PHPs and the meaning of “assessment”

I was reading Michael Langan’s post PHP Approved Assessments on the conflict of interest that PHPs (Physician Health Programs) maintain in coercively referring to their “preferred centers.” Michael however makes an error in carry forward the party line that PHPs do not conduct (diagnostic) evaluations or provide treatment. While the latter may or may not be true, depending on whether the physician presents voluntarily seeking “services,” the former is most definitely false and little more than the ruse PHPs would have you – and the state – believe.

Clearly it’s a problem when a state-run psychiatric evaluation program (a PHP) operating as a tax exempt non-profit public charity and enjoying state immunity claims that a) it is not conducting diagnostic evaluations but only some ill-defined “assessments” and b) is only making “recommendations” (which the Board invariably acts on to compel compliance – quite the “recommendation!”).

And then, as a result of that “assessment,” the results of which the subject physician is not allowed to see, you are “recommended” to now submit to an “evaluation” at one PHP’s “preferred evaluation centers” out-of-state for a 4 day multi-disciplinary evaluation where the staff roster proudly features a polygraph expert. People – listen up. No legitimate mental health facility in the country has polygraph experts on staff. This would be a profound violation of psychiatric ethics, not to mention the law.

Should not that concern everyone? You’re being sent to a non-mental health facility staffed by a polygraph expert for “evaluation.” Whatever you say can – and will be – used against you. And you will have no right to have your lawyer present. And you will have no appeal. What I can’t understand is not only why are state governments permitting this, but why aren’t all physicians absolutely alarmed about this?! And what in the hell are physicians’ counsel doing while all this is going on? Talk about asleep at the bench! (My personal belief is that every lawyer who has failed in his/her duty to protect their physician client from this gross abuse needs to have their license lifted, be brought before their Ethics Committee and held liable for malpractice.)

But here also we have an evaluation facility which is “preferred” and which is privately owned and which depends for its referrals on the national array of PHPs in every state. Is there perhaps any chance of bias in their returning a diagnosis which supports the initial PHP diagnosis?

What in the hell is a PHP ”assessment?”

Go back for a moment to this idea that a PHP does not conduct diagnostic psychiatric evaluations. This is what they contend, and even deny physicians they evaluate their medical record from that evaluation on the basis that they really didn’t conduct a diagnostic assessment but rather did “peer review” (this despite the fact that the Board may have explicitly ordered them to conduct a “mental evaluation). If they are conducting such “peer review,” then they have violated every one of the criteria of the Health Care Quality Improvement Act (HCQIA U.S.C. 42.11101 et seq.) which governs all peer review.

But we know it’s not peer review as no peer review ever consists of a diagnostic psychiatric evaluation. But perhaps only those familiar with the world of psychiatry and how diagnostic evaluation reports are constructed would know what a diagnostic psychiatric evaluation report actually looks like. And based on records reviewed, that is what they are conducting. But you would never know it because you’re prevented from seeing their record. Convenient, eh?

Look at this another way. The various states’ laws are creatively written to skirt the issue of what actually comprises a PHP “assessment.” So, your medical board receives an anonymous complaint about you seeming woozy or alleging that you smell of alcohol. (It may surprise you to know that in some states, the investigations department can open an investigation without the “board proper” – i.e. the appointed physicians on the board – even knowing.)

They don’t vet the legitimacy of the complaint but rather order you to go to PHP. The only way they can do this is to bypass all laws protecting civil liberties with regard to involuntary mental evaluations. This is de facto a compulsory psychiatric evaluation, ordered by one’s medical board, aimed at assessing whether you have a mental illness or substance abuse problem or some other behavioral disorder that is adversely impacting patient care.

Now, before the wise and compassionate PHP evaluator can send you anywhere, doesn’t it stand to reason that the evaluator has to have sufficient expertise to know what type of specialist to send you to? For one, you don’t send a mentally ill person to an addiction treatment center, and you don’t send an alcoholic or addicted person to a mental hospital. Probably only people in mental health understand this fundamental distinction. So, the PHP evaluator at the very least has to have some knowledge of whether one is dealing with a “mental illness” or a “substance abuse” problem. Even making this preliminary determination constitutes using one’s professional medical knowledge to make a preliminary diagnosis. Clearly, we’re dealing with an agency whose assessment function is at least fundamentally diagnostic.

However, to make an assessment of a condition in either domain, whether mental illness or substance abuse, one must have sufficient knowledge of the range of disorders within those categories. Is it “depression?” “bipolar disorder? “panic disorder?” etc. Likewise with regard to substance abuse – is it alcohol? Narcotics, hallucinogens, amphetamine-like substances? And you have to know what questions to ask. How often, when taken, how long’s this been going on …? Correct me if I’m wrong, but isn’t this what constitutes making a medical diagnosis?

Now, even with that, you still need to know how SEVERE the problem is and whether it is ADVERSELY IMPACTING PATIENT CARE. So the evaluator has to know how to assess that, because you don’t want to cause needless intensive treatment for a problem that can be addressed on an OP basis and conversely you don’t want to jeopardize patient care and the physician’s health for a serious problem that requires intensive in-patient treatment.

So, a PHP evaluator is having to meet face-to-face with a physician and conduct an interview. And then ask the right questions to elicit appropriate information about the condition under question. (This is starting to seem like a diagnostic interview, isn’t it?) And then the evaluator is having to ask specific questions which elicit factual data and symptom data to clarify what is the nature of the condition. Does this not strike one as having the qualities of a diagnostic evaluation? And then the evaluator is having to make a preliminary determination about what the specific or even general nature of the problem is and whether it merits further investigation or even mandatory treatment. And the evaluator then conveys that in a top secret report to someone back at the Board who then issues an order for that person to go to the evaluation or treatment as “recommended” by this PHP. Am I missing something here?

So, what’s this notion that PHPs don’t conduct diagnostic psychiatric assessments? Why does it persist? I believe it persists because that’s the party line from FSPHP. And the reason that’s the party line is likely because alleging that they conduct such a “non-diagnostic assessment” would spare them the assertion that they are conducting diagnostic psychiatric evaluations for which they could be held medico-legally liable. That could be very messy – tort-wise and constitutionally.

And an additional reason is that, by denying that they’re conducting such, they avoid that even messier area of state and federal law having to do with the state being involved in ordering compulsory psychiatric evaluations while not protecting the patient’s civil rights. There is in fact a whole body of law pertaining to protecting a citizen’s rights against involuntary commitment for psychiatric purposes. Issues of involuntary search and seizure, government abuse of psychiatry for other than treatment purposes (e.g. locking up dissidents…), violation of one’s civil rights….

It’s way past the time to pull back the curtain on this powerful state-supported wizard!

If a physician doesn’t have a problem with this arrangement, tell you what … just tell me your name and what state you’re in, and I’ll file an anonymous complaint with your board about you, say, being woozy or that I smelled alcohol in the examining room or that I saw you hug a patient   – I don’t even have to be your patient! And that’ll let you experience for yourself the whole shebang. Should move quickly, but once started, could take a year or two to move you through the system to a point of immobilization. You probably won’t thank me for it, but I can guarantee you this – you’ll come out at least $100k lighter, what with extended evaluation and treatment at “preferred programs,” and then ~ $25k for lawyer fees (sadly, just for them to tell you you have no rights). (That’s not counting lost practice time or endangerment of patient well-being from unwarranted interruption of care.)

And bud, that’s before you even start your 5 year “monitoring program.” Just to ensure that you’re not still a danger.