EmailMeForm
Professional Health Program (PHP) Survey
This is a confidential survey. If you have concerns about anonymity please create an alternative alias email address. For further information visit:
http://disruptedphysician.com/professional-health-program-php-survey/
1. What was the primary reason you were referred or reported to your state PHP program?
2. Was it voluntary or involuntary?
Voluntary
Involuntary
3. If involuntary, who referred or reported you to the state PHP program? ( patient, colleague, hospital administrator, anonymous report, etc.)
4. When you first met with the PHP were you:
A) Asked to provide a sample. Was it collected by the PHP or an outside lab?
B) Evaluated by a licensed clinician by physical examination, psychometric testing or in any other way?
Please provide details:
5. Did this encounter result in a referral for further assessment?
If yes, were you provided a rationale for further assessment.
6. Were you informed of specific facilities where you could be evaluated?
If yes, which facilities did the PHP recommend?
Were you given a written list of these facilities? If so please list the names and locations.
7. Did you request an alternative assessment center?
If yes, please list the names and locations of the assessment centers you requested.
8. What were your concerns about the PHP recommended assessment centers? (quality, cost, travel, conflicts-of-interest, 12-step ideology, etc.)
Please provide details.
9. Did the PHP approve or reject your request for an alternative assesment?
If rejected what were the reasons?
Did you appeal to your board for approval?
Yes
No
10. Were you told you were in denial? Was this based in part on:
A) A polygraph test
B) MMPI or other validated neuropsychological testing
C) Non-validated neuropsychological testing (e.g. "360 degree assessment")
Do you have a copy of these results?
If yes, please explain what was reported.
11. What diagnosis or diagnoses were given at the conclusion of the assessment?
12. Were you provided a copy of your diagnostic assessment?
Yes
No
13. Did this same facility offer treatment for this diagnosis?
Yes
No
14. Were you given the opportunity to seek a second opinion for this diagnosis by the PHP or assessment center?
Yes
No
15. Did your established treatment providers (outside of the PHP conclusions) give a report from your assessment or diagnosis and provide written documentation?
Yes
No
Did either the PHP or board take these reports into consideration?
Yes
No
16. What was your length of stay at the facility?
17. Was 12-step treatment mandatory?
Yes
No
18. Did you voice any concerns or objections to 12-step?
Yes
No
19. Were you told or threatened that your license would be in jeopardy if you did not comply with these recommendations?
Yes
No
20. When you signed a monitoring contract with the PHP were you told there were certain attorneys who had experience in medical board interactions?
Yes
No
Did they provide a list of these attorneys?
Yes
No
21. Were there any concerns that were brought to the attention of your attorney that you feeel were not sufficiently addressed or ignored?
If yes, please provide details.
22. Did you have concerns regarding procedural irregularities, error or misconduct regarding drug and alcohol testing?
Yes
No
Were there any issues regarding false positive or erroneously positive tests?
Yes
No
Were there any drug or alcohol tests that you felt were in error?
Yes
No
What was the test? (eg. EtG, Peth etc.)
23. Did you request copies of lab reports?
Yes
No
Were requests for copies of the lab reports refused?
Yes
No
24. Did you or your attorney contact the lab directly?
Yes
No
If yes, What was the labs response?
Did your attorney sufficiently address these concerns?
25. Did you bring up any concerns with your attorney regarding mandated 12-step?
Yes
No
Did your attorney address these concerns or tell you you have no choice?
26. Were you ever threatened with being reported to your board for "noncompliance?"
Yes
No
27. Were you reported to your board for "noncompliance?"
If yes, what was the reason?
What action was taken by your board?
28. At any time did you provide the PHP or board with outside assessments, drug-testing etc. that contradicted the PHP?
Yes
No
What was the response from the PHP?
29. What is the current status of your license?
30. Please provide any other relevant information or concerns?
Your Details
Please note: Providing personal details is optional. This is a confidential survey. If you have concerns about anonymity please create an alternative alias email address, then use the alias email address as your “name” for future correlation.
Name
First
Last
Email
Phone
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