Some Takeaways from "PHPs: A Critical Look"
For one, there's great risk in engagement without fully understanding what they do
I’m delighted we had a great turnout for both Parts 1 and 2 of our webinar “Physician Health Programs (PHPs): A Critical Look.”
(Missed it? Don’t worry, we’ll be posting replay links when available. We’re awaiting those from our host organization, Physician Just Equity.)
Clearly, there was a yearning for more information about the PHP movement, a national franchise of sorts. And after Part 1, it seems social media and word of mouth sparked increased interest as we had double the turnout for Part 2 as for Part 1. Given that it was after all a CRITICAL LOOK, it wouldn’t surprise me that it caught the attention of both those who are currently or soon to be PHP-involved as well as those in leadership positions within the MRTC axis who may not be keen on hearing critique about the PHP enterprise.1
As we discovered in preparation and the hours devoted to chiseling down the 2 session outline, this was a massive undertaking. The number of immediately relevant topics were enough to make a full-day workshop out of it.
The Primary Aim of “PHPs: A Critical Look”– Encourage Full Awareness
Our prevailing aim for the webinar was to help physicians get educated as quickly as possible about potential dangers in their engagement with the PHP enterprise. This was not intended to be a promo piece, encouraging physicians to reach out to their PHP to get help. That PHPs may benefit some in certain circumstances is worth exploring – elsewhere.
We offered this webinar series with one main objective: helping physicians encountering these programs have sufficient information regarding their nature and the implications of involvement so they could make the wisest decisions about how best to proceed, with the triple goal for them of
most appropriately addressing whatever alleged impairment concerns have been raised;
maximally protecting their due process, civil, and other rights; and
avoiding the immense reputational and psychological harm that for many has come to be associated with PHP engagements.
There’s no “PHP Textbook” that anyone, including me and co-presenter Louise Andrew MD, JD, can turn to. And so our perspective was essentially that of informed opinions based on extensive observation, the study of numerous current and past position statements and operational policies, and in-depth interviews with hundreds of physicians over an extended time frame – in my case, 13 years. And of course, a reminder then and here: our considerations, offered as knowledgeable and concerned physician peers, didn’t and don’t constitute legal advice.
The Reality Is – There’s Real Jeopardy
In dealing with PHPs, the reality is that, for many, the risk for irreparable career harm is exceedingly high.
One thing we wanted to stress at the outset: In these matters, ignorance, even based on innocent naivete, is not bliss. What we’ve discovered is that docs are ignorant of the whole fitness-for-duty evaluation (FFDE) apparatus, at that operating under the misleading "physician health program" moniker. They assume that a PHP, if they have any hunch at all, is a legitimate, independently operating mental health entity that is affiliated in some advisory but arms-length way with a MLB, and one abiding by customary psychiatric ethics.2
And thus they have virtually no idea what they will need to know to – in very short order – to protect themselves if they head into a coerced PHP referral, whether from a medical board or their hospital. That referral will essentially be for some sort of forensic fitness for duty evaluation, based on a presumption of some type of impairment.
Too many have reported innocently walking into what can become an inescapable situation where they are deprived of their rights on the threat of adverse credentialing or licensure action, and have naively signed those rights away before they could make a fully informed decision as to whether participation or even consent to evaluation is right for them.
PHPs’ Initial Vision and Mission Seemed To Have Been Beneficent.
We looked at what a PHP is and how that enterprise got started 30 or so years ago. It apparently had genuinely beneficent intents. Docs, like any profession but especially those in high-intensity ‘people-service’ work, are prone to a host of stress-related syndromes and the subsequent development of mental and behavioral illnesses, with a predictably negative impact on one’s work-life and patient care.
As the PHP movement evolved from a loose-knit gathering of physician impairment committees at hospitals, it became known as a go-to resource for docs troubled with substance abuse and, later, for the diversity of other problems in the psychosocial realm including mental illnesses like depression and anxiety, and even trauma-related disorders like PTSD. The PHP movement lobbied medical licensing boards not to treat these wounded healers simply as cases of wayward docs needing discipline, i.e. punishment, for falling prey to a work-related illness, but as vulnerable human beings, just like the patients they treat, susceptible to the extraordinary stresses that can cause anyone to become ill.
And they built in an assurance to boards that they’d really take care of these docs, enabling them to take time away from practice - with dignity and privacy - guiding them to treatment resources knowledgeable of the uniquely stressful healthcare environment. These physician-oriented specialists would help them mend so that they could return to practice repaired, healed, replenished with new vigor for the work, and move forward with a healthier lifestyle committed to self-care and wellbeing.
Alas, the PHP Reality Evolved Into Something Quite Different.
But it seems that things got complicated over the years as PHPs assembled more clout and developed their exclusively-referred-to “preferred programs” and promulgated pseudoscientific justification for “early intervention” for “potential impairment” and extraordinary detentions for maximal periods of inpatient treatment followed by probation-like monitoring for conditions that warranted nothing of the sort.
And PHPs took on less of a beneficent doctor-rehabilitation slant and more of a punitive, medicalized disciplinary – if not opportunistic – role. They started referring out docs for evaluations at specially selected centers they chose (on no clinically efficacious criteria); they started treating docs as though they were all scheming addicts (as some of them had been – part of the syndrome they say) lying about the severity of their problem, just as they themselves had.3 And to assert their authority, they then became the rehab enforcement disciplinarian, recommending under virtual board order, in-depth assessment and then involuntary treatment at private centers in their network. They shifted their focus from physician rehabilitation to being the "protector of the public." That no doubt gained them great accord with the tightly aligned medical boards they were partnered with, and also with the hospitals which sent their alleged-to-be troubled docs to them.
No more compassionate approach, they seemed to be saying. No more individualized case analysis and treatment plan. "Got docs with problems? Just send ‘em to us. We'll take it from there.” And “there” meant being routed through the PHP’s well-oiled “impaired physician” rehab assessment and treatment network.
“Don’t make me unleash the flying monkeys ….”
PHPs seemed to have taken a “my way or the highway” approach. If WE think you’re ill, then you’re ill, no questions about it; no, we won’t consider independent assessments. You go to OUR preferred assessment program, including polygraph interrogation if needed. You follow OUR treatment program, or else. Recover as WE define recovery for the illness we’ve determined you have, whether you agree it exists or not. Abide by OUR monitoring contract under pain of law. And if WE determine you’ve relapsed or become impaired and are unsafe to practice, then that’s it. You ARE impaired and unsafe. Don't even think about challenging our infallibility. And if you force our hand, we’ll get the board to publicly declare you an impaired and unsafe doctor. And you’ll be under our watch for an eternity if need be.
Immense Authority Over Mandated “Potential Impairment” Assessments of Physicians
PHPs conduct potentially career-destructive fitness-for-duty evaluations with virtually no due process, in an environment absent of oversight and medicolegal accountability.
Over time, this national enterprise grew in influence and authority, backed virtually 100% of the time by its partners, the medical boards, the referring hospitals, and the medical societies that originally founded them.4 And incrementally, this exclusively contracted enterprise had also built up quite a coterie of eagerly receptive "impaired physician” programs across the country that the franchise sends its newly diagnosed people to.5
And what comes of these converging dynamics is a program operating with no discernible oversight, including by its national trade association The Federation of State Physician Health Programs (FSPHP) which seems to eschew any role critical of its dues-paying members’ self referential, due process-deprived operations.
PHPs comprise an enterprise that possesses immense power over physicians’ careers. And as their partnered medical boards seems pleased with PHPs’ adopting and prioritizing medical boards’ “protecting the public” mantra, they continue to uniformly endorse its assessments and courses of action, backing their recommendations with threat of license suspension for noncompliance.
But the fallout from that is that we see docs with non-severe illness and no actual impairment – some with no discernible illness or impairment to begin with – being wrongfully referred and then wrongfully assessed as impaired or having a “potential for impairment,” and, by implication of which, posing a "danger to the public." And they are being funneled into a virtually inescapable national PHP system, a medicalized para-judicial complex of its own order, deprived of any access to due process.6 7 And yet we see boards and hospitals going along with the incontestable PHP diagnoses and compulsory treatment regimens while these docs are deprived of any means to protest any aspect of the cascade – whether the fundamental procedural unfairness or unwarrantedness of the original referral; the PHP assessment; or the ensuing referral-mandated treatment and intrusive long-term monitoring program. It’s not difficult to imagine what impact on a physician’s mental health that injustice might have.
Eventually, as I and others have discovered, a threshold is reached where docs start to share horror stories and their bitter resentment, and generalized distrust is the inevitable result.
Our webinar focused on these developments and particularly on PHPs’ dangerous incursions into the ethically grounded and legally bound domains of appropriately warranted fitness for duty exams conducted with integrity, assurance of confidentiality and, if not beneficence, at least striving to do no harm.
We began an examination of the current status of the rights of those alleged to be impaired in some way to voice their objection, and the current and potential legal mechanisms for remedy of those harms.
Capping off Part 2, we offered some pointers on dealing with the PHP enterprise, how a physician might protect him/herself and challenge procedural wrongdoings.
In the next post, I’ll unpack the rest of the compressed content from our back-to-back webinars. And, yes, we also offered some words of hope for change that I’m eager to share in the next post.
In the meantime, if you’re a physician – whether in practice or still in training – who’s in the vicinity of beginning an involvement of some sort with a PHP, and these concerns resonate with you, you’re welcome to contact me to set up a curbside consultation (see the scheduling form on the website; additional resources are available there as well).
The medical regulatory therapeutic complex (MRTC), a term I and co-authors came up with to describe a previously invisible entity, consists mainly of medical licensing boards (MLBs), physician health programs (PHPs), and health care entities (HCEs) that have control over all physicians’ licensing – in that state and by reciprocal agreement throughout the nation, and all institutional credentialing whereby one obtains and maintains medical staff appointments at all licensed HCEs (health care entities) in that state.
I’m certainly one who was mistaken and only came to this understanding after years of study.
This recounting of their reasoning, curiously quite psychodynamically projective in nature, is not a fabrication. It’s drawn from frequent references from the PHP leaders themselves describing their own resistances to treatment.
In fact, some of these medical societies have signed secret memoranda of understanding delineating exclusive referral arrangements with the PHP and the compliance mandating medical licensing board.
As a general pattern, it and its downstream preferred programs’ diagnostic pronouncements are considered infallible and virtually incontestable. It appears that a number of these programs are owned, staffed, or run by prior PHP directors.
It was on these grave concerns brought forward to the state auditor by Dr. Jesse Cavenar Jr. and three senior psychiatric colleagues that NC State Auditor Beth Wood undertook a highest priority performance audit of the NCPHP. That year-long audit revealed that NCPHP had apparently violated the statutorily requisite due process rights of all 1,140 physicians it had evaluated over the prior decade. (Of further concern, by other reports, the number of physicians evaluated by NCPHP during that time frame was likely twice that reported.)
It may come as a surprise that, once in a medical assessment and treatment system and outside of the administrative and civil legal system, the concept of legal due process doesn't actually exist per se. It’s of course worth exploring further whether administratively ordered FFDEs and treatment programs, compliance with which is mandated under threat of deprivation of rights and liberties, are truly outside of the due-process-requisite domain of the legal system.
Some Takeaways from "PHPs: A Critical Look"
How do you get medical professionals to care about this issue when they're not involved with these programs? It must be too easy to discount criticisms from doctors in the system as just the carping of miscreants.
Hi Kernan,
It been a few years since we’ve spoken. Your work on PHP is great and appreciated. I’m considering allowing LifeGuard (not a PHP but as you know, also, like the PHP, potentially suspect for and subject to corruption influences of the medical boards from which they receive their victims) to take a crack at me in order to be approved for practice. I recognize that the odds are not good but wonder if you have any documentation to support investing the 15 k that they require versus letting it go as a bad investment.
Thanks,
Jon Strauss