The impact of illegitimate authority on regulation of the medical profession: The overdue need for critical analsysis

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It is not wisdom but Authority that makes a law—Thomas Hobbes
In Questions of science, the authority of a thousand is not worth the humble reasoning of a single individual— Galileo Galilei

Regulatory Decisions and Public Policy 

Making sound decisions about regulation calls for an understanding of the problem it is intended to solve. Legitimate policy must be based on recognized institutions and experts. Regulatory changes demand methodologically sound science and evidence-based facts arrived at through rigorous peer review and professional oversight. The science must be reliable and unbiased. Legitimate policy must be based on legitimate institutions and expert authority grounded in wisdom. Authoritative opinion needs to be assembled with facts and best available evidence guided by science and critical reasoning to best solve a particular problem and benefit the greater good.

If the information regulatory agencies rely on to make regulatory decisions and public policy is unreliable then bad decisions, wrong decisions and flawed public policy are inevitable.   Consequences can be far-reaching and grave.

The impact of the close alliance between state medical boards and their state physician health programs (PHPs) and their national organizations on this failure to achieve the public goals with which they have been tasked has not been considered. It needs to be as the consequences of relying on this illegitimate and irrational authority have indeed been far-reaching and grave. Some of the nonsense pushed forth by the PHP movement and given “regulatory sanctification” by state medical boards is beyond belief. It would be comical if the results were not so tragic.

State Medical Boards

A physician’s right to practice medicine is granted by the state medical board in the form of a medical license. Each state has a medical practice act that defines the practice of medicine and used to regulate the medical profession. The medical board is empowered to identify and take action against doctors for substandard care, unprofessional behavior and other violations as defined by the state medical practice act. Given that medical boards are state agencies, their authority is subject to traditional constitutional constraints including equal protection and procedural due process limitations.

State Medical Boards have faced criticisms for being lax in their duty to protect the public from dangerous doctors.1,2 A recent study in the New England Journal of Medicine found that just 1% of physicians accounted for 32% of paid malpractice claims.3 One physician had at least 31 malpractice totaling more than $10 million in damages and nine of those payments were related to “failure to use proper aseptic technique” while another had at least 21 malpractice payments including eight improperly performed surgeries, three unnecessary surgeries and two surgeries on the wrong body part.   Neither of these doctors faced disciplinary action from their state medical board.

Failing to recognize the germ theory by failing to meet even the most basic standards of cleanliness and wrong-side surgery are egregious. The fact that these are not isolated one-offs but repeat offenders is reprehensible.     There is clearly something wrong with a system that allows such unfettered idiocy to flourish.

On the other hand there are increasing reports of excellent doctors with no history of malpractice or patient harm losing their licenses after one-offs, minor infractions or nothing at all.

The public’s goals would be better served if boards exercised their discretion against physicians who violate the most basic standards of professionalism and competency. They are failing to achieve this task.

The Federation of State Medical Boards (FSMB)

The Federation of State Medical Boards (FSMB) is a national not-for profit organization that gives guidance to state medical boards through public policy development and recommendations on issues pertinent to medical regulation.

Shortly after its founding in 1912, the Federation of State Medical Boards began publishing a quarterly journal addressing issues relating to medical licensing and regulation of doctors. First published in 1913 as the Quarterly of the Federation of State Boards of the United States, the publication has undergone several name changes and publication schedules. The archival organization and availability of full articles published sequentially over the past century is historically invaluable as it provides not only the regulatory by the national organization involved in the medical licensing and regulation of doctors and this archival organization facilitates an unskewed and impartial examination in its historical context. A focus on sound decision-making can be seen in the regulatory and legal medicine literature up until the 1990s.

For example when drug-testing was first introduced questions of validity became a genuine topic of concern.

By the late 1980s almost every state medical board was utilizing random drug and alcohol testing.   Noting that “not all testing methods and results are created equal,” South Carolina State Board of Medical Examiners executive director Stephen S. Seeling, J.D. addressed the critical importance of accuracy and reliability in the Federation Bulletin in 1988 and cautioned that “if boards wish to be able to use positive results of drug screens in administrative or legal proceedings, great care must be taken to insure that the results are accurate, reliable and thus legally probative.” 4 Suggesting that board members and board attorneys be familiar with specific testing methodologies Seeling concludes that:

Random drug testing is an important tool for every board in its mission to protect the public and maintain the integrity of the medical profession. Careful attention however must be given to this process to insure the reliability and legal defensibility of testing results. Failure to do so could diminish the board’s credibility in the eyes of the profession and the public, and expose the board to potentially serious legal challenges.”4

This sound decision-making unfortunately took a nasty left turn in 1995. In that year the Federation of State Physician Health Programs (FSPHP) forged a relationship with the Federation of State Medical Boards. They have been going strong ever since.

1995 FSPHP/FSMB Alliance

The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence, published in JAMA in 1973,5 recommended that state medical societies establish programs to identify and treat “impaired physicians” which the AMA defined as “a physician who is unable to practice medicine with reasonable skill and safety to patients because of mental illness or excessive use or abuse of drugs, including alcohol.”

Physician Health Programs (PHPs) were subsequently developed to assist with the goal of rehabilitating and monitoring doctors as an alternative to disciplinary action by state medical boards. Preferring rehabilitation to probation or license revocation so long as the public was protected from imminent danger, most medical boards accepted the concept with support and referrals.

PHPs existed in almost ever state by 1980. Often staffed by volunteer physicians and funded by the state medical society, these programs served the dual purpose of helping sick doctors and protecting the public. As an alternative to disciplinary action these programs advocated for physicians who developed illness, assured they got proper treatment and provided monitoring to assure they remained healthy. The mechanics and mentality of PHPs were initially quite variable.

The model used today came out of the “impaired physician movement,” which according to British sociologist G. V. Stimson is “characterized by a number of evangelical recovered alcoholic and addict physicians, whose recovery has been accompanied by an involvement in medical society and treatment programs. Their ability to make authoritative pronouncements on physician impairment is based on their own claim to insider’s knowledge.”6

In 1987, the Atlanta Journal and Constitution ran a series of reports after five patients in the “Impaired Professionals” program at Ridgeview Institute created by G. Douglas Talbott in Atlanta killed themselves7 and least 20 more died by suicide after leaving Ridgeview.8 It was reported doctors were coerced into Ridgeview and then threatened and bullied to comply with any and all demands under threat of loss of licensure. All patients were indoctrinated into A.A. and forced to confess they were alcoholics or addicts or threatened with expulsion and with not being certified or advocated for with their Medical Boards.

A “recovering” alcoholic and addict who had previously been a successful cardiologist Talbott created the DeKalb County Impaired Physicians Committee for the Medical Association of Georgia in 1975 and subsequently founded the Georgia Disabled Doctors Program for the assessment and treatment of physicians, in part because “traditional one-month treatment programs are inadequate for disabled doctors.” He created the “Impaired Professionals” program at Ridgeview to provide this specialized treatment. The Constitution reported that doctors entered the program under “threats of loss of licensure even when they would prefer treatment that is cheaper and closer to home,” 9 because Ridgeview “enjoys unparalleled connections with many local and state medical societies that work with troubled doctors,” and “licensing boards often seek recommendations from such groups in devising an approved treatment plan”

money1-richdoctorThe Constitution reported that those in charge of the program are often “physicians who themselves have successfully completed Ridgeview’s program.”9  The impaired physician movement emphasizes disease and therapy, rather than discipline and punishment. They believe that alcoholism and addiction is a chronic relapsing brain disease requiring lifelong abstinence and 12-step spiritual recovery. The drug or alcohol abuser or addict is a person lacking adequate internal controls over his behavior and for his own protection as well as the protection of society external restraints are required including involuntary treatment.

“Contingency-management,” or systematic use of reinforcement is a type of treatment used in the mental health field in which patient’s behaviors are rewarded (or less often punished). It has successfully been used in substance abuse treatment by using prizes or vouchers for positive reinforcement by, for example giving prizes or vouchers for negative drug screens or following up for an appointment.10,11. At Ridgeview, a doctor’s medical license was being used as the leverage. This is not contingency management. It is extortion.

Many addiction professionals were highly critical of Talbott’s methods, including LeClair Bissell.7 and Assistant Surgeon General John C. Duffy who said that Ridgeview suffered from a “boot-camp mentality” toward physicians under their care.”8   “”

Talbott justified this length of stay because he claimed doctors were unique because of what he calls the “four-MDs,” ”M-Deity”, “Massive Denial” “Militant Defensiveness” and “More Drugs.”12

lab fraud $$The cost of a 28 day program at Ridgeview was $10,000 but far more for the thrice lengthy stay required by healthcare professionals..8  I would say the impetus behind this is due to just “two-MDs,” “Medical License,” and “More Money.”

A jury awarded $1.3 million to the widow of one of the deceased physicians against Ridgeview,13 and other lawsuits initiated on behalf of suicides were settled out of court, but nothing else has changed.14

These suicides did not generate any reaction from the medical community at large and any doctor referred by a PHP for an assessment today will spend at least 3 months in treatment. ”   It is inevitable. The Dicto simpliciter argument of “terminal uniqueness” has been cemented as in 1995 this PHP model won the lottery.   A 1995 issue of The Federal Bulletin: The Journal of Medical Licensure and Discipline, published by the Federation of State Medical Boards, contains articles outlining PHP programs in 8 separate states. Although these articles were little more than descriptive promotional pieces written by state PHP program directors with no described study-design or methodology the journals Editor proclaimed “the success rate of the programs and others like them approach 90%.” 15 and “cooperation and communication between the medical boards and the physician health programs must occur in an effort to protect the public while assisting impaired physicians in their recovery.” 15 The 8 state PHPs were all based on Talbott’s methodology.

Screen Shot 2015-01-09 at 1.59.40 AMNonsense such as the “four-MDs” and thrice lengthy treatment has been accepted without scrutiny. Logical fallacy is written as science. For example Merlo and Gold use the “appeal to consequences” logical fallacy to justify the extended length of stay stating that “physicians with a substance use disorder are not typical of addicts in general, it is not useful to apply standard professional guidelines… Rather, because of the public health consequences of relapse, most physicians who are addicted are treated more aggressively and for longer periods” than non-physicians.

According to Merlo and Gold “Physicians will lobby for a level of care that minimizes the disruption of their daily life. However, it is generally not advisable to grant the physician’s request for treatment in the least restrictive environment, but rather to maximize the treatment dose and duration to improve effectiveness and reduce the likelihood of relapse and further damage to health, family, and the ability to practice. Depending on the response to treatment, physicians typically undergo 3 to 6 months of intensive treatment in a structured program and 5 years of urine testing with controlled, contingency-managed outpatient follow-up.16 This  gibberish has no basis in reality. It is made up out of whole cloth.  No evidence-base exists and it is  propaganda based fear that defies not only reason but common sense.

“Potentially Impairing Illness” “Relapse Without Use” “Dumb and Dumber”

 The Federation of State Medical Boards House of Delegates adopted an updated Policy on Physician Impairment at their 2011 annual meeting approved the concept of “potentially impairing illness.”

According to the Federation of State Physician Health Programs …”physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years. This is a critically important distinction. Illness is the existence of a disease. Impairment is a functional classification and implies the inability of the person affected by disease to perform specific activities.”

Screen Shot 2016-06-07 at 7.48.20 AM“Process addiction” was added as a potentially impairing illness including compulsive gambling, compulsive spending, compulsive video gaming, and “workaholism.” According to the FSPHP “the presence of a process addiction can be problematic or even impairing in itself, and it can contribute to relapse of a physician in recovery. As such, process addictions should be identified and treated.” They define three levels of relapse. “Relapse without use” is a 12-step concept. G. Douglas Talbott defines it as “stinkin thinkin.”Screen Shot 2016-06-07 at 7.44.04 AM

According to Judith Eaton of the Massachusetts PHP, Physician Health Services, Inc. (PHS), not having “complete, accurate, and up-to-date records” could be a red flag for such a potentially impairing illness as “when something so necessary is not getting done, it is prudent to explore what else might be going on.”

The FSMB and state medical boards have gone on to condone polygraph testing and non-validated neuropsychological testing pseudoscience in their “disruptive physician” exams.   Is the magic 8 ball and tea leaves next? How low does the credibility compass have to go before someone stands up and calls bullshit on this carnival?   The most egregious of indiscretions has been the introduction and acceptance of junk-science.

“Medical Sanctification of Junk-science”

Those behind the Inquisition knew they did not have to convince everyone to get what they wanted, just Ecclesiastical and political authority. The same applies here. Ethyl Glucuronide (EtG) was introduced in 1999 as a biomarker for alcohol consumption,17 and subsequently suggested as a tool to monitor health professionals by Dr. Gregory Skipper because of its high sensitivity to ethanol ingestion.

content-1What is so egregious about this is there was absolutely no evidence base. Skipper, who was convicted of a felony in Oregon and had his licenser revoked but got it back by claiming he was redeemed through A.A. read about it and after a study on just 14 patients pitched it to a drug testing company as a Laboratory Developed Test (LDT). The LDT pathway is a shortcut to get lab tests approved (under the premise that it will be used in treating a person medically and is thus of benefit) but Skipper took advantage of this loophole to develop a “forensic” LDT. He then used his position as the Alabama PHP Director to pitch it to the Medical Board before the ink dried.

As an LDT the FDA has no control over advertising so the lab can make any claims they want and in this case they claimed a positive EtG (> 100) was definitive proof of drinking. The State PHPs started using them on physicians. As PHPs were using them, the labs were able to sell it to other groups seeing they were “medically sanctified.” The test was subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash18,19, hand sanitizer gel20, and nonalcoholic wine.21 Sauerkraut and bananas have even been shown to cause positive EtG levels.

After a Wall Street Journal Article came out debunking the test most monitoring programs abandoned it. PHPs did not. Talbott puts out a list of literally hundreds of products doctors need to avoid including colognes, mouthwashes, and foods.

Skipper simply kept raising the cutoff point from 100 to 250 to 500. It is now known hand sanitizer alone can cause a level of 2000. He subsequently introduced other tests as confirmatory tests.Screen Shot 2015-03-19 at 9.02.57 PM

Many people had licenses revoked, loss of custody of their children, went back to jail, and suffered multiple other losses. If you look at the evidence base it is absent. There is nothing. The emperor has not clothes. This is a racket and the damage has been grave.

These same people are trying to sell the “PHP-blueprint” and its array of non-validated test to other populations as the “new paradigm” just as they did with the snake oil tests. The same carney hucksters are promoting the whole enchilada as a package deal. In “Six lessons from state physician health programs to promote long-term recovery” Robert Dupont and Dr. Greg Skipper attribute a high success rate to the following factors:22

(1) Zero tolerance for any use of alcohol and other drugs;

(2) Thorough evaluation and patient-focused care;

(3) Prolonged, frequent random testing for both alcohol and other drugs;

(4) Effective use of leverage;

(5) Defining and managing relapses; and

(6) The goal of lifelong recovery rooted in the 12-Step fellowships.22

Caveat emptor people. Caveat emptor!  Any argument should be based on its own merits and methodology and evidence must be examined to discern its validity. Hopefully other agencies will look at this with a more jaundiced eye and less obtusity than the FSMB and state medical boards.

Unfortunately the position of the regulatory agencies towards this illegitimate authority and irrational authority has been one of uncritical acceptance and blind faith. It is the absence of objective assessment and critical analysis that has enabled the FSPHP and PHPs to gain tremendous sway in the medical profession and cause tremendous harm to the medical profession. By confusing ideological opinions with professional knowledge the medical boards have rubber stamped whatever’s been thrown their way and for this they should be ashamed. The impact of this close alliance between state medical boards and their state physician health programs (PHPs) and their national organizations on the current state of medicine has not been examined. It needs to be.

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  1. Jost TS, Mulcahy L, Strasser S, Sachs LA. Consumers, complaints, and professional discipline: a look at medical licensure boards. Health matrix. Summer 1993;3(2):309-338.
  2. Galusha BL. Quality initiatives. The role of medical licensing and disciplinary boards. Quality assurance and utilization review : official journal of the American College of Utilization Review Physicians. Aug 1988;3(3):66-70.
  3. Studdert DM, Bismark MM, Mello MM, Singh H, Spittal MJ. Prevalence and Characteristics of Physicians Prone to Malpractice Claims. The New England journal of medicine. Jan 28 2016;374(4):354-362.
  4. Seeling SS. Thoughts on the reliability of drug testing. Federation bulletin / Federation of State Medical Boards of the United States. Aug 1988;75(8):230-234.
  5. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA : the journal of the American Medical Association. Feb 5 1973;223(6):684-687.
  6. Stimson GV. Recent developments in professional control: the impaired physician movement in the USA. Sociology of health & illness. Jul 1985;7(2):141-166.
  7. King M, Durcanin C. The suicides at Ridgeview Institute: A Doctor’s treatment program may be too tough, some say. Atlanta Journal and Constitution. December 18, 1987a, 1987: A12.
  8. Durcanin C, King M. The suicides at Ridgeview Institute: Suicides mar success at Ridgeview with troubled professionals. Atlanta Journal and Constitution. December 18, 1987, 1987: A13.
  9. King M, Durcanin C. The suicides at Ridgeview Institute: Many drug-using doctors driven to Ridgeview by fear of losing licenses. Atlanta Journal and Constitution. December 18, 1987b, 1987: A1.
  10. Petry NM, Alessi SM, Hanson T, Sierra S. Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients. Journal of consulting and clinical psychology. Dec 2007;75(6):983-991.
  11. Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction. Feb 2006;101(2):192-203.
  12. Gonzales L. When Doctors are Addicts: For physicians getting Drugs

is easy. Getting help is not. Chicago Reader. July 28, 1988, 1988.

  1. Ricks WS. Ridgeview Institute loses $1.3 million in suit over suicide. Atlanta Journal and Constitution. October 11, 1987, 1987: A1.
  2. Durcanin C. The suicides at Ridgeview Institute: Staff members didn’t believe Michigan doctor was suicidal. Atlanta Journal and Constitution. December 18, 1987, 1987: A8.
  3. Schneidman B. The Philosophy of Rehabilitation for Impaired Physicians. The Federal Bulletin: The Journal of Medical Licensure and Discipline. 1995;82(3):125-127.
  4. Merlo LJ, Gold MS. Successful Treatment of Physicians With Addictions: Addiction Impairs More Physicians Than Any Other Disease. Psychiatric Times. 2009;26(9):1-8.
  5. Wurst FM, Kempter C, Seidl S, Alt A. Ethyl glucuronide–a marker of alcohol consumption and a relapse marker with clinical and forensic implications. Alcohol Alcohol. Jan-Feb 1999;34(1):71-77.
  6. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. Journal of analytical toxicology. Nov-Dec 2006;30(9):659-662.
  7. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. Journal of analytical toxicology. Jun 2011;35(5):264-268.
  8. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. Journal of analytical toxicology. Oct 2008;32(8):594-600.
  9. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  10. Dupont RL, Skipper GE. Six lessons from state physician health programs to promote long-term recovery. Journal of psychoactive drugs. Jan-Mar 2012;44(1):72-78.

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Physician Health Programs: The Need for Transparency and Accountability

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Accountability, or answerability,  is necessary to prevent abuse and corruption.  This requires both the provision of information and justification for actions.  What was done and why?

Professional guidelines and standards of care, ethical codes of conduct and the law are all objective benchmarks that can be used to assess the actions and decisions of others.  In any free society this necessitates the existence of organizations of truly independent opinion capable of standing in this judgment.

State PHPs are Non-Governmental Organizations (NGOs) over which the state health department has no supervisory oversight.  There is no regulation, no transparency and no accountability.  There is no public scrutiny and they police themselves.

In Ethical and Managerial Considerations Regarding State Physician Health Programs Drs. John Knight and J. Wesley Boyd call for greater oversight and scrutiny of PHPs by the medical community at large.   They recommended periodic auditing, national standards and regulation.  They also attempted to convince the Massachusetts Medical Society to implement changes at PHS where they served as Associate Directors with over two decades of collective experience.

These efforts to promote transparency and accountability at both local and national levels, however,  fell on deaf ears.

State PHPs have systematically removed those not conforming to groupthink.  Threatening them with litigation if they breached “peer-review” statutes and confidentiality agreements has effectively silenced them from reporting any misconduct, abuse or even crimes they may have witnessed.

In Massachusetts John Knight was removed in 2009 and J. Wesley Boyd in 2010.  In Ethical and Managerial Considerations Regarding State Physician Health Programs  they comment “if a PHP highlights a physician as particularly problematic, the evaluation center might–whether consciously or otherwisetailor its diagnosis and recommendations in a way that will support the PHP’s impression of that physician.”  So too will the clinical laboratories.  

How is this any different from the case of Dr. Farid Fata, the Michigan oncologist who intentionally diagnosed healthy patients with cancer so he could charge them for unneeded chemotherapy?  The U.S. Attorney called it the “most egregious” case of health care fraud ever. His acts may have contributed to one patient death.   The institutional injustice of the PHP system is causing countless deaths of physicians.

To consciously “tailor” a diagnosis is fraud.  To tailor a diagnosis of substance use disorder or any other psychiatric diagnosis is the political abuse of psychiatry.  Misrepresentation, dishonesty, deception, and distortion play no role in the Profession and Guild of Medicine.  To do so violates the basic moral principles of Medical Ethics–Autonomy, Beneficence, Non-Maleficence and Justice.

The “PHP-approved” assessment and treatment centers are all staffed by doctors of “like-mind.”  It is a rigged game.

An audit of the North Carolina PHP found essentially no oversight from the Medical Board or Medical Society.  The audit found that “abuse could occur without being detected,” and this is by design.  By removing and blocking the provision of information necessary for accountability, restricting the liberties and freedoms of physicians, and increasing their power and control they have erected a framework of hidden abuse.

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The situation in North Carolina is standard operating procedure for PHPs under the Federation of State Physician Health Programs (FSPHP).  It is not the exception but the rule.

While outspoken in denouncing what they regard as unethical and unprofessional behavior by other doctors, they are resistant to apply even the most minimal standards to their own activities.

To whom are the PHPs accountable? Whom do they represent? These are legitimate concerns.


 

PHYSICIAN OR PROFESSIONAL HEALTH PROGRAM SURVEY

Professional Health Program (PHP) Survey

Please click on the link below and complete the following survey if you have been monitored or are being monitored by a PHP.

Professional Health Program (PHP) Survey

This is a confidential survey. If you have concerns about anonymity please create an alternative alias email address (this video shows you how to create an alias G-mail address), then use the alias email address as your “name” for future correlation.

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Transparency and Legitimacy Needed in Addiction Medicine—Answerability and Accountability Absent in Current Paradigm

The Medical Profession, Moral Entrepreneurship, Moral Panics, and Social Control.

 “Few, no matter how desperate, seek help of their own accord.”  says Dr. Marv Seppala, M.D., Chief Medical Officer at Hazelden, one of the “PHP-approved” drug and alcohol assessment and treatment centers located in Center City, Minnesota.  “Physicians are intelligent and skilled at hiding their addictions.”

“They’re often described as the best workers in the hospital,” he says. “They’ll overwork to compensate for other ways in which they may be falling short, and to protect their supply. They’ll sign up for extra call and show up for rounds they don’t have to do.”

In reality this is ludicrous–knee slapping absurd.   If the results of this authoritative opinion were not so dire these statements would, in fact, be comical.   Such is not the case, however, and opinions like Seppala’s have been taken at face value and, as a result, the aftermath has been and continues to be tragedy.IMG_0706

Addiction, alcoholism and substance abuse to any significant degree produce both physiological and behavioral manifestations in the user. It is cause and effect.  Pathophysiology conforms to law of nature and not the whims of the impaired physician movement.

What anomalous  aspect of intelligence or special skill set would enable a doctor to hide an addiction?

The ASAM definition of addiction is characterized by cognitive, behavioral and emotional changes which include “impaired control” so how would intelligence rein it in?  Furthermore, what unique logical, rational, analytical, factual, abstract, intuitive or objective aspect of intelligence is responsible for this preternatural fortitude?

How is the intelligence of a doctor any different from the intelligence of any other human being?  And what prodigious abilities do doctors have that enable them them to cloak the  behavioral manifestations and stave off the physical consequences chemical addiction to such a degree that they are able to maintain the facade of being  “described as the best workers in the hospital?”  Is it an innate inborn endowment or an esoteric knack acquired during medical training?

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What ability and artistry would allow a profession to weave such a web of fortitude that they can convincingly shroud the myriad signs and symptoms of drug and alcohol abuse unlike the regular folk?    Perhaps access to ophthalmic vasoconstrictors and beta blockers to temper the pupillary dilation and tremulousness associated with stimulants or botox and a testosterone patch to mask the skin changes and maintain lean muscle mass in the throes of alcoholism?

How does overworking “protect their supply” and why would they keep it at the hospital?  These people have prescription pads and last I checked there were no cocktails shakers or bottles of Jameson in the doctors lounge.

And for the life of me I cannot comprehend why an alcoholic or addict doctor would sign up for extra call and show up for rounds on his day off.  What would be the point?

In reality a doctor with a drug or alcohol problem would be erratic with call and show up late for rounds.

This is just another example of authoritative opinion with no substantive value. It is moral entrepreneurship at its finest; the fallacy of appeal to authority and secret knowledge.

If Seppala were asked to provide the evidence-base and rationality of these statements he would be hard pressed to do so.  The question would be met with deflection, logical fallacy, references to the opinions of like minds and thought-stopping memes.  “You need a check-up from the neck up,”  your best thinking got you here,”  there is no “I” in “team,” “denial isn’t just a river in Egypt.”  Oh, yeah?   well “Rogue” isn’t just a river in Oregon and, while we are at it, “Boring” isn’t just a town!

It is this type of misinformation and propaganda that allows the “impaired physician movement” to  drag away the “best worker in the hospital” and deem him “in denial.”

“We were so surprised. We didn’t even know he had a problem”  say the nurses, patients and colleagues left behind.

Well the truth is he probably didn’t!

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Blind-faith and unquestioning allegiance to expert authority deflects scrutiny and analysis.  Few red flags are raised as this type of moral preening promotes misguided plausibility and complacency in the belief that these are indeed experts with good intentions. This needs to be addressed.

But if you look at any of the current “moral panics” that are being used to suggest random suspicion-less drug testing of doctors or promoting the Physician Health Programs as successful and replicable models, you will inevitably find a doctor on this list behind it. It is a given.

And the invitation goes out to Seppala to debate this in a public forum on a level playing field.    Not gonna happen because it would be impossible for him to address and answer the questions rationally,  directly and with any tiny scrap of evidence based data.  This is being shown clearly on Medscape as both the Federation of State Physician Health Programs (FSPHP) and the American Society of Addiction Medicine (ASAM) remain silent despite the mounting horror stories from doctors diagnosed with pathology when none existed who were forced into treatment they did not need.  Diagnosis rigging, forensic fraud, lack of due process and all manner of abuse are being reported but as an organization with power maintained by by lack of accountability and secrecy they will not and cannot answer.  It is time we identify these groups as illegitimate and irrational authority and demand transparency and legitimacy.

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Question Authority: The Need for Anti-Authoritarians in the Medical Profession

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Anti-authoritarians question whether an authority is a legitimate one before taking that authority seriously.  images-24To evaluate the legitimacy of  an authority it is necessary to:
1. Assess whether they actually know what they are talking about.   2. Assess whether the authorities are honest in their intentions.
When anti-authoritarians assess an authority to be illegitimate, they challenge and resist that authority.
There is a paucity of anti-authoritarianism in the medical community concerning groups that have gained tremendous sway in the regulation of the medical profession.    There is, in fact, an absence of anti-authoritarian questioning  of  what is essentially illegitimate and irrational authority.
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Most doctors are unaware of the impact these organizations have had on both the regulation of the medical profession and social control of individual doctors.  Through “moral entrepreneurship” and “bent science” these groups have successfully swayed both policy-makers and the public to support an agenda not supported by reality testing or critical thinking.  This acceptance without investigation has led to a deterioration of professional ethics and evidence-based decision making in the regulation of the medical profession.
 In order for these organizations to maintain power it is necessary that their authoritative opinion remain unquestioned and unchallenged.  Consciously manufactured propaganda has persuaded regulatory and public opinion of their value and to maintain power it is necessary that this authority remain insulated from outside evaluation because the entire system is based on assumptions that can be aptly characterized as “illusions.
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The dogmatic statements and abusive generalizations do not conform to reality.
Everything is adapted to an existing stagnant cognitive system that falls far off the map of the scientific approach to information and evidence based medicine.  Perceiving only confirmations the physician health paradigm embodies and expresses preconceived ideas, values and mentalities based on certitude and absolute truth.

If one looks behind the curtain there is not much there.   Screen Shot 2015-06-16 at 3.39.59 AM

Historical, political, economic and social analysis can all show how the construct that exists today came to be.   This can be factually ascertained by simple reasoning and examination of the documentary evidence.

Any one of these analyses would reveal that the “PHP-blueprint” is a false-construct built on circumnavigation and obfuscation.

An evidence-based scrutiny of the literature would reveal it to be invalid and of little probative value.  A public policy analysis would reveal the logical fallacies involved in trumpeting  their positions including exaggerated rhetoric and  fear monitoring strategies designed to inspire moral panics and exploit fears to further an underlying political agenda

Any critical analysis would reveal cherry picking. proof by anecdote, deceptive propaganda, double talk, contradictory, illogical and incomprehensible jabber,  unprovable and  un-disprovable statements and a panoply of logical fallacy.

These groups  misrepresent, censor and suppress. They  nit pick and split hairs.  Screen Shot 2015-06-16 at 3.40.37 AMThe concept of denial is not just used to force people into treatment and justify abuse during treatment but  to suppress specific questions and deliberately avoid key facts.

So why are we not questioning this “authority?”     They have been left alone and basically thrown in the backyard left to proliferate like feral cats.

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We need anti-authoritarians and we need them now.

I need allies before the door closes for good. And that door may be closing a lot sooner than you think!

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The Need to Speak up Against Bad Science, Bad Medicine, Bad Policy and Bad Actors–Neutrality is not an Option. Use Your Voice and Question Authority!

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The bad science, bad medicine, bad policy and bad actors are easy to identify. It would be like shooting fish in a barrel.

So what are the barriers?

Why has this not been done?

The answer to that is complex but involves a confluence of factors including psychological, political and cultural. “Feel good fallacy,” “political correctness, and moral and policy entrepreneurship have effectively swayed the targets intended. The well-funded misinformation and propaganda was cast with a large net using the same techniques others have successfully used throughout history to accomplish the same. Moral panics, moral crusades, and a plethora of logical fallacy have been used and used with considerable resources and skill.

So what can we do about it?

The first “step into the breach” is to identify the problem with the first one being the Emperor has no clothes. Once this is acknowledged it would not take long to address directly the specific problems and erroneous assumptions of this paradigm through the lenses of science, critical reasoning, ethics and common sense. If this were to be done the entire Potemkin village would fall like a house of cards.Screen Shot 2015-06-15 at 12.05.53 AM

But the very first and simplest step is to use your voice to question this authority. Neutrality is not an option.   Either support what these groups are doing or question them with your voice and the written word.

The bad science, medicine, policy and actors are obvious.   It would be like shooting fish in a barrel and the first target needs to be the “PHP-Blueprint.”   It would be so easy to take down this “research” they are using to promote PHPs as a “gold-standard” and replicable model.  Shooting fish in a barrel requires someone take aim and at this point hardly anyone is even willing to pick up the gun.

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Disrupted Physician

Drug Companies and Doctors: A Story of Corruption.

What we need is a Marcia Angell to take on the multi-billion dollar drug and alcohol testing, assessment and treatment industry.

Screen Shot 2015-06-01 at 7.22.25 PMWhile all eyes were focused on the drug companies these multi-billion dollar industries erected a scaffold of immunity and profit by removing (and blocking) themselves from essentially all aspects of accountability; answerability, justification for actions and the ability to be punished by outside actors.    The 2009 quote in reference to “big pharma”  is just as applicable to the drug and alcohol testing industry,”  the inpatient assessment and treatment centers and the “authorities” pushing public policy and swaying public opinion to accept irrational and illegitimate authoritative opinion as truth.

And unlike the pharmaceutical industries carefully constructed “bent science” which requires a keen eye and critical analysis , the evidence-base supporting the testing, assessment and treatment industry rests on a foundation that can…

View original post 541 more words

The Medical Profession under Dictatorship–Revisiting Dr. Leo Alexander’s prescient warnings from 1949

“Let it be considered, too, that the present inquiry is not concerning a matter of right, if I may say so, but concerning a matter of fact.”–Adam Smith

“Most men endure the sacrifice of the intellect more easily than the sacrifice of their daydreams.  They cannot bear that their utopias should run aground on the unalterable necessities of human existence”  -Ludwig von Mises

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“Science under dictatorship becomes subordinated to the guiding philosophy of the dictatorship.” So begins Medical Science Under Dictatorship1 written in 1949 by Leo Alexander and published in the New England Journal of Medicine. Alexander acted as consultant to the Secretary of war and the Chief Counsel for the Nuremberg trials.

The guiding philosophic principle is Hegelian or “rational utility” and “corresponding doctrine and planning”, Alexander said “replaced moral, ethical and religious values” and Nazi propaganda was highly effective in perverting public opinion and public conscience. He explains how this expressed itself in a rapid decline in standards of professional ethics in the medical profession.   This all “started from small beginnings” with subtle shifts in the attitudes of physicians to accept the belief that there is such a thing as “a life not worthy to be lived.”

In 1985 the British Sociologist G.V. Stimson wrote of a new form of professional control in the United States that had emerged in the preceding decade whose “success rests on the ability to take certain areas of conduct such as alcoholism and drug abuse (which are formally disciplinary issues) and handle them as diseases.”2

Stimson writes:

“The impaired physician movement is characterized by a number of evangelical recovered alcoholic and addict physicians, whose recovery has been accompanied by an involvement in medical society and treatment programs. Their ability to make authoritative pronouncements on physician impairment is based on their own claim to insider’s knowledge.”2

Among these authoritative pronouncements was the use of specialized treatment centers. Many professionals were critical of these programs including Assistant Surgeon General John C. Duffy who criticized the “boot-camp mentality”4 toward doctors and American Society of Addiction Medicine President Leclair Bissel who when asked in a 1997 interview when the field began to see physicians as a specialized treatment population replied “when they started making money..” .” 5

Amid reports of abuse, coercion and control in facilities using a doctor’s medical license as “leverage,” the Atlanta Journal Constitution ran a series of reports in 1987 documenting the multiple suicides of health care practitioners at one of these programs (5 while in the facility and at least 20 after discharge).6   Neither these suicides nor a large settlement against the same facility (finding a non-alcoholic doctor was intentionally misdiagnosed as an alcoholic and forced into months of treatment)  for fraud, malpractice, and false imprisonment involving intentional misdiagnosis7 generated any interest among the medical community at large.

And by 1995 the door had closed as the Federation of State Physician Health Programs ( FSPHP ) relationship with the Federation of State Medical Boards (FSMB), the national organization responsible for the licensing and discipline of doctors,  was forged.  A 1995 issue of The Federal Bulletin: The Journal of Medical Licensure and Discipline, contains articles outlining the high success rates of these programs in 8 states with an editorial comment from the FSMB that concludes:

“cooperation and communication between the medical boards and the physician health programs must occur in an effort to protect the public while assisting impaired physicians in their recovery.”8

The Federation of State Medical Boards (FSMB) has approved any and all policy and regulation put forth by the impaired physician movement  then organized under the Federation of State Physician Health Programs (FSPHP) with no apparent inquiry or opposition.

In 2003 Dr. Gregory Skipper, one of the key players of the impaired physician movement partnered with NMS labs to develop the alcohol metabolite ethyl-glucuronide (EtG) as a laboratory developed test13 14 he proposed be used as a monitoring tool for covert alcohol use in physicians after a pilot study involving just 14 psychiatric inpatients.15

The policy entrepreneurship this group so effectively uses to advance their goals can be seen in the August 25, 2004 Journal of Medical Licensure and Discipline which contains articles both presenting the problem 11 and providing the solution.11   The EtG was then introduced as an accurate and reliable indicator of covert alcohol use and the impact of this cannot be underestimated as it introduce to the market not only unregulated non FDA approved tests for forensic use but tests reaching further back into history then those used by workplace drug-testing programs.

The limitations of any test needs to be understood both in the forensic and clinical context but there is a lot less flexibility in the forensic context when people’s liberties, freedoms or property rights ( as with a medical license) are in jeopardy.

Sensitivity and specificity need to be carefully considered.  The positive predictive value of a test is the true positives over the true positives plus false positives.  If you are going to sanction somebody as a result of a single test that test needs to have 100% sensitivity.

When workplace drug testing was introduced debates over both the accuracy and scope of tests occurred. The employees right to privacy and the employers right to have a drug-free workplace were discussed with the general consensus being testing for impairment was a legitimate concern but preservation of private life should remain.

What was done here dissolves both.

PHP programs require abstinence from all substances including alcohol and strict adherence to 12-step doctrine9 yet many of the physicians monitored by them are neither addicts nor alcoholics. Requiring abstinence from drugs and alcohol while using non-FDA approved Laboratory Developed Tests in monitoring programs is a dangerous combination. The suicides reported by the Atlanta Journal Constitution in 1987 were prior to the introduction of these tests. Adding these tests of unknown validity to an already abusive program of coercion and control would only worsen the situation.

I have been hearing of multiple suicides involving both the fear of results and false results. I have also been hearing of doctors who have killed themselves because they were suffering from depression but did not seek help as their fear of being ensnared into the PHP outweighed the need to get help.

Three decades after G.V. Stimson so accurately defined the impaired physician movement the impaired physician movement defines the professional control of medicine..   Their involvement in medical society physician health programs (PHPs) and treatment programs has evolved into absolute control of both. Pronouncements on physician impairment have evolved from insider’s claims to written edict.   And their reach has extended from impairment due to drugs and alcohol to “potential impairment” and “relapse without use.” Their reach has extended from drug and alcohol impairment to all other aspects of medicine and the impact has been profound.   Medicine has been subordinated to the guiding philosophy of the impaired physician movement and doctors are dying in droves du to institutional injustice.

How does the profession of medicine reconcile the fact that we have allowed an as yet non ABMS recognized “self-certification” specialty full reign over those who are ABMS recognized?  How is it that we allow non-FDA approved Laboratory Developed Tests (LDTs) of unknown validity on doctors coerced into state Physician Health Programs (PHPs)?    A recent debate in Washington calling for regulation of  “clinical”  LDTs just took place and the fact that they are being used for “forensic” purposes in doctors is incomprehensible.   Has anyone noticed it is the same people introducing the tests who are claiming PHPs are the “gold standard,” trying to push them on other EAPs and calling for more widespread use of these tests?

The use of non-FDA approved Laboratory Developed Tests (LDTs) for drug and alcohol testing  is currently limited to PHPs and the criminal justice system. (i.e. monitoring programs in which those doing the testing have power and those being tested have no power). That may soon change. See  Drug Testing and the Future of American Drug Policy and The American Society of Addiction Medicine White Paper on Drug Testing describing the plans for widespread expansion of this drug testing to other groups including kids.

Those involved in the Massachusetts General Hospital Laboratory Medicine, Toxicology and addiction medicine departments looked critically at these tests and decided hands down against using them. Why? Because no evidence base exists and the potential harm far outweighs any perceived benefit.  “Research” has been done on those being monitored by PHPs and the criminal justice system and Drs. J Wesley Boyd, M.D., PhD, and John Knight, M.D. of Harvard Medical School who collectively have over two decades of experience as Associate Directors with the Massachusetts PHP, Physician Health Services, Inc. addressed this research in a 2012 article published in the Journal of the American Society of Addiction Medicine entitle Ethical and Managerial Considerations Regarding State Physician Health Programs.  The allegations that PHPs are engaging in research in violation of the Nuremberg code ( that was a direct result of the Nuremberg trials for which Dr. Alexander acted as consultant ) should have raised some eyebrows.   It hasn’t.

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What do you think will happen when ASAM gets recognized by the ABMS in 2 years as is expected?   These “addiction medicine” specialists will inevitably join hospital formulary , clinical lab, toxicology and ethics panels to do the same thing they have done to get where they are today.   They will do the same thing they have done with state PHPs.  Those with a hidden agenda will be able to outvote those of good conscience and thoughtful intelligence and patient care will then be subordinated to the guiding philosophy of the impaired physicians movement.

This system of institutional injustice is killing doctors by suicide as the medical societies and Departments of Public Health have given PHPs full autonomy and authority and it is poised to impact patient care.

I challenge you to name any other company, organization, group or agency within or related to the profession of medicine and the field of science that is bereft of absolutely all  transparency,  regulation or oversight?  It does not exist.

The PHP scaffold has deliberately  removed themselves from all aspects of accountability including answerability, justification of actions and the ability of outside actors to hold them in judgment of any information provided by answerability.   Heads I win, tails you lose.   That is a big red flag in itself. and those not currently being held accountable they may very well be after you next as their plans include expansion to other groups includes EAPs, the Department of Transportation, athletes, students and even kids!

Doctors are afraid to talk about this for fear of being ensnared themselves.  Those already in these programs will not speak for fear of punishment. This is a legitimate concern and needs to be discussed openly and publicly.  I need allies!

 Help me get the word out –too many doctors are dying.  Three died by suicide in one month alone who were being monitored by the Oklahoma PHP and these suicides did not even make the local papers let alone national news!     They need to.

In The Argument of Fascism Ludwig von Mises wrote:

It cannot be denied that Fascism and similar movements aiming at the establishment of dictatorships are full of the best intentions and that their intervention has, for the moment, saved European civilization. The merit that Fascism has thereby won for itself will live on eternally in history. But though its policy has brought salvation for the moment, it is not of the kind which could promise continued success. Fascism was an emergency makeshift. To view it as something more would be a fatal error.

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Monopolies, Self-Referral and Shell Games: The Need for Antitrust Investigation of Physician Health Programs and their “PHP-Approved” Assessment and Treatment Centers

On the above list can be found the Medical Directors of a number of drug and alcohol rehabilitation facilities. I did not make up this list. An updated version can be seen right here on the “like-minded doc” website.

Talbott, Marworth, Hazelden, Promises, and another two-dozen or so “PHP-approved” assessment and treatment centers are represented on this list. State Physician Health Programs (PHPs) refer doctors to these facilities for evaluations. PHPs are non-profit tax-exempt organizations. They do not evaluate or treat patients. If a physician is referred to a PHP for a suspected problem the assessment must be done at an outside facility which will invariably be linked to a name on the list of Like-Minded Docs.

What most people do not know, however, is that this is an exclusive arrangement. Evaluations are constrained to one of these facilities. It is mandated. No bargaining. No compromises. No choice. In other words it is a coercion.

Disrupted Physician

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Three shells and a pea–ASAM, FSPHP, and LMD.

“PHP-Approved” Assessment and Treatment Centers

On the above list  can be found the Medical Directors of a number of drug and alcohol rehabilitation facilities.  I did not make up this list.  An updated version can be seen right here on the “like-minded doc” website.

Talbott, Marworth, Hazelden, Promises, and another two-dozen or so “PHP-approved”  assessment and treatment centers are represented on this list.    State Physician Health Programs (PHPs) refer doctors to these facilities for evaluations.  PHPs are non-profit tax-exempt organizations.  They do not evaluate or treat patients.   If a physician is referred to a PHP for a suspected problem the assessment must be done at an outside facility which will invariably be linked to a name on the list of Like-Minded Docs.

What most people do not know, however, is that this is an exclusive arrangement.    Evaluations are constrained to one of these facilities…

View original post 95 more words

Drug Companies and Doctors: A Story of Corruption

Drug Companies and Doctors: A Story of Corruption.

What we need is a Marcia Angell to take on the multi-billion dollar drug and alcohol testing, assessment and treatment industry.

Screen Shot 2015-06-01 at 7.22.25 PMWhile all eyes were focused on the drug companies these multi-billion dollar industries erected a scaffold of immunity and profit by removing (and blocking) themselves from essentially all aspects of accountability; answerability, justification for actions and the ability to be punished by outside actors.    The 2009 quote in reference to “big pharma”  is just as applicable to the drug and alcohol testing industry,”  the inpatient assessment and treatment centers and the “authorities” pushing public policy and swaying public opinion to accept irrational and illegitimate authoritative opinion as truth.

And unlike the pharmaceutical industries carefully constructed “bent science” which requires a keen eye and critical analysis , the evidence-base supporting the testing, assessment and treatment industry rests on a foundation that can be aptly characterized as illusions and lies.  The “science” is not just “junk-science” but junk-science of the lowest order–examples of confirmatory distortion and data-dredging to make the data fit the hypothesis abound.   The conflicts-of-interest are not potential but incestual with many of the key players putting their hands in every slice of the pie!

The bad science, bad medicine, bad policy and  bad actors are easy to identify. It would be like shooting fish in a barrel.

So what are the barriers?

Why has this not been done?

The answer to that is complex but  involves a confluence of factors including psychological, political and cultural.  “Feel good fallacy,”  “political correctness, and moral and policy entrepreneurship have effectively swayed the targets intended.  The well-funded misinformation and propaganda was cast with a large net using the same techniques others have successfully used throughout history to accomplish the same.  Moral panics, moral crusades, and a plethora of logical fallacy have been used and used with considerable resources and skill.

So what can we do about it?

The first “step into the breach” is to identify the problem with the first one being the Emperor has no clothes.  Once this is acknowledged it would not take long to address directly the specific problems and erroneous assumptions of this paradigm through the lenses of science, critical reasoning, ethics and common sense.  If this were to be done the entire Potemkin village would fall like a house of cards.

But the very first and simplest step is to use your voice to question this authority. Make it be known.

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History teaches us that silence and secrecy are often the most effective tools of power.   It hides things including very bad things.  It is time to shine a light on this dank dark corner of the medical profession.


It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine” – Marcia Angell 

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“At times to be silent is to lie. You will win because you have enough brute force. But you will not convince. For to convince you need to persuade. And in order to persuade you would need what you lack: Reason and Right”
― Miguel de Unamuno

“I have always found it odd that people who think passive aggressively ignoring a person is making a point to them. The only point it makes to anyone is your inability to articulate your point of view because deep down you know you can’t win. It’s better to assert yourself and tell the person you are moving on without them and why, rather than leave a lasting impression of cowardness on your part in a person’s mind by avoiding them.”
― Shannon L. Alder

Staying silent is like a slow growing cancer to the soul and a trait of a true coward. There is nothing intelligent about not standing up for yourself. You may not win every battle. However, everyone will at least know what you stood for—YOU.”
― Shannon L. Alder


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The Aging Physician—Goodbye Dr. Welby!

IMG_8901The methodology is not new–witches are real, witches are dangerous and witches need to be identified and exterminated at all costs. Convince the authorities to assist you in protecting the public from harm and advance the greater good

In this manner the Federation of State Physician Health Programs (FSPHP)  has convinced the Federation of State Medical Boards state medical boards (FSMB)  to adopt and enforce policies that have incrementally and systematically increased their own  autonomy, scope and power.   This began in 1995 when the FSPHP first cultivated a relationship with the FSMB and subsequently took an uninvited seat at the table of power by offering a non-disciplinary “safe harbor” as an alternative to discipline for doctors impaired by drugs or alcohol.IMG_8900

Since then they have increased their scope from the “impaired” to the “disruptive” to everything else. Arising from the “impaired physicians movement” as “addiction specialists” these doctors whose specialty of addiction is not even recognized by the American Board of Medical Specialties have now become the “experts” in all matters related to physician health. Jacks of all trades covering neurology, psychiatry, geriatrics, and occupational medicine.

A 2011 updated FSMB Policy on Physician Impairment states that Medical Boards should recognize the state Physician Heath Program (PHP) as their experts in all matters relating to licensed professionals with “potentially impairing illness,” and these include those potentially impairing maladies that increase as we age.  This has gone too far.  Isn’t it time we take back the profession of medicine from illegitimate and irrational authority?Slide15

Disrupted Physician

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As a specialist in geriatric medicine I have experience in taking care of a number of  doctors who were referred to me for suspected memory problems. Still operating and teaching residents in his 70s, my first was a well-respected surgeon, a pioneer or Maverick who had made advances in his particular subspecialty.  Known for his detailed knowledge of the history of medicine and sharp clinical acumen, he had not seemed himself for a while.  His colleagues noted he appeared slower,  fatigued and forgetful at times (not remembering his keys, having trouble finding the right word).  An internist friend and co-worker who knew him for 50 years curb-sided me and asked if I would see him.  He did not have a primary care physician or even seen a doctor professionally for decades (a common phenomenon in this age cohort of doctors).

I met him the next week and he readily admitted to having difficulty concentrating and having trouble with his short term…

View original post 1,533 more words