Some California physicians are already calling the idea "naive," "worthless," and "another unfunded mandate." But if the president of the Medical Board of California has his way, all practicing physicians in the state as well as medical school students will enroll in certified wellness programs, perhaps as a condition of licensure.
"What I want is a policy, preferably a statute, that dictates there should be wellness education that starts in medical school, so it becomes part of our culture through all the years of practice," says Richard Fantozzi, MD, a San Diego head and neck surgeon. Such a program would be evidence based, perhaps run through hospital medical executive committees as a condition for staff privileges. It would be administered by the private sector, not the medical board.
Whatever form it takes, the program would help physicians recognize the first signs of depression or burnout, abusiveness, out-of-control anger, inappropriate behavior with patients, peers or staff, serious family issues, as well as problems with substance abuse and dependence.
"Usually," he says, "all of the things that doctors eventually get in trouble for with the medical board are consequences of these unrecognized stresses."
"We want to help physicians realize signs they are going through life changes, and not be afraid to get help." No other state in the nation has such a uniform program, he says.
An eight-person board committee is studying how the education program might work, and has initiated talks with medical malpractice insurance companies about the possibility of offering discounts for the first doctors who enroll. The programs would have no disciplinary functions.
Physician groups, such as the California Medical Association, are staunchly opposed, saying such education programs would do nothing to prevent physicians with behavior problems. They favor a return to a system now discontinued in which physicians with substance abuse problems enter a confidential monitoring program while they recover from their addictions.
Fantozzi says officials from other state medical boards are exploring the idea as well, possibly replacing programs they now run for doctors whose substance abuse problems harmed patients.
"The direction Dr. Fantozzi is heading in is the right one," says Raymond Pomm, MD, medical director of the Florida Physician Health Program.
Today, Pomm says, the way we deal with physician behavior is through coercion, "and that we know doesn't work. We need to empower physicians to take responsibility for their own health, and turn around their concept of what it means to be ill."
Pomm says that it's unfortunate some physicians react so negatively to the concept. “We're talking about a change of culture that's not a negative change, but one intended to lessen stigma, and let people know it's OK to have a problem if it decreases denial so the person can get help.”
The concept of requiring physician wellness education was launched a year ago after the medical board closed down its controversial "diversion" program last June. The program was intended for "diverted" substance-abusing physicians from having their licenses disciplined into a five-year system that attempted to monitor their recovery.
But a series of reports and a state audit concluded that diversion had failed to protect patients from harm caused by enrolled physicians who were still impaired. About 250 physicians were enrolled at any time, without disclosure to patients under their care and often without limits on their practices.
The board decided it could not ethically safeguard patients while being aware that impaired physicians were continuing to practice. The needs of the physician wrongly had more priority than the needs of patients.
A $500,000 effort to correct major loopholes was unsuccessful.
The program's failure prompted Fantozzi to consider what to do next. Whatever the diversion program did or didn't do, it never tried to prevent physician behavior problems in the first place, he says.
Studies suggest that at any given point in time, 3.5% to 4% of physicians are impaired by substance abuse and another 10% are at risk of becoming so. Among California's 100,000 active physicians, "we should have had 3,500 in diversion, but we only had 250. And we know there were 10,000 to 15,000 others who are at risk," he says.
Fantozzi knows most medical schools already expose students to a variety of such wellness education programs. "What's not being done at all is anything consistent for the practicing physician, something that reminds them that the career they've chosen is stressful, and maybe not now, but in 10 or 20 years, they may find the rigors affecting their decisions as a practitioner," he says.
One program he uses as a model is that of Kaiser Permanente Northern California, where 6,800 physicians have a mentoring system, social activities, and educational classes focusing on watching out for and preventing the stresses that can destroy a practice.
"Every one of our 19 sites has a budget and a committee that oversees wellness, in addition to committees that are required by law," says David Schearn, MD, director of physician education and development. "They have various social activities, scheduled retreats, with family or without, to deal with burnout, or address financial issues that can be an enormous cause of stress."
Fantozzi says physician committees that grant physician staff privileges would be a good place to launch such programs. "But when you survey those committees, you see their understanding of what they do is to deal with bad behavior, a doctor who made a bad choice. They don't see themselves providing education. They see themselves as a prosecutor," he says.
But Jerrold Glassman, MD, head of credentials for Scripps Mercy Hospital in San Diego, disagrees that such committees should serve such a purpose, saying it's "another unfunded mandate. You can't pile these requirements on for the general physician population when the problem only affects a few," he says.
Fantozzi's idea is "naïve," says James Hay, MD, the CMA liaison to the Medical Board, who doesn't think such programs would reduce physician addictions that lead to misconduct. "There's no evidence that mandating a course in anything increases quality in anything," he says.
Already, the medical board requires 50 hours of continuing medical education coursework every two years, and requires a one-time 12-hour course in pain management. They don't have time to take more, he says.
Hay and the CMA are still bristling over the Medical Board's vote to end the diversion program, which they felt could have been fixed. "Under the old program, there were 250 doctors in diversion. Now there are 30 on probation. It's clear to us the public is less safe than they were two years ago."
And he thinks it's silly to believe educating doctors about those behaviors will prompt those with problems to come forward. "You never meet an alcoholic who tells you how much they drink," Hay says.
Luis Sanchez, MD, director of physician health services for the state of Massachusetts, also adamantly disagrees with Fantozzi's idea. Instead, he thinks the medical board is using wellness education as a way to side-step the fact that it's no longer overseeing physicians with problems.
"What he wants is so off base," Sanchez says. "He's saying, ‘Let's ram this down their throats, and then we're no longer responsible because we've done what we have to do," says Sanchez, a member of the board of the Federation of State Physician Health Programs. "There's a huge gap between required to take a course and seeking help."
President Barack Obama earlier today applauded businesses that have lowered their own health costs by paying for health and wellness programs for their employees. That concept is the same as his own, Fantozzi says. While California physicians are not in the strict sense of the word "employees" of the medical board, the board has a commitment to promote wellness in its physicians in the spirit of its mission to protect the public.
Fantozzi knows the idea is going to be politically hard to mandate, and already he is getting what he calls "pushback." But he thinks reason will ultimately prevail.
"We shouldn't be thinking about what we can do for one doc, or the next doc. We should be thinking how to help all docs," says Fantozzi.