Partnering With State Physician Health Programs

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The physician’s dilemma of balancing excellent care of others with adequate self-care is not a new one. In 1902, Sir William Osler, MDCM, opined that, “In no relationship is the physician more derelict than in his duty to himself.”¹

The following year, Osler, a professor of medicine at Johns Hopkins University who was known to see as many as 50 patients per day, clarified that the dereliction of duty to self was a threat to his own wellbeing: “In spite of the most careful regulation of my time and health, I was often utterly ‘used up’ at the end of the week and the question was how long could I hold out at the high pressure.”² When offered a less demanding academic position at Oxford that would allow him to downshift, his wife took charge: “Do not procrastinate, accept without delay. Better go in a steamer than a pine-box.”³ Taking her advice to heart, Osler accepted a teaching role and added another 24 years to his enduring legacy. 

The American Medical Association Sounds the Alarm

In the late 1960s, the American Medical Association’s Council on Mental Health started to reckon with the dilemma of physicians who were functioning poorly. Some were actively using psychoactive substances; others manifested psychiatric symptoms that jeopardized their ability to provide competent care to patients. In 1973, the Council published its landmark policy paper, “The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence,” in The Journal of the American Medical Association.⁴ This paper painted an alarming picture. It was noted that a “sampling of boards of medical examiners and other sources reveals a significant problem in this area.” It was acknowledged that, “Ideally, the affected physician himself should seek help when difficulties arise. Often, however, he is unable or unwilling to recognize that a problem exists.” 

The Council cited a number of small studies that consistently found high rates of alcoholism and drug problems in physicians, going so far as to mention “addiction as an occupational hazard.” A note of alarm was sounded in comments indicating that physicians with substance use disorders “come before disciplinary bodies with relatively high frequency,” and that other mental disorders occur “with perhaps greater frequency among physicians.” Sick physicians, specifically those suffering from conditions that are typically treated by psychiatrists and other mental health professionals, were depicted as nothing less than a triple threat—to the physicians themselves, to their patients, and to the medical profession. 

The Council’s level of concern was compounded by its observation that, “Experience in such situations is often disappointing as the physician-patient denies he is ill, lacks insight into his problem, avoids medical assistance, and minimizes his problem outright. Therefore, an element of coercion is often necessary.”

The Council’s 1973 “Sick Physician” paper proposed a solution to this worrisome state of affairs. They surveyed medical societies across the United States and its territories, finding that very few of them had an active committee or standardized approach to assisting doctors who were ill. The Council went on to recommend that each state or county medical society convene a committee with the specific task of determining “whether the physician is suffering from a disorder to a degree that interferes with his ability to practice medicine.” These peer committees should include, but not be limited to, “psychiatrists and neurologists.” In 1973, only 7 such committees were known to exist. In 2021, the number approaches 50. 

In the course of psychiatric careers, most psychiatrists will care for other physicians. However, interactions between treating psychiatrist and state physician health programs occur infrequently. As a psychiatrist who directed the Massachusetts physician health program (Physician Health Services, Inc) for 8 years, I discovered that most psychiatrists deeply appreciate gaining a more nuanced understanding of the physician health program (or PHP), and its delicate interactions with practicing physicians and the regulatory board that licenses them. Doing so can help you provide the best possible care to your physician patients.

State Physician Health Programs—Commonalities and Differences

Today we recognize medicine as an inherently stressful profession that may engender personal and professional burnout⁵ as well as moral injury.⁶ The visibility of physician suicides and the COVID-19 pandemic have brought additional attention to the health and well-being of physicians and other health professionals. Most physicians are now employed by large corporate entities, and some of the leading health systems in the United States now employ Chief Wellness Officers.⁷ The Accreditation Council for Graduate Medical Education now requires all accredited training programs to furnish accessible 24/7 mental health services to all residents.⁸

When compared to the stoic doctors of yesteryear, contemporary physicians appear somewhat less reluctant to acknowledge and address mental health and substance misuse challenges. Although concerns about stigma and licensure still deter some from getting help, it is abundantly clear to PHP professionals, as well as to licensing boards, that the impaired work performance caused by illness, not the treatment of illness per se, is the greater threat to the well-being and careers of physicians.

Although many PHPs make efforts to promote physician health and wellness, these small organizations spend most of their limited resources assessing, addressing, and monitoring physicians who have come to the attention of employers and regulatory bodies (like state medical boards and the Drug Enforcement Agency) as a result of immediate concerns that are suggestive of current or imminent impairment due to a mental health or substance use disorder. Sadly, the “sick physicians” described in 1973⁴ still exist. They are the ones who have failed to effectively address significant health conditions in a timely and proactive fashion.

Some practicing psychiatrists tend to view PHPs as harsh, punitive programs that are an extension of state medical boards. However, by gaining a more nuanced view of the modus operandi of your state’s PHP, you may discover ways in which a thoughtful partnership with the PHP can help your physician patient recover faster and more completely, while reducing the likelihood of recurrent symptoms that may have a deleterious impact on patient care, as well as on the career of the physician.

As a psychiatrist caring for a physician with significant mental health challenges, the following information may help you make more effective use of your state’s PHP.

5 Frequently Asked Questions About PHPs

Should I reveal my patient’s identity to the PHP? Never reveal the identity of a physician patient to the PHP without possessing a comprehensive understanding of the relationship of the PHP with the licensing board. Proceeding with caution is vitally important, because in some (but not all) states, the PHP may be hard-wired to the licensing board. Although this is not a best-practice arrangement, it is, in fact, sometimes a reality. The downside of a hard-wired connection between the PHP and licensing board is the unintended consequence that an informational query may turn into an inadvertent medical board report that has the potential to rupture your therapeutic alliance with your physician patient. To guard against this, carefully review the details of your PHP’s relationship with your state’s medical board. You can ascertain this by reviewing your PHP’s website (see www.FSPHP.org for links to each state PHP), speaking to knowledgeable individuals in your state medical society or state chapter of the APA, or calling the medical director of the PHP and posing hypothetical questions about client confidentiality and the PHP’s relationship to the licensing board.

Can PHPs be helpful to treating psychiatrists even when they are ‘hard-wired’ to the medical board? Yes! If it is possible that your physician patient is unable to practice medicine with reasonable skill and safety, then you, as the psychiatrist, are ethically bound to address the problem at hand so as to prevent patients from being harmed. Beyond the ethical obligation, the state where you are licensed may require you to report potentially impaired physicians to the medical board. Utilizing the services of your state’s PHP can help you navigate these trying and complex clinical issues in ways that may protect patients, enhance your efficacy as a psychiatrist, and improve your patient’s prognosis, both short-term and long-term. In such trying circumstances, calling the PHP before communicating to the medical board may benefit all parties.

How can a PHP help you improve your care of a physician patient? Informational conversations with a PHP may help you identify physician-savvy evaluative and therapeutic resources that will help you to deliver the best care to your physician patient. If a medical leave of absence is called for, the PHP may be able to facilitate this critical step by drawing on its rich experience. This can be reassuring to everyone: physician patients, their employers, and involved clinicians. Over and over again, PHPs have assisted seriously ill physicians in getting the help they need. This helps them to stabilize and regain the ability to practice medicine competently. In many situations, the PHP will recommend ongoing monitoring for recovering physicians returning to the practice of medicine.

How does involvement with the PHP improve a physician patient’s prognosis? In 2017, Thomas McLellan, PhD, an eminent addiction scientist as well as the cofounder and CEO of the Treatment Research Institute, delivered the Massachusetts Medical Society’s annual meeting educational program lecture on “The Winding Road of Addiction: Hope on the Horizon.” McLellan began his lecture by asserting that “we know how to effectively treat addiction in this country.” He explained that state physician health programs represent a best practice for the treatment of addiction, as they utilize highly structured accountability and monitoring structures to promote long-term abstinence and prevent relapse. Indeed, 75% to 80% of the physicians enrolled in these aftercare programs maintain continuous sobriety for 5 years or more.⁹ Fewer than 10% become symptomatic to the point of not being able to practice medicine. Even high-risk groups like anesthesiologists with a history of intravenous opioid use disorder are able to recover successfully, often returning to the high-risk practice of anesthesia, thanks to the meticulous orchestration of assessment, triage, and monitoring services by state physician health programs.^9,10

To what extent do PHPs provide assistance to distressed physicians who are not misusing psychoactive substances? This varies from state to state and from PHP to PHP. Most PHPs can provide assessment, referral, and monitoring assistance for doctors with major psychiatric conditions like bipolar disorder, major depression, and obsessive-compulsive disorder. In some states, PHPs are able to guide doctors (along with their psychiatrists and other involved mental health professionals) with challenges in some of the following domains: anger management, communication, burnout, teamwork, organization, professional boundaries, and adverse outcome stress. As outpatient psychiatrists are well-advised to steer clear of making fitness-for-duty determinations of their physician patients, your PHP can often help you navigate through some of the complex and problematic requests that emerge when you have been treating a physician with significant, potentially-impairing psychiatric conditions.

Concluding Thoughts

In summary, state PHPs are important resources that can be carefully and strategically utilized by psychiatrists who treat physicians with substance use challenges and/or other mental disorders. Before engaging the PHP to be of service to you and a specific physician patient, it is important to clarify the rules of engagement, including the PHP’s relationship with your state’s medical board. When you know how and when to make use of a state PHP, it can be an extremely valuable resource, one that may help you take better care of physicians. It is very satisfying when these efforts trickle down to patients who are being effectively cared for by a recovering physician. 

Dr Adelman, a coaching and consulting psychiatrist, is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched www.AdelMED.com after 8 years directing Physician Health Services, Inc. On the faculty of the University of Massachusetts Medical School, he is a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.

References

1. Bryan CS. Osler: Inspirations from a Great Physician. Oxford University Press; 1997:149.

2. Bryan CS. Caring carefully: Sir William Osler on the issue of competence vs compassion in medicine. Baylor University Medical Center Proceedings. 1999;12:277-284.

3. Silverman ME, Murray TJ, Bryan CS. The Quotable Osler. American College of Physicians; 2008.

4. American Medical Association’s Council on Mental Health. The sick physician: impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA. 1973;223(6):684-687.

5. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking action against clinician burnout: a systems approach to professional well-being. National Academies Press (US); 2019.

6. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.

7. Brower KJ, Brazeau CMLR, Kiely SC, et al. The evolving role of the chief wellness officer in the management of crises by health care systems: lessons from the COVID-19 pandemic. NEJM Catalyst Innovations in Care Delivery. 2021;2(5). 

8. Accreditation Council for Graduate Medical Education. Improving physician well-being, restoring meaning in medicine. Accessed August 5, 2021. https://www.acgme.org/what-we-do/initiatives/physician-well-being/

9. DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009;36(2):159-171.

10. Skipper GE, Campbell MD, Dupont RL. Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs. Anesth Analg. 2009;109(3):891-896.