By Gregory Skipper, MD, Medical Director, Promises Professionals Treatment Program It has long been recognized…
The Professional Evaluation of a Physician: A Peek Behind the Curtain
By Matthew Goldenberg, D.O., and Greg Skipper, M.D.
Doctors with substance use disorders need help finding their way back to health and to the safe practice of their profession. And how that help is given matters.
Twenty-plus years ago, doctors suspected of problems with alcohol or other drugs underwent formal intervention and were referred directly to addiction treatment by their medical board or physician health program (PHP). Usually the process ended up feeling more like ambush than assistance.
A better way was discovered that has revolutionized the intervention process.
In the mid 1990s, Greg Skipper, M.D., and Lynn Hankes, M.D., came up with the idea of intervening to a “formal evaluation” rather than directly to “addiction treatment,” and it proved so successful it soon became the standard of care. So how is this intervention to treatment conducted?
Often by phone, sometimes face-to-face, the doctor is told that a legitimate concern has arisen from a reputable source and an evaluation is recommended to be sure they are OK. The doctor is told that the purpose of the evaluation would be to make sure the doctor is OK and, if not, to formulate a plan to deal with the problem so that they can get back to work as soon as possible.
When specifics are requested, the doctor can be informed that there is concern about a drug or alcohol problem. If the doctor denies the problem, the response should be, “Good, let’s get a thorough evaluation and document that everything is OK.” If the doctor presses for more information, they are told they’ll get the details during the evaluation.
Often the doctor asks if the evaluation is required. The answer is “no,” but the doctor is informed that if they refuse then typically a report is made by those concerned to the licensing board. At that point, the doctor would be known to the medical board and would be required to undergo evaluation to keep his or her license. The doctor is encouraged to “volunteer” and “keep it clinical” and keep the lawyers out of it.
Once the evaluation is agreed to, most PHPs allow the doctor to choose from among several qualified options. These options are selected by the doctor’s PHP, which ensures the choices are impartial and up to the task.
The burden then falls on the selected program to thoroughly evaluate the client, a process that can last three days or more.
This approach, the “professional intervention,” helps get doctors into “safe harbor” where, at the end of the evaluation, a secondary intervention typically occurs. It’s at this point that a diagnosis is made and an appropriate treatment plan recommended.
Taking this tack has many benefits. Among them:
- It minimizes confrontation and thus minimizes resistance. Even for those with obvious substance use disorders, unless they themselves are asking for treatment, it’s been shown to be more effective to “recommend” an evaluation as a first step.
- It’s more expeditious. Since it is less confrontation, the process can safely be performed by phone rather than having several people show up at the doctor’s office from a PHP or wellbeing committee, resulting in delay and higher risk of embarrassment and discomfort.
- It encourages active participation in the recovery process. The evaluation helps the person understand what they’re dealing with and makes it more likely they’ll commit to the appropriate treatment.
An Evaluation Breakdown
So when the doctor accepts and “voluntarily” enters an evaluation, what exactly happens in the professional evaluation? It commonly breaks down like this:
A multidisciplinary team approach is used with a variety of specialists examining all aspects of the “doctor-patient’s” life — work, home and play. Often included are evaluations by an addiction medicine specialist, an addiction psychiatrist, and a psychologist specially trained in mental health and addiction. Collateral sources of information must be interviewed after appropriate releases are signed. A thorough physical and lab testing and neuropsychiatric testing are required, and in some cases, there may be a need for a polygraph, more extensive cognitive testing or more advanced drug testing (including hair and nail), diagnostic imaging, pain management, and consultations with specialists in sexual, gambling or behavioral addiction.
At Promises Professionals Treatment Program (PTP), because we are located in a major metropolitan area and have access to top specialists in all areas of medicine and behavioral health treatment, we are able to individualize each evaluation using local talent. That allows us to bring in specialists as needed without extending the length of the evaluation or requiring the client to travel a long distance to see a particular expert.
A crucial part of the evaluation process mentioned above is interviewing “collateral sources of information,” i.e., those who know the client, such as a spouse or former spouse, a partner, or an associate. The client must sign releases for these interviews. If the client refuses, then the evaluation team must decide how critical the particular collateral information is. Ultimately, the client may be advised that the evaluation cannot be completed if a release isn’t signed. Once appropriate releases are signed, the evaluation team will gather important insights of family, friends and colleagues.
Finally comes the so-called “secondary intervention.” The evaluation team has determined based on established criteria if a diagnosis of addiction, another mental illness or other behavioral disorder(s) are present. If so, formal recommendations are made to address the problem(s), which may include inpatient or outpatient treatment and a variety of modalities. The evaluation team will also determine fitness for duty, whether the doctor can return to practice and if so under what limitations, prior to complying with recommendations. Most often it is recommended that the doctor not return to work until thorough treatment is completed.
By the end of the evaluation process, all the pieces of the puzzle usually come together, and the doctor and their loved ones come away with a better understanding of what underlies the substance use as well as the nature of addiction itself and any co-occurring disorders. For example, issues such as anxiety and depression or past trauma often co-occur with drug and alcohol issues. Research makes clear that for best outcomes, all significant problems must be treated and stabilized.
Such knowledge empowers the doctor-patient to make effective treatment and lifestyle choices, becoming a partner in their own recovery. Most important, the evaluation approach makes it more likely the doctor will accept the help being offered, and that means they can more quickly return to safely helping others.