Hi, everybody. I'm Amy Harrington. I'm the Vice Chair for Ambulatory Psychiatry at UMass. And in a previous life, I was an Associate Director for the Massachusetts Physician Health Program. I left but stayed on the Clinical Advisory Committee and kind of have participated a few times in the Federation of State Physician Health Programs annual meeting and done a couple of workshops. And the last time I had been at that meeting is, I want to say it was 2019. And definitely when I was at that meeting, it was like, you know, here's a lecture on like five different drug tests to catch doctors that are doing drugs that they shouldn't be doing. And it was very focused on sort of identifying physicians that may be putting patient safety at risk. And then I went this past spring, and it was almost like some huge societal transition had happened. And the whole tone of the conference was so much different. It was much more looking at physicians as people who experience burnout and challenges. It was much more sort of focused on how these are people that have dedicated their lives, financial costs, you know, like sacrificing things in our lives to get the training to be doctors. We don't have an endless supply of doctors. We really need to make sure that we're helping people and helping them through difficult times. And it was a very positive sort of vibe. And so Rebecca Payne, who many of you may know, you're the vice president of AAAP and medical director for the South Carolina PHP. And then Mark and Paul, we said, let's put something together for AAAP and try to keep this enthusiasm moving forward. Unfortunately, Paul and Mark were both unable to be here. But we're going to keep going, and we're going to talk a bit about this is sort of like a physician health programs 101 with a little bit of how the emphasis on physician burnout and wellness has trickled into the physician health sphere. So none of us have any financial disclosures. And so as I said, today we wanted to talk about sort of how burnout has been a huge topic in health care professionals, both before and then after the COVID-19 pandemic. We want to talk a little bit about physician health programs, the history of it, and how they're structured today. We want to talk a little bit about how physicians as a group are unique as a patient population. And thinking about if a physician walked into your office as an addiction psychiatrist, what might you be thinking about in terms of how you would evaluate them and how you would determine the treatment? And also thinking about some of the regulatory issues that are specific to treating a physician with a substance use or mental health condition. So as we're going through this workshop, we're going to be coming back to this case. So I just want to take a minute to introduce this case to you. So this is Mary Smith. She's a 43-year-old widowed female with three young children. She is coming into you with a chief complaint of depressed mood. She's been depressed since her husband passed away from cancer about 18 months ago. In terms of her psychiatric and substance use history, she has a history of obsessive compulsive personality traits, has done a brief course of cognitive behavioral therapy in 2013, but otherwise no other treatment, no medications, has a history of migraines, fibromyalgia, and a motor vehicle accident in 2021 where she was prescribed opioid pain management for some orthopedic problems. The medications were continued by her primary care up until about three months ago when the medications were stopped, has a family history of alcohol use disorder and a paternal grandfather. And in terms of her social history, she is working as a locum tenens anesthesiologist. So this is a case that we pulled together that's sort of an amalgam of many cases but is not representative of one specific case and we're not describing any one specific doctor in this. So, you know, just sort of thinking about where we are, you know, it's been sort of a perfect storm. So there was already a mental health crisis and a mental health access crisis that was going on in the United States before COVID-19 started. And I sort of love when, you know, when I'm meeting with my CEO, for example, I refer to it as like the mental health epidemic that followed the respiratory epidemic of COVID-19. I truly try to hit home that this is an epidemic. Then, you know, COVID-19 came in and it made everything worse. And it was very much a collective traumatizing experience, especially for physicians. And then you sort of look at what's going on in our country right now. We're dealing with social, political, and economic unrest that we haven't seen in over 100 years. It's a very challenging time, challenging patients, challenging for everybody. And so we know that with the COVID-19 pandemic, the demands that were put on healthcare providers exacerbated an already preexisting burnout issue. In 2022, the U.S. Surgeon General put out this advisory on building a thriving health workforce, highlighting the burnout issues. And in some ways, it was a precursor to the next slide I'm going to talk about, but it was really focused on healthcare professionals. And I think what I sort of took away from this is this concept that we have to shift thinking about burnout from being a me problem to a we problem. So I think with physician burnout, many people, the intervention is, oh, you're burnt out. You know, here's a list of resources. Go out and get that taken care of and then come back, as opposed to what I'd like to think that my organization is doing, which is thinking about how do we make our institution less burnoutogenic in the first place? Like, how do we as an institution make it so that we're eliminating administrative burden or creating an environment where we aren't supporting physicians throwing things across the OR, or that kind of behavior is just unacceptable. And really, I think we were sort of reflecting on this yesterday at the BU. We all went out to dinner and we were saying, like, how lovely it is to just be connected and be around other people and how much we lost that. And, you know, we know that during COVID, healthcare workers experienced high rates of stress, anxiety, frustration, exhaustion, and isolation. Like, I was even struck by, I had a family member who wanted to limit contact with me because I was a healthcare provider. And I'm like, I'm a psychiatrist. I literally am in a locked room with my door closed and I'm on Zoom, but just the fact that I was a healthcare provider, that person was like, well, I want to be safe. So, but, you know, it kind of exacerbated those feelings of isolation. And then, you know, going from like being highly valued to then feeling undervalued. Sleep loss. We know that there was increased rates of substance use that was going on during the pandemic and suicidal ideation. And then in 2023, the Surgeon General came out with the advisory about loneliness and isolation and just the effects that the isolation can have on health. And this was a quote, over four decades of research has produced robust evidence that lacking social connection, and in particular, scoring high on measures of social isolation is associated with significantly increased risk for early death from all causes. And that lacking social connection is worse than smoking 15 cigarettes a day or drinking six alcoholic drinks a day. It can be that devastating to, you know, to your health. And I was thinking, you know, I actually in like May of 2020 got shingles. And I remember going to my urgent care and the urgent care doc being like, you're like the fourth woman, like, you know, under the age of 50 with young kids, you know, who's like, just the stress has made them immunocompromised. And, you know, the impact of the pandemic on our overall health is pretty profound. And so, you know, sort of taking that as context, now we wanna jump into talking about the impact on physicians. And so I'm going to back up and I wanna get into the case. Sure, and so as you as the addiction psychiatrist, here, I got some pens here. I know, I'm all over it. What are some things about this case that you either wanna know more about or that are jumping out at you as like things that you're noticing? Questions that you have? Yeah. Is she getting pain killers somewhere else? I think that's a good question. And so, yeah, you know, as we are talking with her, I mentioned that her husband had passed away from cancer and had been prescribed opioid pain medications. And when her doctor stopped prescribing the pain medications, she did begin taking the pills that were left over in the house and has purchased some from some friends of hers. And yeah, is now that you mentioned it a little bit concerned about that? It was about 18 months ago. Yeah, I sort of think that maybe he would have stopped even sooner knowing that, but was a bit, you know, here's this poor woman whose husband just passed. She's got three young kids. She's got so much going on. The last thing I want to do is make her life worse by taking away this medication that's helping her chronic pain. Eventually, yes, yeah. And now she's having some signs of tolerance and withdrawal and is struggling a bit and is trying to seek that out. Yeah, yeah. In this, you know, we wanted to highlight that she's, you know, has some family support, but is in locum tenens and so is going from place to place. And so, you know, maybe she's, you know, first of all, hasn't built up that social network that you might get if you were in one location. Also, maybe isn't in any one place long enough for people to start picking up on the fact that, you know, she's making mistakes or coming in late, or, you know, I don't think we've necessarily had a pill count go awry in this case, but certainly something that is a bit concerning. It was a taper, but it was a you've been on this long enough and she had been sort of asking to continue it over and over and finally the PCP said maybe the PCP has some oversight where their charts get audited and if they have people on for too long they have to justify why they're on so long. But it was tapered in a safe way, but the patient still is actively seeking it out. So, yeah. Yeah, so in this she's denying other substance use, but yeah, Lily. Yeah, you know that's I mean and I think everybody here kind of knows that you know anesthesiologists are particularly at risk, very high risk, yes. And in terms of like you know I remember like when I was in med school and I was doing my anesthesia rotation and the anesthesiologist gave the fentanyl and there was still like a little bit left in the bottle. He made a joke like hey you can take that if you want. It was a joke like I mean you know. But it was like it would have been very easy like that was not part of the count that was just like residual stuff that was in the thing. So, yeah. Yeah. I think there's a lot about this that would worry me about her ability to sustain this long-term, and yet now here she is with three young kids, and she's the sole breadwinner. I think it's incredibly important that she be able to stay in her job and need supports that are going to help her to be successful and stay in her career. Yeah. Yeah. Well, you know, I think she's got a daycare, but yeah, it could be a problem if she had to go somewhere overnight. Well, let's say she lives in, like, Massachusetts where she can pop out to Springfield and do a locum's position there, no problems. Massachusetts is fairly small, like all the populations in Boston, but, you know, you can get out to Springfield pretty easily, so. So any other things that are jumping out or questions that you have? I think, you know, sort of over the course of our evaluation, we are pretty certain that she's developing a problematic relationship with opioids, and we're concerned about that there might be an opioid use disorder, and it's on our differential. Yeah, I mean some people might look at it as like she is feeling so bad that she took the potential risk to her career of seeking treatment for a mental health disorder, which in many states now she would have to disclose as having sought treatment for mental health problems. Why, I'm in this as an addiction. Like she walks into your office. Yeah, yeah, we're not at PHP quite yet, yeah. Maybe we won't get there, I don't know. We'll take the advice of the crowd. The chief complaint was depression. That is why she is seeking treatment with you, but I'd like to think maybe she Googled and saw you were board certified in addictions because maybe she was a little bit worried about that. So, yeah. Yeah. Yeah. I mean, I have to imagine as an anesthesiologist, she has a pretty strong belief in the ability of medications to do very powerful things, so, yeah. Do you meet criteria for depression or not? Yes. So, in this, she does meet criteria for a major depressive disorder. Yeah. So, do you do that on a daily basis, or do you do it on a weekly basis? Well, it's... I guess we haven't really... We didn't really decide if it was ruled out or not. But she does meet criteria for a major depressive episode right now, and certainly on digging, we believe she meets criteria for a substance use disorder. Yeah. In the course of the CDC, how much... What was the criteria about how much she preferred... Yeah. So, she was in medical school at the time and was having some difficulty with acclimating and went to her student counseling service and, you know, got referred to CBT and said, well, okay, well, it's, you know, this isn't mental health treatment. This is just, you know, learning some skills to cope with the stresses of medical school, and that's how she kind of rationalized it. Is that where she picked up the history of depression and what was that like? Yeah, you know, a lot of doctors are pretty perfectionistic. You know, we got high standards, and if we fall below them, we can feel pretty bad about ourselves and not tolerate that. So, yeah. Yeah, in the back. Yeah, this is one of those cases where I would say duloxetine's a great — it's for pain. Like, oh, it might also help your depression, but that might be one of those ones that she might be willing to try. But in this case, no other psych meds. But, yeah, there are certainly untapped non-opioid strategies for pain management that she hasn't explored yet. So. All right. So what did you feel earlier? Well, I think that is something we're going to need to explore in therapy. I don't think she was expecting to have to be working to support three kids. That her husband was also a physician and was making more money than her, which allowed her some flexibility, and now she's in this position where she now has full responsibility and wasn't expecting that. So what about working conditions? Working conditions. Like, in terms of hours. Working conditions, did she get gratified by her work? Did she get gratified by her work? Did she play sports with her partner? Was there anything like that? Yeah. We didn't really come up with that, but that is a good question for us to explore. What was your introduction about, you know, service risk? Yeah. Does she like her job? Yeah. All right. We'll do one more, and then we'll move on. So, yeah. I read a sentence, too, about why now? And did she have any stated goals in therapy? Yeah. She wasn't trying anything particular. Yeah. Yeah. It seems like a major stressor, a major trigger for seeking treatment was the opioid being stopped and sort of the withdrawal and the dysthymia that she's having. And so now she's seeking treatment and sort of felt like that was the main catalyst. All right. I will turn things over to Rebecca. All right. And actually, Amy, can I take the advancer? Thank you so much. Can you hear me okay with this? Okay, good. And usually I can just project and make it happen. But so as I was writing this, first of all, I was a little scared. Oh, yes. Thank you. I was a little scared it was going to bleed through, and I didn't want to damage the hotel. And then I also realized that my chicken scratch is probably not something you can see from where you're sitting. So that's a good thing for me. Hi, everyone. My name is Rebecca Payne. I am currently the medical director at the South Carolina Recovering Professional Program. And I do think as we're talking about PHPs and the intersection of addiction psychiatry, kind of thinking about how one might enter into this field. And I'll tell you a little bit about my story. So, you know, I graduated from addiction psychiatry fellowship. I went to the VA for a couple years on the inpatient unit and then went over to an academic institution. And while I was there, you know, in the mornings, I would round on the detox units. And then in the afternoons, hustle across town to a partial hospitalization program, an intensive outpatient program. And all along we had learners, right? Students, residents, all that. And as sitting in my office in that capacity from time to time, a healthcare provider would walk in. And I'd go, hmm, what do I do with this person? Oh, you're a nurse? Hmm. Okay. All right. And it really sort of would catch me aback, if you will, because I'd go, well, what do I do with this person? I knew what my reporting requirements were for my state. And then that was where it ended, right? That was it. And then, lo and behold, you get voluntold to get involved in certain things. And, you know, I thought Dr. Petrakos' talk this morning was very, I loved it because it sort of, I think, demonstrates most people's paths as people ask you, hey, you want to do this? And you go, sure. And then you find yourself in that area. So similarly, I got voluntold to begin to evaluate some of our healthcare employees in our academic institution when some sort of issue happened. In our division, we had a wellness department. And if there was ever a sniff of a substance disorder, it was, well, call Dr. Pang. Okay. And so I became involved in those, and I started doing those more and more and began to collaborate with my forensic colleagues there. And it really gave me an appreciation for some of the nuances in managing and helping healthcare professionals, in evaluating healthcare professionals, I should say. I ended up doing a forensic fellowship and then landed here, so it's sort of my way of bringing all of these things together. But what I hope to convey to you today as we're talking about this is that physician health, addiction psychiatrists are very well-suited to help healthcare professionals and have significant roles in PHPs. So what is a PHP? You can read the definition there. And I'm going to actually unpack each of those in the — each of the — some of the information in the slides as we move forward, but the confidential resources for professionals that have an impairing condition or a potentially impairing condition. In this concept — and we actually just had an interest group and we were starting to talk about some of the history and the impetus, if you will, behind physician health programs and that it really has its basis to some degree in 12-step work, but people began to recognize the need for physician health programs in a documented way in the 1970s. And the AMA was really the institution that said, hey, let's take a look at this. We have these doctors that are trained. Some type of issue comes up and what's — what is our — what's happening to these folks? And what was happening is the boards didn't know what to do, right? So the — one of a frequent response to that, to the concern, was shut their license down and then we'll figure it out, right? So really the idea of a physician health program or a PHP is as an alternate pathway. So let's find out what's actually going on and see if this is something that we can treat or remediate in some way and keep that person working, keep their profession. So they've been around for about 40 years. They are fairly structured and there is typically, you know, a fast response in the event that some type of recurrence of illness or drug use is detected. And there's been a lot of developments over time. This is somewhat of an intimidating conversation for me to have as I have Dr. Gendell sitting in the audience who could give this presentation five times over. But there's been a lot — there have been developments over time. You know, anytime you do something for decades, you're going to learn from that, right? The more experience that you have. I joke with my staff sometimes because, you know, you get — you get to the point where you kind of feel like you're in a rhythm, you have a handle on what's happening, and then this one particular case comes in and you look at each other and you go, ha, what are we going to do with that? So it's very — it's a very individualized approach and we learn from those individuals every day, I could say. Also, too, the scope of PHPs has changed over time. You know, when these were conceptualized, it was addressing substance use. I think it's — you know, scopes have expanded to include mental health conditions as well and other — some other conditions. And then there's conflicts. I put the word conflicts up there. There's some controversy surrounding physician help programs. Sometimes when I give this talk, I actually have a slide that just sort of directly addresses some of the controversies that exist surrounding PHPs. And you can do a quick Google search and find them all, right? So a concern about, you know, the level of care that might be recommended, a concern about conflict with evaluator or treatment facilities and, you know, monetary involvement and relationships. And also, too, you know, Amy talked about how COVID-19 has really sort of changed — I would say it helped us to recognize that our healthcare providers were suffering. We already knew — the story is healthcare professionals were not well. Then COVID happened and they became even more unwell, right? Increase in substance use, increase in mental health disorders. And so we're learning, even after the COVID-19 pandemic, how do we help our healthcare workers? Interestingly enough, as — obviously as mental health problems and substance use increase in response to, you know, either the direct or indirect effects of COVID, you would anticipate that referrals to PHPs would, what, go up or down? Up. That would be the expected response. Well, and we have some other folks here in the audience that do this work as well. You know, nationwide, the trend is actually referrals are down. And you kind of scratch your head and you go, what's that about? Referrals are down. And I think across the board, people would agree that complexity is up. We could talk — you know, I think people have some ideas about why that took place. I would like to think on the optimistic, glass-half-full side of things, that COVID, at least in some silver-lining way, created a dialogue about seeking mental health treatment, whether that's in the general population or among healthcare providers. So maybe perhaps why these referrals are down is that it became more okay, less stigmatized, for a healthcare provider to go and get treatment or help before the development of an impairment. And I'm going to talk about illness and impairment in just a moment, but maybe that's part of the reason. You know, probably, chances are, it's multifactorial. I think there's probably other reasons that aren't so positive, right? I can tell you, I came into this position in July of 2020, so I'd never had the experience of working in this group prior to COVID, but interestingly enough, when someone would be asked to refrain from work for some type of issue, we would get calls, angry calls, from human resource departments, when is this person coming back to work, okay? Why? When is this going to happen? What do you mean? And they were desperate because what was happening during COVID? People were leaving healthcare, right? You saw these reports every month, 3.1%, this percent. People were just leaving, and droves, and facilities were desperate to fill those, keep those slots filled. So my guess is why are referrals down? It probably is very multifactorial, and I do know that there are some individuals that are looking into that in a more sort of systematized way, doing some research specifically in the nursing population about reasons for that, but that is something that we have seen. So I touched base on, oh, sorry, we'll talk about illness and impairment in a moment. Just some, I think of these as foundational building blocks for what PHPs are and what they do, and there's several building blocks, but these are some of the most important. So we're dealing with a population that is safety sensitive, right? This seems very obvious, but I do think that it plays into how we evaluate and how we move forward with treatment with our healthcare providers. So safety sensitive simply means that you are responsible for the safety of yourself and other people, right? And you can consider a couple of different factors when you think about the degree of safety sensitivity of somebody's profession. So how many people they impact or could potentially impact, depth of damage to one particular individual, and then also how much trust does the public put into that profession. So you see a couple, well, or you don't. It's a pretty small picture. So you see a couple of professions here. Some are very clear, you know, pilots. If they're flying 300 people, that's fairly safety sensitive position, right? And they are also a highly regulated group. A nuclear engineer, I think somebody mentioned, Dr. Westreich mentioned nuclear engineers earlier this morning. You know, they also have the potential for reaching numerous people. And even within healthcare, there's degrees of safety sensitivity. So our Dr. Smith is an anesthesiologist. That is, you know, one of the more safety-sensitive positions that we have within healthcare. I'll use myself as an example. You know, as a psychiatrist prescribing some medications, that's a different degree of safety sensitivity than a neurosurgeon creating a burr hole or drilling a burr hole in my cranium to relieve pressure or what have you. So, and we can make that same sort of, you know, extrapolation to the nursing professionals, et cetera. So, another building block foundation for PHP. So, we're dealing with individuals that have a safety-sensitive profession, and these are also individuals that have an impairment, not simply an illness, okay? There's a couple of definitions. So, illness is, we know, the presence of a disease, and then the impairment is really as that illness has progressed, it has impacted your ability to do something, and we're talking about our profession here. So, usually, too, if you think about how impairment develops, again, it's your illness progresses over time. There's an old statistic that I didn't put up here because I think it's from the 1990s, but it looked at the onset of problems from substances that physicians experience in the lapse of time until treatment, and the average for that was somewhere between six to seven years, and that's just the average. So, obviously, some were shorter, and then some were certainly longer, and it's interesting, and some of the, you know, some of the folks that have experience working with healthcare professionals might have some antidotes on this as well, but physicians in particular really seem to, I use the word bubble wrap. I don't know if that's an appropriate term, but they really seem to protect or bubble wrap their profession, if you will. So, life might be falling apart for their family, their finances, et cetera, but they'll draw very clear lines, and then as you, you know, they'll tell you about how those lines got to be blurred. You know, for instance, since we're dealing with an anesthesiologist, you know, they may tell you, well, early in my, you know, drinking or whatever the problem might be, I never drank on call, not once. If I was on call, I didn't drink, and then you might hear them say something to the effect of, okay, well, and then a couple years later, I started having that first drink an hour after I'm about to go off call, and then I started drinking the night before I went on to call, and so you hear that progression, that loss of control, you know, those efforts to control and inability to do so creep in. So, building blocks are we're dealing with individuals that have an impairing condition, and they are safety sensitive. The AMA defines impairment. You can read it there. You'll hear that phrase reasonable skill and safety quite often, and I love this list because it pretty much just throws everything, you know, at the wall and it sticks. So, any type of illness can become impairing, and they actually estimate that a third of physicians, so one out of every three, if we go one, two, three, one, two, three, will have some type of impairment over the course of their career. They didn't get more specific than that. They didn't say from what, but I think that's a pretty staggering statistic or estimate, rather. Okay, so there's lots of etiologies of impairment. I appreciate coming to a group like this. I don't have to convince you that comorbidities are the rule rather than the exception, right? So, this is an easy concept for this group. Sorry, the green and the green are the same color, so. But, yeah, so, I mean, you can see here, really, any sort of etiology, and often, it's multifactorial, right? That's absolute, that seems to be the most common presentation is multiple. And then we can certainly get into chicken or egg questions. I think somebody posed the depression or the opiates first, right? And I think it's different for different people, but, so, oftentimes, very multifactorial and very complicated. All right, so, and Amy alluded to this, you know, healthcare professionals come to the table as a unique group in some way, right? They have some factors that make them a unique population. Much as we would talk about adolescents, much as we would talk about the LGBTQ population, there are certain factors that contribute or make their development of illness and impairment perhaps a little bit different from someone else. So, you can see here, the development of mental health and substance use, pre-existing personality constructs. We talked about this a little bit already, right? So, Mary has some, or Dr. Smith, sorry, Dr. Smith, has a history of obsessive-compulsive personality traits, right? I'm gonna pick on myself. I'm gonna pick on myself. I have always considered myself somewhat of a structured, organized person. Some might say I'm rigid, right? So, there's some personality characteristics that we bring to the table and we're self-selecting into healthcare profession, right? That is also a factor, but we self-select into this, and some of those traits are very helpful. You know, it kept me organized. I could create a study schedule and actually stick to it, and then some of them are not so helpful, right? So, when I get behind an hour in clinic and I'm, you know, stressing out the entire day because I'm an hour behind and my rigidity gets in the way, that's, you know, the line has been crossed. It's now not helpful, okay? Disruption in training and work. So, you think about these, I call them adult developmental milestones, right? Becoming financially independent, and I don't mean, like, you know, excessively wealthy. I just mean independent. Financially, partnering with a significant other, whether you choose to parent, those issues are impacted by the fact that people have self-selected into healthcare, right? Things are delayed often, maybe not always, and then even after graduation and out of the training environment, the demands are still there, the long hours, the strange hours, what have you. Also, too, healthcare professionals, I have internal and external pressure here. More than anything that I see, and I'm sure people could kind of comment on this, is the pressure that healthcare professionals and physicians put on themselves is excessive. It's not from outside. It seems to be primarily internally driven. Access to medication and prescribing is also a unique factor for this group. Prescribing capabilities, whether that's to oneself or for family members or individuals with, you know, with whom you do not have a doctor-patient relationship, those factors are there. There's familiarity with medications. A lot of time people have this idea, you know, hey, I prescribe this to my patients all the time. This may be appropriate for myself. That familiarity can also sort of translate to others. I'll give you one example. There was a surgical subspecialist that came into our program, and this individual was in a group of four, and essentially what had been happening over years is that the individual had approached some of his partners and said, hey, I have ADHD. I took this quiz online. See, I need you to prescribe my Adderall, and they did, and it went okay until it didn't, and they, you know, started scratching their head and becoming concerned when, you know, a couple of them talked to each other and said, well, how often are you writing it, and how often are you writing it, and those types of things, so familiarity can lead to a lot of problems. I mean, we could also spend another hour on boundaries as well, but ... And then there's this culture of silence, right, and by that I mean a couple of things, so obviously there's stigma still around seeking treatment. Hopefully that's diminishing for lots of different reasons. There's also this idea that doctors don't want to be wrong, so if I approach my colleague and I express a concern and I'm off base, uh-oh, did I offend that person? I don't want to be wrong, and then there's either a conscious, unconscious, or subconscious idea that, hey, if this person goes and needs treatment for several weeks and is working part-time because they need to be in an intensive outpatient program or what have you, who does that work burden fall to? Right? The group. So there are several factors that make them a unique group, and then there's all the general stuff too, right? Our hereditary exposure to adverse childhood events, all of those things play a role. Okay. So, and we're going to actually talk about this, yep, in just a minute here, but all of these factors that make these individuals, these characteristics, and make these individuals more unique also play into how we evaluate them, right? So asking questions about their prescribing, you know, do you prescribe for family? Do you prescribe without a doctor-patient relationship? You know, talking about their, you know, how they typically approach situations, what characteristics have been helpful or not helpful. So there's, some of these factors play into how we both evaluate and also treatment, right? So oftentimes with healthcare providers, they might have limited insight. I put denial in quotations because we're trying to kind of shift away from those types of, that type of language, but there may not be a recognition that there's a problem. How do we support their families during this time? They're scared. The healthcare provider is scared. The families are scared, not just for finances, but what is happening down the road. How do we help you navigate if, in fact, your board is involved? Okay. Not every person, not every physician has a board involvement. We're going to talk about that and that pathway. And what I see the most is really just this shame. It's so great. And how do we help people through that? How do we surround them with some support to help address that? And then also, you know, dealing with any ethical violations that may have occurred at the time of the, or around the time of the impairment. So with those things being said, we have an exercise. Let's see. How are we doing on time, Amy? Are we okay? 43 minutes. 43 minutes. Super. All right. So what we're going to ask you guys to do is look across a couple of chairs to your neighbor, maybe groups of two or three. Okay. And we want you to think about some of these questions. So what do we need to consider in this evaluation? And you guys already did some of that as we were talking about her case and what other information we would like. But also, too, what do we need to think about as it pertains to her profession? Is this someone you would refer to a PHP? And are you mandated to report to the medical board? Well, how does that articulate? So we're going to talk about it for a few minutes, five or six, and then have some people sort of offer some answers up. And then we're going to talk about PHPs in South Carolina and Massachusetts. Yes. Did everybody hear that? Dr. Drexler, I may have you say that all over again if you don't mind. Okay. So our group would like to know what state she lives in. Not her emotional state, but which state she lives in. We represent four different states, and the rules and regulations are different in every one. Yes. Yes, sir. Make it big and loud. Yeah. Excellent. Can you expand on collateral? Collateral from the time of her mother and the time of her family. Sure. Would you call the employer? I'm just curious. I'm just asking the question, just posing. I probably would, because are they the ones who referred her? Good question. We don't know. Because if they're the ones who referred her, then yes. If not, then maybe not yet. Okay. Yeah. And so remember, she came to you with her chief complaint of depression. So fair. Yes, sir. We had a request for you to talk into the microphone. Just kind of like questions on like did we run a PDMP on her prescribing habits? Is there a UDS or thinking about UDS to see unclear if this is misuse or yeah. And when you say run a PDMP on her or on her prescribing or did you have thought either way? That's a great point. Yeah. Probably both. What else? Anybody else? Yes sir. Since alcohol is the most common substance abuse by physicians I would like a PATH or an ETG. She's not avoiding alcohol use but that is the most common. Yeah. Or you said ETG maybe a PATH test? ETG. Does everybody here familiar with the PATH? There were nobody's raising their hand saying no. Yeah. I think it depends. The cut offs depend based on the lab but it is an indication of how much somebody has been drinking over the last two weeks whether it's been a regular heavy use or one really big heavy use. I had a physician who was like oh well I went to my cousin's wedding over the weekend. There was an open bar and I'm like well you knew you were coming to PHS on Monday. Why did you drink? You said 2275? That would be dead right? That is the highest I've ever heard. I think that the physician was drinking about three bars of wine every day for the last four weeks. Over 40. 20 is the cut off and there's some debate about what the numbers actually mean. And you'll have a couple of camps tell you different things about the levels but 2000 is that's high. Generally a level of 100 is the report's core standard drink every day for the last four weeks. Average. If someone gets a DWI test it's over 700. That's interesting. I hadn't heard that before. But yeah. So toxicology, collaterals, medical records, state. Yes ma'am? you know, widow mom, three kids, boy locum kind of stuff. I mean, no definite there, but is that kind of just like a little dine and dash situation with, you know, with Suffolk and wherever she goes? Or, you know, I think we need to kind of just talk more about the nature of her job itself. Absolutely. Absolutely. One thing that we're, you know, so a big part of the monitoring contracts is having a workplace monitor. And so what do you do if somebody is in a locum's position and they're moving around to different positions? Like sometimes you can have a locum's, somebody from the locum's company can serve as the monitor, but I also would be a bit concerned about that situation. It would be sort of hard to kind of get to know, somebody knowing, hey, this person's coming in and acting differently than they usually do. There'd be loss of that, so yeah. Yeah, yeah, like carrying that over. Well, this, I'm gonna put it over here, but. Yeah, you know, and also, I remember, I'm on the credentials committee for my organization, and there was somebody who had a history of being, wasn't currently on a monitoring contract, but had a history of being on one who was applying for a nocturnist position, and there was a lot of concern, if he's working as a nocturnist, what happens if something goes on? There's nobody around to sort of notice if his behavior's unusual. I did push back, because I was like, this is not an active, this is not an active issue, he's not on an active monitoring contract, we shouldn't be doing it again. But it was an interesting point, this whole idea of having that community around you that can kind of know when things, pick up on when things are not going the way that they should be going. So, we'll go over here, and then over there. I don't think we asked this yet. So, yeah, maybe one more and then we'll... Are we allowed to ask for personal information? So, we would need consent, yeah. Yeah. Correct. And that's a piece of information by itself, right? That's grist for the mill in some ways. Yes and no. I mean, who in their right mind would say, yeah, sure, you call my work, but that's the, you know, how I'm doing. Well, when we were doing this, when we were creating the case, I said, OK, you in the case, you're the addiction psychiatrist. But let's say we did it a different way and said, OK, you're the chief medical officer. And this person has, you know, there's some concerns. So how would you then pursue it? It might be a different sort of path that you would take if the person was coming to you because they are your direct report as opposed to they are coming to you for treatment. So that actually, oh, yes. Did everybody hear that? Dr. Desai said support network. Dr. Gendale? All these ideas are great, but I just think it's not really practical for what's going to happen in the university. Absolutely, and that actually drives to kind of the first consideration when we're talking about evaluation and a lot of the questions drive to this. What is the evaluation? In this particular case, this is a patient in your clinic. So you're absolutely right. That's a different scenario than if this person was and depending on how your PHP functions, you know, oftentimes PHPs have an initial evaluation that determines if there's a problem, if there's a use disorder or some other type of disorder. So kind of a, if you will, diagnostic initial evaluation. You know, also too this person might have already had that initial diagnostic evaluation through the PHP and it was determined that they need treatment. So maybe this is the evaluation that you have as their treatment provider, right? In this case, this is somebody at 2 o'clock in your clinic. So all really understanding what type of evaluation you are being asked to do is important. We'll talk about reporting and questions around that even in sort of the clinic patient scenario in just a little bit. Again, this is all the type of evaluation is going to really drive your type of collateral resources or collateral sources. You know, making phone calls to families, employers, that's all going to be informed by where is this person in this process and why are they coming to you. To your point about PMPs, it's fascinating so, well I don't know if it's fascinating. I'm fascinated by it. I think this is also very state dependent. Depending on how your entity that manages the PMPs, you may not be able to run a PMP outside of a treatment capacity relationship. Like in South Carolina for instance, unless otherwise permitted by the Department of Public Health, I can't just randomly run a PMP as I'm evaluating somebody in a PHP. And you'll get different takes on that depending on who you talk to. Do you mean you can't provide a report on what she has received or what she's prescribed? So if I'm treating this person I can run it all day long. Like what she's received herself. Not prescribed. Okay, but not what she's prescribed. Correct. Yes. Sorry. Yes. I apologize. I should have clarified that from the outset. What evidence do we have in the first place that she may be in trouble? With substance abuse? I might have missed that. Was there evidence? There was stuff on the presentation that makes us concerned that there might be an overuse of PMPs. We're not certain, but in the presentation we are concerned. And so now we're trying to figure out how would you proceed with that? How do you assess it? So it's just the way she's presenting as a person in your office. Okay. Yes ma'am. So if this is a diagnostic evaluation where there is some type of let's say this person was referred from their employer or from the board you can ask, depending on how your PHP functions, we would ask for a release to speak to the employer. Yeah? Thank you. The first thing you want to know is the intoxication, the withdrawal, is there a potential for withdrawal? And how am I going to treat this patient? She has a position where she's thinking about everything else, and we haven't really... Absolutely. Did everybody hear that? So this person is in your treatment clinic. Are they in? Are they in withdrawal? Massachusetts. Yeah, absolutely. What goes on in other states and hearing other people's experiences. And we've sort of touched on some of these. You know, the toxicology testing, we touched on that. Prescribing, dispensing capabilities, and then determining the degree of their safety sensitivity within the healthcare profession. Alright, and this is where we're going to talk about differences in PHPs. Oh yeah, you've got yours. You need that. Sorry, I'm going to hand you the wrong item. So the health and well-being of physicians and medical students of the Massachusetts Medical Residence. It's a 501c3 subsidiary of the Massachusetts Medical Society. So unlike some states, physicians in Massachusetts do not have to pay for access to the Physician Health Program. They do have to pay for a lot of the things that the Physician Health Program then recommends, but the actual monitoring that happens is independent of the Board of Registration and Medicine, but if somebody doesn't turn to a monitoring contract, then they couldn't get reported to the Board. So it's confidential, peer-review protected, and voluntary, but you know, you also, the PHS can communicate with others. So for example, if somebody there's a suspicion of substance use outside the workplace, maybe somebody's getting drunk at night, and then they come in and they're hungover the next day, so the organization sends the physician to the Physician Health Services, and they're supposed to do their job, you can sign a lease, and then they communicate, say they're in adherence with the contract, and that might help protect their employment. So there is a law in Massachusetts that you are mandated to report to the Board for practicing while impaired or quote, habitually drunk, whatever that means, but there is an exception to mandated reporting, which is if the physician cooperates to a Physician Health Program to the satisfactory of the Board, and there's no patient part. If the physician gets referred and if they don't follow the first 30 days, that can't get reported to the Board, but if there is any concern about directly directing harm, you have to report to the Board. You can't use this exception to provide health support reporting. Again, it's all physicians, trainees, and students, and there's a professional staffer of physicians, a counselor, there is one attorney, and the idea is to identify and assess, refer to when appropriate, and then support and monitor. 30-40% of the people are truly self-referred. They come in on their own. People come in for substance use, behavioral health reasons, cognitive issues is sort of growing, and then there's a sort of disruptive physician behavior that is a growing percentage of the referrals that we're getting. And so basically, if somebody gets referred, they come into the Physician Health Program, they have an intake assessment. At that point, if somebody's clearly there for burnout, they might speak information, give some resources, there's a class on disrupting workplace conflict that they might get referred to. If there is concern about that there might be impairment, then a more structured PHS assessment happens, and that's where you get collateral. You might get the PEP testing and your drug testing. If the results of that are not enough to allow the Physician Health Program to determine if there is impairment, there may be a recommendation for an independent evaluation. That is where a patient might get referred to one of these diagnostic facilities that are out of state, that most insurances don't cover, and that can be quite expensive. And so that can sometimes be a big barrier when people get referred to those. When I was there, we did try to make that assessment as much as we could but sometimes that's just absolutely necessary in order to get a referral evaluation. And then there may be recommendations for monitoring that come from that. And then the monitoring contract. It's a three year meeting with an associate director on a monthly basis. You're in drug testing that happens every twice a week at the beginning. There's required participation in the 12-step recovery program or something similar to that. But not just a support group, but something that is more geared towards recovery. Yes? Can you give an example of the time period between referral to intake or intake? You know, a lot of that is dependent on how involved the physician is. I've had it where the physician comes in and is like, I'm here, here's all the information, let me sign all the consents, here's everything you need. And then I've had it where okay, we need this release of information signed and it takes two weeks for the doc to sign that release. It really varies. It can take weeks. It can take months. And a lot of that depends on how engaged the person is and how complicated the story can be. If it gets to the point of a PHS assessment, though, it's not just a one day thing. It's a much more involved thing. And then we need a treatment team to discuss it and come up with recommendations as a group. So if we're just about... So this now, we're talking about the Massachusetts Physician Health Program, so they've gotten referred. There absolutely is going to be a release of information for the workplace to comment. Well, I think it depends on your state and what the, like, if there's any suspicion of impairment, are you mandated to report or do you have to have evidence of impairment? And I think each state is going to have a different standard, and so that might be something that, like, I personally would call the general counsel for my hospital and get their opinion about it if I suspected that there might be, you know, that there might be some concern. But I certainly have talked to some other people at this conference who have physicians that they're treating in their private practices and they don't report because they're adherent with treatment and they're, you know, not concerned. All right. I'm going to jump ahead. I'll let Rebecca talk about... Yeah. I think we're trying to leave a good 15 minutes for some discussion, so I'm going to zip zap through these. So this is specific to South Carolina. If there's one take-home message that I have for everybody today, it's if you want to learn more about interfacing with PHP, call your state's PHP. One of their primary integral functions is to educate their stakeholders on their policies, procedures, the law, et cetera, in their particular state, and they want to talk to you. They should want to talk to you, and most do. So we are not provided for in state statute. We are funded through our labor licensing and regulation. So when you renew or you apply for a new license in South Carolina, a portion of those funds becomes a line-item budget to fund our program. We are housed under a nonprofit county drug and alcohol treatment facility and we receive our directives specifically from each of the boards and so every two to three years we approach our boards with different scenarios and situations that have arisen. If it's more immediate than that we will approach them at that time and ask their thoughts and provide information on on how we could move forward in those in those type situations. We actually are a small state geographically and so we manage all the health care boards and engineers. I don't know why engineers but and sometimes I joke and say it's like herding cats but that's okay. Our mission is to keep to return people safe to practice. So if you are licensed by the state in engineering so it's like this broad swath you know civil engineers yeah so I've learned to look at a lot of job descriptions. Assist boards in the safety the public safety right that's our by our mission twofold mission and we refer to and Amy touched on this briefly we refer to folks in our PHP as participants we don't provide treatment we refer we can evaluate we monitor but we are not providing the treatment. I think that's something that a lot of individual there's a lot of misunderstanding about and I have a little Venn diagram here of some of the conditions that we are charged with helping to manage and our scope in South Carolina broadened five years ago to include mental health professional misconduct and burnout. This is a schematic that just kind of tells you it's kind of an organizational chart I'm going to skip through that this is a really this just looks at our current participant at any one time we have about 400 people they can come to us voluntarily or involved with their board can't really tell the difference in these colors but I'll just highlight physicians here this this first bar most of our physicians are voluntary and then 34 are board referred and then if you look at our RN category it's sort of the opposite and you can see that's our primary population that's not because nurses have more problems that's because if you just look at numbers that's the you know they have the the most populous licensees so about a third of our participants at any one time are voluntary that's a little bit different than Amy's our voluntary can be absolutely I'm walking in off my own accord and then there's also voluntold which is hey we need you to as an employer we need you there and and they would sign a release and we would communicate in that way that they were adherent with what we are asking them to do and they can go through monitoring whatever that period is and remain unknown to their board throughout that and be successfully discharged funding matters I've very taught you how we're funded if somebody's referred to that to us it does not mean they're automatically enrolled in monitoring they have to have some type of diagnosis that actually equates to the need for monitoring or a recommendation much like Amy there are some costs and we do have small benevolent funds available to help cover those that aren't such as LPNs those sort of lower income earners and that's our schematic and I'm gonna leave this feedback from participants I purposely included the good the bad and the ugly and and you know you get a lot of great feedback at the end about getting life back on track and then there's also the logistic concerns cost testing those types of things and then I think what the part that we really wanted to kind of have a little bit of time to chat about is experience in other states and countries yeah so we were just kind of curious like what is the experience that people have had with PHP's in other states how are other states set up do any of you from a state that you think is doing it particularly well I see a hand in the back and because the Texas Senate said yes we can do the PHP but we don't want any special authority that won't be Texas yeah so and then there have been some changes in medical records over the years but we have some stability in the hospital and we've had more medical records so that's good the challenge is rural positions Texas is such a large state so some of the practices in North Howard, Alpine, West Texas, East Texas the total testing center is 70-80 miles so how do they and in particular if you're tested once a week how do you do that so those are some of the challenges that we're trying to introduce so we'll keep those kind of devices and so that's good and interestingly some testing collection sites are very compact and some are like I have one female physician who has such a bad experience she was told to unrest and she felt very humiliated so testing sites can vary some female physicians went to Europe for a vacation or a conference or a talk came back and then the PHP instead of doing it they did a test but also the CSSC and for some of the female physicians that was very very embarrassing because they take a big travel here it's about 100 miles so that was really embarrassing and unaffected and so they complained to the PHP manager and said if you can just go back why do you want to test when you're coming but I said overall I think they try to be supportive and not be punitive there's been a shift in the design many physicians had a problem with the immediate reaction was that they had to go inpatient there's a shift that they are accepting recommendations from physicians or others they know I think our patients, the HPI people, they don't have to go inpatient so those are some of the challenges so I hate to tell the people in here that have Massachusetts licenses but there's a chance that their license fee might go up each year because like to increase the funding for the PHP in Massachusetts right now it's, no one is paying for it at all I think it's, what is it, the medical society I'm looking at Lily to see if she knows but I think it's all through the medical society but now there might be an additional fee added did you say $1,500? yeah, $1,500, yeah it's not a big amount, but yeah for per person? like each physician has to pay $1,500? each doctor pays $1,500 a year for the participant oh the participant, oh ok, I gotcha yeah, yeah I'm sorry? no, this is each that's what I thought no, no, no, no yeah each doctor pays $1,500 per year for one yeah, so we're, Massachusetts they're going to say each physician has to, as part of their license fee is going to have a surcharge to help fund it so that it's, we're all collectively paying for yeah yeah what about other states? Edwin, did you want to comment on Pennsylvania? yeah Edwin Kidd, medical director of the Pennsylvania PhD Pennsylvania, we are we so in our state in our medical practice act physicians are required or mandated to report if there's a concern that their peer is impaired and not seeking active treatment I think there's room for interpretation there but I think that covers pretty much I don't know how many people actually know about their responsibility in the medical practice act but that's another story Pennsylvania does not collect a licensure surcharge per licensee unfortunately the PHP covers quite a few licensee types now MDs, DOs, physician assistants dental professionals veterinarians, podiatrists and most recently nurses and similar to South Carolina the nurses by far outnumber any other profession just by the nature of how many are licensed in Pennsylvania yes, and pharmacists, thanks we collaborate in a pretty unique system in which the Bureau of Professional and Occupational Affairs has a kind of an entity at the state side and they are the liaison between us and all the licensing boards so a lot of what we do is to work with participants and our mantra is you want to work with us as much as you can so that we don't have to break that break the ceiling so that you talk to the state entity and you want to work with them as much as possible before they have to break the ceiling and they have to report to the licensing boards so multiple steps along the way similar to South Carolina I believe about 30% are kind of self-referred well-in-told come to us because their employer has suggested it we have really good relationships with our health systems that's been key residency programs and some medical schools we've had participants come in because past participants have recognized an impairment and they've suggested they reach out to us two-thirds of our participants are kind of in that the state is kind of involved kind of space I think as a PHP we have room to improve I think there's been a huge shift as the presenters have alluded to it's not just about the impairment it's about trying to intervene as early as possible and trying to trying to capture physicians and other healthcare professionals in a way that they feel comfortable reaching out even if they just have a question about well-being even if they have a question about how do I engage in health before this becomes an issue at work or before an issue becomes becomes problematic and the board is involved I want to say that our participants if they make it through monitoring they usually have pretty a positive regard for us they do have their constructive criticisms finances, that's the big thing I think availability of treatment providers and evaluators which is why it's so important I think for everybody in this audience because we are, in Pennsylvania we are in dire need of addiction psychiatrists those who are specialty trained to diagnose, to be compassionate empathetic and to make these hard decisions to have the difficult conversations that maybe a primary care physician may not be able to have happy to answer any other questions should I? here thank you in Texas I'm a medical director emeritus in Colorado and I'm not going to go into details of my program we've heard from enough programs and they're all different as you know but I want to thank you both for the presentation which was very well done and it's so nice to have this subject back in our back in the repertoire of this organization the only thing I would like to say is that one thing I would recommend to any of the other PHPs if they don't already have this is that we formed a committee of participants that is an advisory committee to our board of directors and it's staffed by in this case me, but it could be any of our medical directors and one of our staff members and so in the course of over a number of years we've, this group has undertaken to review all of our processes from you know initial referral calls to the moment they walk into the office assuming they do walk into the office these days because a lot of it's now remote and it's been extremely effective in terms of helping us help them and I think it's kind of a nice ongoing organizational piece Thank you so much I think that's a good note to end on we're right at time so thank you so much

physician health programs

burnout

well-being

substance use

COVID-19 pandemic

mental health

supportive environment

case study

stigma

PHPs

healthcare professionals

Amy Harrington

Rebecca Payne

addiction psychiatrists

confidential resources

program funding