"I truly feel that diversion saved my life," says Shannon Chavez, MD, referring to the California Medical Board Diversion Program that is scheduled to end on June 30. "I had a difficult time with drugs and alcohol," continues the medical director of UC San Diego outpatient psychiatric services and chair of its well-being committee. "It was a very difficult period in my life."

After July 1, there will be no state government-level confidential system for identifying doctors struggling with substance abuse or mental illness, driving them into treatment and monitoring their progress. Instead, the board's Enforcement Program will handle all cases, without confidentiality and with its own style of monitoring. "Without the monitoring piece in a confidential, supportive environment, I don't think that I would've been able to get clean and sober," Dr. Chavez explains. But while no program is currently scheduled to take the Diversion Program's place, a coalition of groups including the California Medical Association is trying to fill the gap before impaired doctors who can't go public begin to harm patients.

After July 1, if the Medical Board believes a doctor with substance abuse problem does not present a danger to the public, he or she can be directed to a treatment program. Otherwise, these doctors will be referred to enforcement, but without confidentiality. In her UCSD well-being committee duties, Dr. Chavez sees the problem with that arrangement at close range: "We have doctors who are scared, who are afraid to talk about their problem for the fear that they will be turned over to enforcement, or that they will lose their license automatically."

And without a special focus on treatment and monitoring, the Enforcement Program might just do what it does best. "The problem now is that if you come to the attention of your employer or even the Medical Board, the chances are more likely that you'll have a disciplinary action taken against you, rather than be given the opportunity to seek treatment," says David Pating, MD, speaking as the immediate past president of the California Society of Addiction Medicine.

A significant share of doctors suffer from substance abuse or mental illness, while most will know a peer who suffers from one of the two. "The evidence is that 11 percent to 13 percent of physicians, over the course of their lifetimes, will have a substance abuse problem," says Dr. Pating, who also works as chief of addiction medicine for Kaiser Permanente in San Francisco. "Over the course of a career, it's quite possible that many physicians could need treatment assistance," he says.

A System With Problems of Its Own
Of course, the Medical Board did not just cancel the Diversion Program on a whim. Of the five audits conducted on the program during its 28 years of operation, not one reported that it functioned well. Conducted last June, the most recent of these was typical. The Bureau of State Audits reported that the Diversion Program monitored substance-abusing physicians inconsistently; it exercised inadequate oversight of its drug testing program; and the Medical Board itself had not exercised proper oversight of the program.

But the BSA audit's finding that physicians continued to game the system-by abusing drugs or alcohol only when they knew they would not be tested-best explains the Medical Board's current dislike of confidential treatment and monitoring programs. "Essentially, the medical Board has to warranty to all consumers that they are completely safe to see participants in the Diversion Program, and they will not suffer from a participant's actions," writes Board President Richard Fantozzi, MD, in its November 2007 newsletter.

As part of a July 2007 Medical Board meeting to determine what to do about the Diversion Program, the group heard particularly persuasive testimony from patients who had suffered botched surgeries conducted by participants, writes Dr. Fantozzi. A later effort to carry on with a diversion effort that protected patients was unsuccessful, he says. "The operation of a diversion program which demonstrably does not adequately monitor substance abusing physicians, while concealing their participation from patients, is obviously inconsistent with that mission," Dr. Fantozzi adds.

With and Without Diversion
Under the Diversion Program, most of the complaints reaching the Medical Board originated with peer doctors who smelled alcohol or noticed odd behavior in an impaired physician, says Dr. Chavez. "There are actually pretty few complaints about bad medicine-more bad behavior," she says. "The Diversion Program could [then] step up and say, 'You need to go for an evaluation,' [and] depending on what it said-is this an alcohol problem, is this a drug problem, is this a mental illness-you would be directed to get treatment," she adds. If a doctor failed to get treatment, the Medical Board would then decide to take additional, possibly punitive, action.

Without the Diversion Program's confidentiality and ability to compel treatment, "there is no in-between," says Dr. Chavez. Impaired physicians are left with few options. "There is just going underground and not reporting your problem until it gets to the point where you do something wrong-or you're impaired at work in some way-and then you go directly to enforcement," she says. That situation leads to more harmed patients, she adds.

Filling the Gap
Jim Hay, MD, agrees. The San Diego family practitioner and CMA Speaker of the House also serves as chairman of a multi-organizational working group assembled by the CMA to fill the Diversion Program's gap. "The tip of the iceberg will have been cut off, and only those physicians who have come to the awareness of the Medical Board will be monitored, and they'll be monitored essentially through probation, through enforcement by the Medical Board," Dr. Hay says. "All the other physicians who have alcohol, chemical dependency or mental health problems will be under the surface, and they're not going to [be detected] unless they've created harm," he explains. "And we think that couldn't be any more wrong."

Formed in August by the CMA executive committee, the working group, which has no official name yet, includes representatives from the California Society of Addiction Medicine; the California Psychiatric Association; Kaiser Permanente; the Federation of State Physician Health Programs; the former director of Virginia's diversion program equivalent; the California Hospital Association medical director; and a representative from the California Society of Anesthesiology, Dr. Hay says.

In a flurry of conference calls and a few meetings since its inception, the working group has managed to synthesize its ideas into actual legislation, which it is currently revising for introduction through an unnamed sponsor by June 1, but after this magazine goes to press. "We tend to believe that [a Diversion Program replacement] needs to be a non-profit entity that responds to some piece of the government, and we recommend strongly that it not be the Medical Board," says Dr. Hay. Such an entity could be up and running by next summer, and it should be accountable through regular audits, confidential and financed by physicians, he says. The new organization should also have the power to tell physicians under treatment when to stop practicing and when they can resume, Dr. Hay adds.

Financing for the new system can be provided through the ashes of the old one. Previous legislation built the Diversion Program's funding source into physician licensing fees. "Now that the Diversion [Program] is sunsetting, the Medical Board has to return that money to licensees," says Dr. Hay. "We're saying, 'Don't do that, keep that money and use it to pay for this new system.'"

Until new legislation takes effect, the state is left with only a stopgap measure. Beginning July 1, the medical well-being committees, which have played the part of intermediaries who received complaints and sometimes referred doctors to the Medical Board and its Diversion Program, will try to take up all the slack. "We knew that they would get a thorough evaluation and a good monitoring program [through the Diversion Program], Chavez says. "So the burden of helping those doctors is falling to all of us."

Although well-being committees are required by the state for every medical staff, the extra workload will be considerable. "We're not overloaded with people, we're overloaded with work," Chavez says. "There's no way that we can duplicate a full-time monitoring program," she says.

Dr. Hay says that the post-Diversion Program working group will also take a few steps to help those physician well-being committees. "Everywhere throughout the state, there are hospital medical staffs and medical societies and medical groups that are creating their own systems to monitor doctors who have difficulties," he says. "You're going to have a year in which there will be many new organizations throughout the state, and now they're going to need some kind of way to link to each other, ways to set standards, ways to monitor what they do, [and] to make sure that they are doing a good job."

In the meantime, the Medical Board hasn't given up, says spokeswoman Candis Cohen. "The wellness committee and the education committee continue to work on the problem," she says. as a start, the education committee has asked what students learn about substance abuse, and it is considering related continuing medical education. It is also collecting information from the medical academic community about how best to prevent and treat once there is a problem, in the absence of the Diversion Program, she adds.