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Top 8 Mistakes Made by Well-Being Committees and Physician Health Programs

In 2001 the Joint Commission, with input from the Federation of State Physician Health Programs (PHPs), developed standards that require hospitals to have functions similar to what the state PHPs provide for state licensing bodies. These functions include: Education (about problems that can cause impairment, primarily substance use disorders), Early Intervention, Referral for Evaluation and Treatment, Long Term Monitoring and Advocacy. At the hospital level, Well-Being Committees (WBCs) or Physician Health Programs  can fulfill these requirements. In states that have a functional PHP, the hospitals can designate a working relationship with the PHP to fulfill these requirements.

The concept is to encourage early referral of physicians that may have problems, such as addictions or other mental health issues, that if unchecked can cause impairment. The idea is that if a non-punitive supportive resource run by peers were available, physicians would be referred sooner, thus avoiding progression to the point of causing patient harm and potential career ending events. Everybody should like this idea (i.e. getting help for troubled physicians as early as possible) including patients, physicians, hospitals, medical groups, malpractice carriers, etc.

Each of these programs or committees have policies and procedures and their own style of doing things. Because the PHPs serve an entire state, they are busier and typically have paid staff who become very experienced. WBCs are typically staffed by volunteers or appointees who are rotated periodically. Thus, the level of expertise can vary considerably.

So here is my list of the Top 8 Mistakes Made by Well-Being Committees and Physician Health Programs:

1. Failure to emphasize that participation is voluntary. PHPs and WBCs are run by clinicians and have no disciplinary authority. While the program staff may be highly motivated to help, they must temper their desire to help and remember the program is voluntary. The physician being referred should be told that the program is a clinical alternative to being referred to the legal authority, the Medical Board (Board) or Medial Executive Committee (MEC). Participation is an opportunity to deal with the issue in a collegial manner without attorneys and a legal process. The requirements of participation in the program should be explained, and the physician encouraged to participate, however, if a physician does not wish to participate, that is their choice. They should never be coerced. They should be informed, however, that if they choose to not participate the matter may be referred to the Board or MEC. This issue may come up repeatedly, for example, if a drug screen is requested, the physician may refuse. In which case, they should be informed that they must follow the procedures of the program to participate. Because the program is clinical and not a legal process, laws that govern drug free workplace testing, due process, and other legal requirements do not technically apply. Everything done should be voluntary. If they say, “I don’t really have a choice,” they should be reminded that the program (that is trying to help them) did not exist in the past and their case would have gone directly to the disciplinary body. They do have a choice. If they decide to participate, an agreement should be signed that states that their participation is voluntary and spells out the requirements of the program.
2. PHPs and WBCs conducting their own evaluations on physicians who have been referred. Because the staff of the PHP or WBC are usually clinicians, they may be tempted to explore the history and interview the doctor being referred and conduct an “initial evaluation.” Unless the program has the resources to conduct a very thorough evaluation (including physical, labs, drug testing, contacting collateral, psychiatric, addiction medicine and psychological screening and cognitive and personality testing) this essentially becomes an invitation to convince the staff that there is no problem. Most PHPs and WBCs are not equipped to conduct thorough evaluations. Their duty should be to determine if the referral is legitimate and then refer the individual for a thorough evaluation, to a program that does comprehensive evaluations on physicians. By engaging in an interview process, the staff of the program becomes the focus of denial. Basically, the less they explore the history, the better. The doctor may make every effort to convince them that the referral is erroneous. The staff of the program should say, “It is essential that you undergo a thorough evaluation to document you are okay. Save your explanation for when you are in the evaluation process.”
3. Being overly concerned about the cost of evaluation and treatment. It is tempting to care too much and be concerned that specialized programs for evaluation and treatment of physicians are expensive. The illnesses being addressed (e.g. addiction or other mental disorders) are serious, career and life-threatening illnesses. The cost of not fully and thoroughly addressing them are huge. The individual can die from their illness, can injure patients and if they relapse, there will often be legal fees and disciplinary action the cost of which far outweighs the cost of evaluation and treatment. The staff should not succumb to pressure that, “my insurance won’t cover it” or, “I have to do outpatient treatment,” etc. There is a rare physician who cannot somehow come up with the financial resources to obtain the best care possible. Often the insurance company that denies coverage initially will cover a substantial portion of the cost with the assistance of the treatment program staff arguing on their behalf. It is an odd thing that a physician with cancer or any other life-threatening illness will seek the best possible care, no matter the cost, but with addiction they often want the least intensive, lowest cost program.
4. Referring to less competent evaluation or treatment programs. Allowing a physician to be evaluated by someone or a program that does not have an established track record of thorough evaluation is an invitation to disaster. Basically, you get one shot at a diagnosis. If the first evaluator does a shoddy job and renders a faulty opinion, it is very difficult, if not impossible, to redirect to a competent program. The physician will keep repeating that they went for an evaluation and they were told they were okay, etc. This is why evaluations must be very thorough. By all means, never allow someone to go to a local psychiatrist or psychologist. The orientation of private practitioners is usually to ally with the patient, to find out what they want and then help them achieve their goals. This is not the approach that is needed. Programs that conduct physician evaluations take a more paternalistic approach, knowing that addiction is unusual in that the best results for the patient are often not their initial goals. Physician patients must be encouraged to face their denial in a supportive evaluation process.
5. Failing to trust the evaluation and treatment programs to whom they refer. Maintain a list of evaluation and treatment programs that have demonstrated competence that you trust and turn the case over to them for evaluation and/or treatment. Make every effort to avoid trying to influence the evaluation or treatment processes. The Federation of State Physician Health Programs (FSPHP) is in the process of establishing an independent accreditation for evaluation and treatment programs. Ask the program to give you regular updates but do not put pressure on them to make a certain diagnosis or to treat the individual a certain duration of time. Allow them to do their job. If they make serious mistakes and disappoint you, you can take them off your list. But while they are on your list of approved programs, you must trust them and let them do their job. Of course, it is desirable to ask questions and/or provide additional information if it becomes available.
6. Leadership of the PHP or WBC making decisions without the backing of their oversight committee. It is tempting for the director of a program or chairman of a committee to feel the responsibility to shoulder all the decisions. It is much better to be the messenger rather than the director. For example, if someone appears to have relapsed and needs to go for a thorough reevaluation, it is totally acceptable to say, “I understand your concern, however, the committee (or the policy of the program) dictates that you must stop work and undergo further evaluation. It is not my decision. I sympathize with you but there really is no choice.” If they try and talk you out of it you can repeat, “It is not my decision, I’m sorry.” Or something along those lines. Why make yourself the target of their anger? You are, in fact, simply upholding the policy or decision of the committee. You should feel free to assemble the committee and get their support in difficult situations if needed.
7. Having the mindset that there is a standard of care that is not flexible (for example, addiction requires treatment for 90 days to be effective). While there is proof that longer duration of treatment for addiction is more successful, there is really no magic number regarding best duration at a particular level of care. There is evidence that stepping down to lower levels of care may be advantageous. Every case is different. When someone returns home from inpatient treatment they will usually be continuing treatment by seeing a therapist, participating in therapy groups, etc. The treatment program should have a system for assessing progress and not treat everyone the same.
8. Failure to maintain rapport with leadership. Every PHP or WBC exists at the discretion of a Board or MEC. It is important to develop a relationship with the leadership and keep them apprised of your approach and activities, even if specific names are not mentioned. Without this relationship, all too often, things can go sour and the leadership can misunderstand what is going on, that physicians are not being handled properly and that they may become embarrassed that they are not exerting enough control. It is worth your time to visit them and keep them updated. It is a good idea to develop an annual report describing how many cases were referred and how they were handled, i.e. how many cases were referred to evaluation and treatment, how many are in monitoring, etc.

Running a Well-Being Committee or Physician Health Program can be a difficult job but it is much easier if good boundaries are maintained.

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