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Physician health programs under fire

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3568 (Published 30 June 2016) Cite this as: BMJ 2016;353:i3568

Re: Physician health programs under fire

The vignette concerning Dr. Perlin represents exactly what Physician Health Programs should be and how the PHPs should function. He had a recognized problem, got appropriate treatment, and did well. Certainly, I believe all physicians would recognize this to be entirely in keeping with a PHP’s mission.

However, as I am mentioned by name in the article, I want to offer these comments highlighting performance activities at one or more PHPs that I do not consider to be appropriate and in fact are contrary to fundamental ethics of the medical profession. When I and several other psychiatrists happened to share our concerns about the lack of diagnostic substantiation in the physician patients we had in our practice and their marked variance with what a PHP clinician had diagnosed them with, I and my colleagues became quite alarmed. We met with the Governor’s Chief of Staff and after being referred to the state auditor, both our creditability and the gravity of our concerns led to a Performance Audit by the State Auditor.

I have now personally spoken at length with scores of physicians and have observed that there are physicians who have been ordered for evaluation at a PHP and who do not meet the required diagnostic criteria for any disorder, yet find themselves forced into signing a contract of five years duration with the PHP upon threat that if they don’t, the PHP will report them to the Medical Board as a substance abuser or mentally ill individual whereupon they will lose their license for non-compliance and suffer immense and irreparable humiliation.

In the initial case that raised my concerns, Dr. Anonymous (Dr. A) was accused of smelling of alcohol at work but was refused a blood alcohol or Breathalyzer test. Five different evaluating substance abuse physicians told him that he did not meet the required diagnostic criteria for alcohol abuse. I personally investigated this case by going to the hospital where this physician was employed and talking in detail with his fellow physicians, co-workers, treatment team, supervisor, and the Human Resources office. I found nothing to substantiate the allegations against Dr. A and further found that multiple components in the documentation of both his PHP assessment and his “PHP-preferred” program evaluation were severely flawed.

However, curiously, one substance abuse physician who had been on the Board of Directors of that PHP and who had evaluated and treated other physician patients for the PHP stated in writing to me that even though Dr. A did not meet the established DSM diagnostic criteria for alcohol abuse, the PHP clinician could still diagnose an evaluated physician as having alcohol abuse. However, that substance abuse physician could not or would not tell me how one makes a diagnosis when the patient meets none of the required diagnostic criteria for making a diagnosis. Dr. A was given a choice of signing a five-year contract with the PHP or being reported to his Medical Board as a substance abuser. Dr. A spent $94,000 in attorney’s fees, laboratory testing, and time before his attorney obtained his release by the PHP.

Dr. A requested in writing that the PHP Medical Director inform him in writing exactly on what basis he was being detained in the PHP when in fact he did not meet any of the required diagnostic criteria for the diagnosis of alcohol abuse which the PHP had listed as the diagnosis on the five-year contract that Dr. A had signed. The PHP Medical Director refused to respond to both his and his legal representative’s written request. This sort of behavior should never be allowed in the medical profession, and certainly not in the context of such a career-critical state-sanctioned forensic psychiatric “fitness for duty” evaluation.

Numerous letters were sent to the Executive Director of the Medical Board, the Medical Director of the Medical Board, the President of the Medical Board, the attorney for the Medical Board, the Chairman of the PHP Board and others asking how one makes a diagnosis of any disease when in fact the patient meets none of the required diagnostic criteria for that disease. To date, there has been no response from any of these parties to this question that I have posed for several years.

Yet another patient, Dr. B., was ordered to be evaluated at the PHP. Dr. B had reported to the police department in his hometown that he had concerns that individuals were following him and this complaint led to his being referred to the Medical Board and subsequently to the PHP. Dr. B was given a provisional diagnosis of delusional disorder, and Dr. B lost his license to practice medicine. However, a well-known and respected psychiatrist who actually investigated the anonymous complaint against Dr. B evaluated Dr. B and found no evidence of mental disorder. I have known Dr. B for over five years and I have never seen any evidence of mental disorder. A former FBI agent investigating Dr. B’s whistleblower complaint signed a written statement that stated in fact individuals were following the patient and that he (the former FBI agent) himself observed the surveillance. There goes the delusional disorder diagnosis! However, Dr. B is still without a license to practice medicine.

The cases of Dr. A and Dr. B cause me great distress. Unfortunately, I believe there are many such cases. I believe the gravity and scope of this should cause every physician immediate concern. I remain bewildered that the world of organized medicine, such as the American Medical Association (AMA) and the American Psychiatric Association (APA), after learning of such alleged abuse, allows such alleged behavior by PHPs and medical boards to continue without thoroughly investigating these alleged abuses and demanding immediate correction and reparation by all appropriate authorities. Having raised these issues myself individually and in concert with others to the APA, I remain perplexed how they do not see profound ethical violations in the conduct of these evaluations as well as contamination of the name of psychiatry itself with documented abuse of its evaluation and treatment expertise by a state agency (which PHPs seem to assert themselves to be).

To maintain credibility in the integrity of their organizations, I believe that it is incumbent upon both FSPHP and FSMB to initiate comprehensive investigations into these alleged abuses, cause immediate remediation and implement full transparent and medico-legally accountable annual audits of both PHPs and medical boards.

Jesse O. Cavenar, Jr., M.D.
Professor and Vice Chairman Emeritus
Department of Psychiatry
Duke University

Associate Chief of Staff (Ret)
Department of Veterans Affairs Medical Center
Durham, NC

Colonel, Medical Corps, U.S. Army (Ret)

Patient consent obtained.

Competing interests: No competing interests

05 July 2016
Jesse O. Cavenar Jr.
physician, psychiatrist, psychoanalyst
Emeritus Professor and Vice Chairman, Department of Psychiatry, Duke University
Chapel Hill, NC