Cambridge, MA…State physician health programs (PHPs) play a key role in helping doctors with substance abuse problems. But the current PHP system is inconsistent and prone to potential conflicts of interest and ethical issues according to an article which will be published in the December issue of the Journal of Addiction Medicine and has just been released online.
The article points out "substantial variability in states' PHP policies and practices, often raising serious ethical and managerial questions." Harvard Medical School researchers and article authors J. Wesley Boyd, MD, PhD, and John R. Knight, MD, served as PHP associate directors for more than 20 years; based on that experience, they "recommend that the broader medical community begin to reassess PHPs as a whole in an objective and thoughtful manner."
Most states currently have PHPs, which help physicians with substance abuse disorders. State PHPs meet with, assess, and monitor doctors referred for substance abuse or other mental and behavioral health problems. They also make provisions for follow-up and monitoring of treated physicians, including random drug testing.
While the PHP system achieves good results in treating substance abuse disorders in physicians, with much higher success than reported for other groups of patients, the authors have identified several ethical concerns related to the "coercive" nature of the system. "Once a PHP recommends monitoring, physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine," they write.
One issue is the high cost of evaluation and treatment. Evaluations recommended by PHPs are generally not covered by insurance and are very expensive—$4,500 or higher. If treatment is recommended, the cost may be prohibitive: one often-used facility charges $39,000 for a "standard" 90-day length of stay. That's much longer than the 20- to 28-day stay typical for other patients undergoing substance abuse treatment—despite a lack of evidence that health care professionals need longer treatment.
Many centers that perform PHP-recommended evaluations also provide treatment, thus raising the potential for financial incentives for treatment recommendations. Drs. Boyd and Knight note that close relationships between treatment centers and state PHPs are "replete with potential conflicts of interest."
They also point out problems related to the practice of some PHPs that "any and all" positive test results be reported to the state licensing board—even if they don't indicate substance abuse or relapse. Today's highly sensitive tests can give a positive result even in a person who has used alcohol-based hand sanitizer, as well as some types of asthma inhalers and pain medications. PHPs may instruct doctors to avoid these exposures to simplify interpretation of test results, "rather than what might be in the best interests of the physician."
"Given the anxiety and fear that being reported to the licensing board elicits, it is ethically indefensible for a PHP to ever report a physician for a false-positive test or any result they know doesn’t indicate relapse,” said Dr. Boyd, a psychiatrist at Cambridge Health Alliance, assistant clinical professor of psychiatry at Harvard Medical School, and author of the just released book Almost Addicted. "One physician who herself was reported for one of these false positives told us that one of these days a physician was going to commit suicide over one of these reports."
Use of information about physicians in research by PHPs and their closely intertwined relationships with state licensing boards raise concerns as well. Because most doctors know little about them, PHPs "operate outside the scrutiny of the medical community at large," the authors write. "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."
The authors recommend that independent ethical oversight of PHPs be considered, along with a formal appeals process and a nationwide system for licensing and periodic auditing. They also call on specialty organizations such as the American Society of Addiction Medicine "to review PHP practices and recommend national standards that can be debated by all physicians, not just those who work within PHPs."
"Ethical and Managerial Considerations Regarding State Physician Health Programs." J. Wesley Boyd, MD, PhD, and John R. Knight, MD. Journal of Addiction Medicine, published online on October 15, 2012.
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