality Based on “success” of PHP to Move to Other Occupations and Kids.

To move this “new paradigm” to other populations they had to gain control of the doctors first.  They have not only created a monopoly but buffered themselves from physicians who may disagree with what they are doing to others.  This current system essentially stifles them.

The power, immunity and impunity this group yields over doctors was done silently and with no opposition. It was done by sequential public-policy steps.  This is why anyone interested in civil liberties and human rights should recognize the menace this presents to society.   The scaffold is in place and they are just adding more nooses.  Just ask the airline pilots.  They plan to impose similar systems on teachers, students and athletes.

And this is all spelled out in the ASAM White Paper on Drug Testing.   What people need to realize is what is described therein is just a few public policy steps away from them.  The only organization they have to convince is the organization that regulates any type of professional license, employment or benefit.

Gaining regulatory sway in the medical field and control over individual doctors was necessary to move this model to other populations.  It is merely a stepping stone for things to come.  It is only a few public policy steps from us to you.

This impacts us all.   It enables control of research, public policy and public health.   It is a system that suppresses dissent and shapes conformity.  The FSPHP  encourages the confidential referral of outliers.

The ASAM is pro-drug war and anti-medical marijuana.  This essentially silences most doctors for fear of being recognized and being brought in.  I know many doctors who will not even talk about it in public.

This is fixed doctrine and will not change.

That is why the ACLU and other groups who promote civil rights, those who are against the drug war and anyone involved in Medical Marijuana need to step in.    These  groups need to recognize the reality of who these people are, what they have planned and understand why they need to be stopped.   They are currently not even in the public eye and by outward appearances they appear to be benign.   In truth they are malignant and rapidly metastasizing without any symptoms.

In Order to Stop This the Following Must be Done

1) get a team of epidemiologists/statisticians to attack the “evidence-base” and “research” that the ASAM/FSPHP has used to support their claims (junk science, pseudoscience, success of 12-step, etc) and do a Cochrane type meta-analysis that will show there is little to no basis for it.

2) Demand accountability of the PHPs. Assign accountability to the Medical Societies and Departments of Public Health. Demand they be accountable for state-contractors with the Medical Boards (many of whom are complicit–in Massachusetts the Board of Registration in Medicine is simply an extension of the state PHP-i.e. Like-minds.

3) Demand that the criminal activity taking place within these PHPs be addressed by law enforcement.

4) Demand the Attorney General enforce the rampant Establishment Clause Violations occurring with mass 12-step coercion.

5) Identify and expose the  backgrounds of many of the individuals involved including felons and double felons who reinvented themselves as “addiction medicine” doctors. Many of these individuals are repeat offenders with a history of manipulating the system who should have never had their licenses returned.  In my opinion the ASAM/FSPHP/LMD rigged system is an example of corporate psychopathy.  While corporate level psychopathy is estimated at around 3% the numbers here appear to be much higher if one looks at the moral disengagement, unethical decision making, lack of empathy and externalization of blame evident in their personal histories.

6) Correctly identify that this system of institutional injustice is responsible for the astronomical suicide rate in physicians. This is due to the fact that doctors who need help are not getting it for fear of being ensnared by the state PHP and those already ensnared are being subject to coercion, abuse, institutional injustice, degradation, dehumanization, delegitimization and civil and human rights abuses and that this is a public health emergency that needs to be addressed.

7) reveal the scam set up between the PHPs, rogue labs, and “PHP-preferred” assessment and treatment gulags.

8) show how this is only a few public policy steps from Doctors to Pilots to Teachers to students to kids. etc. etc.

This necessitates that we get the conversation going before it is too late.

AA and 12-step may be the best treatment for some individuals with addiction and substance use disorders. If it works for you, then more power to  you. I have no problem with that.

What I do have a problem with is imposing and mandating 12-step  treatment on others.

Under a dictatorship everything else becomes subordinated to the guiding philosophy of the dictatorship.   Corresponding doctrine replaces professional guidelines, standards-of-care, and evidence based medicine.  And unfortunately in the case of Addiction Medicine the guiding philosophy often trumps autonomy and ethics.

Inherent in the current chronic brain disease model of addiction is the importance of external control over individuals and political correctness and medicalization of addiction is allowing it.   Demanding scientific literacy and discriminating good from bad science would prohibit what is occurring and In order to save American Medicine the problem needs to be clearly recognized or we will become a profession that is essentially defined by the impaired physicians movement.

 

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Physician Health Programs (PHPs) are not above the law; They just think they are

mllangan1 4 Comments

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Physician Health Programs are not Above the Law

Are Physician Health Programs (PHPs) above the law?  

 Unable to get law enforcement to take cognizance of reported abuse, many doctors I have spoken with believe that the actors involved are impervious to criminal liability.  Complaints of fabrication and fraud involving PHPs and their affiliates to the police, the Attorney General and other law enforcement agencies have been given no credence,  tabled or dismissed with little investigation.

Believing these agencies are deliberately ignoring credible complaints and the documentary evidence placed before them, some have concluded that state PHPs have been given the power to commit crimes with impunity and immunity.

PHPs are not above the law.  It is by removing themselves from and blocking the usual routes of accountability and absolute operational control of the testing, assessment and treatment process that has enabled misconduct to remain hidden, unrecognized or excused. The crimes exist but they remain undetected, unnoticed and unpunished.

Removing Accountability

The essence of accountability is answerability which means having the obligation to answer questions regarding decisions and actions.   This requires the transmission of information when it is requested.  The accountable actor provides the information to the overseeing actors in a transparent manner.

Accountability also requires explanation and justification for the information provided. What was done and why? Standards, rules, regulations, codes, laws and other benchmarks are then applied by the overseeing actor to determine if the information provided was appropriate or inappropriate.

The availability and application of sanctions for illegal or inappropriate actions uncovered through answerability is also a necessary component of accountability. This is necessary to impose restraint on authority and power.  Lack of enforcement of sanctions contribute to the creation of a culture of impunity.

The usual mechanisms that exist to impose restraint and create incentives for appropriate behavior and actions are absent. No outside oversight exists to limit their power or subject them to a set of rules.  No regulation exists to curb abuse.

A Culture of Impunity

The authority accorded PHPs and the power they exercise exist in a culture of impunity.

The key findings of the2014  North Carolina PHP Audit are below:.

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No indications of abuse were found,  a point brandished by the PHP as redeeming  and proving no abuse was occurring. In actual fact it is an ominous finding that also relates to their apparent ability to violate the law. 

The audit found no indications of abuse but that abuse could occur and not be detected because of an absence of due process for the complainant, excessive control of the complaint process by the PHP and absence of oversight by either the medical board or medical society.  What this means is that a doctor with no power is making a complaint against an unsupervised agency with enough power to influence the investigation of a complaint against itself.  The reason no indications of abuse were found is because the system is specifically designed to hide abuse.  That is the intent.

Absence of transparency, regulation and oversight coupled with control of information enables both censorship and doctoring of records.   Strict Confidentiality is enforced by HIPAA, peer review protection, and drug and alcohol confidentiality law.  

Quest Diagnostics

PHPs are able to suppress and conceal criminal activity but they are also able to  manufacture information designed to hide misconduct.  

The North Carolina Audit found no objective selection criteria for the out of state assessment and treatment centers because none exist other than ideological mindset and monetary gain.  The same facilities are used by most state PHPS.  They are, in fact, mandated as they are the “PHP-preferred” facilities.  

In 2011 The American Society of Addiction Medicine (ASAM) issued a public policy statement on coordination between PHPs, regulatory agencies, and treatment providers. recommending only “PHP-approved” treatment centers be used and the statement specifically excludes ‘non-PHP” recognized facilities.  

What the Audit diid not discover is the medical directors of all of the “PHP-approved” facilities can all be seen on this list of Like-Minded Docs.  It is a rigged game    Every aspect of drug-testing, assessment and treatment is kept hidden and secret and within control of the PHP.

It is a rigged game in which they have removed themselves from all aspects of accountability.  They have, in effect, manufactured a culture of impunity at our expense.

 “PHP-Approved Attorneys”

My survey has revealed an additional factor stacking the deck and removing accountability from PHPs.  The attorneys ostensibly representing doctors are also part of the racket.

A doctor referred to a PHP will be given a list of 3 or 4 attorneys by the PHP who are “experienced in working with the medical board.” What they do not tell you is that theses attorneys are hand-picked or cultivated to abide by the rules dictated by the PHP.

They will not “bite the hand that feeds” and any procedural, ethical or criminal misconduct by the PHP will not be addressed.     Laboratory fraud, false diagnoses, and Establishment Clause violations are off limits.

The primary purpose of these attorneys is to enforce payment for laboratory fees and demand compliance with whatever the PHP demands.  Their primary purpose is to keep doctors powerless under the PHP and prevent misconduct, including crimes, from being discovered.

The attorney pool is currently over-served by those serving two clients and most of those outside simply do not know enough about the “physician health”  legal issues related to doctors.  When they appear before the board it is as if they are a deer in the headlights.  It is a new terrain where all due process and familiar protocol have been removed.  Of course this was all facilitated by changes in administrative and medical practice acts orchestrated by the physician health movement “in the interests of protecting the public.  This must be recognized and addressed.

Skilled negotiators and lawyers with administrative law experience would do well to consider representation for doctors before medical boards regarding “physician health” matters.

It is not that esoteric, complicated or difficult.   As with the rest of the population, most have just not critically analyzed the issues behind the curtain.

Crooked Board Attorneys

Perhaps the lowest bottom feeders  playing a role in this culture of impunity are those whose job is to ostensibly ensure that due process and fundamental fairness are followed.    It is becoming quite clear that some of the state employed attorneys within medical boards control the flow of information by picking and choosing what is before the board for consideration.    Many of these attorneys go on to represent doctors in cases before the board.   If these attorneys acted as zealous advocates on behalf of their clients they would never get a referral again and because of this the system is plugged with an attorney pool unwilling to win but simply compromise.

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