In medical school, the powerful concept of Adverse Childhood Events (ACE) was presented to us as if it would always happen to someone else – The Other. There I sat, feeling beleaguered and alone, wondering how much my lifespan would be shortened with an ACE score of six. We walk amongst you. We are your colleagues. I entered the medical profession with an exquisite understanding of how childhood sexual abuse, parental mental illness, alcoholism, drug addiction, neglect and longitudinal chaos could have lingering effects into adulthood. Overwhelmingly, I felt that my life experiences would help me be a good physician.

Personally, I never thought I would have to navigate the invalidating, turbulent waters wherein medical paternalism, misdiagnosis, and inappropriate treatment would threaten to sink me. I never imagined that a mental health crisis triggered by a constellation of impossible situations would result in five years of mandatory treatment, shrouded in a gossamer rhetoric of “physician wellness”. Looking back through the proverbial “retrospectoscope”, I can appreciate how my own Savior Complex sustained me on the arduous road of medical education and training while also instilling a blind naivety which I continue to deconstruct. Indeed, most doctors have no idea that the system I am about to describe even exists, and I was no different.

As a female physician and mother, I expected my medical career to be fraught with challenges unique to these designations. I expected frustrations centered around the fundamental inequities upon which American medicine is built – prior authorizations, patients unable to afford medications or travel to see specialists, insurance denials. As a white cis-gendered woman, I endeavor to provide medical care that is individualized and considers social determinants of health, race and ethnicity, gender identity, sexuality and disability status. I have devoted my career to providing primary care to the rural underserved, and I find great meaning and purpose in my work. 

Unfortunately, I chose to have children with the wrong person, and we ended up married after a rocky five-year engagement that spanned medical school and residency. I remember him saying, “I hope your career doesn’t end up ruining mine,” although I forget the context. My longtime therapist tried for years to help me see that he was painfully insecure, and this trait manifested as narcissism and resentment.

 About four years into my first job as an attending, I began to sense that the marriage was slowly killing me – muscle twitches, hypertension, nausea, headaches, insomnia. However, divorce was terrifying. I poured thousands of dollars into marriage counseling, to little avail. My therapist was worried that my husband was becoming abusive. Emotional and psychological abuse slowly corrodes one’s innermost sense of self, eventually uprooting the foundation upon which the psyche rests. The sequela slowly seeps in, first through cracks in the floor, and later through an open door. Like a colorless, odorless gas, the poisoning and disorientation are at first unnoticed until, at high enough concentrations it becomes lethal. Honestly, I would’ve preferred physical abuse rather than psychological, because at least there is concrete evidence one can point to.

Eventually, I filed for divorce, which brought a sense of relief and agency over my own life that I hadn’t felt in a long time, but it was short-lived. Naively, I hired an expensive attorney whose strategy was creating contention and delay. Several times, I attempted to hire someone else, but the rural county where I live offered no alternatives. It’s hard to pinpoint exactly when I began a slow, jagged descent into dissociated anguish – perhaps it was being told by my husband that he planned to “ruin me”, or the $35,000 loan I had to take out to pay my turgid, verbose attorney. Perhaps it was when my husband convinced a physician colleague to write a formal Declaration that publicized my history of childhood sexual abuse, claiming that the divorce was a result of willfully unresolved childhood trauma rather than a loveless, psychologically damaging marriage. Perhaps it was when my mother moved in, fresh out of a homeless shelter, draped in the dark cloud of her own recent suicide attempt and untreated mental illness. Amidst all this chaos, I chose to drink alcohol during my free time, frequenting a local bar to throw darts and sing karaoke. Looking back, my life was in flames and I chose to douse it with a highly flammable substance

Whatever it was, late one fateful night, my life ceased to make sense and I found myself at the bottom of a fetid psychological pit, where all was dark. My heart hurt, my mind was numb, and I wanted to witness my own blood flowing from my body. It was a strange urge – entirely foreign up until that point and that still defies rational explanation. Slowly, I took a scalpel and cut my left antecubital vein. I did not want to die – I wanted to feel my own blood coursing over my skin. Seeing the warm, red substance flow down my arm and onto the porch was cathartic. Not wanting to make a mess, I began to let the blood pool into a bowl. Soon, the realization that I had crossed a line dawned on me, and I applied pressure. When this was ineffective, I took a pair of needle drivers and some suture and closed the wound, using my right hand to maneuver the needle and my teeth to maintain tension on the string. Now, it seemed, was an appropriate time to cry for help. The wound needed cleaning and revision. I HAD crossed a line, and I knew that, one way or another, my life was about to change dramatically. Feeling too faint and dizzy to drive, I called 911, and an ambulance took me to the hospital where I work. A colleague attended to me and revised my wound as I laid there in a defeated fugue of abject resignation.

Four days later, I was called to meet with the CEO and CMO of my organization. They told me that someone had reported the self-harm incident, and I would need to get a fitness-for-duty evaluation through the Washington Physicians Health Program (WPHP). Through tears, I begged them for an alternative, because I had heard that the WPHP sent physicians to out-of-state, expensive rehabilitation centers for months on end. I had heard that careers had been ruined and physicians had completed suicide while in the program. Standing firm, they took my badge and escorted me off the property, closing the door behind me as if I might try to dash back in. The WPHP already had my name, and I had no other recourse if I wanted to continue practicing medicine. 

In a few days’ time, I submitted to comprehensive toxicology testing (hair, blood, urine) and was evaluated by two WPHP social workers via Zoom, who quickly determined that I would need three months of treatment at one of their preferred centers. I had three options – Colorado, Florida and Mississippi. Until I completed this requirement, I was not considered safe to practice medicine. If I refused, I would be reported to the Washington Medial Commission, with the guarantee that they would suspend my license. It should be noted that I was never impaired at work, nor was there concern for my medical judgment. No patients had lodged complaints, and there were no inappropriate medication prescriptions. 

Shortly thereafter I was on a plane, headed for Mississippi. Upon arrival, they repeated the toxicology testing. I was evaluated for two weeks and eventually received the diagnosis of borderline personality disorder, severe alcohol use disorder and complex PTSD. I was not allowed to take my ADHD medication because, I was told by the Treatment Team, I did not have ADHD. Surprisingly, the extensive evaluation did not include validated testing for attention deficit disorder, nor did they consult the psychiatric prescriber or therapist I had been seeing since 2001.

The diagnostic criteria for Alcohol Use Disorder (mild, moderate & severe) are clearly outlined in the DSM-5, and I did not fit the criteria for severe AUD, but had been using alcohol as an unhealthy and counterproductive crutch in the months preceding my decompensation. I certainly had the genetic predisposition for alcoholism and had struggled with moderation during my early twenties - total abstinence was undoubtedly the wisest path forward as I rebuilt my life. I recognize that disputing a qualifier like mild, moderate or severe may seem like the dying treatise of an addict saturated with denial whilst being backed into a corner; however, after being told we were being evaluated by those with the highest diagnostic acumen, inaccurate labels were a hard pill to swallow.

I didn’t get a discharge date for six weeks, and being separated from my children for three months was excruciating. At the time, my son was four years old and angrily demanded to know why I’d left.

However, it wasn’t all bad. For one month, I received intensive eye movement desensitization and reprocessing (EMDR) therapy for trauma, which was very helpful. Ironically, EMDR has enabled me to cope with the subsequent institutionalized gaslighting and ongoing financial strain that are well-known hallmarks of the WPHP. 

For the remaining eight weeks, I was in an outpatient residential program known as the Professional Enhancement Program (PEP) alongside pilots, dentists, CEO’s, priests, nurses and physicians. Often, the treatment team used polygraph testing, discounting the fact that many of us had significant trauma histories, which such duress might worsen. The core of the program was daily participation in “Community” wherein we sat in a circle of chairs in a windowless room. Nothing was allowed by mouth (food, drinks, mints), feet had to be flat on the floor, hands folded in our laps. The purpose was to bring forward topics of discussion that would “hold up a mirror” for each participant to gaze into. Once, during introductions to newly admitted professionals, I said I was “a rural family physician”. Later, this was put on the agenda for Community. The therapists commented that it seemed to be unnecessarily boastful and potentially narcissistic. From that day forward, I was “A doctor from Washington state”.

When I returned from Mississippi, I was obligated to sign a five-year contract with the WPHP which included random urine and blood toxicology testing and mandatory participation in Alcoholics Anonymous as well as a weekly WPHP support group. The toxicology testing alone costs between $400 and $600 per month. I was assigned a new psychiatrist and could not take ADHD medication. The diagnoses issued from the “Evaluation and Treatment” facility in Mississippi to WPHP are considered irrefutable. If we -- as physicians—dare to disagree - there is no consideration given to any outside evaluation, no matter how reputable the source. The overarching prescription from the organization is to surrender, utterly and completely, exactly the ethos promulgated by Alcoholic Anonymous. At one point, for debilitating insomnia, I took an over-the-counter medication containing diphenhydramine, which is alleged to be a potentially addictive substance. For this, I was questioned and had to submit to additional testing. 

Then, striking like a bomb, I was mandated to return to Mississippi six months after discharge for a weeklong, $4,000 “recheck”, which I was told is standard operating procedure for this particular facility. For months I had heard the projectile whistling menacingly in the distance, but I could only continue rebuilding my life while preparing for the inevitable impact. The only issue with my toxicology testing over the previous six months had been the diphenhydramine, yet the supervising psychiatrist ordered the nurse to cut out a huge swatch of my hair. I had to choke back tears as the scissors sliced through my already thinning strands. I felt proud that no tears actually fell, even when they threatened to sample my pubic hair for another test if the blond highlights I had gotten over a year ago invalidated the test. This time around, I did not escape the polygraph examination. After paying the $400 fee, I was questioned for an hour and a half while hooked up to monitors. I passed, although one cannot describe the sheer terror and anxiety this legally invalidated test induced. Those of us who are forced to take the polygraph later ask each other, “What did you stare at to stay calm?” I stared at a light socket. 

At the Professional Enhancement Program, we complete our treatment alongside professionals who are guilty of serious sexual boundary violations, whether it is having sex with a patient or being arrested for child pornography. The therapists dictate how the women must dress and present themselves. Open toed shoes are not allowed in case someone has a foot fetish. If we wore yoga pants, we had to be sure our bottoms were covered with a baggy shirt. We are all frequently reminded that we are “mentally ill.” 

I returned from the Mississippi recheck plagued by nightmares and flashbacks, which were not a feature of my pre-existing complex PTSD. Now, as a result of my treatment, I had developed acute PTSD and often woke up drenched in sweat and sobbing. My partner, a lovely person who came into my life when everything was falling apart, could only hold me tight while I repeated, “Please, don’t make me go back” over and over. I also developed chronic insomnia that has proven recalcitrant to most standard pharmaceuticals and cannot access previously effective medications I took in the past because they are potentially addictive controlled substances and would interfere with my mandated monitoring. 

Each day, I offer my patients empathetic, compassionate care that meets them where they are and scrupulously honors diagnostic criteria. Most importantly I believe them. I hear their stories and synthesize a comprehensive image of their personhood in my mind, which I use to tailor an individual treatment plan. While, as a physician with a disability who is “voluntarily” under contract with the WPHP, I am prohibited from disputing my diagnoses as well as accessing first-line, evidence-based therapies. There is no alternative, no middle path. It is the PHP way, or the Highway. Refusal to comply would result in having to go for another evaluation at Pine Grove or before the Washington Medical Commission (medical board). Many of my fellow participants and I live in fear of being found “noncompliant”, which would put our careers at risk.

On top of all this, I am financially insolvent. The divorce itself would have resulted in monetary hardship, but coupled with my prolonged and repetitive “treatment” in Mississippi and the costs of ongoing monitoring, I had to file for bankruptcy. When the numbers refused to add up and I realized I would not be able to pay my mortgage, I sold my only vehicle. At one point, my electricity was disconnected. When people think of a physician, they do not think of someone who cannot pay their bills. Yet here I am, working as hard as I possibly can, yet barely making ends meet. 

As a doctor enrolled in a “physician health program”, HIPAA and Cures Act mandating access to my own medical information do not apply to me. I was compelled to sign away every right to privacy, and yet I am prohibited by regulation from seeing a copy of my file from the WPHP, which they consider to be “Business records” rather than medical records, although they are composed entirely of my personal health information. 

Frequently, I offer my patients treatments or medications I feel would be helpful and they refuse, for various reasons. Perhaps they can’t afford the recommended treatment, or maybe they want to discuss alternatives. It is not my job to force another human being to take medication or participate in a treatment modality. My patient’s right to refuse treatment is always a poignant reminder to me that I cannot refuse. As I write this, I can predict with 100% accuracy how any physician health program in the country would respond, “Participation in our program is voluntary”. But is it, really? How many of us would be willing to give up our careers on the principle that we have a right to medical records and standard of care diagnosis and treatment? What about those of us who came from economically disadvantaged backgrounds, have no family support, or are saddled with crushing student debt? Many of us say to each other, “They can’t stop time”, meaning that eventually the five-year contract will end, and we will be free. Until then, we shoulder their misdiagnoses and inappropriate treatment recommendations like beasts of burden. We accept prolonged stays at preferred treatment facilities many states away, paying dearly out-of-pocket, yet go to work each day and know we cannot accept even a ballpoint pen from a pharmaceutical representative. We know that contesting a PHP’s or their Preferred Evaluation and Treatment Center’s erroneous diagnoses is dangerous, because they answer to no one – there is nobody to hear our cries. They have posited themselves as the sole purveyors and saviors of physician health and well-being, operating from an ironclad silo that grants them qualified immunity within the comfort of a static echo chamber. Gradually, PHPs have convinced medical schools, residency directors and healthcare employers that they are the only solution if impairment is suspected or even a possibility. The same people who speak passionately about the need to invest in physician health and wellbeing will not hesitate to order a broken, traumatized doctor to take a polygraph examination repeatedly.  Absolute power corrupts absolutely. My story remains unfinished – my career is just beginning and my experience as a patient being treated by the WPHP is simply another obstacle I must surmount – it isn’t the first and it certainly won’t be the last.