Christopher Bundy, MD, FASAM, Spring 2022

Christopher Bundy, MD, MPH, FASAM

The Equivalence Problem

“Sometimes the light’s all shinin’ on me
Other times, I can barely see
Lately, it occurs to me
What a long, strange trip it’s been. . . .”
—From “Truckin’” by the Grateful Dead

It is traditional for the outgoing FSPHP president to use this space to reflect on the organization’s progress over the prior two years. Like my predecessor, Dr. Paul Earley, I will spare you the accomplishment inventory. We’ve done a lot of stuff, in a short amount of time, driven by necessity and the pressures wrought by a global pandemic. Yes, we can all be proud of our progress. It has been nothing short of remarkable and we are well on our way to the future that Dr. Earley envisioned in his message in the spring of 2020. But I don’t really want to talk about that. Before I go, I want to talk about something I call the “equivalence problem.” 

Over the last several years, many new players have entered the physician health and well-being space, offering an array of mental health, wellness, and other services aimed at beleaguered health professionals. While I am hopeful that these additional resources
will be utilized and beneficial for our colleagues in distress, I am also concerned by the emergence of the equivalence problem. The equivalence problem is born of a mistaken belief that other organizations or individuals that assist (or want to assist) health professionals are essentially interchangeable with PHPs.

At the June 2021 meeting of the American Medical Association (AMA), a report from the Council on Judicial and Ethical Affairs (CEJA) was passed that revised the AMA Code of Medical Ethics Opinion 9.3.2 to remove reference to the utilization of PHPs for those impacted by risk of impairment. At the subsequent November 2021 meeting of the AMA House of Delegates (HOD), the Pennsylvania Medical Society delegation (Marilyn Heine, MD), with support from New York (Frank Dowling, MD) and Wisconsin (Michael Miller, MD) delegations, introduced Resolution 23 to the HOD in an effort, among other things, to restore the reference to PHPs in 9.3.2.

Resolution 23 passed by a very wide margin in the HOD, signaling widespread support for restoring the reference to PHPs. However, it only recommends that CEJA reconsider the removal; it does not require it to be restored. In the lead-up to the vote, reference committee testimony from a member of CEJA revealed that some among AMA’s ranks believe that there are many resources to support physician well-being and that PHPs should not enjoy the privilege of special recognition in 9.3.2. As your AMA observer, I testified in strong opposition to this notion. It contradicts several existing AMA policies that support the PHP model as an alternative to discipline. A few follow here for reference:,

While it remains to be seen whether CEJA will reconsider these ideas and restore a reference to the utilization of PHPs in the Code of Medical Ethics, the experience reinforced concerns about the equivalence problem that had been gnawing at me for some time.

Recent revisions to the American Society of Addiction Medicine (ASAM) and the Federation of State Medical Boards (FSMB) policies relating to physician health were strongly supportive of PHPs and the PHP model. However, these policies also contain statements acknowledging that physicians and other health professionals may seek care from “other clinicians with expertise” without the oversight of the PHP. On the surface, this is not surprising or particularly problematic. We all want health professionals to get care when needed, and PHPs certainly do not want or need to be involved with all physicians who are ill. That said, such language edges toward the equivalence problem.

FSPHP and its members have a responsibility to educate our participants and stakeholders about our model and what makes us unique among the many resources now available to health professionals. In my view, the equivalence problem is ours to solve. In short, it is critical that we better manage our brand.

FSPHP recently contributed to an update on the AMA Advocacy Resource Center (ARC) Issue Brief: confidential care to support physician health and wellness. There, we began to define the characteristics of PHPs that set us apart from other resources available to healthcare professionals. I think it is worthwhile to expand further here:

1. Legal authority: Depending on state law, a PHP may be the only legally authorized entity that may receive reports of impairment or potential impairment in lieu of a report to the disciplinary authority.

2. Special accountability: Through statute, rule, or contract with the disciplinary authority, PHPs have special accountability and mandatory reporting obligations designed to protect the public. Non-PHP providers may also have mandatory reporting obligations but, in our experience, even expert clinicians are unfamiliar with reporting obligations, and consequences for failure to report are often lacking.

3. Trusted verification: PHPs are trusted by employers, credentialing entities, licensing boards, medical specialty boards, and others to provide objective and ongoing verification that a health professional is safe to practice. PHP program compliance is often a requirement of continued employment or medical staff privileges. Non-PHP providers are often unwilling to provide opinions regarding the safety to practice or unable to meet the reporting needs of the involved entity. Such entities may also be reluctant to act in reliance upon information received from a nonPHP provider who is ethically bound to act in the interest of their patient.

4. No treatment relationship: PHPs do not provide treatment to participants and therefore do not have a treatment relationship that could create conflicts of interest with their obligation to act in the interest of public safety. PHPs seek to balance the rehabilitative needs of the participant with protection of the public. Non-PHP providers have a primary obligation to the interest of their patients, which may help health professionals feel more comfortable disclosing worsening symptoms or very private information.

5. Care management: PHPs provide oversight, communication, and coordination of healthcare to promote effective and sustained remission of chronic illnesses. PHPs also receive functional information from employers and key supports that, along with other monitoring data such as toxicology testing, can optimize the care a participant receives from their treatment providers. Outside of PHPs, this level of care management is virtually unavailable to health professionals. 

These five characteristics (and perhaps there are more) carve out our niche in the healthcare ecosystem and provide an answer to the equivalence problem. 

Over the last year or so, three state-member PHPs have been under serious threat. Those threats were all founded on the flawed idea that the existing PHP could be easily replaced with another resource (another version of the equivalence problem). Fortunately, in New Hampshire and Colorado, reason prevailed. In Montana, it did not. I am saddened by the loss of the Montana Professionals Program and our dear member, Michael Ramirez, who spent twenty-seven years building a model program there. Such threats demonstrate why it is critical that we are prepared to respond to misguided notions of PHP equivalence. 

This issue of Physician Health News is devoted to your efforts and accomplishments aimed at supporting and strengthening the PHP model, especially the confidentiality that is the cornerstone of all we do. Here, we showcase that which demonstrates the excellence and exceptionality, the specialness, of who you are and what you do. This work adds credibility to our rejection of PHP equivalence.

In closing, I want to express what an honor and privilege it has been to have your support, trust, and camaraderie these past two years. Serving as your president has been a career highlight and I am grateful to have had the opportunity. I have made many great friends along the way and find comfort knowing that I am leaving the position in the capable hands of Dr. Scott Hambleton. Finally, I would be remiss if I did not publicly thank Linda Bresnahan (my sister from another mother). She remains a tremendous asset to FSPHP and has been an exceptional leadership partner and friend. I will always cherish her kindness, grace, and patience she has always shown me!

I hope to see you all in New Orleans for some joviality, jazz, and jambalaya!

Read more on this in the Spring 2022 issue.