Our Guests: Michael Baron, MD, MPH, DFASAM, FAPA Medical Director, Tennessee Medical Foundation – Physician’s Health Program; Chris Bundy, MD, MPH Executive Medical Director, Washington Physicians Health Program; Linda Bresnahan Executive Director, Federation of State Physician Health Program
This episode tackles the crucial issue of physician recovery and the role of Physician Health Programs (PHPs) in their journey back to safe practice. Terri is joined by a panel of esteemed experts from the Federation of State Physician Health Programs (FSPHP) and leading state PHPs. Together, they delve into the world of PHPs, exploring:
- The Role of PHPs: We’ll hear how the FSPHP supports and connects individual state PHPs, ensuring a nationwide network of support for physicians in need.
- The PHP Model Explained: Leading PHP directors will provide a comprehensive overview of the PHP model, including referral criteria and the unique approach taken by PHPs compared to traditional disciplinary actions.
- Safe Return to Work: The panel examines the challenges and considerations for physicians returning to work, particularly in high-risk specialties.
- Beyond the Core Issues: Our insightful conversation revealed a critical aspect of successful re-entry: clear communication and collaboration between PHPs, hospitals, and diversion specialists.
We explore the challenges of each side potentially overlooking crucial information from the other, and how open communication can bridge this gap, ultimately ensuring the best possible outcome for the recovering physician and patient safety. For more information on Drug Diversion mitigation and resources, visit Rxpert Solutions
Transcript:
Terri
Welcome back, everybody, to drug diversion insights. Today’s guest list represents years of experience, and we are going to be learning about recovery programs for physicians. First, we have Linda Bresnahan, the executive director of the Federation of State Physician Health Programs. We also have Doctor Chris Bundy. Doctor Bundy is the executive medical director of the Washington’s Physicians health program and past president of the Federation of State Physician Health Program. And to round out our guests, we have Doctor Michael Barron, the medical director at the Tennessee Medical foundation, which is Tennessee’s physician health program, and the president elect of the Federation of State Physician Health programs. So those are a lot of, well, you may hear the acronym PHP in this podcast, and that stands for the physicians health program. Those are a lot of words there that all go together.
Terri
But essentially, we’ve got two physicians representing two different states, and they both have a connection to the Federation of State Physician Health programs. So we’re going to start with Linda today. And Linda, can you tell us a little bit about yourself and then explain to us what is the relationship of the Federation of State Physician health programs to the various state phps?
Linda
Sure. Thank you, Terry. Thanks for having us. I’m currently the executive director for the Federation of State Physician Health programs. I’ve been in this role full time since 2016, for about eight years. Prior to that, my background was with the Massachusetts Medical Society’s physician health services, another state physician health program. I was a member of the Federation of State Physician Health Program since 1991 until I took on this role. That’s a little bit about my background. So in terms of the Federation of State Physician Health programs and the relationships with its members, our members are our state physician health programs. So the Federation of State Physician Health Programs is made up of 48 state physician health programs and some canadian physician health programs as well. We are a membership association. We’re a nonprofit membership association that serves our members nationally.
Linda
The purpose and mission of our organization is to help bring together state physician health programs along the lines of best practices and education, and aligning what we do to reduce variability and increase consistency. We have annual meeting, and we are connected through e groups and content all year around what our state physician health programs to do. I think it’s important to note, too, that over 50% of our state physician health programs are now healthcare professional programs. We think what they have been doing well and so effectively has been recognized by other professions in their state. And typically, state physician health programs are then approached by these other health professionals, nurses, veterinarians, the list goes on. So when you look through our directory and we have a directory@fsphp.org. Of state physician health programs. You’ll notice more than 50% of them are named healthcare professional programs.
Linda
We still use the acronym PHP, but I think it’s important to note throughout this conversation that when we say phps, we’re also referring to healthcare professional programs in our membership.
Terri
Okay. All right. Yeah. In interviewing different states, some don’t have the physicians attached, so I guess those would be the exception to, yeah, they’re different. Okay. All right, that makes sense. And I looked through the list of your members, and it looks like I did count correctly, because I found a couple of states that seem to be missing from the program. Does that mean that they don’t have a position specific program at all, or just that they’re not members of FHDev PHP?
Linda
A little bit of both. I can explain that. So, to qualify to be a physician health program member of the federation, you need to demonstrate that your program is a therapeutic alternative to discipline in your state. Typically that means you’re recognized through legislation or maybe board regulations to allow referrals to come to your program in lieu of a report to a medical board. And you need to be recognized by organized medicine or supported by organized medicine. So those 47 current state programs meet that criteria. I should mention two states have two programs, Missouri and Arizona. So there’s four states, therefore, that do not, are not currently members, and they’re for different reasons. So Maine has a physician health program that meets the eligibility for membership, and it’s the only state that’s not a member that meets eligibility.
Linda
The other three states that do not currently have a program that meets eligibility for the state membership is California, Wisconsin, and Nebraska. I will say we’re working with all three states. In Wisconsin, the medical society is actively engaged in development efforts. They have been for several years. They’re looking to create legislation and establish funding for a program. They recognize the model successful. They want a program that meets that criteria, and they are a member, just not a state physician health program. Similarly, Nebraska’s medical society association is very invested in establishing a state physician health program in the near future. Both of those medical societies do quite a bit for physician health and wellbeing and offer counseling and coaching type of services, but they don’t have a physician health program that meets the model. But we’re working with them.
Linda
I’m excited about the future for those states. California as well, working with both the medical society and the medical board. They do have regulations that call for a program. They have not put out the RFP to establish it. And the regulations really don’t meet the requirements of what we would expect of a physician health program. It’s attached to the medical board and it doesn’t really have the alternative to discipline separation that we would expect of a physician health program. So they’re looking at creating changes to that current legislation so that in the future they could have a program that meets those requirements. So making progress in those states?
Terri
Yeah, yeah. Interesting. Surprised to hear, I mean, California is such a large state that I’m not surprised to hear that they have lots of regulations because we know that California does that, but interesting. Okay, well, good. I’m glad they’re all making progress because it is such an important thing. Doctor Bundy. Bundy, excuse me. Tell us about you and give us a description of what the PHP model is.
Dr. Bundy
Thanks, Terry. Good morning. It’s great to be here. Thanks for having me on. I’m Chris Bundy. I’m the executive medical director of the Washington Physicians Health Program. I’m a psychiatrist by training, addiction medicine specialist and geriatric psychiatrist. I have been with the Washington physicians health program for ten years now, actually ten years yesterday. And I think I like talking about the model because I actually feel fortunate in Washington that the people who came before me that really built this program, really did it with an eye towards what the ideal model really should be. Those individuals were founders of the Federation of State Physician Health Program, wrote the bylaws for the organization originally.
Dr. Bundy
And so we’ve been around in Washington for about 40 years, and I think the model really stems out of this idea that came out of the seminal article in JAMA in 1974 called the sick physician. And the idea there was that doctors get sick like everyone else. They don’t have any special, unique protections against the kind of illnesses that can impure safe practice. And at the time, really because of the kinds of conditions, mental health and substance use disorder, conditions that people were struggling with that would put them at risk for unsafe practice.
Dr. Bundy
Those diseases are often characterized by really denial and the feeling that you’re not really sick, but you might be bad, or that you’re not really sick, or you should hide it, because if it’s known to your peers or colleagues, you’ll feel, you know, the stigma and bias and shame associated with those conditions you would not necessarily want known to your peers or colleagues. So it would recognize that there was this culture of silence in medicine, and there needed to be a way for physicians to confidentially get support that was therapeutically oriented, rather than oriented towards punishment or discipline. That’s really the crux of the model. Over the next ten years, physician health programs started evolving out of their state medical associations. It was really a call to action for state medical associations to set up these peer assistance programs.
Dr. Bundy
And early on, they operated kind of in what I might consider a tense relationship with the medical boards who didn’t really know what to think of what these new and emerging phps were all about. Were these programs that were hiding doctors that were going to potentially put patients at risk, or could these programs really help and actually protect patient safety?
Dr. Bundy
So I think the second decade really was about building that relationship and trust, both locally with the state medical boards, but then nationally with the federation partnering Federation of State Physician Health Program, partnering with the Federation of State Medical Boards to really flesh out this idea of a confidential, peer based support that could provide help and treatment, and then post treatment monitoring for physicians to ensure and verify ongoing safety to practice for any third parties that might be involved or might have reason to know. I think it’s really important that people understand, however, that the modern PHP, for the vast majority of referrals, are not people who are really discipline involved. In my program, 86% of our participants are never known to the licensing board.
Dr. Bundy
They’re coming with referrals from, you know, concerned peers from the workplace, where there have been performance concerns, maybe related to mental health or substance, maybe not. We have a fair number of referrals today that are for non psychiatric medical issues as well. 60% of our referrals are for non substance related concerns. So I think while we started as programs that were really focused on substance use disorder, again, the modern, evolved PHP sees the full spectrum of conditions that can impair safe practice and provide support fairly far upstream, I think, of impairment. So I think sometimes people imagine that the average PHP participant, somebody who’s in trouble, they got in trouble with their licensing board, and now they have to go see the PHP. And actually, that couldn’t be further from the truth.
Dr. Bundy
The vast majority of people are getting help early, before patient safety is put at risk. They’re not discipline involved. There may be some external motivation, there may be concern, and there may be some professional consequences if they elect not to participate with the PHP, because that employer or medical staff wants the reassurance from the PHP that the individual is safe to practice, but they’re not at that level of concern where they’ve actually put patient safety at risk. Complaint has been made. I think I’ll stop there and see if you have any questions. About the model, but that’s sort of how it works. Or if my colleagues have anything to add about the model that I’m forgetting.
Terri
Yeah, that’s interesting. When I see the physician that is in trouble there, I mean, they have put patient safety at risk because the hospital knows about it. And that’s why we’re like, hey, something is happening here I don’t think of. It’s really good to hear that they’re actually coming to the PHPs even before that, and that they are feeling comfortable to kind of self report to a large extent, or at least listen to people that identify something early on. That’s good to hear.
Dr. Bundy
Yeah, we absolutely work with folks who are in the situation of selfdevelop use of substance through diversion. Diversion is, as you know, commonly for self use in the context of addictive illness. And folks who work in hospitals and healthcare organizations were absolutely ready to help those people as well. But I just, I think it’s also true that a lot of our folks are not so situated.
Terri
Yeah, okay. All right, great. Doctor Barron, share us. Give us some information on your background as well, and if there’s anything that sets the PHP program in general apart from other programs for other disciplines, or if there’s something different about your state. And I’d also like to know too, if the provider is discovered at the facility doing something diverting, is it a mandatory requirement to then report to the licensing, or is it still kept confidential?
Dr. Barron
Sure. And you might need to remind me of that question as we go, but.
Terri
I wanted to ask it upfront because I didn’t want to forget. So now the four of us will have to work together to remember.
Dr. Barron
Great. Well, first off, thanks for having me. My name is Mike Barron. I’m the medical director for the Tennessee Medical Foundation’s physician health program. I’ve been in this role for, I’m in my 8th year, and I’m anesthesiologist by original training, board certified still, and a psychiatrist by retraining, and an addiction medicine specialist. I’m in recovery from a substance use disorder. I’ve been sober for almost 25 years now, and I got interested in this field basically through my own health. I was intervened on by the initial medical director for the Tennessee Medical foundation, and we’ve only had three medical directors, so the lifespan of our medical directors is quite long. We’re one of the original programs, like the Washington program, where we got our start in 1978 at the physician of the Tennessee Medical association.
Dr. Barron
We became a freestanding foundation in 92, a non profit foundation.
Dr. Bundy
I was a pregnant.
Dr. Barron
Out and reached for alcohol to help. Long family history of alcoholism. And obviously that didn’t work. I was intervened on. I referred for treatment, went back to work as anesthesiologist, and lasted about two years. I just was miserable. I was unhappy. I was doing pediatric anesthesia, high stress, high hours, and just knew I needed change. So with the help of my institution here, my employer institution, that is, they were very gracious and allowed me to leave the university and go back into residency, also at the university. So I left one day as an associate professor and came back in as a second year resident, completed a psychiatry residency, and developed a niche in treating healthcare professionals, as you might imagine, as well as treating people with pain and addiction.
Dr. Barron
And that led to treating some people in the governor’s office, and they asked me if I want to be on the licensing board, on the board of medical examiners for the state, and then kind of joke and say they don’t usually want people in recovery. On the licensing board, it’s usually political appointees and some people with inside tracks to the governor, none of which I had. But yet, in 2010, I was appointed to the Tennessee Board of Medical examiners, and I had marching orders from the governor, who said were losing too many physicians to punitive action, and we needed to not only help that, but also train and educate fellow board members, most of which had no mental health experience whatsoever, that addiction is an illness, not a weakness.
Dr. Barron
So with those marching orders, I’ve been very involved, and still am very involved in educating board members. Medical board members turn over with quite. With a lot of regularity and frequency. I was reappointed after five years to the board, but many board members are not reappointed. So the average lifespan is about five years to our medical board. So I educated, I wrote many of the rules and regulations regarding opioid prescribing in our state and office based opioid treatment. I’ve written rules and policies for the Federation of State Medical Boards, but I resigned from that appointment in 2017 to take over as the third medical director of the Tennessee Medical Foundation Physicians Health program. And that’s been just wonderful.
Dr. Barron
We get to see physicians on the worst day of their life, when they feel like the world has ended, that they won’t ever practice medicine again, when their family won’t be speaking to them. And we get to see them change over the next few months to few years, and really have gratitude for what we do. And that, to me, is very rewarding to answer your question about.
Terri
Is it a mandatory reporting if they come to you through the healthcare facility?
Dr. Barron
In Tennessee, there’s no statutory requirement for reporting impairment. Some states have a statutory requirement. Where I draw the line is if there’s patient harm, I will report that to the licensing board. And we’ve had a great understanding. We don’t have to report return to use in my state, I will report non compliance, however. So if someone’s under contract with me and they return to use, as long as they’re compliant with what we ask, and there’s no patient harm or threat of patient harm, they are unknown to the licensing board. And we basically have a confidential program. We don’t have as many confidential participants as they do in Washington, 60% confidential and 40% that are board ordered.
Dr. Barron
And when they’re board ordered, it’s usually because of an application process that they have had a prior DUI or some other type of criminal conviction or prescribing problem or boundary violation or things of that nature. So there’s no mandatory reporting. We do have a weird kind of law that was legislated in 21, I believe, where if somebody, if a licensed healthcare professional gives a urine drug screen in a licensed health care facility, they need to be reported to the chief medical officer of the state or to the appropriate peer assistance program, and that is if the urine drug screen has something in it that should not be there. We take care of physicians and many other healthcare licensees. We do not take care of nurses. Some physician health programs or professional health programs do take care of nurses.
Dr. Barron
And what I can say between the differences between programs that do and don’t, there’s minimal difference. What the big difference is really the licensing board themselves. Nursing boards have kind of a reputation for eating their young. They’re really very mean to fellow nurses. They don’t look at behavior or addiction or illness as reparative, so much so nurses are getting trouble. And there’s a great example here in Nashville of a nurse that inadvertently injected medication that led to the demise of a patient. She was thrown under the bus, literally thrown under the bus, that had nothing to do with impairment or what we’re talking about. Nurses tend to eat their young. And I think that’s a big difference between licensing board of medical examiners, board of nursing, and those programs that do take care of nurses. We do not.
Terri
Okay. Yeah. Well, I can tell you that in just about every facility that I have been involved in, either, you know, as a consultant or working or anything, whenever we talk about their diversion program, and what they have set up, one of the things that people always say is the process we have is very different for nurses and other disciplines than it is for physicians. And they’re angry. Right. They think that physicians get a pass. So it kind of sounds like they don’t get a pass. They just keep it more confidential and they’re working with them, whereas nurses, as you said, kind of get thrown under the bus, they lose their job, they get reported, and it’s just a different pathway.
Dr. Barron
It is. And it’s really important to remember that the goal of the physician health program is very similar to the goal of licensing boards, and that’s to protect the health and welfare of the citizens of the state. Medical boards. Licensing boards do it through punitive action. Physician health programs do it through a reparative process. But the end point is exactly the same.
Terri
Right? Right. Okay. Doctor Bundy, any different in your state with mandatory reporting, or probably not because you have so many that are in there, but I just, what I’m used to hearing is a lot of states, if a hospital discovers it, then you got to report it to the licensing board, even if there is that option to come into the recovery program anonymously.
Dr. Bundy
Yeah. So it’s interesting that you mentioned that because Washington is a mandated reporting state, and about two thirds of states, actually, according to the Federation of State Medical Boards, have mandated reporting laws with regard to concerns of impairment. In Washington, any DoH license holder is a man being of concerns for impairment. And in Washington, you can discharge that legal requirement by calling us rather than calling the licensing board. The statutes are often vague. So, for example, PHPs can’t be safe harbors for people who have caused patient harm. So you actually can’t discharge your mandated reporting obligation in Washington if a patient has been harmed as a result of impaired practice. So we can still provide help and support, but that can’t happen within the safe haven of the PHP confidentiality protections that has to be reported to board. And we advise people accordingly.
Dr. Bundy
If we get a call like that. The vast majority, you know, what constitutes patient harm is subject to, you know, some judgment at times. You know, some types of diversion might clearly result in patient harm or other types of diversion. Other circumstances, maybe not so clearly. So there might be some judgment in there. And I think that when we talk about one, the differences between different types of boards, like nursing boards and medical boards, I think it really depends state by state on what level of trust has been developed between that nursing board and the monitoring program or the diversion program that exists for nurses because in some states, there’s very strong, long history, well developed relationships where the board trusts the nursing program and I think are less likely to take punitive action. In some states, the statutes are such, it’s just different.
Dr. Bundy
Or the regulations for nurses or the requirements for confidentiality are different. So when we talk about confidentiality, we’re talking about really three kinds of confidentiality. Can you be confidential from the board and participate in the PHP? And I think we’ve kind of gone over that. Yes, you can be confidential from the board, you can participate in the PHP. There are limitations on that confidentiality. For example, cases in which there’s been patient harm, there’s also record confidentiality. So to what extent can those records be released in legal proceedings? And, you know, in Washington, again, as in many other states, there are special protections for the records within the physician health program that determine how they may or may not be used. And in most cases, it’s very difficult to get a PHP record. So that’s sort of the second piece.
Dr. Bundy
And then I think the final piece is, what am I forgetting, Linda? There’s safe haven, there’s, oh, licensure questions. Thank you. So can you answer no to licensing questions about prior mental health history diagnoses? Can you actually not answer the personal health items if you’re known to, the physician health program in Washington is an example where you actually don’t have to answer those questions if you are known to the physician health program, and that’s defined in the question itself in Washington, we actually now have an advisory model that doesn’t even ask the question, but provides guidance to physicians and other health professionals that we serve around the fact that you can get help. You’re expected, as part of your professional and ethical obligations to attend to your health and well being and to not practice impaired.
Dr. Bundy
And so if you have a concern about your ability to practice safely, you have an obligation to work proactively with your physician health program or appropriate professional monitoring program to ensure that you are safe to practice and you are testing that you’ve been advised of this professional.
Terri
Okay, so the PHP programs, they’re just monitoring programs, not treatment, right. Do you work with treatment programs?
Dr. Bundy
I should have mentioned that early on. So we provide usually some type of intake and initial assessment. Some programs call it kind of a triage assessment to really determine what the next best step is. Typically we use outside independent evaluators to diagnose, and then once we have a diagnosis that will indicate what would be the next steps in terms of treatment, we utilize experts who have specialized training and expertise, experience in the complex management of safety sensitive healthcare professionals and other safety sensitive workers that are specially qualified, really to do that work.
Dr. Bundy
And they can provide the exhaust evaluations, return to work recommendations, fitness for duty, things that you can’t get in usual care for our health professionals so that we can successfully then reintegrate them into an aftercare program and back to practice if they’ve been required to cease practice for a period of time while their illness has been stabilized. So all of those pieces get into place and then I don’t like to use the term monitoring. I like to use the terminal health support and verification, because really our goal is to keep that individual safe and sustained in their health condition and then provide any verification of health status and safety to practice to an employer or credentialing entity or someone who might have need to know that this individual continues to be safe in practice and is adhering to the requirements of the program.
Terri
Okay. Doctor Barron, anything different in.
Dr. Bundy
No, no.
Dr. Barron
We also have pure immunity from liability, and we have protected records under the peer review and peer assistance statutes, which is why we do not treat our participants or evaluate them in house. We do a triage assessment to make sure they get the help they need and can point them in that direction. But our charts are protected from discovery as a result of, not as really a result of statute, but so we do not treat our participants in house.
Terri
Yeah. Okay. And I, you know, the trust issue, I think, is really important. I will tell you again, from being on the other side, and I find out, like, not in real time, that a physician, specifically anesthesiologist, because that’s typically on the inpatient side, the ones that you’re going to be working with, they’ve come back or they have restarted. It’s a little disconcerting. I will tell you to the pharmacist in charge who’s responsible for all the controlled substances, to then find out that somebody is there that they didn’t know about that might require additional monitoring from a diversion perspective, just to make sure that there’s nothing happening, because there’s an accountability piece there. And so I think the trust is a huge piece of that.
Terri
I know on the front side, you know, if I have trust in that chief of anesthesia, that they’re going to take care of things. If I have a concern, I don’t need to know what their thoughts are and what the results of their investigation are, but I know that they took care of it as opposed to a chief that I don’t think takes it seriously. And then I just don’t really know if they’ve really looked into it. And then, same thing for when they’re coming back. So I think that understanding what the PHP program in that state is doing and what the requirements are really would go a long way to all the pharmacists in charge at the facilities in those states to recognize that, you know, they are being supported, they are being, you know, monitored, and things are good.
Terri
And if they’re there working, then they can be confident that, you know, people are keeping an eye on things.
Dr. Barron
A lot of what we do, a lot of what I do is education. And when we do have anesthesiologist or other individual that has easy access to medication, I know, make it a point to speak with their medical executive committee, including the representative from the pharmacy, from the Department of pharmacy at that hospital, to educate them, but also to ask, and this is not well known, and it really should be to ask the pharmacist to check the waste for the actual drug, that it should because many times when anesthesiologist uses, they replace the waste with like water or some other solution. So we always ask the pharmacist, randomly and unknown to the practicing anesthesiologists, to check the waste to make sure that it is truly waste and that it’s fentanyl, it’s 50 mics per cc.
Dr. Barron
So we bring them into our plan, and that helps to alleviate stress and worry and like, oh my God, I didn’t know what was going on. Type of responses.
Terri
That’s fantastic. Well, I can tell you they don’t do that in every state, but that is wonderful.
Dr. Bundy
Can I, can I comment on that as well? Yeah, I think, you know, in the time that PHPs have been doing this work, we’ve seen a lot of actual, you know, I would say, variation in hospitals and healthcare organizations. Diversion control programs have really come online more recently. And I see this really as both an educational opportunity for physician health programs to recognize that these diversion control programs do exist within hospitals. I don’t think in our history we’ve been really trained oriented to be thinking about how those services, kind of in the way that Mike just described, can actually enhance our ability to effectively monitor health professionals in the workplace. Like that partnership. You can see things through a lens that we can’t, and we can also see things through a lens that you can.
Dr. Bundy
So being able to put those things together to powerfully protect the folks that are most at risk. These are very high risk cases for us. Returning anesthesiologist to practice in the or is probably one of the most high risk things that we do. So anything that we, I mean, I think we’re motivated to do that. I think that there’s a lack of education, understanding, and I would say also within healthcare organizations. So where I see oftentimes, and I think you’ve mentioned this before in our prior conversations, is that some healthcare organizations are much better at communicating between the medical staff and the other people that hold responsibility for safe care in the organization. Sometimes the medical, you know, the chief medical officer, HR, the medical executive committee all knows what’s going on with this individual.
Dr. Bundy
He’s really felt like it’s done its due diligence in coordinating a safe return to work plan. But you all have been left out of the discussion, and we don’t necessarily always know who needs to be in the discussion in which organizations in which we’re working. So it’s also, there’s an opportunity. I think we do a lot of education in the healthcare ecosystem, so we can also partner with our pharmacist in diversion control to make sure that when we’re talking to healthcare leadership and others, you know, that we can also push for that coordination. Has diversion control been involved in this discussion? Do they know what’s going on? Are they comfortable with the plan for return to work from the perspective and the responsibilities that they have with the board?
Terri
Yeah. Excellent, excellent points. Yeah.
Dr. Barron
Well, one thing that, if I could add is that even though we are a confidential program, that doesn’t mean that the participant returned to work is unknown. We do use work site monitors, someone that is at the job, at the office, at the hospital, at the place of employment, that knows what’s going on with that individual and is very observant of that individual, and write us quarterly reports that everything is fine, or that there’s an issue, or has my phone number and can call me if there’s something urgent so they’re not in a vacuum. When someone does return to work, it may not be known to the full medical staff, but they’re generally one or two or more individuals that are aware of their history and do monitor it. Lifetime.
Terri
Yeah, yeah. All good points. And I think it is just making sure that everybody knows. Some people may know, so it’s covered, but maybe not all the essential people that need to know, including the pharmacy. Yeah, this is a great discussion. So let’s talk about the anesthesiologist. Back to work, both of your programs sound like you support that. Is there a criteria that they need to meet, a certain duration of time? They need to be in recovery. What does that look like? Because it’s high risk, as you said.
Dr. Barron
Doctor Bundy, they are high risk. We really individualize the care of the individual, and we let our treatment centers individualize that care with their recommendations. So anesthesiologist whose drug of choice is not opioids or propofol or anesthetic drugs is treated differently than anesthesiologist whose drug of choice is a anesthetic drug, a pharmaceutical grade fentanyl or propofol or volatile agents. So they’re treated very differently. We do use medication for opioid use disorder, generally naltrexone, with anesthesiologist that is returned to the or whose drug of choice is an opioid. If there’s a return to use, they generally stay out of work for up to a year or longer. If there’s multiple returns to use, we generally strongly recommend or even require that they choose another specialty. But actually, that’s pretty rare.
Dr. Barron
Anesthesiologists are at higher risk access, but that’s really not the main reason they’re at such high risk. They’re using these drugs. If they’re drug choices and opioid or prophyl, that very quickly change their behavior. I think that’s why they’re intervened on so early in their disease process. The average alcoholic is in their forties, fifties, or sixties. The anesthesiologist that uses anesthetic drug in opioid or falsetto hypnotic is intervened down within a few months of their use. These are very strong drugs, so the detection is actually pretty easy. We call propofol, kind of jokingly the thud drug, because if there’s use, you hear a big thud when the person is falling off the commode usually is where the use happens. There’s also a higher percentage treatment, probably because of exposure, too, anesthesia exposed to these drugs even when they’re not using.
Dr. Barron
There was some work out of Florida by doctor Gold that was able to extract fentanyl and volatile agents and propofol from iv poles and from the anesthesia machine, because it gets volatilized, it gets leaked through the mask, and it’s in the air. So those with the genetic predisposition are subclinically introduced to these drugs, even if they’re not wanting to use. So that might trigger the actual clinical cascade of addiction. And they’re around other people more than any other specialty. Now, the NSC does not work in isolation. They work with the or nurse, with the circular nurse, with the surgeon, with the recovery room. So most physicians are pretty isolated. They’re in the exam room by themselves or their office by themselves. Anesthesiologists are not. So the detection part is pretty easy once anesthesiologist is using these strong drugs.
Dr. Barron
So I think that’s why they’re over represented. But as far as return to work, that’s very individualized. It depends on their degree of recovery, how quickly they get the concept of recovery. Do they have gratitude? Do they have insight, things like that?
Terri
Okay.
Dr. Barron
All right.
Terri
There was a lot in there. Boy, that exposure just in the air, that is quite disturbing because that kind of leads back to, we need to figure out who is at risk more than the others. I mean, you know, and then in terms of their behaviors and stuff, you can really see this change pretty quickly. Would you say then from your experience? I mean, you know, there’s data and software programs, and I’ll just tell you, it’s hard to monitor in the or because the physicians write their own orders. Right, and give their own meds. And so it’s not like the nurse who has accountability to adhere to the order. And you can see if they deviated from it. And the waste, I mean, they’ve got that they say the time behind the curtain, and they’re all alone.
Terri
So you do your best to try to look at the data. Look at are the dispenses getting more, but then you got to dig into the patients and how much they need and all of this. I mean, what would your recommendation be for monitoring in the or does it simply come down to educating everybody in the or to just watch for changes in behavior?
Dr. Barron
Absolutely. That and checking the, again, going back to checking the waste for what it actually should be, the validity of the waste. And also letting the NSC know that if there is a return to use to get help immediately, don’t wait for a horrible event or unfortunately, some detection is learned at autopsy of a return to you. So, you know, we don’t want to wait until there’s no illness impairment and a lethal overdose. Yeah, it’s rare.
Terri
Are they more inclined to ask for help the second time around, or is it? Then it’s just they’re so embarrassed and devastated that it’s maybe even worse.
Dr. Barron
I don’t have any data to support that one way or the other.
Dr. Bundy
No, but I have a couple of comments. I mean, I think it’s worth noting that there’s other pieces. I don’t know how much you touched on all this, Mike, but oftentimes we’re putting people back to work with protective medications. They’re thinking in terms of prevention. Were maybe setting up some of our programs set up to really encourage self reporting and that different things happen for a self report versus a detected use under monitoring. For example, through toxicology testing, most of us test pretty robustly. I mean, we test in four matrices, body fluid matrices, across a pretty wide variety of substances that are cued to drugs of choice and prior use substances. I think working with diversion control to make sure that we’re testing for the things that they’re worried about.
Dr. Bundy
Maybe the individual never used propofol, but diversion control really would like us to be testing for that, so we can do that if that’s desirable. So I mean, I think us being flexible and working together, there are multiple ways in which we can detect return to use. Sometimes it’s a family member, a friend, sometimes it’s their healthcare provider. So we’re getting reports from their healthcare providers who may be seeing something, their counselor that may be seeing a warrior concern, a family member that may be seeing a warrior concern. So I think we’re about as good as you can get with somebody who has this history versus the unknown population of folks who have yet to be identified or treated.
Dr. Bundy
I think our outcomes are really demonstrating that, you know, for a house employed individual, your risk of return to use is about 50% in six months. Our data have consistently shown both at the individual PHP level and national samples that return to use. You know, most people remain absent. 80% of program participants are abstinent at five years, which is considered in the field to be an adequate safeguard to reassure a safe return to practice again, versus an unknown cohort. We also have malpractice studies that show that individuals who are in a PHP have lower malpractice risk and malpractice claims filed against them then they would have prior to their PHP participation, and that once graduated from the PHP, their risk is about 20% lower for malpractice type events. So there’s a number of things that give us some reassurance.
Dr. Bundy
You know, we did a study back in the early two thousands that showed that anesthesiologists, I mean, it was a little underpowered to detect, but there was no increased risk of return to use for anesthesiologists versus the 250 plus other physicians that we had followed in the program. And there’s some controversy around whether anesthesiologists are at increased risk for return, largely biased by, I think, the kinds of traumatizing outcomes that Mike described. I think when you look at the data, an assertive, robust, modern PHP, using all of the tools that we’ve discussed, can really, I think the data shows that you can safely return those anesthesiologists to practice, and that there are no greater risk for return to use than the general population.
Terri
Interesting. Okay, well, this has been a fantastic discussion. I think the listeners out there, too, that can see the disparity between, you know, nurses and physicians and that recovery, this will be good for them to hear as well as to what it is. And I think, I mean, it’s, we need to adopt the PHP, the solid PHP in the states that have all of their disciplines wrapped under that are very fortunate, because it does sound like it’s quite comprehensive.
Dr. Barron
I would go even further than that to say we need to adopt the PHP model to the general population. It’s expensive to know, but with success rates of 80% to 85%, it’s a no brainer.
Terri
Yeah, good point. I wonder. Yeah. Do you think that healthcare professionals are more motivated to succeed, or do you think that the general population, by and large, would do better just with this type of program? Do you know what I’m trying to say? I don’t know if the licensed individual is more motivated than somebody who isn’t.
Dr. Barron
Physicians are not unique. They are prone to any illness that the general population is prone to, if not more, through exposures. So it’s hard to tease that out.
Dr. Bundy
Yes.
Dr. Barron
That we have leverage over them, but they’re also monitored for five years, and their return to use in most states is not mandatory reported to the board. So I don’t think they’re unique from that aspect. I just think with accountability. And the PHP model works.
Terri
Yeah. 30 days in a recovery program, a treatment program, and then you throw them out the door is not enough.
Dr. Barron
Absolutely not.
Linda
Can I comment on that?
Dr. Bundy
Because I think that what we’re dealing with right now is this horrible epidemic of overdose deaths. It’s the worst that it’s been in history in the United States, and our addiction treatment systems are failing. And so it begs the question, where are the models that exist that are they’re being successful? You know, Mike has worked with female drug courts and people who are in those situations. Similar model in some ways, accountability, chronic illness management model, and that works highly successful programs there as well. Everybody has external motivation until they don’t. So, I mean, it’s finding those levers of accountability and really having people being willing to engage in programs that will hold them accountable so that they can stop using the substance that has become a culprit for them. And I think that there are ways to do that.
Dr. Bundy
I also can’t, you know, I don’t think that addiction cares whether you have a medical license at the end of the day.
Terri
True.
Dr. Bundy
So people want. You know, I think it’s tempting to say, well, it’s the toxicology testing and the pain of losing your license and getting caught and having bad things happen. You know, that’s certainly part of it. And we can impose those kinds of accountability measures in our personal relationships, in vocational relationships, outside of medicine, there are lots of. Lots of people who have accountability, jobs, teachers and bus drivers and, you know, all kinds of folks that have accountability to others as part of their work, where those levers can work. But it’s also the chronic illness management model. It’s actually somebody providing oversight of care, making sure that you’re getting to your appointments, that you’re doing the care that we know works. Addiction is as responsive to the appropriate care as any other chronic condition.
Dr. Bundy
The problem is that we don’t have systems that are set up to ensure that people can get it. And medications alone will not cure addiction. It really needs to be a holistic approach. If you have diabetes, you need diabetes medications, but you need a holistic approach to your healthcare that includes getting your eyes checked and diabetic foot care and management of weight and physical activity. That kind of comprehensive approach is cost effective in the long term for that chronic illness. And that’s the same number of people who are afflicted with addiction have type two diabetes. So we have a model for diabetes that we know that works. And if I think were doing some of the same things in addiction treatment, we’d be getting our arms around this illness a lot better.
Terri
Great. Well, these are some great things to think about. Go ahead.
Dr. Barron
No, I just say very.
Terri
Yes, well said. I don’t think there’s any more that I could say to add to that. So I’m just going to thank all three of you for your time and this wonderful discussion. And hopefully there are those out there that hear this, that become motivated to make a change and to do something and to get involved to improve this in their states. So I thank you all very much for your time.
