President's Message: Doris Gundersen, MD, March 2015

Sunday, March 1, 2015

Twenty-Five Years: A Remarkable Journey!

As far back as 1958, formal efforts were made to address issues pertaining to physician illness and impairment. Historically, the Federation of State Medical Boards (FSMB) identified addiction among physicians as a disciplinary problem rather than a health problem, consistent with the belief that addiction was a moral failure, rather than the disease we know it is today. Ultimately, the FSMB called for the development of a model program to assist physicians through rehabilitation and protect the public by placing recovering physicians on probation to monitor their health. About 10 years later, the FSMB approved a resolution — another call to encourage the development of physician health programs (PHPs) nationwide.

The Sick Physician

In February 1973, the Journal of the American Medical Association published a landmark policy paper prepared by the AMA Council on Mental Health, “The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence.” The council emphasized the ethical responsibility for a physician to address a colleague’s inability to practice medicine adequately due to physical or mental disorders, including alcohol and drug addiction. The article identified factors to overcome, including poor identification of illness, lack of knowledge or competence to intervene on an ill colleague’s behalf, and lastly, the “Conspiracy of Silence” that was prevalent in the medical field. The AMA publicly acknowledged the existence of physician impairment, providing a catalyst to address it in a timely fashion. In the early 1970s treatment programs specifically designed to treat addicted physicians emerged. Many of the thought leaders in this field were recovered physicians with a passion to help colleagues similarly afflicted.

PHPs Launch

In 1974, model legislation was developed that offered a therapeutic alternative to discipline related to physician illness. The AMA held a physician health conference in April 1975 and another in 1977, officially addressing the health problems physicians may be vulnerable to. A flurry of articles published in the late 1970s served to educate and raise awareness about physician addiction. By 1980, less than a decade after the AMA’s policy paper, all but 3 of 54 U.S. medical societies (of all states and jurisdictions) had either authorized or implemented “impaired” physician programs.

FSPHP Established

In 1990, the FSPHP was born out of a need for individual state programs to work together in discussing and promoting best practices, and especially to influence national public policy. The first annual meeting, following the development of bylaws, was attended by approximately 20 state PHP representatives. The FSPHP was very fortunate to receive assistance from the AMA in the form of a central office, plus staff and support services.

Over the next decade, the FSPHP annual meeting grew in popularity, content, and sophistication. Each year, friends and colleagues convened and shared program developments, new ideas, and wish lists. While lacking in uniformity from state to state, the members of the FSPHP worked hard to create clinical guidelines and other policies, derived mostly from collective clinical experiences working with physicians, given the limited research on physician health.

The Joint Commission Standards on Physician Health

In 2001, the State PHP e-group formed, providing a platform for immediate consultation from the nation’s experts on physician health, an avenue for disseminating important contemporary clinical data, and a means to keep abreast of legislative and other changes impacting individual state PHPs. That same year, The Joint Commission (TJC) created a new Medical Staff Standard (2.6) requiring hospitals to separate disciplinary matters from those pertaining to a physician’s health status, an early effort to focus on assistance rather than punishment for ill or impaired physicians.

Another TJC standard, MS.11.01.01, pertaining to the health of licensed independent practitioners, came out in 2001. FSPHP had a voice with TJC on this standard. Before it was officially implemented, TJC agreed to permit PHPs to provide the “process” for meeting the standard. Rather than creating an in-house committee, hospitals were allowed to make direct referrals to PHPs if a physician developed or was suspected of having a health concern, thereby reducing the hospital’s burden and increasing confidentiality for the physician.

AMA Physician Health Policy

In 2004, the AMA House of Delegates adopted a physician health and wellness ethics policy, reinforcing “The Sick Physician” mandate: “To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness, construed broadly as preventing or treating acute or chronic diseases, including mental illness, disabilities, and occupational stress.” The policy stated that every physician should have a physician to avoid compromised objectivity. It appealed to physicians caring for colleagues to maintain strict confidentiality for their physician-patient and provide only the minimum amount of information as required by law or to preserve public safety be disclosed. This policy reinforced what the PHP community was striving to promote.

FSPHP and FSMB Collaboration

In 2005, the FSPHP celebrated its first joint session with the FSMB, paving the way for the development of a mutually respectful and interdependent relationship, as well as the realization that we have overlapping goals: physician health and public safety. The FSPHP was granted official “observer status” with the AMA, allowing FSPHP representation at the AMA’s House of Delegates meetings. While not able to cast votes, the FSPHP earned a new opportunity to offer opinions about proposed resolutions as well as improve our networking capacity. I believe this connection further strengthened our relationship with the AMA and allowed cross-pollination of ideas to support physicians in an ever changing health care world.

FSPHP International Membership

As our organization grew and matured, it was important to have the ability to articulate our mission and respond to media inquiries. That year, the Public Policy Committee was established and we also created a new category of International Membership, establishing an even larger pool of experts and information to inform our work and advocate strongly for physician health. One of the most important accomplishments this year was the development of FSPHP guidelines on the treatment and monitoring of physicians with substance abuse or mental health problems. Guidelines for addressing professional boundary problems followed shortly thereafter.

The Joint Commission and Disruptive Behavior

As more physicians abandoned private practices and became employees, hospitals began to grapple with “the disruptive physician.” In 2007, a proposal was made to have the TJC create a new standard regarding disruptive behavior, later softened to “behavior that undermines a culture of safety.” Even before this standard was established, PHPs were presented with a new opportunity to educate health care organizations about how and when to intervene. In working with physicians engaging in disruptive behavior, we have learned that many of them are very distressed, rather than “bad doctors,” and have the potential to rehabilitate behavior through treatment.

Challenges to PHPs

Sadly, in July 2007 the California Medical Board voted to end its 27-year-old diversion program, creating more than a chill up the FSPHP’s spine. While a bill introduced in 2008 to create legislation to establish a new PHP passed, the governor of California vetoed it. A similar bill introduced in 2009 had a similar fate. This did not deter PHP advocates in the least, though. Later that year, several organizations mobilized under the leadership of the California Medical Association and formed California Public Protection and Physician Health, Inc. (CPPPH), whose mission remains to develop a comprehensive physician health program for the state. For now, private monitoring organizations continue to provide some services in California, attempting to fill the needgap created by the loss of the diversion program.

Milestone Outcome Study Supports PHP Model

The Blueprint Project (McLellan, Skipper, Campbell and Dupont, 2008) elevated the status of PHPs by highlighting the excellent recovery rates achieved with our model of treatment and monitoring.

Confidentiality for PHPs Reaffirmed

In 2009 we also became more vigilant, as detractors, such as the Citizen Advocacy Center (CAC), wanted to dismantle physician confidentiality for those physicians affiliated with PHP. Several FSPHP members volunteered, at their own expense to attend CAC meetings in the summer and fall of 2009. We were successful in delivering several cogent points via a roving microphone concerning the importance of confidentiality in assisting ill physicians who may otherwise go underground, eventually become impaired, and pose a danger to patients. Over the years, the tone has thankfully softened with this organization.

FSPHP and AMA Collaboration Continues

When the AMA formed a new department, Physician Health and Healthcare Disparities, it afforded the FSPHP a new opportunity to enhance our communication and collaboration with the AMA. The FSPHP provided input to an updated resolution regarding the health of physicians. In June 2009, the resolution entitled “Model Physician Health Program Act” was put forward at the AMA Annual Meeting in Chicago. The promotion of physician health then became part of the AMA’s strategic plan.

Challenges to a PHP

Another hiccup on the FSPHP roadmap: In 2010 the Oregon PHP was eliminated by the successful passage of House Bill 2345, heightening our awareness of the vulnerability each state faced in having our nonprofit organizations usurped by for profit entities. There is movement in the state to create a new PHP.

Further AMA and ASAM Collaboration

In 2011, a taskforce of FSPHP members submitted a draft of revisions to the AMA’s Model Physician Health Program document. Our draft was accepted by the AMA and incorporated into a formal report, which was then accepted by the AMA’s Council on Science and Public Health. The same year, FSPHP worked together with both FSMB and the American Society of Addiction Medicine to help them update policies pertaining to PHPs.

Updated Mission Statement

In the fall of 2011, the FSPHP board of directors (BOD) developed a new mission statement and ordered priorities for our organization. Our mission is to support physician health programs in improving the health of medical professionals, thereby contributing to quality patient care. In terms of priorities, we vowed to continue in our efforts to form alliances with all organizations connected to the physician health movement, bravely embrace new technology to enhance our communication with members and overall messaging and continue on our quest to polish our guidelines, improve our accountability, and find ways to pursue research to build our evidence that PHPs save lives and protect the public.

A New PHP Launches in Georgia!

Another celebration was in November 2011, when the Georgia Professional Health Program, Inc., was awarded a 501(c)(3) status as a charitable organization and a successful request for proposal (RFP) with the state of Georgia followed.

Administrative Changes

The AMA gave us roots as well as wings. We knew we had established ourselves as an authority on physician health when the AMA gently nudged us in the direction of independence, a true watershed point in our history.

Beginning in 2012, we began the process of moving the administrative responsibilities of the FSPHP away from the AMA headquarters in Chicago to Waltham, Massachusetts. We are fortunate to have the administrative and executive support from the Massachusetts Medical Society (MMS) subsidiary, Physician Health Services (PHS), Inc. The FSPHP BOD voted to sign an administrative contract with MMS effective January 2013 as we continue in our evolution.

FSPHP Collaboration Surges with FSMB, AMA, ASAM & ABMS

The FSMB convened the “Special Committee on Reentry for the Ill Physician” in the fall of 2012. Again, FSPHP was invited to the table and provided input that ultimately led to a new FSMB document supportive of physician health and rehabilitation. Additionally, FSPHP contributed to the FSMB Policy on Physician Impairment and played a role in developing physician health policies with the AMA and ASAM alike. FSPHP earned a seat at another table in 2012 as we began discussions with and provided education to the American Board of Medical Specialties.

FSPHP Memership Opportunities Expand

While I sometimes evaluate federal prisoners in “lockdown,” I never anticipated experiencing the same. Our 2013 Annual Meeting took place in Cambridge, shortly after the Boston marathon bombings. We were literally on hotel “lockdown” while local law enforcement hunted down two terrorists only blocks away. We had one of our best conferences ever with robust attendance, attesting to an unwavering commitment to our mission. In 2013, the BOD voted to expand membership categories to include individuals and organizations aligned with our mission. We are now benefitting from the addition of new colleagues, with energy and fresh perspectives. In step with our 2011 retreat goals, a Website Taskforce was formed to jettison our organization into the 21st Century.

In June 2014 we said goodbye to our Executive Director Jonathon Dougherty and wished him well in his pursuit of his county medical association work. We will be forever grateful to Jonathan for guiding FSPHP through rapid stages of development. Several FSPHP board members stepped in to help with the transition and Brenda Williams from the Tennessee Medical Foundation has been generously offering her time assisting with meeting minutes. Michael Todd, FSPHP treasurer, began improving our accounting system and is making good progress in this area.

ABMS Collaboration Continues

Representatives from the FSPHP continued our dialogue with the ABMS about the hurdles PHP participants face when attempting to obtain board certification or recertification. We are participating in the development of an ABMS policy to address this problem and are optimistic that this joint venture will result in a more friendly process. Finally, we initiated contact with the FSMB about the Interstate Compact Licensure being developed and learned that as long as PHP participants were in good standing with their state medical boards, they would be eligible to apply for this licensure.

Current FSPHP News and Progress

In December 2014, Deb Anglin of the Iowa PHP entered into retirement. FSPHP is extremely grateful for her service on the BOD. We wish her a wonderful retirement.

On January 5, 2014, I provided a “Happy New Year” update of all FSPHP activities and will be brief here. We continue into our second year of administrative contracting with PHS. Jessica Vautour and Debbie Brennan, not to mention Linda Breshnahan (who in September 2014 the FSPHP BOD voted to serve as Interim Executive Director through December 2015), have been extraordinarily efficient, productive, and enthusiastic. Dr. Warren Pendergast has generously agreed to take over FSPHP’s “observer status” with the AMA, following Dr. Luis Sanchez who served effectively in this role for several years.

A particularly important new FSPHP undertaking is the Taskforce on the Promotion of Accountability, Consistency, and Excellence. This year, Maureen Dinnan and Charles Meredith, MD, are charged with leading an expert group of FSPHP volunteers in developing a procedure for measuring our progress and efficacy in updating and developing new FSPHP guidelines. Your Public Policy Committee is working diligently to provide us with effective tools to assist us with media inquiries. 123SignUp, a complete software solution for providing automated member management and event registration, is coming along. Stayed tuned for the official launch along with a new website later this year. All of the active FSPHP initiatives of 2014 remain active in 2015. I plan to keep you posted with all new developments, and to my FSPHP family, Happy 25th Anniversary! I will look forward to seeing you at the annual meeting in April 2015.

--Doris Gunderson, MD
President, Federation of State Physician Health Programs
Medical Director, Colorado Physician Health Program