If a doctor in Massachusetts is suspected of having a drug problem or a mental health issue, where are they referred? McLean Hospital in Belmont, the number one facility in the U.S. according to U.S. News? Almost never. Massachusetts General Hospital in Boston, the number two psychiatric facility according to U.S. News? Also almost never. Or my hospital, Cambridge Health Alliance? Never.

Instead, physicians in Massachusetts and all around the country are often told that they need to go to centers in Kansas or a handful of other states to receive comprehensive psychological evaluations. And if they refuse to go—even if they say they want to receive an evaluation at McLean, Mass General, or any local facility or provider—they risk losing their ability to practice medicine.

To understand why this is happening, some background information is necessary. If a physician seems impaired in some way in the workplace—behaving erratically or smelling of , for example—then a clinic chief or chief medical officer might demand that the physician meet with someone in the state physician health program (PHP). Or, if a state licensing board suspects a potential problem, they too might insist that a physician meet with a PHP. After a meeting with someone at a PHP, many physicians are told that they need a four-day evaluation from facilities in Kansas (or several) other states. These evaluations generally cost about $7,500 and are not covered by insurance.

Not infrequently, the outcome of one of these four-day evaluations is that physicians are told that they need to stay for 30-90 days for treatment, which can cost tens of thousands of dollars and is also not generally covered by insurance. If a physician balks at any stage of this process, the evaluation center will generally tell the PHP that the physician is being non-compliant. The PHP then will often inform the board of medicine about the non-compliance, which can then result in the physician losing the ability to practice medicine.

Why force a physician to go out of state when we have some of the best medical schools in the country here in Massachusetts with excellent and psychiatry programs?

One answer I have heard is “privacy.” Another is “special expertise.” I suspect the real reason is that these evaluation and treatment centers have bidirectional financial ties to PHPs. These centers depend on PHPs for a steady stream of referrals to stay afloat, and in turn, these centers sponsor state, regional, and national meetings of PHPs, ponying up big bucks to make ensure they make the list of “approved centers.”

(For an excellent summary of the issues, have a look at PJ Randhawa's investigative report on KSDK television in St. Louis available here.)

Why is any of this important? Because a lot of physicians are being coerced into costly evaluations and treatment stays if they want to able to continue practicing medicine. (I’ve seen physicians who couldn’t afford this treatment and stopped practicing medicine as a result.) Although PHPs often defend themselves by saying that they have no authority over licensing for physicians—which is generally true—the reality is that almost every board of medicine in the U.S. defers any and all concerns about mental health and substance use to its own state PHP and then mandates physicians to comply with any and all recommendations of its PHP if a physician wants to continue practicing medicine.

The upshot is that PHPs are supremely powerful and also completely conflicted with these evaluation and treatment centers. I have previously called for national standards and routine external audits of PHPs. To date, this has not happened. Even though the national organization of PHPs has some guidelines for state PHPs, these guidelines are not enforced.

To compound matters, the power of PHPs is largely unchecked because they are generally seen from without as benevolent entities helping doctors in need and often only ever questioned by physicians who’ve been referred to them, who largely are seen as bellyaching and/or addicts in denial of their substance abuse habit.

Physicians in the U.S. deserve better. They should be able to be evaluated by clinicians who are free of conflicts of interest. Everyone in the U.S. ought to care about this issue because some good doctors are being prevented from practicing medicine and others are often forced to go through a deeply unfair process to keep their license.