Can Physician Health Programs Really Help Doctors in Crisis?
By Gregory Skipper, MD, Medical Director, Promises Professionals Treatment Program
It has long been recognized that physicians face heavier workloads and more intense stressors than the average working professional. We expect a lot from doctors, who must juggle their personal lives with extremely demanding schedules and often daunting medical challenges.
Running the gauntlet of burgeoning patient consultations, medical procedure schedules and professional commitments that reach far beyond the clinic would be stressful for anyone. Add to this the additional stress associated with learning new Electronic Medical Records software, arguing with insurance companies to justify needed care, running a medical practice and, of course, caring for patients who have complex cases, acute injuries or terminal illnesses. Further, the distress experienced by patients is often absorbed by the treating physicians. Doctors are only human. Yet, as the consulting experts in these scenarios, physicians are expected to be strong, if not infallible.
The stress of a busy medical career can become unbearable, especially when added to any issues with family members who feel neglected. For many doctors, there is simply no time to take the steps needed to alleviate the burden. Unfortunately, this sets up the perfect storm for a community of medical professionals who are stressed out, and who may develop substance abuse problems or other addictive behaviors as a way of coping. Addictions, of course, can negatively impact work and the level of care these doctors provide their patients.
Physician Interventions and Physician Health Programs
In the 1970s, physician burnout and the associated depression, anxiety (sometimes leading to suicide) and related addictions were recognized as significant issues. By the end of that decade, Physician Health Programs (PHPs) were beginning to be developed that could conduct interventions on potentially impaired physicians early, thus protecting the public and the physician.
Prior to the implementation of Physician Health Programs, the Medical Boards seemed to have no other option than to discipline impaired doctors who had substance abuse and psychological problems. They felt punishment was the only tool they had. The physicians were typically placed on probation, often resulting in increased professional and personal humiliation and shame for the physicians involved.
In an effort to improve the situation, Physician Health Programs were developed, thus giving the Medical Boards a clinical option to refer impaired doctors directly to treatment programs. Different states developed differing approaches wherein PHP leadership had differing relationships with the Medical Board, resulting in varying degrees of support and flexibility vs. rigidity. The earliest PHPs were only designed to address addiction, but over time the programs expanded their scope to include all psychiatric illnesses, which often co-occurred with addiction.
In 1980, JAMA published an article by Ralph Crawshaw, MD, et al titled, An Epidemic of Suicide Among Physicians on Probation, which highlighted that among 40 physicians on probation and directed into treatment, 13 had committed suicide and two were recovering from suicide attempts. Almost one-third of physicians placed on probation had committed suicide. Something had to change.
The Evolution of Physician Health Programs
In 1993, Lynn Hankes, MD, and I developed the idea of referring physicians in distress for discreet, non-confrontational evaluations as an initial approach, instead of direct interventions into treatment. The “physician evaluation” was developed based on the professional experiences of addiction treatment specialists and PHP directors. These were designed to determine if a diagnosis existed and to make recommendations.
The evaluation process began to serve as a “secondary intervention.” This approach encouraged increased cooperation in the evaluation process and, when appropriate, in the development of a treatment plan. The 96-hour evaluation evolved as the best approach, and PHPs rapidly began to employ it, as it was less confrontational and better tolerated among physicians. The 96-hour assessment utilized a multidisciplinary team that included an addiction physician, psychologist, psychiatrist and internist, as well as lab support for ongoing drug tests and interviews with associates and family (who could provide important information).
While there have always been inherent challenges in treating physicians for addiction and co-occurring disorders, including denial of a problem or symptoms, this model proved to be very successful and grew to include most PHPs in the United States. Intervention to multidisciplinary evaluation has become the standard of care.
In 2008, the British Medical Journal published an article on a national Blueprint Study of the Physician Health Programs in the U.S. that I participated in with Drs. McLellan, Campbell and DuPont. The seminal study revealed that out of 904 physicians participating in these treatment programs, 78% demonstrated successful recovery without relapse over an average period of 7.2 years. If physician-participants who suffered a brief relapse but ultimately achieved recovery were included, the success rate was closer to 90%. Further, it was reported that there was a lower than 1% suicide rate among the physicians who were evaluated and received treatment under the direction of PHPs during that time period.
New Troubles Surface Surrounding Physician Health Programs
Despite much success over the years, recent criticisms have surfaced among physicians enrolled in PHPs. A September 2015 article titled “Physician Health Programs: More Harm Than Good?” claimed that many doctors have become disgruntled with state-run PHPs, citing them as being too expensive, poorly run or even causing additional stress, rather than helping to alleviate it. This article, heavily criticized by the American Society of Addiction Medicine (ASAM) as relying on weak and unreliable sources, implied that the doctors running these programs may even increase the likelihood of suicide among their physician-patients. The ASAM summed up its criticism of the article with the statement, “The loss of PHPs and the safety they provide to physicians in crisis would do ‘more harm than good.’”
The criticisms of PHPs that were cited in the article came from a few physicians who were disgruntled. Do PHPs lead to an increased number of suicides among physicians? The statistics prove otherwise. The Crawshaw study published in 1980 reported a 20% suicide rate, whereas in 2006 after Physician Health Programs had been implemented, the suicide rate had fallen below 1%. Those who criticize the PHPs have not experienced the disciplinary measures taken by the Medical Boards in previous decades. It is understandable that physicians may not be happy when they are being intervened upon and referred by PHPs for evaluation and treatment, but things are much better now than they were. On the one hand, PHPs have to be firm when a potentially impaired physician is referred, but on the other hand, they have to be supportive in order to attract early referral. There is always room for improvement.
Making Physician Health Programs Better
So how do we improve the PHPs? Here are a few ideas:
Customizing the process to optimize outcomes. The next evolution in the process of physician evaluation is to increase the level of customization. This involves developing a plan and a team for each patient, so that they receive individualized evaluation and treatment. Rather than assigning every physician to a fixed group of people that do evaluations at a fixed price, it makes more sense to develop an evaluation team that is more precisely selected to meet each individual’s unique needs, and at various price points. For example, physician evaluation teams might be customized to include a:
- Pain specialist
- Anxiety specialist
- Trauma specialist
- Sex/intimacy disorders specialist
- Compulsive gambling specialist, and a
Altering the length of stay to suit the individual. The standard of care for physicians entering addiction treatment has been 90 days, but the 90-day standard may not be necessary for all physicians. No other illness is treated primarily by duration, but rather by response to treatment. Therefore, addiction treatment duration should be individualized according to response to treatment as well. This being said, there are a number of reasons why longer is better:
- Relapses are more likely to occur after shorter treatment stays, and relapses are extremely costly. Physicians can lose their careers, patients can be harmed and programs can be put in jeopardy.
- Three months, or 90 days, is the DSM-5 duration for achieving “early remission.”
- It takes time for the brain to heal from addiction and addictive behaviors.
Some factors that are taken into account in determining a longer length of stay include:
- The physician-patient’s area of medical specialty (e.g., emergency room physician)
- Drug of choice
- Route of administration of the drug
- Co-occurring disorders, such as personality disorders
- Family turmoil
- Work-related turmoil
- Legal consequences
- History of relapses
- Resistance to recovery activities
The importance of treatment milieu cannot be underestimated. As the director of a treatment program for professionals with addiction and mental health issues, I have seen how supported patients feel when they are among peers from their professional milieu, especially if those in the milieu are of similar age and education level. While we provide treatments and therapies to meet a range of needs — including stabilizing any co-occurring disorders, providing education on new behaviors, routines and coping mechanisms, providing tools for self-care, individual psychotherapy, group therapy, and milieu therapy — I have found that milieu therapy is the most important among these.
When milieu therapy is emphasized in a professional substance use disorder program there are several benefits, including:
- Professionals tend to be more open to learning from peers in the same position.
- They are typically more honest with peers.
- Confrontation is better received, and they tend to push each other.
There is definitely room for growth for PHPs, but if they evolve in directions that emphasize customized treatment plans and milieu therapy, outcomes will surely improve. The ultimate success of PHPs is their ability to attract physicians in distress, and to effectively help them heal prior to overt impairment.
An Epidemic of Suicide Among Physicians on Probation, by Ralph Crawshaw, MD, et al; JAMA 1980.
The Impaired Physician, by Ralph Crawshaw, MD; JAMA 1983.
Treating the Chemically Dependent Health Professional, by Greg Skipper, MD; Journal of Addictive Diseases 1997.
Physician Health Programs: More Harm Than Good? By Pauline Anderson; Medscape 2015.
ASAM Responds to ‘Physician Health Programs: More Harm Than Good?’ by R. Jeffrey Goldsmith, MD, and Gary D. Carr, MD; Medscape 2015.
Do Physician Health Programs Increase Physician Suicides? By Pamela L. Wible, MD; Medscape 2015.
Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States, by McLellan AT, Skipper GS, Campbell M, DuPont RL; BMJ 2008.