October 2000 Bulletin

‘Impaired’ doctors get a helping hand

Programs assist physicians with drug and alcohol dependence, behavior disorders, mental illness

By Carolyn Rogers

Three recent court cases involving Massachusetts physicians accused of violent crimes prompted the Massachusetts Medical Society to send out packets to all of the group’s 27,000 members in early August, reminding them of the availability of Physician Health Services (PHS)–a free, confidential counseling service for physicians.

Although crimes of violence involving physicians are highly unusual, physician health programs such as PHS routinely respond to situations involving variously "impaired" doctors. The Massachusetts program provides ongoing, confidential support for physicians in recovery from chemical dependencies, mental illness and physical illness, as well as referral, liaison with colleagues, recovery monitoring and documentation, and support groups for physicians and their families.

While mental illness and chemical dependency account for the majority of the cases PHS handles, it’s seeing an increasing number of cases involving interpersonal and behavioral problems, according to Louis Sanchez, MD, director of the Massachusetts program.

"It might be that those kinds of problems have always existed with certain physicians, but because of the high status of doctors, no one confronted the doctor in the past," Dr. Sanchez says. "That seems to be changing as medical practice changes–with the onset of more management of care and more accountability of physicians, inappropriate and arrogant kinds of behaviors are no longer being tolerated. Physician health programs are quite helpful to doctors and organizations in developing programs to correct those behaviors, and, as a consequence, improve the physician’s capacity to practice medicine."

Programs such as Massachusetts’ PHS–which has been in existence for more than 20 years–now exist in every state in the country. The programs themselves vary greatly from state to state, however, because they must operate within the parameters of state regulation and legislation. Types of impairment addressed by the programs typically include drug and alcohol dependence, behavioral disorders, mental illness (stress/anxiety/ depression), senility and physical impairment. Most programs were initiated in the late 1970s, but many have grown dramatically in recent years.

"There hasn’t been a medical-cultural enforcement over the years for doctors to divulge any kind of problem or weakness or embarrassment," Dr. Sanchez says. "It’s still relatively new for doctors to be able to say ‘I have a problem.’ Doctors seem to be held to the highest standard of all professionals; we’re expected to be one step below God. In saying that, what doctors are now learning is we are not God-like figures–we’re very human, despite having an MD behind our names. We’re subject to the same frailties, problems and illnesses as our patients."

So how do physicians end up as clients of a physician’s health program? While it varies from state to state, a certain number of physicians contact the service directly, and many referrals come from the medical community–various office staff and medical colleagues. Reports also come from lawyers, concerned friends, spouses and others.

"In our state, most physicians are self-referred, " Dr. Sanchez says. "We tend to get calls directly from the doctor requesting some assistance or support. Most physicians call because a problem has developed in the hospital or practice, and they have been advised to get some help. We also get referrals from administrators and colleagues, etc, which is good, because it’s critical to our work and success that our presence and availability be very well-known to the medical community throughout the state."

In Washington state, however, Lynn Hankes, MD, director of Washington’s Physician Health Program (PHP) and president of the Federation of State Physician Health Programs, says most of their clients come to them through "some sort of coercion."

"First of all, physicians–like other people–have a huge amount of denial," Dr. Hankes says. "As we like to say, ‘M.D. stands for malignant denial.’ Also, because physicians are trained with the mentality that they are invulnerable, when they do get sick they feel a lot of guilt and shame. And even when they figure it out, they fear disciplinary sanctions."

In addition, Dr. Hankes says there is still considerable reluctance by medical professionals to report their colleagues. "Many think they are overreacting, and that the situations will get better with time or when circumstances change."

This reluctance or delay is labeled as potentially "deadly silence."

When the Washington program receives reports of a problem, Dr. Hankes says, "We’re not a reactionary, right-wing, knee-jerk operation. Our first step is to very discreetly gather some corroborating data–reasonable suspicion that we might be dealing with a potentially impairing condition. If we reach the threshold, we’ll do an intervention and then do a screening assessment. Then we’ll refer the physician out for an independent evaluation. If a diagnosis of chemical dependency or mental illness is established, then we require treatment."

After treatment is completed, clients enter into a five-year monitoring contract with PHP, which includes total abstinence from addictive chemicals, continuing treatment, behavioral monitor- ing, random toxicology testing, work site monitoring and attendance at mutual help meetings. The Washington program currently has 148 physicians "under contract."

"Confidentiality is the key," Dr. Hankes says. "Potential physician-patients know they can come to us and their identity will remain confidential provided that they jump through all the hoops," he says. "Our state law allows our program to provide a therapeutic alternative to discipline, provided there’s not been any patient harm or criminal activity. Because of that, they’ll come to us more readily."

There are three kinds of state programs, according to Dr. Hankes.

"First, there’s the kind that’s attached to a state medical association, like New Jersey or Illinois. Second is the kind that is attached to a state medical board like California or Iowa. The third kind is a separate entity–it’s at arm’s length from medical associations or medical boards. That’s the kind that works best."

Programs that are independent have the luxury of providing total confidentiality, Dr. Hankes says.

"In the state of California, about 300 physicians are under contract. In Washington state, we currently have 148 physicians under contract. That’s about half as many, but California has six times as many doctors. So you can see, reports just won’t go as readily to programs that are hooked up to medical boards, and physicians will not participate as willingly."

In 1993, Massachusetts’ Physician Health Services changed its status to a 501 (c)(3) corporation; it is now a separate subsidiary of Massachusetts Medical Society. Massachusetts PHS currently has behavioral health monitoring and chemical dependency monitoring contracts with 130 physicians.

"We can maintain confidentiality and peer-review protection so that contacts made to us are kept separate from any other organization," Dr. Sanchez says. "This is critically important in working with physicians–they need to have a sense that what they’re going to say is protected information."

The best physician health programs enjoy success rates in the 85 to 90 percent range, according to Dr. Hankes.

"That’s a very high percentage. Physicians with alcohol and drug dependency have the highest success rates of any chemically dependent sub-population. The physicians’ program is modeled after the commercial airline program, which used to have a higher success rate than ours."

Why are the recovery rates so high for physicians?

"There are three reasons," Dr. Hankes says. "Monitoring, monitoring and monitoring."

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