Medical schools comprehensively address students’ mental health

In recent years, there has been growing awareness of the mental health issues facing medical students. The pandemic has only exacerbated concerns about the well-being of medical students, making it more crucial than ever to ensure that future doctors suffering from mental health issues have access to top-notch confidential and affordable care.

But does this happen? I am a psychiatrist and former associate director of a national Physician Health Program (PHP). For over a decade, I’ve written extensively about concerns I had with standard PHP practices. As a result, I am contacted several times a week by medical students and/or practicing physicians from across the country.

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

A student was grieving the death of a close relative and began turning in assignments late and was slower than usual in responding to pages. When asked by a faculty member about her change in behavior, the student shared her recent loss. Shortly after, the student was referred to the state PHP and the dean told him to comply with whatever the PHP asked. The PHP then told the student she would have to travel to an assessment center thousands of miles away, at a cost of $6,000 to $10,000, even though the state she is studying in Medicine has several top-notch psychiatric departments that would. will probably accept his insurance.

Another student from another state was about to complete his third year of medical school – with no prior problems of any kind – when he was disciplined for unprofessional behavior. He was referred to his state’s PHP and told to comply with whatever the PHP asked of him. Likewise, even though he was from the East Coast and attended a medical school not far from home, he was referred to a Midwestern institution he had never heard of for an evaluation that would likely result in a recommendation for an extended stay. for “treatment” costing between $60,000 and $100,000, although I recently began treatment with a local psychiatrist for newly diagnosed ADHD, which undoubtedly played a role in the behaviors nonprofessionals who caught the attention of the dean’s office.

It is not uncommon for medical students like those above to be referred to state PHPs and asked – just like these two students – to comply with all PHP requirements if they want to stay in school. On the surface, such a requirement seems simple, as PHPs are designed to support physicians with mental health and substance use disorders by providing confidential assessment, treatment referrals, and follow-up to ensure that medical professionals can continue or resume their practice in complete safety. As such, they are generally the reference state entities responsible for ensuring the well-being of doctors and medical students. Although PHPs have undoubtedly saved the lives of some health practitioners, they have also forced treatment and taken advantage of many others who would have been fine without their heavy hand.

Some state PHPs have psychiatrists and/or psychologists who work for them and perform their own evaluations of people sent to them. These state PHPs generally only refer individuals for further evaluation if their complexity warrants it.

But most PHPs perform little or no assessment themselves and reflexively steer most people who come through their doors toward costly third-party assessments, often to distant states, as was the case for the two students in medicine above.

The reality is that such references are anything but simple. PHPs often have conflicts of interest with the very expensive assessment centers to which they frequently refer students. And to make matters worse, once a PHP makes a recommendation for evaluation or treatment, medical students typically have few, if any, opportunities to appeal that recommendation.

When a medical student is referred to a PHP, this referral can result in significant financial costs. First, some PHPs charge a user fee to anyone who walks through their doors. And second – and much more important – being sent to a PHP often involves a referral to a third-party reviewer. Such referrals can cost tens or even hundreds of thousands of dollars.

Such costs can be very problematic for anyone, but particularly for medical students from lower socioeconomic backgrounds, who are less likely than their affluent peers to have the financial support systems necessary to comply with the recommendations of the PHP. Given that these students may be less able to access mental health care, imposing PHP compliance on students with fewer financial means constitutes a dual attack on their well-being and their ability to remain in medical school .

Furthermore, each time a medical student is referred to a PHP, school administrators are essentially entrusting that student’s fate to a financially and ethically conflicted system rife with the potential for coercion and abuse.

PHPs and the processing centers to which they refer students have two-way financial ties to each other, because the centers used by PHPs fund state and national PHP meetings. In return, the PHPs place these centers on their “preferred list” for referrals. PHPs are thus encouraged to direct students to certain establishments, whether these centers provide the best or most profitable care. And just as bad, these reviewers have an incentive to recommend as many people as possible for the extended treatment stays they offer, given that anyone who lands in their lap is usually obligated to comply with all of their recommendations and the Treatment stays can generate tens of thousands in profits.

This reality undermines the trust students place in these programs and also raises questions about the integrity of PHP recommendations. Unfortunately, medical school administrations are likely unaware of these multiple conflicts of interest and blindly continue to send their students into an adversarial, profit-driven system that does not take students’ best interests into account.

Consider this: If medical students ask to be seen locally by mental health experts, the PHP usually tells them “no” – even if they ask, as the first medical student above did, to go to a national level psychiatry department in their area. hometown. Instead, they are largely forced to travel to remote “preferred” centers in Mississippi, Kansas and elsewhere that are often not covered by insurance and are unaware of the financial ties between these centers and the PHP. To make matters worse, some of these facilities require patrons to take polygraph tests before allowing someone to return to school or work, even though polygraphs are widely considered junk science. One facility charges $400 for each polygraph test and allows customers who fail to retake the test as many times as necessary – as long as they pay $400 for each test – until they pass. PHPs know this and other “preferred” facilities use polygraphs but continue to refer clients to these assessment centers.

The answer to why is unfortunate but obvious. In the apocryphal words of Deep Throat of Watergate: “Follow the money.”

Despite their ethically strained relationships, PHPs operate with almost no transparency or oversight, leaving anyone referred to them without clear avenues of appeal or redress if they believe they are being treated unfairly. Some seek legal counsel and file lawsuits, but those who do so are usually out of school or working for months or even years, and also losing thousands of dollars, with no guarantee of success.

Given this reality, the sad reality is that when medical students who have been trapped in the PHP system contact me, I too often feel obligated to tell them that if they want to complete medical school, they probably need to do the following. their deans and medical schools demand of them. Deans and others might think they are doing the right thing by entrusting the student’s fate to PHP, but medical school administrations are probably just as ill-informed as everyone else about the conflict-ridden and focused PHP system. on profit.

Until that changes, I’ll probably continue to advise medical students to hold their noses – while also holding my own – take out loans if necessary and move forward with what’s asked of them .

The reforms are long overdue, to say the least. As I have previously called for, first and foremost there needs to be greater oversight and regulation of PHPs to ensure transparency and accountability. There should be national standards for PHPs, and independent audits conducted by people outside of PHPs – instead of the PHP internals that many state programs have used – should be routine, to ensure unbiased fairness in their practices.

Additionally, medical schools should also reconsider their policies regarding mandatory PHP credentials. Alternative, less expensive options for mental health treatment should be provided, and students should have the autonomy to choose the care that best fits their needs and financial situation. This includes increased access to confidential, third-party therapy resources that are not affiliated with PHPs or the School of Medicine.

To be clear, some people absolutely need extended treatment stays. To determine who these candidates are, PHPs should stop using institutions with which they have financial ties. Instead, they should refer medical students and others in need of evaluation to top-tier academic institutions or private practitioners with strong qualifications who do not themselves offer prolonged treatment and do not would therefore have no conflict of interest in recommending treatment.

For the reasons above, forcing medical students to engage with PHPs and then comply with all PHP recommendations is wrong. Medical schools need to think more about directing students to PHPs. Additionally, they also have an ethical duty to advocate for greater transparency and regulation of PHPs. In the meantime, medical students will continue to be drawn into a costly system rife with conflicts of interest and questionable practices.

And unfortunately, my inbox will remain full.

J. Wesley Boyd, MD, PhD, is director of education at the Center for Bioethics at Harvard Medical School and lecturer in global health and social medicine at Harvard Medical School.