Physician Health Programs May Not Help Med Students

There has been a growing awareness about the mental health challenges faced by medical students, and the pandemic has only exacerbated those concerns. It is more critical than ever to ensure that future physicians with mental health issues have access to top-notch, affordable, confidential care.

I am a psychiatrist and former associate director of a state physician health program (PHP). For more than a decade, I have written extensively about concerns I have had about standard PHP practices. As a result, I am contacted by medical students and or practicing physicians from all over the country more or less daily.

And what I hear makes me concerned that the exact opposite is happening.

One student was grieving the death of a relative and started turning in assignments late and was slower than usual to respond to pages. When asked about her change in behaviors by a faculty member, the student shared about her recent loss. Soon thereafter, the student was referred to the state PHP and told by the dean to comply with anything the PHP asked. The PHP then told the student that she needed to go to an evaluation center thousands of miles away at an out-of-pocket cost of $6,000 to $10,000, even though the state where she attends medical school has several top-rated psychiatric departments that would likely accept her insurance.

A different student in another state was near the end of his third year of medical school when he was written up for unprofessional behavior. He was referred to his state PHP and told to comply with whatever the PHP asked of him. Similarly, he was referred to a facility he’d never heard of in another state for an evaluation that was likely going to result in a recommendation for an extended stay for “treatment” at a cost of anywhere from $60,000 to $100,000, despite having recently entered treatment with a local psychiatrist for newly diagnosed ADHD, which no doubt played a role in the unprofessional behaviors that caught the eye of the dean’s office.

Not infrequently, med students like the ones above are referred to state PHPs and told to comply with whatever the PHP demands if they want to stay in school. At first blush, such a requirement seems straightforward, because PHPs are designed to support physicians with mental health and substance use disorders by providing assessment, treatment referrals, and monitoring to ensure that healthcare professionals can safely continue or return to practice.

But many who walk through PHP doors are reflexively sent out for evaluations by a third party, frequently in far-flung states.

These referrals are anything but straightforward. First, they can be very expensive, frequently costing tens or even hundreds of thousands of dollars. Such costs are especially problematic for medical students from lower socioeconomic backgrounds, who are less likely than their wealthy classmates to have the financial support systems necessary to comply with PHP recommendations. Since such students might be less able to access mental health care, to begin with, mandating PHP compliance for students with fewer financial means is a double whammy on both their well-being and their ability to remain in medical school.

To complicate matters, PHPs often have bidirectional conflicts of interest with the very expensive evaluation centers to which they frequently refer students, because the centers PHPs use underwrite state and national PHP meetings. In return, PHPs place those centers on their “preferred list” for referrals. PHPs are thus incentivized to refer students to certain facilities regardless of whether those centers provide the best or most cost-effective care. And just as bad, these evaluators are incentivized to recommend as many folks as possible for the very expensive extended treatment stays that they offer, given that anyone who’s landed in their lap generally is compelled to comply with all of their recommendations.

This reality undermines the trust students place in these programs and also raises questions about the integrity of the PHP’s recommendations. Unfortunately, medical school administrations generally aren’t aware of these multiple conflicts of interest and blindly continue to send their students into a system that doesn’t have the students’ best interests in mind.

In response to my previous writing about PHPs, the current president of the Federation of State Physician Health Programs (FSPHP) wrote that his state program in Tennessee “often” obtained grants to cover evaluations for med students.* (He also wrote that the Washington program did the same, but many Washington state med students I’ve heard from beg to differ.)

Even if a portion of the evaluation is covered, the evaluations themselves are relatively inexpensive compared with the tens of thousands of dollars that are required to cover the extended treatment stays that these evaluations frequently recommend.

The FSPHP president also stated that PHPs “operate transparently.” If true, why won’t they make public their list of annual meeting sponsors and their list of “preferred” network of evaluation-treatment centers, which overlap virtually one-for-one? Or submit to unbiased audits from non-PHP insiders?

Because of these significant conflicts of interest, if med students ask to be seen locally, they are generally told “no” by the PHP; even if they ask, like the first med student above did, to go to a local nationally ranked psychiatry department.

To make matters worse, some of these facilities require clients to pass polygraph tests before they will clear someone to return to school or work. One facility charges $400 for each polygraph test and allows clients who fail to retake the test as many times as necessary, provided they pony up $400 for every test until they pass.

Despite their ethically fraught relationships, PHPs operate with almost no transparency or oversight, leaving anyone referred to them with no clear avenues for appeal if they believe they are being treated unfairly.

Reforms are overdue. There ought to be national standards for PHPs as well as independent audits conducted by individuals external to PHPs — instead of the PHP insiders that many state programs have used.

Additionally, medical schools ought to reconsider their policies regarding mandatory PHP referrals. Alternative, less costly options for mental health treatment should be made available, and students should be given the autonomy to choose the care that best fits their needs and financial situation.

Just as importantly, PHPs should stop using facilities with which they have financial ties. Instead, they ought to refer clients to first-rate academic facilities or private practitioners with solid credentials who don’t offer extended treatment themselves and thus wouldn’t have conflicts of interest in recommending such treatment.

Forcing medical students to engage with PHPs and then comply with any PHP recommendations is wrong. Additionally, they also have an ethical duty to advocate for greater transparency and regulation of PHPs. Until that happens, medical students will continue to be railroaded into a costly system rife with conflicts of interest and shady practices in a system that is anything but transparent.

And, unfortunately, my email inbox will remain full.

Reference:

* Baron M. In defense of state physician health programs’ work with medical students. STAT News. Dec 21, 2024. Available at:

**A previous version of this piece has been published on STAT News.