About 10% of all people – including physicians – will develop an addictive disorder sometime in their life, says Katie McQueen, MD, a board member and former medical director of the Texas Physician Health Program (TXPHP).
What happens when that disorder or another behavioral health problem impairs the physician’s ability to practice medicine with reasonable skill and safety?
Dr. McQueen hit that question head-on at the Texas Medical Association’s Fall Conference in September, discussing how TXPHP can help physicians with behavioral health problems avoid potentially career-ending discipline by the Texas Medical Board (TMB). “Sometimes we like to think that physicians are immune to certain problems, and that they should be immune to addiction because we’re stuck in some of the preconceptions that the addict is a homeless person on the street,” said Dr. McQueen, who is an addiction specialist. But addiction, mental health, old age, and other health problems impair physicians just like everyone else.
“Approximately one-third of us will be impacted by conditions that could influence our ability to practice medicine over the course of our career,” Dr. McQueen said.
TMB investigates about 9,000 complaints a year against physicians, according to the agency’s website. In 2009, the Texas Legislature established TXPHP, with support from TMA, to deal with complaints tied to health issues that can potentially interfere with a physician’s performance.
Governed by an 11-member board made up of physicians and other mental health professionals, TXPHP is based on similar physician health programs used in all other states, Dr. McQueen says. Some physicians are wary of TXPHP because of its tie to TMB, which can publicly discipline a physician and suspend or remove the physician’s license.
But they shouldn’t be, she says.
“We are administratively part of the Texas Medical Board but confidential from the Texas Medical Board,” she said at Fall Conference. “Our function is to enhance public safety to be a therapeutic alternative, in lieu of discipline. The two words I want you to walk away with are ‘confidential’ and ‘nondisciplinary.’”
Physician health programs also have a track record of success, Dr. McQueen says. TXPHP monitors physicians and documents their progress so that “those who have these conditions – but are taking care of these conditions – have an opportunity to practice with as few barriers as is possible.”
Addiction studies show that about 30% of the people who seek treatment will improve significantly and no longer meet the criteria for substance use disorder at five years, she says. By contrast, between 70% and 90% of physicians with substance use disorder who are monitored by PHPs are sober and licensed at five years.
“There is no medication or clinical intervention that begins to approach this success rate,” she said.
Also, physicians who have successfully completed monitoring with a PHP experience lower risk of malpractice claims after monitoring.
“The fear is that that if [physicians] seek out help that they’ll be discriminated against,” she said. “And what we have is evidence that says that physicians who are monitored [by a PHP] are safer to practice.”
Many physicians fear getting help for substance use disorder or other mental health problems because when they apply for or renew their medical license with TMB, they must answer this question:
“Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment, or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner?”
Until 2020, that question’s language was more intimidating and all-encompassing, asking physicians if they had ever been treated for such a condition, Dr. McQueen says. That broader language needlessly forced many physicians to defend any mental health treatment they may have obtained. In fact, Dr. McQueen herself faced this.
“I had my second child as a fourth-year medical student [in 1997] and I [had] depression,” she recounted. “I sought out help that was available to all medical students. And when I applied for my Texas license, I had to answer that question ‘yes.’ I got called to Austin for a one-on-one meeting with the president of the medical board, which was very friendly. … But the entire process was horrible. It was very stigmatizing. … And certainly, it was a reason then and continues to be a reason why medical students, residents, and physicians don’t seek help.”
Since then, the Texas Legislature created TXPHP as a way for TMB to address behavioral health problems among physicians in a therapeutic way. Also, the Federation of State Medical Boards and the American Medical Association partnered to change the question to the less-intimidating language used by TMB today, Dr. McQueen says.
The question now asks if the problem is current, and if the person still has not sought appropriate treatment.
Even for those who answer yes, the answer is confidential, Dr. McQueen says. Those physicians can expect to provide more information to TMB about the nature of the impairment. The board usually refers these cases to TXPHP.
“Many people, in my experience, will answer yes to this question and come to Texas PHP, and we may find out that they are being appropriately treated, and there isn’t a need for monitoring,” she said.
When there is a problem, physicians dealing with behavioral health problems can come to the attention of TXPHP in three ways: self-referral, referral by a third party, and referral by TMB. All three types of referrals are confidential, Dr. McQueen explained.
“You cannot call up and find out if your colleague was referred,” she said. “You cannot call and find out if your colleague referred themselves. You cannot find out if someone was confidentially referred from the medical board. If you get a letter saying the Texas Medical Board is referring you to the TXPHP, that is not public information.”
The program does not provide drug treatment or counseling. Instead, it meets with the physician to assess whether he or she has a behavioral health problem and then determines if that requires further evaluation or treatment, Dr. McQueen says. If more help is needed, TXPHP draws up an agreement with the physician that might include a worksite monitor, peer support meetings (including a 12-step program), drug testing, and treatment with a psychiatrist or counselor.
At Fall Conference, Austin internal medicine specialist Tony Aventa, MD, asked Dr. McQueen what happens if a third party makes a malicious accusation against a physician. She says the worst case for the physician is that he or she may have to pay fees to TXPHP and for the evaluation process. Those fees can cost more than $1,500.
“But contrary to popular belief, those evaluations sometimes say there’s no evidence of a problem, and that’s the end,” she said. “We report it back to the medical board as resolved. … And the medical board doesn’t get any details about how it was resolved.”
Temple internal medicine specialist Mammen Sam, MD, asked if information from TXPHP actions can be discovered as part of a lawsuit. Dr. McQueen replied that in some cases lawyers have attempted to obtain records from the companies doing TXPHP evaluations. However, the laws governing TXPHP records are far stricter than those for medical records.
“The confidentiality part of the Texas PHP is practically sacred,” she said. “In my time as medical director, we’ve had participants who couldn’t even get any part of their own files because it’s confidential.”
Most other aspects of TXPHP are strictly confidential – unless a physician first goes through a TMB disciplinary process and is publicly referred to TXPHP, Dr. McQueen says. That information is public, just like other disciplinary actions.
But TXPHP was created in part to help physicians get help, recover, and resume their careers before any disciplinary action is needed, she added.
Physicians making a third-party report to TXPHP on a fellow physician in trouble should remember that their report does not necessarily absolve them from also reporting the situation to TMB, Dr. McQueen clarified. Physicians who are not sure if they should report a colleague to TMB should consult a lawyer.
But it’s clear that by the time a physician shows signs of a substance use disorder or other behavioral health problems at work, the physician already is in crisis, Dr. McQueen says. The symptoms of that crisis typically show first in the physician’s personal life.
“Our careers, our licenses are so important to us that often the physician with an impairing condition will let everything fall apart – everything before work,” she said. “The consequences [at home] are racking up long before anything happens at work. So, I really encourage you: If you have even a little [feeling of], ‘Hmm, that’s odd,’ remember that by the time it gets to work, we have reached an emergency.”