What doctors need to know about physician health programs [PODCAST]

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“Change is overdue. Physicians who need help for mental health issues or substance use disorders need to get it in a manner that is free of financial and other conflicts of interest. They need to be able to go to academic centers and/or the best clinicians possible and get unbiased opinions and advice.

Boards of medicine need to stop giving PHPs carte blanche to dictate what physicians need if there is suspicion of a substance use disorder.

Every physician in the U.S.—and, in fact, every patient—ought to join in calling for fairness and transparency in PHP recommendations. Until there is a groundswell of opposition against standard practices, physicians will continue to get extorted, and they and their patients will continue to suffer.”

J. Wesley Boyd is a psychiatrist.

He shares his story and discusses his KevinMD article, “The extortion of physicians: If doctors don’t pay up they don’t work.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

On today’s show, we have J. Wesley Boyd. He is a psychiatrist. His KevinMD article is titled “The extortion of physicians: If doctors don’t pay up they don’t work.” Wes, welcome to the show.

J. Wesley Boyd: Thank you, Kevin. Delighted to be here.

Kevin Pho: We’ll get into the article in a little bit, but first off, share your story and journey to where you are.

J. Wesley Boyd: Well, I actually started off hoping to be a philosophy professor, so I majored in philosophy in college and then went to graduate school in philosophy. I had picked a bad-fitting philosophy program. I’d always wanted to be a psychiatrist, so I decided to start doing all the premed stuff I had not done in college, which was a lot. I ended up finishing a PhD in religion and culture along with my medical school training at UNC Chapel Hill.

I went to Cambridge Hospital, back in the day, for psychiatry training and stayed on faculty there and at Harvard for many years. For the last two years, I’ve been in Houston working at the VA hospital and on faculty at Baylor College of Medicine in both psychiatry and medical ethics.

Kevin Pho: So as a medical ethicist at the VA, tell us about some of the difficult cases that you have to handle on a daily basis.

J. Wesley Boyd: Yeah. My co-chair and I took over the ethics service about a year and a half ago, and the number of consults on an annual basis went from about 25 before we took over to about 140 a year now. We frequently see cases where there are veterans who are in intensive care, they are unable to make decisions for themselves, and there is nobody that we can find to act as a surrogate decision maker. In those situations, the ethics committee itself has to step in and make recommendations, and some of those can be literally life-and-death decisions. So it’s pretty weighty.

Kevin Pho: So give us an example. Take us into that decision-making room. With a typical case, how exactly would the ethics committee handle that? Just give us a peek inside that room.

J. Wesley Boyd: If a patient is incapacitated, you know, unconscious or has a serious dementing illness or something like that, and is unable to make decisions for themselves, the first thing we do is actually comb through the hospital record in order to see if, when that person did have capacity, they ever weighed in on what they would like in an end-of-life situation. In fact, in one case just last week, my co-chair in the ethics committee here at the VA combed through 40,000 different pages of documents looking for some indication about what a veteran, in this case a veteran, would have wanted, and we couldn’t find anything.

At that point, if you don’t have an indication of what the person would have wanted themselves, if they don’t have an advance directive or something like that, the next thing you look to see is if they have a legal guardian. If they don’t have a legal guardian, you then look to relatives, and there’s a hierarchy of relatives that you go to to try to find someone to make decisions on behalf of somebody. It’s slightly different here in the state of Texas than it is in the VA, but both in Texas and within the VA nationally, there’s a hierarchy of surrogate decision makers, starting with a spouse, for example, adult children, etc.

If you can’t find anyone who fits that bill who could serve as a surrogate, then we, as the ethics committee, generally act on the best interest standard: What’s in the best interest of the patient? Often that can be fairly straightforward, but many, many times it’s not. If you’re deciding between two situations where in neither case is it likely that the person is ever going to leave the hospital, then you start making end-of-life decisions, and those can be really quite difficult.

Kevin Pho: All right, so let’s talk now about your KevinMD article. It’s titled “The extortion of physicians: If doctors don’t pay up they don’t work.” Now, for those of you who get a chance to read your article, just walk my audience through it and share the story of why you decided to write it.

J. Wesley Boyd: Well, a number of years ago I was actually an associate director in the state physician health program in Massachusetts. While I was there, and then certainly afterwards, I started seeing things nationally, not even within Massachusetts, that were somewhat concerning to me.

Basically, most physicians don’t know anything about physician health programs, but in fact most states have them. Forty-seven out of 50 states have physician health programs. Physician health programs were created many years ago by doctors who themselves frequently had a substance use problem. They were designed to help doctors recover from substance use problems, so they really had humble origins. But over the last number of decades, physician health programs have grown into pretty powerful, in many cases corporate, entities.

Their purpose is to have a place to refer physicians where there are concerns about a substance use problem or a mental health disorder, where those physicians can get the help they need, be monitored, have their treatment overseen, and have random drug screens. In the years I’ve been practicing, I’ve certainly seen many physicians with very serious substance use problems who have benefited from physician health programs.

But what I’ve also seen, starting about a decade ago when I wrote my first peer-reviewed article about ethical and managerial concerns in physician health programs, are a number of instances where physicians were referred to physician health programs for essentially very minor, in my opinion minor, concerns.

So one example is a physician in a state where marijuana is legal who was using CBD tincture three times a month in the evenings after work to help with menstrual cramps. She was working part time at her hospital, and they said, “Oh, we really like your work. We’d like you to come work with us full time.” So she said, “OK.” Then they said, “Yeah, you’ll just have to do a physical, and with that you’ll have to do a drug test.”

She goes to do the drug test, and it turns up positive for THC. She talks to the hospital lawyer, and the hospital lawyer is like, “Just go to the physician health program. Let them clear you. Let’s just do it, right?” So she walks in naively to the physician health program, and they tell her that she needs to go for a four-day evaluation at a cost of $6,000 to $10,000 out of state. She’s like, “Wait, wait. I just was using CBD three times a month after hours. I’ve never had any complaints about my work or anything like that.”

She goes to the four-day evaluation. They do a hair sample at that point, and as you may know, hair samples can give a three-month window of drug use. She had stopped using anything the second that first drug test turned out positive, and her hair sample was negative. Nonetheless, they diagnosed her with severe marijuana dependence and told her that she needed to stay for a multi-month stay at a cost of $60,000.

When she balked and said, “I’m not going to do that,” the four-day evaluation program informed the physician health program in her state that she was noncompliant. The physician health program in her state notified the board of medicine that she was not compliant. The board of medicine then said, “We want you to sign this voluntary agreement not to practice, or else we’re going to come after you and really investigate you.”

That story, unfortunately, is all too typical of what I hear on a regular basis. I get random emails, at this point roughly one every 10 days, from physicians, sometimes in training, many times attending physicians, sometimes medical students, where they’ve been referred to a physician health program for what is definitely a minor offense. Then, the second they say no or raise any questions about what the physician health program is telling them, they end up getting reported to the board, and then their license is in jeopardy.

To really top things off, the problem with the state physician health programs now is that the national Federation of State Physician Health Programs actually has a list of preferred treatment centers. Those treatment centers are the same centers that sponsor state meetings of physician health programs, regional meetings of physician health programs, and national meetings of physician health programs. And those same preferred centers actually rely on referrals from physician health programs for their financial viability. So there are bidirectional conflicts of interest.

Anytime you go into one of these evaluation centers, they have a serious conflict of interest in recommending treatment, because in general you’re going to stay for treatment at the very same place you went to get the evaluation. So there’s a lot of money at stake.

The problem is, and this may be one of the take-home messages, that most physicians don’t know anything about these programs until they’ve been referred to them. So they don’t realize, in fact, that they ought to be very leery of these programs and cautious about them. And really, I think there ought to be a public outcry.

Kevin Pho: So a couple of questions arise. Let me ask the first one. It doesn’t sound like the approach of the physician health programs is very nuanced, right? This seems very heavy-handed, especially from the story that you told me. Is that lack of nuance because of that financial conflict of interest? Why can’t they adjust their treatment recommendations based on the severity of the offense?

J. Wesley Boyd: State physician health programs actually vary pretty widely around the country. There are a couple I’m aware of that employ psychiatrists as associate directors, as was the case in my state, and those programs often will do their own in-house evaluations and only refer folks out for the most complex evaluations that they can’t handle in-house. But many states don’t employ psychiatrists, and basically for anyone who walks through the door, unless it is just completely obvious that there is nothing whatsoever, they just send every single person out for these multiday evaluations, frequently out of state. Yeah, there’s a lot of nuance that’s lacking in that approach.

When I’ve approached some directors of state physician health programs and said, “What’s this about?” they say, “We have to use the preferred centers because they’re the ones that are approved by the national federation.” When I’ve said to them, “Why do you have to send somebody for an out-of-state evaluation at a place that may or may not actually be a solid evaluation and treatment center? Why can’t I send them to the best addiction psychiatrist in my city?” Right? I was in Boston for many years. I said, “Why can’t I send a physician to a psychiatrist at McLean Hospital or Mass General?” Those are two of the top-ranked psychiatry programs in the country. And I would uniformly hear, “No, because we need to use our preferred evaluation and treatment centers.”

Kevin Pho: So if a physician gets referred to a physician health program, a lot of them, like you said, just kind of jump into it as a next step without really thinking. What should they do instead?

J. Wesley Boyd: If I were referred to a physician health program, even if it was for anger in the workplace or something that had nothing to do with substance use, I would stop drinking alcohol instantly and not use any other intoxicating substance. The first thing that often happens when you walk into a physician health program, no matter what the referral is about, let’s suppose you have depression, or there’s untreated ADHD or something like that that’s affecting your ability to do your job, no matter what you’re referred for, a lot of times the second you walk in, they’re going to drug test you.

And they’re not just going to test frequently. They’re not just going to test for, say, ethanol, which is alcohol, which stays in your body, what, 4 to 12 hours, let’s say. They’re going to test for metabolites of ethanol, which can last four days, or there’s another test that can go out as far as 12 days. So you walk in the door, you’ve been referred for some issue, and they find alcohol, metabolites of ethanol, in your drug test. They’re going to say, “You drink.” You might reply by saying, “Well, drinking is perfectly legal, right?” And they’re going to say, “How much do you drink?” They’re going to ask questions like that. So the presumption is that any amount of anything in your system is enough to be incriminating. The first thing I would do is stop using any and all intoxicating substances, including alcohol.

The other thing is, I would not sign documents. Frequently they’ll put documents in front of you. If you sign a monitoring agreement with them, that is going to allow them to talk to the board of medicine if you balk at any other thing they’re going to say. So I would be very leery about signing documents at a first visit. And again, I would make sure that my urine was going to be completely and totally clean.

Kevin Pho: So it sounds like physicians need some guidance whenever they’re potentially referred to a physician health program, and you’re certainly giving a lot of advice here on the show. Should they hire some type of counselor, get some type of legal advice to help guide them through this process before they sign anything?

J. Wesley Boyd: Let me back up. When someone is referred to a physician health program, frequently at that moment of the initial referral, they don’t have a choice but to go forward with meeting with the physician health program. Here’s why: If a department chair or a clinic chief has some concern about you and they say, “Listen, we want you to go get checked out by the physician health program,” frequently, if you say, “I don’t want to do that,” they’re going to threaten your privileges. So from the moment you first get referred, often you don’t have a choice but to go forward.

Despite that, I would still, in most circumstances, not all, consult a lawyer before signing a monitoring agreement with the physician health program. Again, unfortunately, once you’ve been referred, frequently you don’t have a choice but to go forward with doing whatever the physician health program tells you, and that’s part of the problem, right?

So clinic chiefs, department chairs, and boards of medicine don’t know enough about standard PHP practices, about the evaluation centers they use. They don’t know enough to be skeptical about what PHPs tell them. PHPs are physician health programs. Most states’ boards of medicine defer any and all questions about substance use to their PHP, and what that means is, if they’re deferring any and all questions, the board of medicine is just going to do whatever the PHP tells it. So PHPs will say, and technically this is correct, “We don’t have control over licensure. That’s the board of medicine.” But in reality, if boards of medicine listen to PHPs and take their advice and word as gospel, then in fact the PHPs do have control over licensure, even though it’s indirect.

Kevin Pho: We’re talking to J. Wesley Boyd. He’s a psychiatrist. His KevinMD article is titled “The extortion of physicians: If doctors don’t pay up they don’t work.” So, Wes, what’s the path forward on a lot of the issues that you bring up with physician health programs? Do you see any potential for reform to address some of the issues that you raise?

J. Wesley Boyd: There have only been a couple of investigative-type pieces around standard PHP practices. The British Medical Journal had one a few years ago. A reporter in, I believe, St. Louis, P.J. Randhawa, a couple of years ago had a couple of investigative journalism stories on TV news. But so far, standard practices by PHPs have been vastly underreported. That’s why doctors don’t know anything about them until they get referred. Once you’ve been referred to a physician health program, you start seeing exactly what’s happening, like with this poor woman who was referred out of state at a cost of $6,000 because she was using CBD tincture in the evenings. I mean, that is all but criminal. That person, unfortunately, has not worked as a doctor in the last six years.

I’ve also seen people walk into PHPs and have a positive test for ethanol, again, with no indication of alcohol abuse, no DUIs, nothing like that. The PHP says, “How does alcohol make you feel?” And they say, “Oh, I feel relaxed, my dream.” “Oh my goodness, you do.”

So what do I think needs to happen going forward? There needs to be simply more awareness by all physicians about PHPs. Until there is a large base of understanding and awareness, there is not going to be any reform to PHP practices.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

J. Wesley Boyd: If you get referred to a physician health program, you should consider that your license is potentially under threat and your ability to practice medicine is potentially under threat, and you should proceed with caution. A lot of the people who end up contacting me, unfortunately, went into their PHP referrals somewhat naively. They may have signed documents right away, and then they’re already ensnared. So one take-home message, perhaps the biggest one, is if you’re referred to a PHP, go and proceed with caution.

And secondly, my take-home message is we simply need more awareness about standard practices, because I think that if everyone knew what was happening, there would in fact be a pretty large outcry, and there would be reform happening pretty quickly.

Kevin Pho: Wes, thank you so much for sharing your time and insight, and thanks again for being on the show.

J. Wesley Boyd: This is a real pleasure. Thank you so much, Kevin.

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