Dear Dr. Callahan:
You may recall that I wrote to you previously, as directed by ASAM President, Dr. Marc Galanter, to inquire about the ASAM's position regarding the judgment of liability for false imprisonment, fraud, and malpractice against Dr. G. Douglas Talbott [Chapter 6]. Is ASAM discussing the implications of this decision against its past president and founder? I am in touch with a physician member of ASAM, who informs me that he has seen nothing about the case in any of your publications.
At the time I contacted you, I also inquired to whom an ethics complaint concerning an ASAM member must be submitted. You did not answer that question, and so I am advising Captain William Smythe to mail directly to you a complaint he wishes to submit against ____, M.D., FASAM, who is listed as an ASAM fellow at the ASAM web site. I have written this report at the behest of Captain Smythe in support of his complaint.
I have reviewed the case of Captain Smythe. Capt. Smythe completed a residential treatment program at the _____ Treatment Center. He was compelled to attend this program by his employer, ABC Corp. (ABC hereafter), under threat of losing his job and his ship's pilot's license. The basis for this treatment was a diagnosis of alcohol dependence by Dr. ____, to whom Capt. Smythe was referred by ABC and its EAP, headed by Ms. Ann Jones. Dr. ____ further indicated to Capt. Smythe that he was required to create a follow-up therapeutic/rehabilitation plan with him.
I have reviewed the records of this case, including an evaluation of Capt. Smythe by Dr. ____ (June 22, 1998); Capt. Smythe's written narrative of these events, including a statement by his wife; Capt. Smythe's rejection of a therapeutic agreement with Dr. ____ (dated September 23, 1998); Capt. Smythe's offer of his own therapeutic agreement with Dr. Kramer (dated October 27, 1998) and accompanying rehabilitation agreement, which was subsequently rejected by ABC through its attorney (October 30, 1998); Dr. Kramer's interview and diagnosis notes on this case; Capt. Smythe's subsequent proffer of an additional therapeutic/rehabilitation agreement with Dr. Walton (no date noted); and the subsequent acceptance (with some additional conditions) of this last agreement by ABC through its attorney (November 10, 1998).
Narrative (as provided by Capt. Smythe)
In May of 1998, Capt. Smythe was reported for having alcohol on his breath when he reported for duty as a ship's pilot, although the complainant has never been identified. Capt. Smythe's partner, who traveled with him for some hours on the way to work, and other people at his workplace have stated that they did not smell alcohol on Capt. Smythe's breath or notice any strange behavior on his part that night (as described in Dr. ____'s report). Capt. Smythe had not consumed alcohol since dinner, five hours before reporting to work and nine hours before actually piloting the boat. He has never seen this initial complaint. I have not seen this complaint.
(Capt. Smythe ceased drinking and has not consumed any alcohol since this incident, which I confirmed independently in a phone call with his wife. The primary reasons for this abstinence were Capt. Smythe's and his wife's concern over the child they were adopting, as well as his concern over his pilot's license.)
Two days following this incident, the ABC directors asked to meet with Capt. Smythe. They indicated that he must see the company EAP counselor for an assessment and that if he refused to go he would be fired. Two weeks later, Capt. Smythe met with the EAP counselor, whom he saw two times. This counselor repeatedly stated that their interview was confidential. Following their two sessions, the counselor stated she felt everything was fine and that Capt. Smythe would be permitted to return to work. However, since Capt. Smythe had been on medical leave during this process, she told him it was first necessary for him to meet with Dr. ____ in order to return to work.
During an initial phone call, Dr. ____'s office informed Capt. Smythe that the fee for Dr. ____'s services and tests would be $1500. Capt. Smythe indicated that this bill should be sent to ABC. Capt. Smythe then met with Dr. ____ for about 30 minutes. During this meeting, according to Dr. _____'s report, he explained to Capt. Smythe that "we do not have a true doctor-patient relationship; I will compose a report based upon the information acquired during the assessment; and the report will go to the party who has contracted with me to perform this service." Dr. ____ indicated that Capt. Smythe signed this informed consent notice. Capt. Smythe, however, does not recall signing such a form. He claims, instead, that Dr. ______ assured him their meeting and its results were completely confidential. Capt. Smythe has repeatedly requested this signed form from Dr. ____ and from the EAP, but he has not received a copy.
Dr. ____ subsequently interviewed Capt. Smythe's wife briefly by phone. In a letter signed by Mrs. Smythe (which I confirmed in a phone conversation), she says that she does not believe Capt. Smythe has ever lost control of his drinking or suffered negative consequences from this drinking as claimed in Dr. _____'s report, and that Dr. _____ misattributed these statements to her.
About 20 days after the interview with Dr. ____, Capt. Smythe called the EAP to find out his status, but got no return call. About this time, when he thought he was about to resume work, Capt. Smythe contacted an ABC director, who informed him that he would not be permitted to return to work. This was the first time Capt. Smythe had any indication this was to be the case.
Capt. Smythe then attempted several times to contact the EAP. When he finally reached the EAP, Ms. Jones informed Capt. Smythe that she had Dr. ____'s report declaring that Capt. Smythe was alcohol dependent, and that he would have to enter a treatment center for four weeks. Capt. Smythe objected, and a meeting was scheduled with the directors of ABC. In the meantime, Capt. Smythe contacted Dr. ____. Dr. ____ indicated that there was "some evidence of dependency and you have to go through an intense four-week program with a follow up of twice-weekly visits to him and weekly AA meetings." Dr. ____ further stated that the treatment and aftercare process was required given Capt. Smythe's safety-sensitive job. Capt. Smythe started to ask questions, but Dr. ____ brushed them off and hung up.
When Capt. Smythe met with his directors, they indicated that his pay was cut off as of the last day he worked in May, and that the money he had been paid in benefits was to be treated as a loan and would have to be paid back to ABC. During this meeting, one of the directors blurted out, "Well, Dr. ____ told us that you are only in the very early stages of dependency and you have a better than 90 percent chance of a full recovery!" Capt. Smythe looked at him and asked, "How did you know that?" The director said, "The doctor and Ms. Jones had a meeting with us and told us that you were alcohol dependent and stand a good chance of a full recovery." The directors then threatened Capt. Smythe, telling him his pilot's license could be suspended, perhaps permanently. In fact, he learned during the meeting that his licensing organization had been told of ____'s diagnosis.
Capt. Smythe was naturally concerned about losing his license. In addition, he and his wife were in the process of adopting a child. As a result, he agreed to enter a treatment program. He considered several. When he mentioned one to Ms. Jones, she said that that center was not 12-step-oriented and that Dr. ____ insisted that he enter a 12-step center, and that he was to comply with Dr. ____'s orders. Ultimately, Capt. Smythe entered the _____ Treatment Center.
At _____, Capt. Smythe encountered numerous patients who had been in treatment previously one young woman said it was her eleventh time in treatment. Capt. Smythe completed the program (of the 33 people who entered along with him, 12 either left or were thrown out for drinking or using drugs, thus belying _______'s claims to patients that it had a 95 percent success rate). Ten days after he returned home, he was informed that he had to contact Dr. ____ again in order to be certified for work. In the meantime, Capt. Smythe did research on his own and discovered that there was strong disagreement about approaches to alcoholism treatment in the addictions literature. Among other programs and practitioners, he contacted Rational Recovery a non-12-step, non-spiritual recovery group and myself.
When Capt. Smythe met with Dr. ____ following treatment, he was informed that he had to enter into a two-year contract with Dr. ____ and with ABC. Dr. ____ elaborated, "It's a therapeutic contract between me and you and you're going to do certain things for me. If you are in violation of our contract then the employer will be notified and you'll have to answer to them. This is what you are going to do for me. First you will attend at least three AA meetings a week. You will be involved with a weekly step group and a weekly home group. You will get yourself a sponsor. You will provide us with urine and blood samples on a regular and random basis at my lab. You will see me every two weeks until I feel you're doing all right, then we'll increase the time in between visits. You are responsible for all the associated costs." Dr. ____ indicated to Capt. Smythe that the Captain was fortunate, because his contract was for only two years, while some contracts were for five years.
However, Capt. Smythe was now in a position where, if he did not sign the contract with Dr. ____, he could not return to work. If he did sign the contract, if he missed so much as a single AA meeting, he would be in violation of the contract. At the same meeting where Dr. ____ reviewed the contract with him, Capt. Smythe complained that officers of ABC and other employees knew details about his diagnosis and had apparently seen Dr. _____'s report. Dr. _____ at first denied that he had turned over such information to ABC, saying it would be an ethical violation to do so. Capt. Smythe then asked for Dr. _____'s medical report. At this point, Dr. ____ indicated he couldn't give Capt. Smythe this report because whoever purchased his services "owned" the report. This was the first that Capt. Smythe was aware that this was the case. After the meeting, Capt. Smythe immediately called and left a message for Ms. Jones saying he wanted a copy of the report as soon as possible.
Meanwhile, Capt. Smythe received a call from one of ABC's directors. In a highly aggressive manner, the director told him, "Ms. Jones just called and said you wanted the medical report. You can't have it! It's not yours. We own it and you can't have it!" Capt. Smythe consulted with an attorney about the contract and searched for alternative providers of his contracted posttreatment plan. He and his lawyer developed an alternative plan with fewer meetings, and involving a Rational Recovery group rather than AA. In addition, Capt. Smythe contacted a family physician, Dr. Lawrence Kramer, who had been medical director of a detoxification/substance abuse clinic for seven years and had seen hundreds of patients with substance abuse problems over 15 years in private practice. This physician was not a 12-step practitioner indeed, he opposed this approach. Capt. Smythe met with this provider twice and found his approach amenable. Dr. Kramer diagnosed Capt. Smythe (according to Dr. Kramer's notes) as a "habitual but not compulsive" drinker, and later indicated in a letter that he did not find Capt. Smythe to be alcohol dependent.
ABC had meanwhile written Ms. Jones and copied Capt. Smythe a release for Dr. ____'s report. At the same time, ABC was threatening Capt. Smythe with consequences if he did not sign the contract proposed by Dr. ____. Capt. Smythe responded with the alternative contract and aftercare provider. Capt. Smythe continued to try to get Dr. ____'s report from Ms. Jones. Capt. Smythe finally received a fax of Dr. ____'s report after the initial deadline he had been given to sign the contract with Dr. ____ and ABC. Capt. Smythe sent this report to Dr. Stanton Peele, whom he had contacted in the interim. ABC refused to accept Dr. Kramer, saying he was unqualified, and insisted that Capt. Smythe sign an aftercare agreement with Dr. ____. However, after the initial deadline had passed, ABC now provided a list of 15 additional providers. One of these providers worked in a rundown part of town and was not a 12-step practitioner, but also specialized in drug-addicted AIDS patients. Capt. Smythe agreed to aftercare with this physician, Dr. Walton. Dr. Walton, as had Dr. Kramer, did not find Capt. Smythe to be alcohol dependent. Nonetheless, he signed an aftercare agreement with Capt. Smythe that was accepted by ABC.
My Assessment of the Report (see Attachment)
A single alcohol-related incident was reported in connection with Capt. Smythe's employment as a ship's pilot. Capt. Smythe reported to work at 11:00 p.m., when an agent smelled alcohol on his breath. Dr. _____'s evaluation indicates that Capt. Smythe said that he had two beers at dinner approximately five hours before reporting, and nine hours before he piloted the ship. (In a phone call, Mrs. Smythe told me that Capt. Smythe had three beers with dinner, was not intoxicated when he left for work, and that he was not to pilot a ship until 3:00 a.m. the next morning. Capt. Smythe told me, and his wife corroborated, that the Captain did not drink on working days.) He had had a total of six beers that day. As far as the record indicates, no breathalyzer or blood test was administered, so that no BAL (blood alcohol level) was determined. A fellow pilot who accompanied Capt. Smythe reported that he noted no impairments in Capt. Smythe's behavior or performance (this is included in Dr. _____'s report).
From both a legal and a clinical standpoint, I would judge that this incident did not provide sufficient cause for either legal or mandatory clinical action. In fact, it prompted the subsequent examination by Dr. ____, in which a diagnosis of alcohol dependence was made. But a diagnosis of alcohol dependence is not, in my judgment, established by Dr. ______'s report.
Violations of ASAM Principles of Medical Ethics
I proceed in this section by matching the performance of Dr. ____ against the Principles of Medical Ethics listed at the ASAM web site (ASAM, 1992). (Only those sections of the ASAM principles relevant to Captain Smythe's ethics complaint are reproduced here, and particularly relevant passages appear in bold italics.)
Preamble: The American Society of Addiction Medicine supports a body of ethical statements developed primarily for the benefit of the patient.
It can certainly be said that Dr. ____ was not primarily oriented towards the betterment of the patient, or towards Capt. Smythe at all. Dr. ____ did not communicate his diagnosis directly to Capt. Smythe, did not respect Capt. Smythe's preferences for treatment or requests for information, and seemed most directly concerned with the EAP's and employer's needs, as well as his own financial benefits (see Conflict of Interest below). Capt. Smythe appears in this matter to have been a recipient of secondary consideration throughout.
1. Because of the prominence of denial in patients suffering from chemical dependence, treatment may be mandated or offered as an alternative to sanctions of some kind. In other circumstances, a chemically dependent person whose judgment is impaired by intoxication may be brought to treatment when unable to make a reasoned decision, or may be treated on an involuntary basis. It is the duty of the addictionist to advocate on behalf of the patient's best interest and to prevent any abuse of this coercive element. The goal for patients is to restore, as quickly and safely as possible, their ability to make responsible decisions about their own recoveries.
Capt. Smythe's treatment was mandated. Alcohol dependence was diagnosed, although I seriously question this diagnosis (see Attachment). In any case, Dr. ____'s self-centered, dictatorial, nonresponsive, and paternalistic approach continued well past treatment. Captain Smythe was not in a medical emergency when he was referred to treatment, having ceased drinking a month earlier. Yet he was not allowed to select a treatment program he felt was best for him. Moreover, any potential emergency was certainly well past after he had completed treatment. Nonetheless, Dr. ____ refused to allow Capt. Smythe any say in his treatment and aftercare arrangement (e.g., particularly in regards to his preference for alternatives to AA and 12-step treatment), and to allow Capt. Smythe free choice of a provider with whom to create an aftercare contract.
2. All patients with problems of chemical dependence, regardless of how dysfunctional they may appear, retain the right to be treated with respect. The physician practicing addiction medicine will maintain a decorum that recognizes each patient's dignity regardless of possible conflicts in values between patient and physician.
Dr. ____ displayed no concern for Capt. Smythe's values, in regard either to his desire for full disclosure or his treatment preferences. Dr. ____ appears fully committed to the 12-step model of alcoholism treatment. Capt. Smythe found this offensive to his values. Dr. ____ seemed incapable, as a professional, of acknowledging and respecting this difference between his and his patient's values.
Section II, Preamble:
A physician shall deal honestly with patients and colleagues and shall attempt to notify appropriate authorities promptly regarding those physicians whose conduct is illegal, unethical or incompetent or who engage in fraud or deception.
Capt. Smythe contends that Dr. ____ lied to him primarily (but not exclusively) about what Dr. ____ communicated to Capt. Smythe's employers. That is, Dr. ____ had no compunction about conveying his diagnoses directly to the EAP and ultimately to Capt. Smythe's employer. Dr. ______ says he had Capt. Smythe sign an informed consent agreement, one that Capt. Smythe has not subsequently been able to obtain. Instead, Capt. Smythe maintains, Dr. _____ initially told him their consultation was confidential and then attempted to obfuscate who would receive and had received Dr. _______'s report.
3. Addiction treatment services, like all medical services, are dispensed in the context of a contractual arrangement between physician and patient and which is binding on both. Addictionists should avoid misrepresenting to patients or families either the nature, length or cost of treatment recommended. This is particularly important when the physician may profit from the recommendation or when the physician holds power over a patient's legal or professional status or when the physician's income is based on census within an institution as opposed to services rendered to patients.
Dr. ____ did reveal the costs of the various services he was to perform for Capt. Smythe. However, Capt. Smythe was anything but free to accept or reject this proposed arrangement and to seek alternative services and/or providers. Capt. Smythe's initial selection of a non-12-step treatment program was rejected by the EAP on an understanding that Dr. _____ would not accept such a program. Capt. Smythe's employer negotiated consistently to compel Capt. Smythe to adopt the aftercare contract proffered by Dr. ____. It is hard to avoid the conclusion that ABC and Dr. ____ were in contact not to say in collusion in their efforts to force Capt. Smythe to accept Dr. ____'s contract.
2. Addictionists are often in the position of acting as role models for recovering patients. As such, they carry the responsibility to be aware of the laws that govern both their professional practice and everyday lives and to respect and obey these laws. While most unlawful behaviors would have a direct or indirect bearing on suitability to practice, there may be situations such as an act of civil disobedience in protest against social injustice in which unlawful activity might not automatically be equivalent to professionally unethical conduct.
Dr. ____'s conduct regularly clashes with these Principles of Medical Ethics. He repeatedly violated, among other medical and ethical precepts, confidentiality and informed consent. Confidentiality is a separate part of the ASAM's Principles of Medical Ethics (see below).
Section IV, Preamble:
A physician shall respect the rights of patients, of colleagues and of other health professionals and shall safeguard patient confidences within the constrains [sic] of the laws.
1. Physicians practicing addiction medicine often treat patients who feel stigmatized and are reluctant to disclose medically necessary information because of suspicion, fear and distrust. In this special physician patient relationship, it is essential that the rights of the patient be recognized, respected and protected by the treating physicians.
2. When addicted patients are coerced into treatment by external agencies and are under threat of legal, social or professional sanctions, demands for information from these agencies may at times conflict with a patient's desire for confidentiality. The physician has the obligation to consider the short and long term consequences of disclosure and to advise the patient who must give consent. The patient's right to limit the content, purpose and duration of consent should be respected within the limits of the law.
Dr. ____'s June 22, 1998 report is labeled an "Independent Medical Evaluation." However, the report was authored at the behest of the ABC and/or its representative, Ann Jones, expressly for the purpose of deciding whether Capt. Smythe should be compelled to undergo treatment and for the purposes of work assignment. In and of itself (other than mislabeling the assessment "independent"), this is of course a legitimate company function. However, the recipient of such an evaluation must be informed in some clear and unmistakable way that this is the case. Capt. Smythe maintains that this never happened, and that he was repeatedly assured that his consultation with Dr. ____ was confidential, and that Dr. _____ only told Capt. Smythe otherwise later, when confronted with his actions. Capt. Smythe maintains that Dr. ____'s assurance in his report that "I explained the nature of this evaluation" was thus a misrepresentation, and that in any case he was never cognizant of the purpose of the evaluation and a report based on it. This situation is compounded in that the report or its contents were apparently conveyed to Capt. Smythe's licensing body.
The principle that a patient must be informed if an interview with a professional is intended or can potentially be used for legal or employment actions is acknowledged ordinarily by a so-called Lamb warning. A standard Lamb warning reads as follows:
I am retained by __________. I am not your doctor/therapist, and this is not treatment/therapy. What you say to me is not confidential and I may report it to [the retaining party] and what you tell me may be used in court. Thus, what you say can benefit or harm your case, or have no effect on it. You are free not to answer any questions but I may make note of that fact in my report.
3. Addictionists should treat individuals only with their consent, except in emergency and extraordinary circumstances in which the patient cannot give consent and in which the withholding of treatment would have permanent and significant consequences for life and health. In cases where the patient has been found to be incompetent by appropriate mental health professionals and/or by the judicial system, physicians may assist in their care.
Dr. ____'s assurance in his report that "informed consent" standards were being followed is inaccurate in as much as this term is usually understood very differently (see Chapter 5). Clearly, Capt. Smythe was not given a free choice about whether to enter treatment, based on Dr. _______'s diagnosis of alcohol dependence. The attachment to this letter makes clear that this diagnosis is flawed. If treatment was recommended, clearly an outpatient alternative should have been considered. Informed consent not only requires gaining the patient's consent for his or her treatment, it also requires full disclosure of the patient's diagnosis, the nature of the proposed treatment, and possible alternative treatments. Informed consent then requires that the patient's judgment and decisions be respected with regard to treatment. Dr. ____ provided none of this information; nor did he respect Capt. Smythe's choices. He did not explain the nature of 12-step treatment and its alternatives to Capt. Smythe. Indeed, it is clear that Dr. ____ would accept only a 12-step treatment program. After Capt. Smythe learned of such alternatives, in fact, Dr. ____ resisted all initiatives by Capt. Smythe to seek alternatives to 12- step aftercare.
4. The physician will be extremely careful of any dual role relationships with patients. Assuming the doctor-patient role with employees, business associates and vendors, students, family members and others may compromise professional judgment. Conflict of interest or an advantage of power over the patient outside of the treatment relationship can lead to exploitation or interfere with the fiduciary nature of the professional relationship. While such treatment is not frankly unethical, there are potential dangers and conflicts in such roles and the physician should enter into them only with great caution.
Dr. _____ evinced several conflicts in his dealings with Capt. Smythe (see Strasburger et al., 1997). Initially, Dr. ____ had a stake in assessing, in a supposedly "independent" evaluation for an employer and EAP, that Capt. Smythe was alcohol dependent, since Capt. Smythe was required to sign an aftercare arrangement with Dr. _____. Dr. ____'s refusal (operating through the employer's negotiations with Capt. Smythe in the creation of an aftercare contract) to allow alternative treatments or providers was clearly financially and professionally self-serving for Dr. ____. Furthermore, requiring that Capt. Smythe sign a rehabilitation agreement with him while in fact he was employed by ABC Corp. to make decisions regarding Capt. Smythe's employment and professional status is an additional conflict.
Misdiagnosis of Alcohol Dependence
The ASAM is aware, I know from my prior correspondence with you, that its past president, Dr. G. Douglas Talbott, was found liable in his treatment of a patient for fraud, false imprisonment, and malpractice. An essential element of this judgment was the decision by the jury that the patient, Dr. Leonard Masters, was misdiagnosed as alcohol dependent, on the basis of which the defendants coerced him into treatment at the Talbott-Marsh Recovery Campus (now the Talbott Recovery Campus). As you may know, Dr. Anne Geller, president of ASAM prior to Dr. Talbott, testified for the plaintiffs in support of the argument that Dr. Masters was misdiagnosed. Among the points Dr. Geller made were that the defendants neglected to interview Masters' family, friends, and colleagues (Ursery, 1999b); and that Dr. Masters' record gave no evidence of loss of control, of an increase in drinking (tolerance), or of withdrawal (Ursery, 1999a).
It is my contention (see Attachment) that Capt. Smythe's was an even more blatant case of misdiagnosis, displaying the same limitations and oversights as Dr. Geller pointed out in the Masters diagnosis and more.
Although the record does not rule out the possibility of excessive drinking or a diagnosis of alcohol abuse on Capt. Smythe's part, clearly the diagnosis of alcohol dependence on which Dr. _______'s actions and Capt. Smythe's treatment were predicated is not justified by the record or by Dr. _____'s report. More importantly, the record establishes a host of violations of proper clinical procedures and professional ethics in this case.
Stanton Peele, Ph.D., Esq.
Dr. ____ authored what is titled an "Independent" Medical Evaluation. I elsewhere address what is meant in this instance by "independent." The assessment also includes what it claims is an "informed consent" clause. I address this claim elsewhere as well. The assessment cites the one above-mentioned incident. Its past medical history comprises seven lines, and refers to a motor vehicle accident in which alcohol was not involved, and a mild case of hepatitis, in which, Dr. ____ reports (according to Capt. Smythe's family physician), "Alcohol may have been an exacerbating factor." No independent record of this physician's assessment is provided. Capt. Smythe maintains that Dr. ____ never spoke to this family physician, and so I remain puzzled about the source of this information. The report notes that Capt. Smythe had his last drink a month prior (confirmed by his wife and a negative alcohol screen), which would be clinically relevant to a diagnosis of alcohol dependence.
Collateral reports. The pilot who accompanied Capt. Smythe the evening of the reported incident indicated he did not believe Capt. Smythe had an alcohol problem. The only other collateral contacted was the subject's wife of 17 years, Susan, who Dr. ____ reports "has been concerned about his drinking for several years." Dr. ____ reports that she expresses "the belief that Capt. Smythe has a drinking problem" and that "he appears on occasion to lose control of his drinking and suffer negative consequences from his drinking." However, I have a copy of an independent statement from Susan Smythe that maintains these statements were purportedly taken from a phone call and were, she says, "either taken out of context or were distorted." According to the document I have, Mrs. Smythe reported that her husband has never lost control of his drinking and that "I do not recall Capt. Smythe suffering any negative consequences" (from his drinking).
(I spoke by phone with Mrs. Smythe, when Capt. Smythe was not present. She agreed that she felt Capt. Smythe was drinking too much, but that he displayed no negative consequences from his drinking and always remained in control of it. Mrs. Smythe confirmed that Capt. Smythe quit drinking after the incident and has not drunk again, that he never drank on days when he worked, and that he had three beers with dinner the night before piloting the boat as scheduled during the reported incident. She was always confident Capt. Smythe could quit drinking, because "he has extremely strong will power," citing his successful loss of 60 pounds two to three years earlier. She confirmed for me the contents of her letter in regard to her interview with Dr. _____. She said this about what he subsequently wrote in his report: "Dr. _____ wanted to hear that my husband loses control when he drinks, but he doesn't." In regard to Dr. ______'s report, she told me: "It was like he was taking me out of context, and trying to twist what I said around.")
Negative consequences. Negative consequences are often summed in assessments of alcohol dependence, and so the total number of negative consequences and their nature/severity are clinically relevant. Dr. ____ lists a total of four such consequences: "[A]bout 15 years ago . . . He was charged with failing to provide a breath sample [no details provided]. He has had medical consequences in that his hepatitis was likely [above Dr. ____ states that the reporting physician said "may have been"] made worse by his continued drinking. His wife Susan has been concerned about his drinking for several years. He has had vocational consequences [the single incident above], resulting in this assessment." This list of consequences, even without the alternative/additional information provided here, does not justify a diagnosis of alcohol dependence.
Quantity drunk/test results. Dr. ____ reports that Capt. Smythe typically drinks nine beers per day, and occasionally more at parties. He notes that this drinking is characteristic of non-working days. Captain Smythe reports, and his wife confirms, that he does not drink at all on working days, which is both clinically and professionally relevant. Dr. ____ reports an AUDIT (screening) test score of 14, where cutoff of 8+ "makes a diagnosis of alcohol use disorder likely." Since this is a screening rather than a diagnostic test, it cannot assess alcohol dependence, as Dr. _____ notes.
Family history. Capt. Smythe presents no family history of parental alcohol abuse, but Mrs. Smythe does have a family background of alcoholism, which might make her highly sensitive to signs of alcohol abuse.
Overall health. Capt. Smythe is healthy, does not smoke or drink coffee, is not depressed, sleeps well, recently lost about 60 pounds, and displays no symptoms of chronic or acute illness (except as described in next section). Dr. ____ assesses his cognitive acuity and memory to be good, finds no signs of mood or thought disorder, and states that he displays no (other) obsessive or addictive behaviors.
Medical tests. Dr. ____ reports liver dysfunction indicating "excessive alcohol intake." Dr. ____ reports that Capt. Smythe had not drunk alcohol since May 18, 1998 (this was on June 22, so that Capt. Smythe had been abstinent over a month); it was two months after this point (in August) that Capt. Smythe entered inpatient treatment. Dr. ____ administered an alcohol drug screen, which was negative. Signs of an ulcer were noted.
Diagnosis of Capt. Smythe
Dr. ____, under "Diagnostic Impression," lists an axis 1 diagnosis of "alcohol dependence," based on "negative consequences + loss of control + compulsive use." Given Capt. Smythe's job as pilot, this diagnosis requires, according to Dr. ____, "thorough treatment and monitored follow-up." If not for this sensitive work, Capt. Smythe would still require "follow-up by an addictions counselor. . . and regular attendance at Alcoholics Anonymous . . ."
Alternate View of Diagnosis
Dr. ____'s assessment of alcohol dependence seems inadequate in a number of regards. No diagnostic test was administered, and no computation of alcohol dependence symptoms in reference to a set of diagnostic criteria (such as DSM-IV) is reported. Sources for many of his claims are inconsistent, unsubstantiated, or disputed. At this point, it may be valuable to review the DSM-IV description and criteria for substance dependence (alcohol is included here with other substances):
The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance- related problems. There is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug- taking behavior. (American Psychiatric Association, 1994, p. 176)
DSM-IV further elaborates:
Individuals with Substance-Related Disorders frequently experience a deterioration of their general health. Malnutrition and other general medical conditions may result from improper diet and inadequate personal hygiene. Intoxication or Withdrawal may be complicated by trauma related to impaired motor coordination or faulty judgment. (pp. 189-190)
Capt. Smythe seems to be a far cry from this description.
DSM-IV lists a specific set of criteria:
Criteria for substance dependence. A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
Note, first, that these symptoms must occur over the same 12- month period, and thus the unspecified refusal of the breath test 15 years ago would not be relevant to this diagnosis. Note also the descriptor, "clinically significant impairment or distress." Dr. ____ makes no representation that criteria (1) (3) are met, i.e., tolerance, withdrawal, or increasing use. As to (4), no such unsuccessful efforts to quit or cut back are reported. Indeed, Dr. ____ notes at the time of his assessment that, prior to treatment and following the job incident, Capt. Smythe has ceased drinking, and Capt. Smythe reports having ceased drinking earlier in the year when he developed hepatitis. No reports of criterion (5) are included in Dr. ____'s assessment. In addition, as to criterion (6), no mention of sacrifice of work or any other activities in order to drink (other than the involuntary cessation of work caused by Dr. ____'s assessment itself) is made.
Note that, for a diagnosis of alcohol dependence, three of these types of criteria need to be met in the prior 12 months. In fact, three events are reported in Captain Smythe's case, but all fall within category (7), which is not sufficient to qualify a person for a diagnosis of alcohol dependence. And even these three events all have questionable elements, some dispositively so. Arguably, drinking contributing to hepatitis would meet criterion (7), but Capt. Smythe claims instead to have ceased drinking when he learned of his hepatitis, and no report from his physician contradicts this. Once again, when a single job incident occurred, Capt. Smythe by Dr. ____'s own tests was shown to have abstained, which again refutes this criterion. All that remains is the claim that Capt. Smythe drinks despite his wife's objections, although his wife has subsequently denied central elements of Dr. _____'s report on his interview with her. Furthermore, Dr. ____ reports negative tests for depression and no other sign of psychological dysfunction, thereby contradicting the possibility of drinking despite "a persistent psychological problem."
Dr. ____ emphasizes "loss of control" and "compulsive use" in his report. These elements are approximated by items (3), (6), and (7) of the DSM-IV alcohol dependence criterion. The only basis for establishing loss of control in the case record is the claim made over the phone by Mrs. Smythe, the accuracy of which Capt. Smythe contests with a signed statement from his wife. (I have confirmed that she disagrees with the loss-of-control contention.) Loss of control indicates that, once an individual has begun drinking, he or she cannot halt until unconscious, intoxicated, or some similar state has been reached. In other words, he or she cannot drink moderately. But no case evidence is presented that Capt. Smythe ever had a single loss- of-control experience. This type of behavior is difficult to cover up, and would typically be widely noticed. Other case data included in Dr. ____'s report dispute the loss-of-control assessment, as well as that of compulsive use not the least being Dr. ____'s report that Mrs. Smythe "believes he will be able to stop drinking," when, in fact, the case record indicates that Capt. Smythe had already done so and that he continued to do so for several more months prior to treatment. Previous contradictory indicators of compulsive use have been noted above in regards to criteria (3) (7).
The failure to establish a solid alcohol-dependence diagnosis is significant. An inpatient program for alcoholism requires a very firm diagnosis of this type, since the differential benefits for inpatient treatment for lesser degrees of alcohol problems are not established; in fact, what differences have been measured favor less intensive, or outpatient, treatment for such less severe alcohol abuse (Miller & Hester, 1986). It is my professional opinion that the original referral to an inpatient hospital program was not justified on the assessment reported here. An outpatient program would surely have been sufficient if any treatment were required. Likewise, the need for AA attendance which presupposes a firm diagnosis of alcohol dependence or alcoholism is simply not appropriately established by this assessment.
ASAM referred this complaint to its attorney, Edward A. Scallet, of the firm LeBoeuf, Lamb, Greene & MacRae, who responded to Captain Smythe as follows:
"The ASAM Bylaws do not include a formal process for reviewing complaints against members. . . ." and that ASAM takes action only when "a member has been sanctioned by a licensing board" or has been convicted of a crime. The letter further indicates that "your complaint seems to be at least as focused on your employer and how your employer treats confidential information it receives in connection with its EAP[!]"
Thus, ASAM, which lists on its web site as a primary goal to "establish addiction medicine as a specialty recognized by the American Board of Medical Specialties," has no mechanisms in place to evaluate violations of its professional code of conduct short of commission of a felony (thus, allowing past president G. Douglas Talbott to escape readily from professional consequences for being found civilly liable for fraud and malpractice) and seems not to be concerned at all that a member might have committed malpractice by violating ASAM's own and general medical standards of care and ethical principles with respect to informed consent, confidentiality, and conflict of interest.
The complainant continues to pursue this matter with Dr. ______'s licensing body and potentially through legal action.