The socioeconomic study of what motivates people is a fascinating field of study, not the least of which is because of how counter-intuitive it is. For example, it seems normal to assume that the more someone is rewarded for their efforts, the more effort they will put forth toward those rewards. These rewards (increasing salary, bonuses, benefits, status, etc) are known as “extrinsic” motivators and for  menial and/or repetitive jobs that have little need for regular complex planning, evaluation, or creative problem solving like unskilled manufacturing, manual labor, or GOP membership, the system works as expected with bigger monetary rewards leading to bigger efforts.

However, this simple linear model of economic motivation begins to break down as “intrinsic” motivators start to dominate the picture. Intrinsic motivators are such psychological variables as the perception of autonomy, mastery of the task or role, and purpose. It turns out that not only do extrinsic variables not work as predicted for motivating a worker tasked with performing complex work that requires thought and problem solving skills but this kind of motivation actually reduces job performance (particularly time spent per task).

This counter-intuitive result is what economists refer to as “crowding out” of the intrinsic values with the extrinsic values. The offer of an extrinsic reward tends to cheapen or dampen the intrinsic rewards and the negative effect on your intrinsic motivations is enough to negate and even reverse any positive extrinsic motivators. External motivators tend to come with conditions that hamper autonomy, mastery, and purpose. A job that was once “fun” has now become burdened with the demands of higher expectations even though a reward is bundled in there somewhere. Extrinsic rewards also impair creativity and thinking by narrowing down the focus of the task (i.e. getting it done faster or more efficiently).

The key to having a happy employee who’s job involves cognitive skills, creative thinking, and problem solving is to 1.) ensure that they are paid enough to close the gap between what they are paid and what they think they should be paid based on their education, training, and experience so that base pay is no longer an issue and 2.) allow the intrinsic motivators of autonomy, mastery and learning, and purpose to flourish. There is a great “whiteboard” animation of a presentation on this by Daniel Pink for those who think I’m crazy. This is not neo-hippy, socialistic, Montessori style, feel-good new management methods. This is real world and is already yielding benefits for companies like Google.

This got me thinking about physicians and motivation. We like to say that what motivates us is the chance and desire to save lives and improve lives. That’s purpose. We like to be our own boss and work on our own schedule. That’s autonomy. And we like what we do. We find it interesting and strive to learn more and improve our skills. That’s mastery.

With so many intrinsic motivators for doctors, why then, do many appear to defy the evidence for the establishment of motivations stated above and simply increase their work loads to obtain the higher salary or bonus or base income? I have seen physicians who round on 15-20 complex hospitalized patients in an hour and others who see a complex medical patient in the span of a 3 minute office visit. Then there are those who push the boundaries of the vast gray area of test and procedure indications (like ordering expensive nerve studies on every diabetic patient regareless of symptoms) and then there are those who commit outright fraud.

Many doctors are employees but the type of excessive extrinsic motivated behavior I’ve seen comes from physicians who are self-employed, while the studies for the effects of extrinsic and intrinsic motivators were done mostly in the context of employee-management relationships. Is this the reason for the discrepancy? I don’t think so. Self-employed doctors function as employee-owners, doing the brunt of the work for their practices while being beholden to insurance companies and the government for their compensation. It’s still very much of an employee-like relationship with the promises of increased compensation for increased work. The same basic motivator mechanisms should still apply.

I believe that the problem starts with insufficient compensation which in of itself is an extrinsic motivator that compels the worker/doctor to try and close the gap between effort and proper compensation. This seem to help explain why higher paid specialists, though they work hard, tend not to follow a pure profit motive pattern. Surveys have found that specialists are more satisfied with their jobs than their lower paid colleges in primary care. Specialists are also more likely to be self-employed (autonomy) and in my experience, they tend to express more interest in and a desire for mastery of their field and skills than many primary care docs.

I believe that the second culprit is the per-patient or per-procedure way that doctors are compensated. This a system that already has multiple levels of bonus and reward built into it just like the unskilled laborer who gets paid more to move more rocks, so to do physicians get paid more to see more patients. So how does a physician with a high level of intrinsic motivators convert to a profit driven machine with the extrinsic motivation profile that is on par with an unskilled rock mover?

The key concept is that they convert the essence of their job from creative problem solving of multiple complex tasks to following more linear basic rule sets. In short, they go from practicing medicine to practicing “cookie-cutter” medicine. You would think that this would apply more for specialists who often deal with more linear decision making for their many technical skills and procedures they perform but I’ve seen profit driven “cookie-cutter” medical practice behavior more often in primary care docs and I think that it is their lower compensation that is to blame.

“Cookie-cutter” physicians try to minimize risk while maximizing profits. One way to do this is to minimize the time spent with the patient and on complex problem solving. It is more efficient and profitable to perform a very basic linear diagnostic and treatment evaluation. If knee pain then –> MRI. If nervousness then –> prescribe sedatives. If fever –> antibiotics. If chest pain then –> cardiologist referral. If vomiting then –> gastroenterologist referral. Most of the complexities and nuances of medical care are tossed aside in favor of a rote if-then decision tree that can be done by any couch potato who’s watched too many episodes of “er”.

Usually, this type of medical care increases overall utilization of resources. Expensive tests and procedures are more likely to be ordered both because the physician believes that they reduce their liability risk  which they have acquired from spending too little time with too many patients and/or because they  increase profit. Medications are more likely to be ordered for each and every symptom because it takes less time to explain to and convince a patient – who is usually expecting some type of medication – why they need the medication than why they don’t.

Needless to say, this type of medical practice does NOT improve overall care quality or patient satisfaction and may very well  decrease  care quality in many circumstances. This apparent paradox in decreasing health care quality in areas of high health care resource utilization has been extensively studied using natural  geographic variations in Medicare spending.  These physicians tend to prescribe too many referrals, tests, procedures, and medications and they all come with risks. Physicians who practice this way are likely to be too aggressive with diagnostic modalities and treatments for certain subsets of patients. For example,  in patients with mild conditions in whom the side effects may outweigh the benefits or those with advanced disease for whom aggressive treatment is more likely to hasten death than to prolong life.

The study of economic motivation models may help to explain and predict that inadequate compensation is more likely to change physician motivation and practice patterns from an intrinsic system to an extrinsic profit driven system which increased health care utilization and ultimately higher costs for no quality benefits. This is particularly true for primary care practitioners and does not bode well for Obama’s new-American health care mecca.

There are some obvious solutions. First, pay primary care physicians an increased amount so that they are adequately compensated for their time, effort, and level of training and that this issue is “taken off the table.” Next, change the per-patient, per-procedure scheme to an annual fixed amount based on a set panel of patients.

Greed is “good” in that it leads to capital investment in macroeconomic systems but in the microeconomic context of skilled health care worker, greed – external profit motives – suppress intrinsic motivators and invariably leads to sub-par performance, increased costs, and decreased care quality and decreased satisfaction values among patients and physicians.

On the surface, this re-testing sounds like a good idea for a profession where new treatments, new discoveries, and new medications are constantly emerging. And yet, there is no evidence that board certification or repeat testing of any frequency leads to better qualified doctors or better health care quality. What is the upside to re-certification? Theoretically, it compels physicians to study and keep current with all the latest research and treatments. But this is what a good physician should do regardless and with a testing frequency of every 10 years, those facing re-certification are likely to wait 9 years until right before the test to crack a book or worse, to study for the test and enroll in a  board “refresher” course rather then to enhance their own medical knowledge. Educators with experience with standardized tests know what I’m talking about here.

What are the downsides? Stress and anxiety for one. Board certifications are not just something that physicians do to have another decoration to hang on their office wall in order to give their patients a false sense of security. Current board certification is often a requirement for hospital staff privileges, professional society memberships, and enrollment in most insurance plans. The loss of board certification could have a profound impact on their financial security and ability to continue to practice in their specialty.

Cost is another. The cost of the test itself in addition to a “quickie refresher course” plus time off from work to study for and to take the test can cost several thousand dollars. Though this is certainly not prohibitive considering the average income of most practicing physicians, I have to wonder about the intent and ethics behind an entire industry of specialty boards and study aids and courses that has sprung up to siphon off money from a profession based on a standardized testing scheme that has not been shown to improve or strengthen the delivery of patient care.

Back in medical school we were taught that an organism that benefits in some way from another organism without giving anything back is called a parasite. Thus, specialty board certification remains a parasitic activity until proven otherwise.

Of course, the liberal war machine when into high gear once word of this got out.

“Cassell may be walking a thin line between his right to free speech and his professional obligation”, said William Allen, professor of bioethics, law and medical professionalism at the University of Florida‘s College of Medicine.

The outspoken [U.S. Rep. Alan Grayson], described Cassell’s sign as “ridiculous.” “I’m disgusted,” he said. “Maybe he thinks the Hippocratic Oath says, ‘Do no good.’ If this is the face of the right wing in America, it’s the face of cruelty. … Why don’t they change the name of the Republican Party to the Sore Loser Party?”

To his credit, Dr. Cassell denies having abandoned or refused to treat patients based on their political views and denies even asking patients about their views or who they voted for as a

The Oath: It's Greek to me.

prerequisite for treatment.  Dr. Cassell’s sign is obviously a political statement and not a serious policy if considered in the context of the fact that voting remains by way of secret ballot in this country and that other then bumper stickers there is no way to identify the political affiliation or opinions of Americans.

Rep. Grayson is right about one thing. Taking this sign seriously is about as “ridiculous” as literally believing the intentions of a doctor who puts up a sign stating their refusal to treat anyone who’s favorite color is blue.

But don’t raise such practicalities of common sense with Mr. Grayson who has threatened to file a complaint against Dr. Cassell with the Florida Department of Health.  This is just another perfect example of why the first amendment continues to be so important (actual and real patient abandonment should be irrespective of the reasons for such ethics violations).

This case does raise a troubling issue. Are physicians for all intents and purposes, stripped of their rights to political speech and political activity if such activity directly involves patient care? One of the letters to the editor of the Orlando Sentinel expressed disgust at Dr. Cassell’s mixing of politics and patient care while ironically stating her right to choose another physician if faced with a similar sign. Wait. Don’t doctors also have the right to choose to be politically active just as patients have the right to pick and change doctors?

Though ivory tower bioethicists believe that the Hippocratic Oath binds physicians to an unbreakable doctor-patient relationship until death do us part or until the patient seeks care elsewhere, the fact is that there is nothing in the Oath that specifically forbids political activity by doctors nor compels them to treat a patient indefinitely irrespective of any reason to end the relationship. Practicalities take priority over idealism in common law.  Except for laws that bar discrimination, a physician is allowed to refuse service or to terminate services. In almost all cases, physician’s are allowed to end a professional relationship with a patient after giving appropriate notice and assistance as indicated to help the patient secure care elsewhere while being available for a practical time period to render emergency care as needed.

Ideally, political activity should NOT impact or compromise patient care but sometimes a work stoppage (strike) and refusal to participate in the system is the only way to send an effective message. Nor should doctors be forced by some false interpretation of the Hippocratic Oath to continue to provide care within a health care system that they feel compromises their own economic stability and/or the ultimate care of their patients. In other words, do the ethical constraints of the Hippocratic Oath trump the Constitutional rights of physicians? Absolutely not. The Framers were well aware of the ancient Oath in their time and did not choose to make an exception in that the rights of patients for care would negate the speech and political rights of their physicians.

DWT laws have light years to go before they begin to even come close to DWI laws in severity of punishment and overall societal condemnation. These days you can be fired for being arrested for DWI even if your job has nothing to do with operating a motor vehicle. And this is just for being arrested for DWI. Never mind any conviction.

But DWT laws will probably never reach the hysterical levels of DWI laws and consequences even if DWT related deaths eventually reach those related to DWI (a distinct possibility in the next few years, as cell phone and other text device usage increases). Americans will always have this mentality that crimes committed while under the influence of a substance are considered to be MORE illegal than braking the law while stone cold sober. I suppose this is because being under the influence of a recreational psychotropic substance is considered to be a grand moral failing while taking your eyes off the road for five seconds before plowing into a crowd of school kids at a cross walk is considered to be just “bad judgment”.

Texas law does provide some protections from civil litigation for whistle blowers but – obviously – none for criminal charges.

Though, I have yet to hear of a case where the Texas Medical Board voluntarily turned over the identity of a complainant who has made a flagrantly false and malicious accusation with the intent to cause harm to the named physician.

Dr. Arafiles’ response to being reported to the Texas Medical Board was certainly a unique alternative  (and lucky in many aspects) to the usual options of hiring a lawyer who specializes in defending doctors from the Board at an initial cost of $10 to $50,000 or the “wait and pray” method. His approach  is apparently consistent with the unique ways he practices medicine including treatments for Morgellon’s Disease (a disorder that has thus far not even been proven to exist) with Colloidal Silver, a silver containing gel for the treatment of H1N1 influenza (that he sells), and oxygenated olive oil for . . . I have no idea what this could possibly treat.

Though Dr. Arafiles reportedly surrendered his medical license in New York state and was fined $1,000 by the Texas Medical Board in 2007 for failing to properly supervise mid-level providers, he probably currently has little to fear from the Board for prescribing the very herbs and silver gels that he sells or once suturing a rubber tip to a patient’s finger. That is, he has little to fear from a board that is much more concerned about sex, drugs, and rock-n-roll i.e. coming down hard over things like legal and  consensual sexual activity between doctor and patient, than it is about the potential dangers of alternative and unproven “treatments”.

This strategy is especially true for anti-vaccine conspiracy theorists who ignore the mountains of evidence* for the safety and efficacy of childhood vaccinations and instead point to a scant few studies that, though far from definitively proving a link between vaccines or thimerosal and autism or other neurodevelopmental disorders, do appear to suggest a possible connection.

Popular Mechanics took a closer look at many of these studies and found several serious credibility problems including at least three studies that were connected to the now discredited father of the MMR-autism-link theory, Dr. Andrew Wakefield (formally of the UK), one study that appeared in a non-independently peer reviewed publication, several studies authored by a geneticist who regularly provides “expert” testimony in court cases alleging vaccine induced injury, and one study that appeared in the journal of an anti-vaccine organization. This is equivalent to every study that showed the safety and efficacy of vaccines appearing in journals and publications owned by pharmaceutical companies and vaccine makers or in journals edited by researchers employed by vaccine makers.

And then there are the quality and accuracy issues. One study commentary falsely claimed that the symptoms of mercury poisoning and autism are very similar. There are hypotheses of a neuro-toxin caused by the MMR vaccine that is supposed to cause the autistic spectrum of disorders but none is ever identified or isolated. Studies point to statistical connections between increasing numbers of childhood vaccines and the increasing diagnosis rate of autism but don’t propose any plausible mechanism to explain this. One study found that the ethylmercury in thimerosal may accumulate in the brain more than methylmercury from environmental sources (like fish) but this study was done in monkeys and never duplicated in humans. Another study looked at the toxic effects of thimersoal on tissue in vitro but even regular tap water can be made to kill human cells in a petri dish and animal model studies and in vitro study results do not at all automatically apply to humans. Then there is this,

In perhaps the most telling sign that the mainstream scientific community and the anti-vaccination movement (and the studies it relies on for credibility) are not on the same page: between the 175 references in the Medical Veritas study [The danger of excessive vaccination during brain development: the case for a link to Autism Spectrum Disorders] and the 39 referenced in the Clinical Infectious Diseases literature review, there is, shockingly, only one study that appears in both: Andrew Wakefield’s now retracted 1998 Lancet study.

Multiple anti-vaccine studies that provide little proof or plausible mechanisms for their claims and they all reference each other instead of mainstream studies. That’s a circular definition. It’s another fallacy like the claim that God exists because the Bible says so.

The first problem with the anti-vaccine movement’s “house of cards” strategy is not understanding how science works. Though it does happen, it is rare for a single study to be a paradigm changer and in almost every case the study is well designed and opens up an entirely new area of research that includes several ever larger studies that confirm and expand upon the results of the initial study. More often than not, the results of multiple studies on a topic contradict each other but this does not mean that one or both sides are correct or wrong. Often it takes one or more “meta-analysis” to wade through the data from different studies that use different methodologies on different study populations to reach some type of statistical conclusion. The fact that a few studies appear to suggest an MMR or thimerosal link to autism does not definitively prove anything, nor does it negate the data of much larger and better designed studies.

The second problem with this strategy is in assuming that the prevailing establishment theories on the safety and efficacy of vaccines really and truly constitute a house of cards based on flimsy to little evidence that is ready to buckle and come crashing down at the slightest touch of the truth. Obviously this has not happened which means that what the anti-vaccine movement has in its study arsenal is not really the truth and/or that mainstream vaccine theory is a solid bedrock of repeatedly tested and confirmed evidence and data.

Of course, the conspiracy come into play when the theorists claim that the establishment is suppressing the truth by ignoring or suppressing their study results. Of course they never prove that that this “suppression” is from efforts to prevent the truth from coming out and not because their studies are junk.

Perhaps a little comparison in what a successful scientific paradigm change looks like is in order. For over 80 years, the prevailing theory in the medical field was that excess stomach acid is the cause of stomach ulcers. Though it had been proposed that a bacterial infection might be a cause, it was not until 1982 that Australian physicians Barry Marshall and Robin Warren were the first to isolate the bacterium Helicobacter pylori and find that it is a significant cause of gastritis and peptic ulcers in humans. Initially they met a significant amount of resistance from the scientific community and it took several years for their study to be published and start to be accepted. Hundreds of follow up studies confirmed and expanded upon their results and in 2005 they were awarded the Nobel Prize in Medicine for their discovery that changed our understanding and treatment of stomach ulcers. In contrast,  Dr. Wakefield’s Lancet study and MMR-autism theory was decidedly not followed by a ever growing body of successive experimental, clinical, and epidemiological evidence (quite the contrary) but the study itself was retracted in 2009 and Dr. Wakefield lost his UK job and currently works in Texas without a medical license.

That’s quite a contrast!

*Time trends in autism and in MMR immunization coverage in California. (JAMA 2001 Mar 7;285(9):1183-5), A population-based study of measles, mumps, and rubella vaccination and autism. (N Engl J Med 2002 Nov 7;347(19):1477-82), Thimerosal and the occurrence of autism: negative ecological evidence from Danish population-based data. (Pediatrics 2003 Sep;112(3 Pt 1):604-6), Mumps, measles, and rubella vaccine and the incidence of autism recorded by general practitioners: a time trend analysis (BMJ 2001 Feb 24;322(7284):460-3), No evidence for a new variant of measles-mumps-rubella-induced autism (Pediatrics 2001 Oct;108(4):E58), Autism and measles, mumps, and rubella vaccine: no epidemiological evidence for a causal association (Lancet 1999 Jun 12;353(9169):2026-9), Neurologic disorders after measles-mumps-rubella vaccination (Pediatrics 2002 Nov;110(5):957-63), MMR and autism: further evidence against a causal association (Vaccine 2001 Jun 14;19(27):3632-5). Association of autistic spectrum disorder and the measles, mumps, and rubella vaccine: a systematic review of current epidemiological evidence (Arch Pediatr Adolesc Med 2003 Jul;157(7):628-34).

Of course, the diagnosis of PVS and MCS  are clinical diagnoses since until recently there was not effective way to determine if the higher cortical areas of the brain were actually functioning enough to enable the patient to be aware.

Functional MRI was developed in the early 1990s and measures tiny and very localized changes in blood flow that reflect increased neural activity. Essentially, more active areas of the brain “light up” on the fMRI scan as blood flow changes second to second. Researchers have now used this tool to evaluate the brains of PVS and MCS patients and compare them to scans of normal control subjects. 54 patients with various causes of brain damage (traumatic, anoxic, stroke, infection) were enrolled in the study.

Of the 54 patients, 5 with traumatic brain injuries were able to modulate their brain activity by generating voluntary, reliable, and repeatable blood-oxygenation-level–dependent responses in predefined neuroanatomical regions when prompted to perform imagery tasks. No such responses were observed in any of the patients with nontraumatic brain injuries. Four of the five patients who were able to generate these responses were admitted to the hospital with a diagnosis of being in a vegetative state. When these four patients were thoroughly retested at the bedside, some behavioral indicators of awareness could be detected in two of them. However, the other two patients remained behaviorally unresponsive at the bedside, even after the functional MRI results were known and despite repeated testing by a multidisciplinary team. Thus, in a minority of cases, patients who meet the behavioral criteria for a vegetative state have residual cognitive function and even conscious awareness.

So it is possible that patients diagnosed as being vegetative are capable of having some awareness and cognitive function but they are in the small minority of PVS patients and all were traumatic brain injury victims. In other words, patients who developed PVS from a lack of blood flow (anoxic brain injury) or other non-traumatic injury mechanism like Terri Schiavo are far less likely than traumatic injury patients to be capable of conscious awareness if at all.

It is possible that more sensitive testing in the future may reveal more patient subgroups who are capable of awareness but this remains highly theoretical. If localized blood flow changes in these patients are too small to be seen on current functional MRI scans then the correlating neural activity may be below a level where consciousness is generated.  Much more research needs to be done but this study has already identified a subgroup of PVS patients who may be amendable to treatment once one is developed.

Abstinence-only education advocates then came up with the brilliant idea of having teenagers sign a “virginity pledge” because if there is anything that gets a teenager’s attention it’s a legally non-binding contract used purely for symbolism. And this tended to make things worse since the virginity pledges turned out to be more like a  “no contraceptive use pledges“.

Now a different abstinence-only education program has been developed that focuses strictly on the benefits of abstinence and the risks of sexual activity prior to adulthood and a new study has found that this approach appears to be working when compared to the more traditional comprehensive sex-ed methods.

The classes didn’t preach saving sex until marriage or disparage condom use. Instead, they involved assignments to help students around the age of 12 see the drawbacks to sexual activity at their age. It included having them list the pros and cons themselves, and it found their “cons” far outnumbered the “pros.”

Two years later, about one-third of abstinence-only students said they’d had sex since the classes ended, versus nearly half — about 49% — of the control group. Sexual activity rates in the other two groups didn’t differ from the control group.

That’s an absolute decrease of 16 percentage points. Not bad. It seems that all you need to do is to tell teenagers the truth about the risks of something and they’ll get the message (at least 66% of the time). The abstinence-only advocates were right all along. It’s just that they were hindering their programs with a lot of religious and moralistic tangentials instead of simply focusing on the actual issue at hand.

What’s really suprising is that the abstinence-only group did far better than the traditional sex-ed group and the combined approach group (abstinence-only and comprehensive sex ed), both of which were no better than the control group (general health).  This result may be in the way these sex-ed and general health programs were designed since comprehensive sex-ed has consistently been shown to be better than control groups in decreasing teen sexual activity.

The take home point (THP) is that, when something is not working . . eliminate the religious aspect.

In its first year the clinic has treated NHS staff hooked on drugs including heroin, ketamine, a horse tranquilliser, . . . . said Dr Clare Gerada, medical director of the Practitioner Health Programme.

The service also uncovered six cases of undiagnosed psychosis, in which sufferers see things or hear voices.  Two thirds of the 184 treated in the first 12 months had mental health problems, while one in three who came to the specialist service had some form of addiction. Of these 51 were alcoholics and 16 drug addicts.

Your London medical staff will see you now.

Drug addicted, psychotic, zombie doctors are practicing medical care in London! Or not. Drawing over-generalizations from headlines like this is like assuming that everyone in London is dead after reading an article on the number of bodies in the London city morgue. That’s not to say that it isn’t necessarily true. Zombie doctors might be out there but doing a very good job taking care of the population in London being that everyone is dead and all since it’s hard to screw up the medical care of someone who has passed on to brain eating. But I digress.

The reality is that doctors don’t have an overall higher rate of substance abuse and addiction than the general population  (at least according to US statistics which don’t take into account the sheer number of English zombie doctors out wandering the hillsides). What is different is that doctors use/abuse substances in different ratios.  Doctors are less likely to use tobacco and illicit drugs but more likely to have used alcohol than the general population according to a 1992 JAMA study. This is probably consistent with the substance abuse rates of other over-educated, high-pressure, snobby, “establishment” type professions like lawyers, politicians, and business professionals who will never touch a joint but have no problem with the five martini dinner.

What about the fact that physicians appear to have easier access to controlled medications than the general population? The same 1992 JAMA study did find that while physicians were more likely to use prescription mild opiate pain medications and benzodiazepine sedatives, the use of these medications was mostly for legitimate clinical reasons and daily use of these medications was rare. This usage pattern is probably much more reflective of physician’s awareness and acceptance of the role of these medications for various medical conditions than it is the ease of acquiring these medications. Ergo, it’s a fallacy to think that the availability of substances is what drives abuse and addiction just as there is no proof that the mere availability of seat belts, condoms, or firearms leads in turn to reckless driving, sexual promiscuity, or criminal activity.

ER physicians and anesthesiologists appear to have the greatest risk of developing substance abuse problems compared to the profession as a whole. I.e they are over-represented but the overall abuse rates of narcotics and other controlled medications in these professions are still less than that of the general population.

The idea that physicians as a whole or that certain medical specialists are at higher risk for substance abuse than everyone else appears to be “based on folklore” as a result of ignorance, prejudice, and fallacies of thought. But there are other truths intermingled with this issue. One is that physicians appear to be much more reluctant to seek treatment for substance abuse and psychiatric conditions not only because of the stigmata attached but because of the fear of and perception (mostly true) that various licensing bodies will persecute physicians under the guise of “protecting the public” even in cases where there were no patient, safety, or quality of care issues or occurrences were involved.

This is unfortunate since the other truth is that physicians have phenomenally high recovery rates and low relapse rates from substance abuse compared to the general population. A 2008 study found that 79% of physicians were clean and sober and licensed and working 5 years after undergoing treatment for substance abuse and only 10% had had their licenses revoked (presumably for substance abuse). A 2005 retrospective review of data on 233 physicians with substance abuse problems found a 91% rate of recovery at 6 years (J Addict Dis. 2005).  Compare this to recovery rates as low as 14% for alcoholics and 20% for other substance abuse at 5 years for the general population.

The take home message (THM) here is that even though physicians are not more likely than everyone else to be pill-popping, funny cigarette smoking, boozers, they do have much greater potential for recovery from substance abuse than everyone else and as such should be allowed every opportunity to be treated without undue hindrance I.e. without the fear of irrational and excessively punitive measures masquerading as “treatment” options imposed by various licensing bodies and medical societies or the fear of being ostracized and marginalized by the medical community because of the ignorance and prejudice and stigmata of having a substance abuse problem. It’s a problem that about 15% of any population has but either physicians are not supposed to have it and if they do, are a lot worse off for it and that is total rubbish.