Are physician health programs (PHPs) effective?

Are Physician Health Programs (PHPs) effective? In a groundbreaking study of 16 PHPs across the United States comprising 904 physicians, McLellan, et al.[1] looked to find the answer. Join us as we take a deep dive into this study and other research efforts to better understand the PHP care model, substance misuse among physicians and PHP outcomes. For a refresher on PHPs, check out part three of our newest blog series Mental Health in Medicine.


Understanding the PHP care model

Physicians with substance use disorders (SUDs) receive an intensity, duration, and quality of care that is rarely available in most standard addiction treatments for the general population.[2] First, it’s important to note that PHPs themselves do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, PHPs 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 [3], with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years. Involvement of family, colleagues, and employers in support and monitoring is an important component of the PHP care model.[2]


SUDs among physicians

Approximately 10% to 12% of U.S.-based physicians will develop SUDs during their lifetime,[5] similar to the general population.[1] A nationwide study of substance use disorders in a large sample of physicians showed that alcohol is the most commonly abused substance among doctors in the United States.[4] Data show 12.9% of male physicians and 21.9% of female physicians abuse alcohol, much higher rates than the 6.2% of the overall U.S. population aged 18 years or older with an alcohol use disorder.[6]


In McLellan, et al. the primary SUDs were alcohol (50.3%), opiates (35.9%), stimulants (7.9%), or other substances (5.9%). Fifty percent reported misusing more than one substance and 13.9% reported a history of intravenous drug use. The average duration of substance misuse was five years. Seventeen percent had been arrested for an alcohol or drug related offense and 17.0% reported previous treatment for substance misuse.[1]


The following five medical specialties represented more than 50% of physicians in the 16 PHPs:[1]

Family Medicine - 20%

Internal Medicine - 13.1%

Anesthesiology - 10.9%

Emergency Medicine - 7.1%

Psychiatry - 6.9%


PHP Outcomes

Over the average course of 56 months of random testing, combined with unannounced visits to the physicians’ workplace by a program monitor, the records showed that 81% tested negative for substance misuse at any time. Of the physicians who did test positive for substance misuse, only 26% retested positive in subsequent testing.


The status of the physicians at five year follow-up varied as a function of their completion status of the PHP. For example, 95% of physicians who had completed their contract and 82% who had their contract extended were still licensed and working. In contrast, only 21% of the physicians who did not complete their contract were still licensed.


Research shows that PHP outcomes are positive and help physicians recover from SUDs and return to practice.[2] Here’s the catch - the physician must first self-commit or be referred by someone else to a PHP. In the study of 16 PHPs, 55% of participants were mandated to enter the PHP by a licensing board, hospital, insurer, or other agency. The remaining 45% were mandated by families, colleagues, employers, or some combination, with the implicit threat of formal action pending results of care. In a recent anonymous poll we tweeted, physicians seemed hesitant to vote on whether they would or would not refer a colleague to a PHP. While the sample size was small, the results were 75% of physicians would refer a colleague to a PHP. The mere mention of PHPs may make some physicians uncomfortable. Afterall, we’re talking about sensitive topics like substance abuse, mental illness, and physician impairment. And, no matter how effective PHPs are, if the physician in need doesn’t enter the program, then how effective is it really?


From the evidence provided in McLellan, et al. it is not possible to prove whether a PHP’s form of support and monitoring for physicians with SUDs is appropriate, too harsh, or too permissive. Any episode of substance use in the context of patient care has the potential for considerable harm, thus the easy solution may appear to be invoking immediate sanctions on physicians. But sanctions without the prospect of help in achieving recovery could simply reduce colleagues’ willingness to refer affected physicians—or licensing boards to exercise harsh sanctions—potentially increasing the true prevalence of the problem. Still, one can’t deny the outcomes: 95% of physicians who had completed their PHP contract were still licensed and working; 21% of physicians who did not complete their PHP contract were still licensed.


We’d enjoy receiving your feedback on this blog post and parts one, two and three of Mental Health in Medicine. All feedback will remain anonymous, meaning you won’t see your comment on Twitter or in another blog post. We really just want to hear your thoughts on mental health in physicians and PHPs. Just email kmitchener@instapathbio.com or DM us on Twitter at @instapathbio.


References

1. McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008;337:a2038. Published 2008 Nov 4. doi:10.1136/bmj.a2038


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. Cottler LB, Ajinkya S, Merlo LJ, Nixon SJ, Ben Abdallah A, Gold MS. Lifetime psychiatric and substance use disorders among impaired physicians in a physicians health program: comparison to a general treatment population: psychopathology of impaired physicians. J Addict Med. 2013;7(2):108-112. doi:10.1097/ADM.0b013e31827fadc9


4. Oreskovich, M.R., Shanafelt, T., Dyrbye, L.N., Tan, L., Sotile, W., Satele, D., … & Boone, S. (2015). The prevalence of substance use disorders in American physicians. The American Journal on Addictions, 24(1), 30-8.


5. Goldenberg M DO, Miotto K MD, Skipper GE MD, Sanford J BA. Outcomes of Physicians with Substance Use Disorders in State Physician Health Programs: A Narrative Review. J Psychoactive Drugs. 2020 Jul-Aug;52(3):195-202. doi: 10.1080/02791072.2020.1734696. Epub 2020 Mar 11. PMID: 32156222.


6. National Institute on Alcohol Abuse and Alcoholism. (2019). Alcohol Facts and Statistics.