Righteous Vocational Fury and “the need to be ballsy and capable of rebellion”in the medical profession -apt and universally applicable words from BMJ

 

img_1156The majority of doctors are of good heart and sound mind.  Most doctors strive to do the right thing and the correct thing to the best of their capabilities in any given circumstance. Most doctors by nature are intelligent, inquisitive and caring. Their actions are not driven by self-interest or greed but by  thoughtful reasoning and moral compass. As in any population, of course, vast differences exist in individual characteristics including intellectual acumen, empathy and common sense.  Those bereft of moral compass and the intolerant and prejudiced walk among us in all professions.  Medicine is no exception.  The simple truth to the matter is  overwhelming majority of people are good people. They are honest, have integrity and are guided by conscience.  Most police officers are not trigger-happy racists.   Most Catholic priests do not have an affinity for alter-boys. And most doctors do not hand out opiates like halloween candy.  What we hear about are the exceptions not the rule.

John Forbes Nash was an American mathematician who made fundamental contributions to differential geometry and game theory and portrayed by Russel Crowe in the 2001 film A Beautiful Mind. Nash described a type of equilibrium in which these harmful exceptions were kept at bay by the population majority with empathy and reasoning.  This small minority of the population was kept in check by countermeasures.  Miscreant actions were met with law and other measures that provided consequences for actions outside societal norms. Thus self-serving actions in one’s best interest but at the expense of others was stifled and prevented from gaining a foothold in the majority population.

In regard to the medical profession an apt example of Nash equilibrium is the case of Detroit Doctor Farad Fata  who devised a scam to diagnose cancer in patients who did not in fact have cancer to profit from the unneeded treatment; an unconscionable scheme incomprehensible to those of ethical integrity. His pocket was lined with 34 million dollars over the years.  When he was eventually caught the Federal prosecutor recommended a 175 year prison sentence due to his egregious acts and he was sentenced to 45 years in prison.  Although someone contemplating a risk benefit analysis of diagnosing healthy patients with cancer as a means to put coins in their purse is undoubtedly a rare event the severe consequences of Farad’s action serves as a deterrent.  Criminal reasoning also employs a risk/benefit analysis regarding the chances and consequences of getting caught.

screen-shot-2016-12-13-at-8-01-35-pmWhat might Nash think of a population in which this minority of deviants was not punished for their actions but instead given “treatment” in a communal area where they were able to interact with others of the same constitution ?  What do you think Nash might say if individually and collectively this same population was put in a position of power over others but without any oversight, regulation or accountability?  A disequilibrium would inevitably ensue with grave complications to the rest.

Screen Shot 2016-12-13 at 6.21.28 PM.pngCoraline is a children’s novella written by the British author Neil Garman in 2002. It has been compared to Lewis Carroll’s  Alice’s Adventures in Wonderland and adapted into a film in 2009.  Coraline is a little girl who moves into a new house with her parents.  She is constantly bored and unhappy her parents do not give her the attention she wants and while exploring the house she finds a door that leads to an alternate version of her reality where her parents are fun and attentive and everything seems wonderful but things get creepy very quickly.  Her parents look like her parents but instead of their eyes they have shiny black buttons and she soon finds herself in a horrific and dark place that looks like reality but slightly off and terribly ominous and threatening.  Such is the case with the medical profession today. Somewhere along the line it took a nasty left turn and although looks the same its slightly off nature has become threatening and crippling to many. An erosion in the hierarchy has occurred and much of the practice and policy pushed by the self-interest groups to regulators and administrators is not only bad, it is absurd.

Most doctors strive  to do the “right thing” but it is difficult.  Gauntlets have been put in place that cannot be maneuvered by those who strive to do their best and do not cut corners. The current environment precludes creativity and despises independent thought. Both professional and private life is held to demands of the unthinking obtuse. It defies logic, reasoning and common sense.

Doctors have become nothing more than collared dogs, leashed and led by the authoritative pronouncement of unexamined, illegitimate and irrational authority.  Evidence-base, critical reasoning and common sense have taken a back seat to power and control.

screen-shot-2016-12-13-at-8-05-29-pmMy hero’s in medicine both historically and personally have always been the maverick’s -those doctors with superlative and almost preternatural clinical acumen who can make the  right diagnosis when no one else could or have made daring and unprecedented contributions to the field.

One example would be  Dr. William Morgan who helped Boston win the World Series a dozen years ago by performing a surgical procedure he invented on Curt Schilling’s ankle that allowed him to pitch when all the other experts said it was impossible. It worked.

When someone makes a diagnosis that eludes others or pioneers an innovative mechanism to improve the science of medicine it is an event that should be cheered and applauded not jeered and dismissed.

Of all the sad stories I have heard one particularly hit a nerve.  A patient who was having intractable abdominal cramping and pain remained undiagnosed after multiple colonoscopies and endoscopies.  He went to an older doctor who diagnosed him with an obscure diagnosis (splenic flexure syndrome) that is easily treatable and diagnosed and cured the patient of his pain with dispatch.   When I was in medical school this would warrant three cheers and a toast. That is not what happened.  Those clueless individuals wielding the endoscopes and colonoscopes who could not piece the puzzle were not happy that a general practitioner made a diagnosis that was nowhere on their radar. They reported him to hospital administration and the bullying and mobbing that ensued became too much.  Deemed a disruptive physician he slit his throat during an operation. An assured comeuppance to the dregs that drove him there.

What do those in the physician health and regulatory corner of medicine think of maverick doctors?. The quote below is from an article in The Federal Bulletin, the official journal of the Federation of State Medical Boards (FSMB) entitled Proctoring of Disciplined Health Care Professionals: Implementation and Model Regulations. It is these regulations that helped shape the current physician health paradigm.

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The implication is danger (not all of them mind you) but lets identify and weed them out. The right to “due process” as other practitioners is a curious remark and am unclear what exactly is meant here as:  1. due process is a right that should be afforded everyone and anyone; why is this even be considered unless they dispense it in different ways to different folks, and 2. Physician health programs have completely removed due process from doctors through ‘medicalization.” It does not exist.  One of their selling points to the medical boards was its absence as they could remove a doctor from practice immediately and “without the constraints” of due process.  All it takes is the mere accusation of  a “potentially impairing illness.”  That is what the did with Dr. Morgan. They have also done it to some of the brightest minds I have known in medicine.  It is tragic.  It is also not on the radar of most.  The institutional injustice and absent redress has led to an epidemic of suicides and it is time this be acknowledged.   Physician suicide is not caused buy “student loans” or “overwork.’ Those are challenges that can be overcome.  Suicides occur when one is helpless, hopeless and trapped and that is what is happening here. I cringe every time I read some half-baked speculation on the cause of physician suicide.  Those who need help are afraid to get help and those who do not need help are being entrapped in a system that is more than happy to “loosen” the diagnostic criteria and provide unnecessary treatment for a “tailored” diagnosis.  Follow the money.

And while outspoken in denouncing what they regard as unethical and unprofessional behavior by other doctors, many of those who hold others to account are resistant to apply even the most minimal standards to their own activities. The primary author of the model regulations surrendered his medical license in 2001 after allegations of an “inappropriate ‘extended relationship'” with one of his patients.   A not all that uncommon scenario in this population.

Doctors have been subjected to an intentional diminution of stature and much of this has to do with the moral panics and bogus dangers of doctors that has been spewed to the public by these very same organizations as they have gained a seat at the table of power.

screen-shot-2016-12-13-at-8-33-17-pmAuthority needs to be grounded in wisdom and  guided by ethical principles and codes of conduct.  Such is not the case.   If the information agencies rely on to make decisions and policy is unreliable then bad decisions, wrong decisions and flawed public policy can occur.  The consequences can be far-reaching and grave.

Rank-and-file doctors exist not in a repose of complacency but of disquietude. By nature they do not typically speak up.  Most are afraid to.  They have effectively been stifled by threat and fear.  What is stunning is the commonality of this.

The BMJ paper below by Sophie Cooke refers to the practice of medicine in the U.K. but is apt and applicable in the U.S.  Historically doctors have not vociferously spoke up as much as those in other professions. They tend to remain quiet and do not want to make waves. I have been contacted by many doctors who could speak out and make a difference but they don’t. The question that incessantly tugs at me is when will these people say “enough” and say something.  Can what has been done even be undone at this point.  Cooke speaks of “righteous vocational fury” and that the vocation needs to “be ballsy and capable of rebellion.”   We too need to stand as one and speak out against illegitimate and irrational authority.  We need to proclaim “enough is enough” and identify and remove illegitimate authority.   What does it take for someone to stop bemoaning the current state of medicine quietly and silently and get “ballsy” enough to vociferously protest and rebel?  Stand up.

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Link to BMJ article here.

Editor’s Choice

In search of a good nanny

BMJ 2016; 355 doi: http://dx.doi.org/10.1136/bmj.i6565 (Published 08 December 2016)Cite this as: BMJ 2016;355:i6565

Sophie Cook, clinical reviews editor, Author affiliations,   scook@bmj.com

Nannying, like medicine, is a vocation. The good nanny was everything a family could wish for: she cared for, helped, and guided her family to make their own decisions, knowing when to interfere and, crucially, when to butt out.

This week Simon Capewell and Richard Lilford debate whether, when it comes to states, nannying makes us healthier and whether information or legislation is the way to change health behaviour (doi:10.1136/bmj.i6341). Lilford explains, “There can be no autonomy if the state, rather than the individual, is the custodian of personal values.” He warns, “The nanny state’s impatient and sometimes self righteous zeal could do more harm than good.” Capewell argues that, on the contrary, a “nanny state means ensuring a healthy environment for all” and underpins every health determinant in Ivan Maslow’s hierarchy of needs, such as safety and love, to allow us to enjoy our health and fulfil our true potential.

One group lacking many fundamentals of Maslow’s pyramid is homeless people, who often struggle to access healthcare. Anne Gulland describes how some successful UK projects have broken down barriers to services (doi:10.1136/bmj.i6511). Helpful tips include drop-in clinics, more flexible appointment times, and awareness that lack of a permanent address is not a barrier to registering with a GP.

From a group that struggles to access healthcare to a group offered it in abundance: pregnant women. Karin Nelson and colleagues look at the role of electronic fetal monitoring in labour and at how an intervention that was initially introduced to reduce cerebral palsy (it has not) has subsequently been linked to increased rates of caesarean delivery and litigation (doi:10.1136/bmj.i6405). They call for doctors, courts, and the public to recognise the lack of proof for routine electronic monitoring and remind us that technologies in healthcare can have unintended consequences.

And finally, as we approach the end of a turbulent year in the NHS Margaret McCartney tells us it’s a sense of vocation that keeps it going (doi:10.1136/bmj.i6526), with doctors committed to going the extra mile. But this commitment also means that professionals can be exploited, she says, and that vocation “needs to be ballsy and capable of rebellion.” Will 2017 bring the “righteous vocational fury” she is hoping for?




Please donate to Disruptedphysician.com here to keep this blog running.  It is expiring in 21 days and any contribution would be appreciated.   We are making significant gains with articles such as  Physician Health Programs Under Fire .     These issues may seem small in the current turbulence, a small whirlpool in a maelstrom, but in reality they have enormous implications for all of us.  Please help out if you can-ML

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Massachusetts Governor Charlie Baker Moves to Control Professional Boards

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Baker moves to control professional boards

By Christian M. Wade Statehouse Reporter May 11, 2016

BOSTON — Dozens of independent boards that regulate doctors, barbers, electrical workers and an array of other professionals could soon be pulled under the state’s umbrella — a move that trade groups complain smacks of government overreach.

Lawmakers are considering a bill filed by Gov. Charlie Baker to limit the independence of licensing boards and give the state the power to “review and veto” any action deemed to stifle competition.

The proposal responds to a U.S. Supreme Court opinion last year that boards controlled by members of the profession they regulate are not immune from antitrust lawsuits.

In that case, the court ruled that the state dental board in North Carolina had no protection from antitrust claims when it issued cease-and-desist orders to companies offering teeth-whitening services.

Baker administration officials say the ruling leaves licensing boards in Massachusetts vulnerable.

Even legal actions may be challenged, Mike Kaneb, Baker’s deputy legal counsel, told a legislative committee on Tuesday.

“Individual board members can be sued,” he added.
But exerting authority over the boards is also raising concerns.

Frank Callahan, president of the Massachusetts Building Trades Council, which represents about 75,000 skilled construction workers, said the state needs to address the issue but he’s concerned the governor’s proposal would give the state too much power over the boards.

Boards that oversee electricians and other skilled trades already have state oversight, to varying degrees, he noted, as well as lawyers to ensure their decisions comply with federal anti-trust laws.

 

Baker moves to control professional boards | News | eagletribune.com 13/5/16 11:14 PM

Several representatives of trade groups opposed the proposal at the legislative hearing. Robert Butler, business manager for Sheet Metal Workers Local 17, called it a “solution to a nonexistent problem.”

“This bill would allow the state to make decisions without any public input or recourse,” he said.

Baker, a Republican, has promised to make the state more business- friendly, in part by cutting through red tape. In a statement, he said licensing rules and limits on professionals “have the effect of restraining trade and commerce” and are bad for business.

Donna Kelly-Williams, president of the Massachusetts Nurse’s Association, criticized his plan in comments to lawmakers.

“With this directive, it seems as though the governor would like to turn the Board of Registered Nurses and other similar boards into nothing more than vehicles to spur economic competition at the expense of the public health and safety,” she said.

Baker administration officials said that’s not the intent.

“The only motivation for the governor’s bill is to respond to the changes in law,” Kaneb said Tuesday.

Since the Supreme Court ruling, legislation to exert more control over independent licensing boards has been introduced in least six other states, according to the National Conference on State Legislatures.

In Massachusetts, the Division of Professional Licensure oversees 45 boards, which regulate more than 370,000 individuals and businesses in some 50 trades and professions.

Most board members are volunteers appointed the governor and operate independently from the state.

Baker signed an executive order last year directing the licensing division and other agencies to conduct monthly reviews of recent board decisions to determine if any violate federal laws.

Martin W. Healy, chief counsel for the Massachusetts Bar Association, said the state must act quickly to comply with the Supreme Court ruling to ensure that its boards don’t face legal challenges.

 

Baker moves to control professional boards | News | eagletribune.com 13/5/16 11:14 PM

“This is a major issue for the state that needs to be addressed quickly,” he said. “You would have a very difficult time attracting talented people to these positions if they could held personally liable for the board’s decisions.”

Christian Wade covers the Massachusetts Statehouse for the North of Boston Media Group’s newspapers and websites.

MA – State Oversight of Professional Licensing Boards – annot

Anti-Authoritarians in the Medical Profession: A Critical Need to “Question Authority”

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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.images-4The 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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Moral Crusades and Moral Panics as a Means of Social Control in the Medical Profession

IMG_9005The Medical Profession, Moral Entrepreneurship, and Social Control

Sociologist Stanley Cohen  used the term “”moral panic” to characterize the amplification of deviance by the media, the public, and agents of social control.1  Labeled as being outside the central core values of consensual society, the deviants in the designated group are perceived as posing a threat to both the values of society and society itself.   Belief in the seriousness of the situation justifies intolerance and unfair treatment of the accused.   The evidentiary standard is lowered.

Howard Becker describes the role of “moral entrepreneurs,” who crusade for making and enforcing rules that benefit their own interests by bringing them to the attention of the public and those in positions of power and authority under the guise of righting a society evil. 2

And according to cultural theorist Stuart Hall, the media obtain their information from the primary definers of social reality in authoritative positions and amplify the perceived threat to the existing social order. The authorities then act to eliminate the threat.3  The dominant ideas or ideologies are reproduced by relying on the opinions of the defining authority and then spread through the media. The communal good has been assailed.

As a society governed by organizations, associations,  institutions and regulatory bodies, the medical profession is not immune to “moral panics.”  A threat to patient care or the values of the profession can be identified and amplified.   A buildup of public concern fueled by media attention ensues creating a need for governing bodies to act. Medical Professionalism and the Public Health has been assailed.

Unbeknownst to the general public and most members of the medical profession at large, certain groups have gained tremendous sway within medical society. Through  moral entrepreneurship they have gained authority and become  the primary definers of the governance of the medical profession and the social control of  doctors.  To benefit their own interests they have fostered and fueled “moral panics” and “moral crusades. ” Exhorting authorities to fight these  threats by any means necessary  they have successfully made and enforced rules and  regulations and introduced new definitions and tools with no meaningful resistance or opposition.

The Inquisition did not have to convince  individual citizens or the general public of their beliefs to advance an agenda; just Ecclesiastical and Political Authority.  Similarly, the  “impaired physicians movement” did not have to convince individual doctors or the medical profession of their beliefs  to further a self-serving agenda; just  regulatory and administrative authority.

Addiction Medicine Monopoly, False Authority and Conflicts of Interest

The “impaired physicians movement” can be defined as a group of physicians with alcohol and substance abuse problems who, having found sobriety through 12-step spirituality, banded together to promote the ideology behind their personal  “recovery”  to other doctors and the medical community at large. In the 1980s the movement gained momentum and as their numbers grew  began calling themselves  specialists in “addiction medicine.”  The American Society of Addiction Medicine (ASAM)  is not a true specialty, but a Self-Designated-Practice-Specialty, which simply means that is what they are calling themselves.  It reflects neither knowledge nor expertise..  “Board certification” by the American Board of Addiction Medicine (ABAM) is not recognized by the American Board of Medical Specialties (ABMS).

ABAM certification requires only a medical degree, a valid license to practice medicine, and completion of residency training in ANY specialty.  Addiction Psychiatry, a subspecialty of psychiatry under the American Board of Neurology and Psychiatry  is the only  specialty recognized by the ABMS. and their specialty society is the American Academy of Addiction Psychiatry.

The ASAM is schooled in just one one uncompromising model of addiction with the majority attributing their very own sobriety to that model–the chronic relapsing “brain disease” with lifelong abstinence and 12-step spiritual recovery model.   As the “voice of addiction medicine,” the ASAM has nevertheless defined the dominant treatment paradigm in the United States.   ASAM doctors outnumber addiction psychiatrists by 4:1 and the movement is well funded.   Because addiction is defined as a “disease”, addicts must be “treated” (more often coercive than voluntary), and “cured” (defined as abstinent).  The billion dollar  assessment and treatment industry and the drug and alcohol testing industry  lucratively profits from this model which has grown to monopolize addiction treatment  in the United States.

The goal of the ABAM Foundation is to “gain recognition of Addiction Medicine as a medical specialty by the American Board of Medical Specialties (ABMS).”   A monopoly defined by self-appointed experts without recognized  specialty training will soon likely Robber baron their way to being accepted as  a true specialty.

Physician Health Programs, Regulatory Agencies, and Treatment Centers

Physician Health Programs (PHPs) meet with, assess, and monitor doctors who have been referred to them for substance use or other mental or behavioral health problems. Unless being monitored by one, PHP practices are unknown to most physicians and operate outside the scrutiny of the medical community.  Initially funded by State Medical Societies and staffed by volunteer physicians,  PHPs  served the dual function of helping sick doctors and protecting the public.

As the populations of ASAM physicians proliferated  in the 1980s, many  joined their state Physician Health Programs. PHP doctors who did not agree with the ASAM groupthink were gradually removed  and they  organized under the Federation of State Physician Health Programs(FSPHP).  Other ASAM physicians found employment at treatment centers as staff physicians and medical directors.

The FSPHP cultivated a relationship with the  Federation of State Medical Boards (FSMB) and the state PHPs formed alliances with their  state medical boards. Promoting themselves as offering “treatment” rather than”punishment” they offered an alternative to disciplinary action.  They then began promoting their successful outcomes  in rehabilitating “impaired physicians”,  and this history can be seen by examining the archives of the Journal of Medical Regulation and similar  publications.  In 1995 the   Washington  PHP claimed a success rate of  95.4%,   Tennessee  claimed 93% and Alabama 90%.

Part of this success was attributed  to the specialized  treatment centers for doctors directed by their ASAM colleagues such as  Ridgeview Institute in Atlanta created by G. Douglas Talbott.  Talbott, who helped organize and serve as past president of the ASAM claimed a 92.3 percent recovery rate. He also put forth a Medical Urban Legend–the proposition that doctors were a different species, separate from the rest of society, who needed special treatment three times longer than anyone else.  Amazingly, this dicto simpliciter argument that can, in fact, be refuted simply by pointing it out  was allowed to enter regulatory medicine unopposed.  Simply because, sadly, no one ever pointed out the logical fallacy. It is now entrenched.    Three months or more of treatment is  standard of care for our profession. They did this by getting medical boards and the FSMB to accept fantasy as fact by relying on board members tendency to accept expert evidence at face value.

Physicians are unique only insofar as the unique elements required of the profession to become and be a physician such as going to medical school and completing the required board examinations.  That’s it.    I implore anyone to put forth any sound argument based on science and evidence that justifies a thrice lengthy stay in medical professionals.  Not gonna happen.   Thought stopping memes and logical fallacy is the best they have to offer.  And, unfortunately this type of  rabbling gibberish cuts the mustard in the regulatory medicine venue.   A “low-bar” evidentiary standard is not the problem.  If you look at the documentary evidence from a medico-historical perspective there never was a bar.  The FSMB has essentially given the impaired physicians movement carte blanche authority and unrestrained managerial prerogative.  A bar never even existed.  It’s a laissez-faire Lord of the Flies free-for-all.    The logical fallacy of appeal to authority–illegitimate and irrational authority.  Bamboozled by smoke and mirrors.

A 1995 issue of the FSMB publication  The Federal Bulletin: The Journal of Medical Licensure and Discipline contains reports on eight  separate state  PHPs.   The “almost 90% success rate” was  applauded by the editor, who added  “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.”   And more recent reports suggest PHPs   reduce malpractice claims. They are now being promoted as a replicable model  to be used in other populations.

The problem is no one bothered to examine the methodology to discern the validity of these claims.  There has been no critical analysis or Cochrane type review of any of these studies which are invariably small, methodologically flawed, and biased.

The FSMB has accepted them as  expert authority and  their authoritative opinion as fact.  It  is this acceptance of faith without objective assessment that has allowed the ASAM and FSPH to advance their agenda. By  confusing ideological opinion  with professional knowledge, the FSMB and state Medical Boards have acted as willing gulls each step of the way. No counter-forces existed.  And they still don’t.   Junk science and unvalidated neuropsychological testing is used by these groups unconstrained and willfully.  There is no regulation, oversight, or accountability.  They are using polygraph testing (despite the AMA’s previous public policy statement deeming it junk) to both condemn “disruptive” surgeons and deem convicted pedophiles fit to return to work.  They have introduced junk-science in drug and alcohol testing and unvalidated “neuropsychological” testing to detect “character-defects” by getting regulatory agencies to accept the validity of these tests not by the Scientific Method or Evidence Based Research but by (to coin a term) “Regulatory Sanctification”

To paraphrase one FSPHP member,   “Who needs evidence-based medicine when the boards have already accepted these tests as valid?”  Who indeed?

The ideological bias and financial conflicts of interest between PHPs and the  treatment centers was also not recognized. It still isn’t.  The  spotlights are apparently all  on Big Pharma  in this regard.    Some sunlight needs to be exposed in the direction of the billion dollar drug and alcohol testing and assessment industry as well.

Doctors  were held at Ridgeview three times longer than the rest of the population (and at three times the cost)  under threat of loss of licensure.   Although there is no evidence base or plausible explanation why an entire profession would have a three-times  longer length of stay than the rest of the population this continues to be the reality. There is no choice.

in 2011 The ASAM issued a Public Policy Statement on coordination between PHPs, regulatory agencies, and treatment providers recommending  that  only “PHP approved” treatment centers be used in the assessment and treatment of doctors.  It specifically excludes non “PHP -recognized” facilities.  And what defines a “PHP approved” treatment center?    In addition to finding essentially no oversight by the state medical society and medical board, a recent audit of the  North Carolina PHP found financial conflicts of interest and no  documented criteria for selecting the out of state treatment centers they used.  The common denominator the audit missed was that the 19  “PHP-approved” centers were all ASAM facilities just like Ridgeview whose medical directors can be seen on this list.

The appeal to authority logical fallacy has enabled the FSPHP to become the expert authority on physician impairment through the eyes of the medical boards.  It has also allowed them to increase their scope.

The FSMB House of Delegates adopted an updated Policy on Physician Impairment at their 2011 annual meeting distinguishing “impairment” and “illness”  stating that Regulatory Agencies should recognize the PHP as their expert in all matters relating to licensed professionals with “potentially impairing illness.”

According to the FSPHP, physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years.”

The policy extends PHP authority to cover physical illnesses affecting cognitive, motor, or perceptive skills, disruptive physician behavior, and “process addiction” (compulsive gambling, compulsive spending, video gaming, and “workaholism”). It also defines “relapse without use” as “behavior without chemical use that is suggestive of impending relapse.”

G. Douglas Talbott defines  “relapse without use”  as  “emotional behavioral abnormalities” that often precede relapse or “in A A language –stinking thinking.”  AA language has entered the Medical Profession and no one even blinked.  It will get worse.

The ASAM has  monopolized addiction treatment in the United States.   It has imposed  it on doctors through the FSPHP.  The FSPHP political apparatus exerts a monopoly of force. It selects who will be monitored and dictates every aspect of what that entails.  It is a, in fact, a  rigged game.

Inherent in this model is the importance of external control.  It gives them power to exert control over the individual regardless of whether they need to be treated.

By bamboozling regulatory medicine this was accomplished.    And the maintenance of this relationship is necessary as this  presentation  by an FSPHP physician  warns, “guard this relationship jealously.”

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Moral Panics and Moral Crusades

By introducing and fueling moral panics the ASAM/FSPHP political apparatus has been able to expand in both scope and power.

The Medscape article “Drug Abuse Among Doctors:  Easy, Tempting, and Not Uncommon”published in the “Business of Medicine” section in January 2014 is characteristic example of the authoritative opinion, propaganda, and misinformation spun to maintain a pervasive climate of fear. Proof by anecdote.  Physicians are “5 times as likely as the general public to misuse prescription drugs” according to Lisa Merlo, PhD.  “Given the epidemic of prescription addiction sweeping the nation, that’s a grim statistic.”

Described as a “researcher at the University of Florida’s Center for Addiction Research and Education,” Merlo’s research involving 55 doctors being monitored by their state Physician Health Program published in the Journal of Addiction Medicine in October 2013 found “most physicians who abuse prescription drugs” do so to “relieve stress and physical or emotional pain.”  Nowhere is it mentioned on Medscape that Merlo is the Director of Research for the Florida state PHPProfessionals Research Network.   Physician access to medications through prescriptions,  “networks of professional contacts, and proximity to hospital and clinic supplies” gives them “rare access to powerful, highly sought-after drugs” says Marvin D. Seppala, chief medical officer at Hazelden.  This access “sets them apart” and “not only foment a problem” but”perpetuate it” says Seppala.  “Access “becomes an addict’s top priority” and they “will do everything in their power to ensure it continues.”  

“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.” Physicians are intelligent and skilled at hiding their addictions, he says. Few, no matter how desperate, seek help of their own accord.”  In reality this is absurd.  And if you look at any of the current “moral panics” that are being used to suggest random suspicion-less drug testing of all doctors or promoting the Physician Health Programs as the “New Paradigm” you will inevitably find a doctor, just like Marv Seppala who is on this list as  an author or interviewee.  It is a given.

The terms  “impaired physician” and  the “disruptive physician”  are used as labels of deviancy.  As deviants who allegedly threaten the very core of medicine (patient care) and  the business of medicine (profit)  they must be stopped at all costs.   Belief in the seriousness of the situation justifies intolerance and unfair treatment.  The evidentiary standard is lowered.  Aided by a  “conspiracy of silence” among doctors in which impaired colleagues are not reported  necessitates identification of them by any means necessary.   Increase the grand scale of the hunt.

In this way these front-groups have successfully acted as moral entrepreneurs to make and enforce rules and put forth new definitions and mandates that serve their own interests.     A retrospective non -blinded non-randomized cohort study with serious underlying methodological errors involving 904 physicians being monitored by PHPs is now being used to “set the standard for recovery.”

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Across the Country doctors are going to the media,  law enforcement, the AGO, and the ACLU only to be turned a deaf ear.   Many consider this a “parochial” issue best handled by the medical community. Doctors reporting crimes are turned back over to the very perpetrators of the crimes.   The Medical Societies and professional organizations contribute to the problem by willful ignorance.   Accusations are used to disregard the claims of the accused.   It is a system of institutional injustice that is driving many doctors to suicide.  Hopeless, helpless, and feeling entrapped many are taking this route.  And no one is talking about it.   This cannot be avoided any longer.

The next target is the “aging physician.”   And as they have done with the “impaired” and “disruptive” physician” the FSPHP and their affiliates are setting the stage for another “moral crusade.”

  1. Cohen S. Folk Devils and Moral Panics: The Creatio of the Mods and Rockers (New Edition).Oxford, U.K.: Martin Robertson; 1980.
  2. Becker H. Outsiders: Studies in the Sociology of Deviance. New York: Free Press; 1963.
  3. Hall SC, Critcher C, Jefferson T, Clark J, Roberts B. Policing the Crisis: Mugging, the State, and Law and Order. London: Macmillan; 1978.

 

Backdraft: How Firefighter Arson was Reduced by Admitting, Defining and having Zero-Tolerance for the Problem–A Lesson for the Medical Profession

Backdraft: How Firefighter Arson was Reduced by Admitting, Defining and having Zero-Tolerance for the Problem–A Lesson for the Medical Profession.

Some researchers believe that firefighter arsonists undergo a mental process referred to as RPM: the arsonist Rationalizes the crime, Projects blame, and Minimizes the consequences.
The impact of firefighter arson can be severe. People die or are seriously injured, including fellow firefighters. Homes are destroyed. An arsonist from within the fire department can disgrace the whole department, and his actions diminish public trust.  Several states that have experienced the crime of firefighter arson have developed new legislation that directly impacts the prosecution of firefighters accused of arson.
The most crucial step was admitting that the problem exists.  The second was defining the problem. The third was having zero tolerance for those engaged in the problem.    States that have taken this approach have found a marked reduction in firefighter arson.

Psychopathy and the Medical Profession

IMG_9598Psychopathy is present in all professions. In The Wisdom of Psychopaths: What Saints, Spies, and Serial Killers Can Teach Us About Success, Kevin Dutton provides a side-by-side list of professions with the highest (CEO tops the list) and lowest (care-aid) percentage of psychopaths.   Interestingly surgeons come in at #5 among the professions with the highest percentage of psychopathy while doctors  (in general) are listed among the lowest.

Although by no means a scientific study, Psycopaths, by their very nature, seek power and it would make sense that a psychopath among us might pick surgery over pediatrics or pathology as they are drawn to power, prestige, and control. Be this as it may the incidence of psycopathy or psychopathic traits in doctors of any specialty is low. Statistics indicate that no more than 1% of men in general exhibit psychopathic traits. In Women these characteristics are far less.

Due to irresponsible behavior and a tendency to ignore or violate social conventions and rules,  psychopaths frequently find themselves engaged in conduct involving the criminal justice system or involved in other disciplinary action. Juvenile delinquency, arrests, school suspensions and misconduct related issues are barriers that preclude professional careers for many and, with around 15% of the prison population estimated to be psychopathic, incarceration and recidivism are common final pathways. Because of this tendency it would be highly unlikely for most sociopaths to follow a standard professional career pathway involving academic rigor and normal professional and societal expectations,  because impulsive irresponsible actions commonly blocks it. This would predict a probably much lower prevalence of psycopathy in physicians compared to the general population.

That being said, such self imposed removal from a potential  career is the sole product of getting caught for misconduct and being held accountable for it.   Psychopaths possess several traits that make this difficult.    With a talent for “reading people” and identifying their weak spots and vulnerabilities they are able to get people to see what they want them to see.  Psychopaths often exude charm, confidence and charisma.  They can lie effortlessly and are very convincing..

The natural history of psychopathy involves risky behavior and the ability to get away with it or out of it. The consequences of this depend on if and when it occurs. It is entirely conceivable that some may live their entire lives undetected. With a need for stimulation and a proneness to boredom the psychopath is particularly prone to drug abuse and addiction and twice as likely as the general population to be diagnosed.

 Psycopathy involves a path of risky behavior as well as the potential for being held accountable for it. At any age the behavior that brings they psychopath to the attention of the criminal justice system is often drug or alcohol related. The natural history of the average psychopath reveals an overrepresentation in prison with a 15x greater risk in general. Any statistics on psycopathy in a population is based on psychometric evaluations retrospectively in specific populations. Being arrested or getting caught for something does not reveal the pathology or the correlation. You have to look for it.

And nothing is known of subpopulations of psychopaths and the impact of intelligence, education, profession and other factors and how they relate to outcomes and consequences over time. Egocentricity and a sense of entitlement drives they do not adapt to the environment but try to make the environment adapt to them. Without empathy and lacking remorse the goal is always self-serving and a question of what they can get out of it.

 Many judges, as an alternative to incarceration, have been requiring people arrested for drug and alcohol related offenses to attend AA meetings and provide proof of participation. As misguided as this is on other levels it is also dangerous. Given a choice between incarceration and attending AA the majority of any population, including those with psychopathic traits, would choose the latter. And as in any situation they would use it to see what they could get out of it. Masters of manipulation and impression management in a room full of potential victims. The reports of rape and theft coming out is no surprise. It is in all likelihood much worse.

And in reality psychopaths exist in every profession, including medicine.

What is the natural history and final common pathway of M.D. psychopaths?  Where do these shape-shifters end up?

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In his book Without Conscience, Dr. Robert Hare notes “If we can’t spot them, we are doomed to be their victims, both as individuals and as a society. ” Dr. Clive Boddy in Corporate Psychopaths observes that unethical leaders create unethical followers, which in turn create unethical companies and society suffers as a result.” And if you look at the Federation of State Physician Health Programs (FSPHP) and those in charge of state physician health programs that is exactly what you will find.     Less than 1/% of the population are psychopaths but they represent more that 10% of those in prisons.  What is the natural history of the physician psychopath? You do the math.

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http://psychopathyinfo.wordpress.com/2012/03/22/characteristics-of-corporate-psychopaths-and-their-corporations/

Urgent Action Needed on Proposed Legislation in North Carolina–Removing Due Process from Doctors a Harbinger of Wide-Scale Political Abuse of Psychiatry

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I received the email below from Dr. Jesse Cavenar, Jr. regarding legislative changes that would severely infringe on the rights of doctors as licensees of the North Carolina Medical Board and subject them to distinctly non-impartial diagnostic psychiatric evaluations and remove all possibility of due process.  These developments could possibly herald the wide-scale abuse of psychiatric evaluation and treatment by two governmental agencies acting in collusion with utterly no oversight or accountability.  Namely the Federation of State Physician Health Programs (FSPHP) and the Federation of State Medical Boards (FSMB).  As a state Representative who is also a physician told me this morning –“this bill is representative of a prevailing attitude that does not realize what is really happening.”


Bill H453 can be seen here:  H543v2 – 04152015[10]

NC Audit can be seen here:  http://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2013-8141.pdf

This is the bill, entitled H453  that is before the NC legislature this session.  My reading of the bill is that the bill is a disaster.  It seems to be an attempt by the lobbyists and lawyers to remove many existing features of the present law. In particular, I would direct your attention to two features:

1) It appears that all mention of due process has been removed from the law. The NC State Auditor found that the NCPHP had not afforded due process as required by law, so one simply changes the law to remove all mention of due process.

2) There is a clause inserted in the law to immunize the NCPHP against civil liability for the performance of the NCPHP function. In other words, the state statute declares that one cannot bring legal action against the NCPHP because they are immune. This is absurd. These people should be no more immune than any other doctor in the state of North Carolina.

In addition, the proposed statute seems to attempt to haze out whether the NCPHP record is or is not a medical record. As you will see, one would be entitled to a copy of an ³Assessment² but it would appear not the entire medical record. This is contrary to the NC Medical Board position paper on medical records. I would urge everyone to immediately contact his or her appropriate Senator and Representative to register opposition to this bill as written, and to urge that an expert panel of disinterested physicians and attorneys be appointed to write a new bill that would be appropriate.

A colleague of mine who is a medical ethicist has reviewed this and had the following to say: ³Well, well!  I think the most interesting thing here is that someone has tried to get the NC Legislature to immunize the existing system against any countering action.  This, it seems to me, is tacit admission of culpability.²  Well stated, I would say.

                 Jesse

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