November 01, 2018 Letter to the Editor

Physician Health Program Outcome Data Should Be Viewed with Caution

By Nicholas D. Lawson and J. Wesley Boyd

In “Physician Health Programs: A Model for Treating Substance Use Disorders” from the winter 2018 issue of The Judges’ Journal, authors Robert L. DuPont and Lisa J. Merlo make a number of claims regarding physician health programs (PHPs) that we believe paint an overly rosy picture of their effectiveness and also fail to note a number of other problematic issues with these programs.

In support of their claims that PHPs offer physicians with substance use disorders (SUDs) “the best long-term outcomes for these chronic, commonly fatal disorders,” the authors cite a study reporting that “64 percent of physicians completed their five-year contract without incident, 17 percent extended their contracts beyond the initial monitoring period (either voluntarily or due to PHP requirements), and 19 percent failed to complete their contract.”

There are considerable reasons to doubt that these numbers reflect actual treatment efficacy. Many physicians who are forced to sign monitoring agreements with PHPs might not actually have an SUD or problematic performance in the first place. We have seen instances in which individuals without SUDs who have a single DUI or who have used marijuana a couple of times a month are diagnosed with SUDs and coerced into signing monitoring agreements with PHPs. If individuals such as these are included in success rates, such numbers are no doubt inflated. Additionally, many programs do not track individuals who drop out of monitoring or who commit suicide while being monitored, which also can lead to inflated success rates. And research on PHP efficacy has, to our knowledge, never compared outcomes of those referred to similarly situated physicians who are not referred for PHP treatment.

DuPont and Merlo also cite long-term follow-up surveys of PHP participants supposedly demonstrating very high satisfaction with PHP engagement and high rates of employment among graduates of PHPs. But their data are derived from surveys sent to only 42 percent of PHP graduates, those whose contact information was known to PHPs. Thus, well over half of PHP graduates were not included, which could include individuals who were dissatisfied and wanted to ensure the PHP no longer had their contact information or who have committed suicide. And even among those who were surveyed, respondents might have much to lose from responding to surveys in ways that criticize these programs, given PHPs’ close ties to boards of medicine.

Additionally, almost all of the literature about PHP effectiveness and outcomes has been written by individuals who have significant ties to PHPs, drug-testing companies, or the evaluation/treatment centers that PHPs often mandate these physicians utilize. As a result, whether consciously or otherwise, authors might design studies to inflate success rates. (And this says nothing about the significant mutual conflicts of interest between PHPs and evaluation/treatment centers.)

We have no doubt that some physicians with SUDs who engage with PHPs may derive benefit from these programs in certain circumstances. But there is considerable reason to doubt the efficacy rates touted in the DuPont and Merlo article. And we also have many other concerns about these programs and physician impairment policies in general that we have not addressed here1 that deserve attention from the legal community. 

Endnote

1. N.D. Lawson & J.W. Boyd, Do State Physician Health Programs Encourage Referrals That Violate the Americans with Disabilities Act?, 56 Int’l J.L. & Psychiatry 65 (2018).

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