About three quarters of US physicians treated for substance use disorders in physician health programmes had favourable outcomes throughout five years. Such programmes seem to provide an appropriate combination of treatment, support, and sanctions to manage addiction among physicians effectively.
Physician health programmes share the dual role of helping addicted physicians attain sobriety and personal recovery as well as providing assurance to colleagues, hospitals, insurers, licensing boards, and the general public that these physicians can practise safe care. The processes used by these programmes include clinical assessment, referral for treatment, and support and monitoring after treatment, usually for five years. Many questions have been raised about the effectiveness of these programmes—one was stopped owing to allegations of poor monitoring.15 16
We carried out a longitudinal, retrospective cohort study of 904 physicians consecutively admitted to 16 state physician health programmes. Objective outcomes were derived exclusively from laboratory results of urine testing and audit of official records.
All the participants entered some period of professional, specialty treatment, typically 60-90 days in a residential setting, followed by continuing outpatient care. Formal treatment was followed by a return to work conditional on continued participation in 12 step support groups, formal meetings with the programme monitor, random alcohol and drug testing, and random visits by programme staff at the workplace. We know of no comparably intensive or protracted form of treatment and monitoring provided to any other group of addicted people in the United States.8 9 10 12
At five year follow-up 14% of the physicians had stopped practising medicine (voluntarily or forcibly) as a result of their identification by and participation in a physician health programme. It is difficult to determine whether this rate for termination of licences is evidence of close monitoring and tough sanctions or inadequate monitoring and lax standards. The urine test results in the 647 physicians who completed their contract with the programme and those whose contract was extended may provide the best evidence.
Over the average course of 56 months of random testing (about 94 urine tests of 20 panels each), combined with unannounced visits to the physicians’ workplace by a programme monitor, the records showed that 81% had no identified substance misuse at any time. Nineteen per cent, however, had at least one incident of substance misuse during the five years of monitoring. Ten of these incidents were in the context of patient care (on duty or on call) and one instance of patient harm was recorded (over-prescribing drugs). It might be expected that any detection of alcohol or other misuse of drugs would result in immediate suspension or revocation of a licence. This was the case only when there had been a period of non-compliance or if the circumstances of the relapse were dangerous. Instead, most of the programmes in this sample increased the intensity of clinical care as well as the frequency of drug testing and supervisory visits—typically with reports to the licensing board. The more serious sanctions included restrictions on, or suspensions of, the licence or prescription privileges. Evidence suggests that this may be a sensible approach as only 26% of the 126 physicians who tested positive retested positive.
Our study has several limitations. Firstly, the sample cannot be considered nationally representative of physician health programmes in the United States. Because of financial and time constraints we needed to audit primary, objective outcome measures rapidly and efficiently, and only 16 of the 42 programmes that volunteered had electronic clinical and laboratory records continuously available from 2001 to 2007; we selected all of these programmes. That these 16 programmes started to keep electronic records seven years ago suggests that they may have been among the best funded or best led programmes at that time. Data from the phase one survey indicated that the programmes included larger samples (mean census 76 v 68), with correspondingly larger budgets; but, importantly, the duration of the programmes, their clinical, administrative, and sanctioning approaches, and the procedural elements of care did not differ.
A second limitation is that we recorded only objective, verifiable information from records, such as drug testing, sanctions, and modifications to licences. We are confident of the validity of these records, and our results are consistent with most other published studies of physicians with substance use disorders.4 5 6 7
However, the official records provide only a limited picture of the broader functional status and personal health of these physicians. A prospective study is needed to enrich these data, with additional information on clinical and administrative processes and a broader range of measures for functional status.
Finally, the focus on official records made it impossible to track 102 physicians who moved out of their programmes’ jurisdiction during the course of care. Although most of these physicians (n=78) were in good standing at the time of transfer, longer term results cannot be inferred. It is a concern that 24 of these physicians moved away without contacting their programme and with no formal referral for continued monitoring. This suggests an effort to avoid detection and is thus a potential danger to patients.
From a clinical perspective we interpret these results as evidence that the combination of identification, intervention, formal treatment, professional support, and monitoring by physician health programmes is effective in rehabilitating most of these addicted physicians, over at least five years. From a public safety perspective we believe these data indicate that most physicians who could not or would not stop their misuse of substances were detected early during the course of formal treatment and this usually resulted in voluntary or involuntary cessation of practice. From a policy perspective we conclude that affected physicians are well advised to enter the supervision of a physician health programme voluntarily, and that regulatory boards are well advised to continue supporting these programmes.
It is not possible from the evidence here to prove whether this form of support and monitoring for physicians with substance use disorders is appropriate, too harsh, or too permissive. Any episode of substance use in the context of patient care has the potential for considerable harm. Thus it will always feel more powerful to invoke sanctions alone in a “get tough” policy. But sanctions without the prospect of help in achieving recovery could simply reduce colleagues’ willingness to refer affected physicians—or licensing boards to exercise harsh sanctions—potentially increasing the true prevalence of the problem. On the basis of these data, and considering available alternatives, physician health programmes seem to provide the best available measures for protecting patients and for recovering physicians’ careers.
What is already known on this topic
- 10-12% of physicians in the United States become addicted to alcohol and other drugs
- Addicted physicians receive treatment through physician health programmes, operating under jurisdiction of state licensing boards
What this study adds
- Most US physicians with substance use disorders managed in physician health programmes had favourable outcomes at five years
- During monitoring 81% had negative urine test results
- Most (95%) who completed monitoring were licensed and working as physicians at five years