I am a former associate director in a state physician health program (PHP). I also hold faculty appointments at Baylor College of Medicine and Harvard Medical School in medical ethics and psychiatry.

There is a little-known nether realm inhabited by a subset of doctors who have or are suspected of having substance use disorders. These physicians often are referred to state PHPs which, because they’re generally considered voluntary in nature, have little to no oversight. PHPs very frequently refer the physicians who come through their doors to evaluation and treatment centers with which they have financial ties, which often result in extended stays that cost doctors tens of thousands of dollars if they hope to continue practicing medicine.

I’ve written about these issues for over a decade, but only recently have I heard that some of the evaluations that physicians are compelled to undergo utilize polygraph tests.

One of these evaluation centers charges physicians $400 per polygraph, and if a physician doesn’t pass on the first or second try, they can keep paying $400 per test until they finally pass. Once they pass, all is forgiven about the failed tests, as long as the check clears for all of the tests.

And mind you, the cost for the polygraphs is on top of the $6,000 to $10,000 physicians are already spending for these multi-day evaluations, as well as the tens of thousands of dollars those same physicians are likely to spend if the evaluation concludes—as happens very frequently–that they need to stay for up to 90 days for “treatment.”

Who are these doctors being mandated to undergo these kinds of evaluations? Here are just 2 of the many who’ve reached out to me:

One lives in a state where recreational cannabis is legal and was using a marijuana tincture three times a month after work hours to help with menstrual cramps. She turned up positive for cannabis on a pre-employment screen and was ultimately told she needed a 90-day stay at a cost of $60,000 for “severe marijuana dependence.” When she refused, the evaluation center asked her, “Don’t you think your career is worth $60,000?” and also wouldn’t provide her with a phone to call for transportation to leave the facility.

Another sought help on her own from her state PHP for recurrent sadness and, when asked, freely admitted that she generally had 3 to 4 drinks of alcohol over the course of a week. When asked how alcohol made her feel, she replied that it calmed her down. The PHP then stated that feeling calmed after drinking was a hallmark of a substance abuser and told her she needed to go for an evaluation for substance abuse.

In the midst of a system that is already full of ethically problematic financial conflicts of interest that lack almost any oversight, having a physician’s career hinge on passing a polygraph is the icing on the cake.

There is a reason that polygraphs are not admissible in courts. The entire nature of a polygraph examination is fraught, with some experts concluding that “given the number of mistakes made by polygraph tests …polygraph results should not be considered …as reliable evidence… (even though) polygraph examinations can serve as a source of intelligence information or a means of lie detection.”* Given their unreliability, the fact that PHPs are mandating that doctors go to centers that employ polygraphs is appalling.

But what if a physician simply refuses to undergo a polygraph? In that case, the evaluation center would report that physician to their PHP as being noncompliant with their exam, and in turn the PHP would generally report the physician to their state board of medicine as being non-compliant. The second that happens the board of medicine generally comes after the non-compliant physician and demands that they stop practicing medicine.

Does the board of medicine care that polygraphs played a key role in the report of noncompliance from the state PHP? Not at all, because boards of medicine generally defer any and all questions of physician impairment to their state PHP, not knowing—or perhaps not even caring–that the PHP has financial ties to the evaluation centers they use.

Change is overdue. PHPs need real oversight and external audits, not ones that employ PHP insiders (as they have done in the past). They need fair national standards that are enforceable. They ought to exclusively refer physicians for evaluations to entities with whom they have no financial ties. And they definitely need to stop relying on polygraph tests.

J. Wesley Boyd is a psychiatrist.