4-1-1 on PHPs

Is there a way for physicians to receive confidential treatment for SUDs or mental illness while keeping their license?

When we set off on the journey of creating the Mental Health in Medicine series, it was our initial hope that we would bring you education about burnout, substance use disorders (SUDs) and mental illness as these issues relate to mental health in physicians. But a new question emerged as we were brainstorming for part three of this series. What do physicians do that need help?


In part two of Mental Health in Medicine, guest blogger Catelyn Aliana Jones writes, “Many physicians enter a career in medicine because of the benefits, such as high pay, respect from their community and the fulfillment that comes with a solid career path.” It’s no surprise that a physician experiencing burnout, SUDs or mental illness would be hesitant to voluntarily enter a treatment program especially if they felt confidentiality or the chance of losing their license is at stake. So, is there a way for physicians to receive confidential treatment for SUDs or mental illness while keeping their license? Enter the arguably controversial PHP.


4-1-1 on PHPs

Created in the 1970s, Physician Health Programs (PHPs) provide support and monitoring for impaired doctors with mental health issues and alcohol or drug problems. PHPs are represented by an umbrella organization known as the Federation of State Physician Health Programs (FSPHP). They exist in 47 states and the District of Columbia.[1] The states without PHPs are California, Nebraska and Wisconsin. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step–oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years.[2]


Consideration and Causes of Physician Impairment

The Federation of State Medical Boards (FSMB) and FSPHP maintain an important distinction in their policies governing functional impairment and potentially impairing illness. Impairment is a functional classification concerning the physician's inability to carry out patient care responsibilities safely and effectively. Illness does not necessarily signify impairment. This distinction has been central to the section on impaired physicians in many editions of the ACP (American College of Physicians) Ethics Manual; the seventh edition states, “Impairment may result from use of psychoactive agents (alcohol or other substances, including prescription medications) or illness. Impairment may also be caused by a medical or mental health condition, the aging process, or profound fatigue that affects the cognitive or motor skills necessary to provide adequate care. The presence of these disorders or the fact that a physician is being treated for them does not necessarily imply impairment.”[3]


Potential causes are not limited to addiction and psychiatric disorders; they can include many treatable and resistant conditions. For example, ACP and FSMB note that disruptive behavior and cognitive decline can cause impairment. Although they may be manifestations of underlying personality, psychiatric, or substance use disorders, disruptive behavior and cognitive decline are not illnesses per se. The former may be due to personality or character traits, interpersonal conflicts exacerbated by gender and cultural factors, or other external stressors, and the latter may be caused by health problems associated with aging. In all cases, different stages of progression or severity may warrant different forms of intervention.[3]


To refer or not to refer

Different causes of impairment require different types of assessment and support. Physicians can self-refer themselves to a PHP or they can refer a colleague. Physicians themselves may avoid seeking medical help because they fear loss of confidentiality and privacy, loss of livelihood, or the appearance of vulnerability. They may deny or subordinate their personal needs to practice demands and therefore do not recognize the impairment. The stigma of addiction and mental illness added to the concern that diagnosis may lead to professional liability or loss of licensure can compel physicians to suffer in silence and delay seeking help.[3]


When identifying and assisting colleagues who might be impaired, physicians should act on collegial concern as well as ethical and legal guidelines that require reporting behavior that puts patients at risk. A stepwise approach should be taken, starting with a sensitive but forthright discussion with the person if patient harm is unlikely and progressing to a report to licensing boards or clinical supervisors if patient harm is imminent or suspected. In uncertain cases, physicians should seek counsel from designated officials or supervisors.[4]


Physicians do not always refer impaired colleagues. In a 2010 survey of 2938 physicians, almost a third with knowledge of an impaired or incompetent colleague did not report this to a relevant authority, and more than a third did not agree that physicians should report colleagues at all.[3] The most common reasons for not reporting were the expectation that someone else would do so (19%) or that no action would result (15%). Other reasons included fear of retribution (12%), belief that it was not their responsibility, and worries about excessive punishment.[5]


The nature and severity of the impairing condition and the degree of risk posed to patients and others should inform best practices for assisting an impaired physician. Rehabilitation should be sought whenever possible so that the physician might safely return to practice. Evaluation and treatment should be clinically based according to standards of care. As stated in the FSMB Policy on Physician Impairment, a physician's voluntary decision to seek or accept treatment should not “in [and] of itself, be used against the physician in disciplinary matters before the board.”[6]


Most PHPs are "diversion" or "safe haven" programs, meaning that physicians who suffer from alcohol or drug problems can have their case diverted to the PHP in lieu of being reported to the state licensing board. If the physician agrees to cooperate with the PHP and adhere to any recommendations, the physician can avoid disciplinary action and remain in practice.[7] If a physician is unwilling to participate in a PHP and is thought to have an untreated/potentially impairing condition, the physician will likely become known to the medical board. Because different relationships exist between state licensing boards and PHPs, there doesn’t appear to be a definitive answer as to whether physicians will or will not be reported to the medical board if they seek and participate in treatment through a PHP. Many states’ PHPs are independent non-profit entities, and some are affiliated with the respective state medical association. Other PHPs may be operated by the respective state licensing board. Many PHPs have written agreements with their state licensing board to define their relationship.[8]


Critics charge that some programs operate punitively, unmonitored, and deprive doctors of due process rights, preventing them from challenging diagnoses they disagree with. At the center of the controversy are agreements between the programs and medical boards allowing state boards to revoke a doctor’s license to practice medicine if he or she is “non-compliant” with evaluation and treatment. Some doctors say their medical license was suspended or revoked without evidence of professional impairment, tarnishing their reputation and ending their career. Simply answering “yes” to an employment or licensing question about past treatment for depression can be enough to trigger what one doctor described as a “Kafkaesque nightmare.”[1]


Still, advocates for PHPs say these programs support confidential and compassionate care for physicians suffering from addictive, psychiatric, medical, and behavioral or other potentially impairing conditions. The FSPHP advocates for the privacy and confidentiality of a physician’s health and treatment history including participation in a PHP.[8]


What are your thoughts on PHPs? Would you feel comfortable referring a colleague, or yourself, to a PHP? Stay tuned for part four of Mental Health in Medicine as we take a deep dive into a groundbreaking study of 16 PHPs across the United States.


References

1. Lenzer J. Physician health programs under fire BMJ 2016; 353 :i3568 doi:10.1136/bmj.i3568

2. DuPont RL, McLellan AT, Carr G, Gendel M, Skipper GE. How are addicted physicians treated? A national survey of Physician Health Programs. J Subst Abuse Treat. 2009 Jul;37(1):1-7. doi: 10.1016/j.jsat.2009.03.010. PMID: 19482236.

3. Candilis PJ, Kim DT, Sulmasy LS; ACP Ethics, Professionalism and Human Rights Committee. Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety: A Position Paper From the American College of Physicians. Ann Intern Med. 2019 Jun 18;170(12):871-879. doi: 10.7326/M18-3605. Epub 2019 Jun 4. PMID: 31158847.

4. Sulmasy LS and Bledsoe TA ; ACP Ethics, Professionalism and Human Rights Committee. American College of Physicians ethics manual: seventh edition. Ann Intern Med. 2019;170:S1-S32 doi:10.7326/M18-2160

5. DesRoches CM , Rao SR , Fromson JA , Birnbaum RJ , Iezzoni L , Vogeli C , et al. Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA. 2010;304:187-93. [PMID: 20628132] doi:10.1001/jama.2010.921

6. Federation of State Medical Boards. Policy on Physician Impairment. April 2011. Accessed at www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/grpol_policy-on-physician-impairment.pdf.

7. Boyd JW, Knight JR. Ethical and managerial considerations regarding state physician health programs. J Addict Med. 2012 Dec;6(4):243-6. doi: 10.1097/ADM.0b013e318262ab09. PMID: 23070127.

8. Federation of State Physician Health Programs. (2018) FAQs. Available at: https://www.fsphp.org/faqs