In recent years, there has been a growing awareness about the mental health challenges faced by medical students. The pandemic only exacerbated concerns about med student well-being, making it more critical than ever to ensure that future physicians with mental health issues have access to top-notch, affordable, confidential care.
But is that happening? I am a psychiatrist and former associate director in a state physician health program (PHP). For more than a decade, I have written a lot 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 several times a week.
And what I hear makes me concerned that in fact the exact opposite is happening.
One student was grieving the death of a close 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-$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 — with no previous issues of any sort — 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, even though he was from the East Coast and attending med school not far from home, he was referred to a facility he’d never heard of in the Midwest 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 — just as these two students were — 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 confidential assessment, treatment referrals, and monitoring to ensure that health care professionals can safely continue or return to practice. As such, they are generally the go-to state entities charged with ensuring physician and medical student well-being. Although PHPs have no doubt saved the lives of some health care practitioners, they’ve also coerced into treatment and profited off of many others who would’ve been fine without their heavy hand.
A couple of state PHPs have psychiatrists and/or psychologists working for them and perform their own evaluations of the individuals who are sent to them. These state PHPs will generally only refer individuals out for further evaluation if their complexity warrants it.
But the bulk of PHPs do little to no evaluation themselves and reflexively refer most of individuals who come through their doors out for costly evaluations by a third party, frequently to far-flung states as happened to the two medical students above.
The reality is that such referrals are anything but straightforward. PHPs often have conflicts of interest with the very expensive evaluation centers to which they frequently refer students. And to make matters worse, once a PHP makes a recommendation for evaluation or treatment, there are generally few if any avenues for med students to appeal that recommendation.
When a med student is referred to a PHP, that referral can come with substantial financial costs. First, some PHPs charge user fees to anyone who walks through their doors. And second — and much more substantial — being sent to a PHP frequently entails a referral to a third-party evaluator. Such referrals can cost tens or even hundreds of thousands of dollars.
Such costs can be highly problematic for anyone, but especially 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 assault on both their well-being and their ability to remain in medical school.
In addition, any time a medical student is referred to a PHP, school administrators essentially turn that student’s fate over to a financially and ethically conflicted system rife with the potential for coercion and abuse.
PHPs and the treatment centers to which they refer students have bidirectional financial ties with one another, 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 extended treatment stays that they offer, given that anyone who’s landed in their lap generally is compelled to comply with any and all of their recommendations and 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 the PHP’s recommendations. Unfortunately, medical school administrations likely aren’t aware of these multiple conflicts of interest and blindly continue to send their students into a conflicted, profit-driven system that doesn’t have the students’ best interests in mind.
Consider this: If med students ask to be seen locally by mental health experts, they are generally told “no” by the PHP — even if they ask, like the first med student above did, to go to a nationally ranked psychiatry department in their hometown. Instead, they are overwhelmingly mandated to go to far-flung “preferred” centers in Mississippi, Kansas, and elsewhere that are frequently not covered by insurance and not told about the financial ties between these centers and PHPs. 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, even though polygraphs are widely considered to be junk science. 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 each and every test — until they pass. PHPs know this and other “preferred” facilities are employing polygraphs yet continue to refer clients to these evaluation centers.
The answer about why is unfortunate but obvious. In the apocryphal words of Deep Throat of Watergate fame: “Follow the money.”
Despite their ethically fraught relationships, PHPs operate with almost no transparency or oversight, leaving anyone referred to them with no clear avenues for appeal or recourse if they believe they are being treated unfairly. Some retain legal counsel and sue, but those who do are generally out of school or work for months if not years and also out of thousands of dollars, with no guarantee of success.
Given this reality, the sad fact is that when medical students who’ve been ensnared in the PHP system contact me, all-too-frequently I feel compelled to advise them that if they want to complete medical school, they probably need to do what their deans and med schools are requiring of them. Deans and others might think they’re doing the right thing in handing the student’s fate over to the PHP, but medical school administrations are probably just as uninformed about the conflicted and profit-driven PHP system as everybody else.
Until this changes, I’m probably going to continue to advise med students to hold their noses — while clinching my own as well — take out loans as needed, and go forward with what’s being demanded of them.
Reforms are overdue, to put it mildly. As I’ve called for before, first and foremost, there needs to be greater oversight and regulation of PHPs to ensure transparency and accountability. There ought to be national standards for PHPs and independent audits conducted by individuals external to PHPs — instead of the PHP insiders that many state programs have used — need to be routine, in order to ensure unbiased fairness in their practices.
Additionally, medical schools should also 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. This includes increasing access to confidential, third-party therapy resources that are not affiliated with PHPs or the medical school.
To be clear, some people definitely need extended treatment stays. To determine who those candidates are, PHPs should stop using facilities with which they have financial ties. Instead, they ought to refer med students and others in need of an evaluation 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 treatment.
For the reasons above, forcing medical students to engage with PHPs and then comply with any and all PHP recommendations is wrong. Medical schools need to be more thoughtful about referring students to PHPs. 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.
And, unfortunately, my email inbox will remain full.
J. Wesley Boyd, M.D., Ph.D., is director of education, Center for Bioethics, Harvard Medical School, and a senior lecturer on global health and social medicine, Harvard Medical School.