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A Crisis of Physician Health in California

California was one of the first states to develop a program for early detection and treatment of physicians with substance abuse problems, but the program was closed in 2007. Now, California is one of the only states lacking such a program. The result has been catastrophic for many physicians and their patients.

Substance use disorders (SUDs) among physicians are an endemic problem. A recent survey sent to 27,276 physicians reported an overall lifetime prevalence of SUDs of 15.3%,[1] (estimates for point prevalence range from .5 – 1.5%) consistent with previous studies. This fact cannot be ignored and a competent plan to address the problem is essential for patient safety.

Physicians use alcohol and other drugs for the same reasons as non-physicians attempting to deal with stress, personal trauma, and chronic pain, often as self-medication. Those susceptible to SUDs slowly progress over time. As the illness progresses it can cause impairment that can lead to patient harm. Early detection and competent management should be the goal, to protect patients and their physicians. The AMA, the Federation of State Medical Boards and the Joint Commission all agree there should be an effective plan for early detection. Stigma regarding mental disorders in general, and substance use disorders in particular, and harsh punishment by medical boards and criminal authorities leads to delayed detection, isolation of those affected and is a significant barrier to early detection and treatment. Lack of training and understanding how to approach these disorders further complicate the issue.

Fortunately, a system of care evolved nationally since the 1970s to better address the problem. Almost all state medical boards now endorse complementary clinical programs for early detection, referral and monitoring of affected physicians. These programs, generically called Physician Health Programs (PHPs), have been very successful, helping physicians and protecting patients. Unfortunately, California discontinued its program and powerful forces have opposed a new program despite the fact that success rates of PHPs are high with no demonstrable risk to patients.[2]

Are Physician Health Programs really effective?

Physicians struggling with substance abuse are embarrassed, afraid and discouraged. They have often attempted to quit on their own many times. They are afraid of what will happen to their career should their secret become known. They repeatedly attempt to quit or moderate their use. They become extremely discouraged when they are unable to stop. Denial is part of the illness. When symptoms become prominent enough, others realize there is a potential problem. Family, colleagues or hospital leadership begin to realize they must act.

If there is a well-functioning, confidential, authorized state PHP, it can be contacted for immediate action. Unlike the slow machinery of the administrative law system wielded by the medical board that can take years, the PHP can act immediately. It contacts the physician and lets them know there is a concern and the physician must stop work and undergo a clinical evaluation. The evaluation must be extensive and not miss the diagnosis, if present. For best results, specialized evaluation programs are preferred. The best evaluations are conducted by a collaborative team including: internal medicine with blood work (liver function testing and other labs), physical exam, psychiatric evaluation and psychological testing (including neuropsychological screening), addiction medicine assessment (including state of the art drug testing of urine, hair, nails, and/or blood as appropriate) and, most importantly, interviews with family, friends and peers.

Why would a physician cooperate after being contacted by the PHP?

Physicians comply because the PHP is confidential and is compassionate in attempting to help and because a refusal could result in referral to the medical board for disciplinary action. An effective evaluation is conducted over 2-3 days and if a diagnosis is made, it is clearly explained. The physician then undergoes treatment, including withdrawal management, psychosocial rehabilitation and extensive aftercare planning. Once the physician is ready to return to practice, anywhere from 1 – 3 months or more later, they return with ongoing monitoring for 5 years or more by the PHP. This model has been proven effective and safe and is active in most states.

Why California does not have a PHP?

California previously had a board sponsored PHP called “The Diversion Program.” Audits of the program were performed by a consumer advocacy group (Center for Public Interest Law, that unfortunately had a prior bias). Faults were found and media attention was elicited. Under pressure, the program was cancelled in 2007. However, no actual patient harm associated with the program was ever detected. It was not a perfect program. There was no medical director, therefore leadership of the program was lacking. The program was run by the medical board rather than being independent. It could have been reorganized and modeled after successful programs in other states but instead it was just cancelled.

Attempts to reestablish a program have faltered. Consumer advocacy groups, in particular the Center for Public Interest Law, have relentlessly continued vigorous opposition to the establishment of a new effective program. Their quest to assure that physicians with substance use disorders are punished has ironically been to the detriment of patient safety. Their argument has been that the old program was ineffective and that the medical board should be a disciplinary body and only advocate for patients and not for physicians. They claim that physicians should seek treatment on their own if they need it and the board should not be involved.

What happens to physicians with substance use disorders in California?

Physicians with SUDs in California are punished with no emphasis on rapid intervention, evaluation or treatment. Substance use disorders are handled as crimes rather than as illnesses. At great cost, for the state and the physicians, the judicial apparatus of the state, utilizing the attorney general’s office, is levied against these physicians. To inflame the situation further, the medical board refers substance using physicians to criminal authorities. Accusations are filed to revoke the physician’s medical license. Hospitals are required to report, not only action against doctors, but even investigations. Many hospitals have all but ignored the Joint Commission requirement to provide safe haven for physicians to receive treatment. Hospital attorneys often recommend the least liability by terminating the physician and referring them to the medical board. The medical board boasts it has invested significant resources into exposure and punishment: providing apps that patients can put on their smartphones to alert them if their doctor undergoes discipline[3] and a new law that specifies that doctors on probation for substance related disorders must obtain signed consent from new patients[4]. This will mean that being on probation will end careers in medicine. The Medical Board of California has shown aggressive zeal in punishing physicians and it has set a tone in the state not conducive to early detection. When probation orders are issued, treatment is rarely, if ever, mentioned, only a requirement to abstain, setting up a high likelihood of failure. Huge amounts of money are wasted and treatment is delayed for years in the process.

In this hostile climate, physicians are afraid to seek help. Colleagues, hospitals and families are loath to make referrals. Therefore, substance use disorders go unchecked until there is a disaster and patients are harmed. Board records show slow resolution following complaints of substance use, up to 3 years, and patient harm occurring during that time. Additionally, there are cases where physicians are fired from jobs, such as anesthesiologists providing contract services for surgery centers, because of suspected substance abuse without referral, later harming patients because of delayed reporting. In response to these cases of patient harm due to delayed referral, consumer groups lobby for harsher punishment, only making the situation worse.

After numerous attempts since 2007, a state law was finally passed by the California legislature in 2016 mandating that the medical board create a new PHP. However, the new program has been bogged down by wrangling about how it will operate, whether there will be a confidential component, and how punitive and restrictive it will be. There appears to be little sign that an effective program will emerge.

It is a sad situation that one of the most progressive states has one of the worst systems of early detection and care for physicians with SUDs. Patients are being harmed. The Medical Board of California should understand that helping physicians and improving patient safety are complementary and not mutually exclusive.[5]  A competent, effective PHP is desperately needed in California and should be established. Ill-founded opposition by consumer groups should be ignored.

Could this happen in other states?

[1] Oreskovich MR, et al. The Prevalence of Substance Use Disorders in American Physicians. Am J of Add. 24:30-38, 2015

[2] McLellan T, et al. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008;337:a2038

[3] https://www.sfchronicle.com/business/article/New-California-app-tells-patients-when-doctors-13107866.php

[4] https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1448

[5] Collier R. Healthier Doctors, Healthier Patients. CMAJ. 2012 Nov 20; 184(17): E895-E896

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