By Leigh Page

An item on the California ballot in November 2014 revived an issue that had been less visible for many years. The item would have mandated physicians to undergo random urine tests for drugs and alcohol.

The ballot measure, called "Proposition 46," was defeated, but the issue does not appear to be going away. Voters actually seemed to like the idea of randomly testing doctors. They just didn't like the companion proposal within Prop 46, which was about raising the state's cap on noneconomic damages for physicians in malpractice cases.

In a poll taken before the vote, potential voters had a chance to weigh both issues separately. They narrowly rejected the malpractice proposal, but they overwhelmingly endorsed random testing by a margin of 68% to 25%.

Physicians themselves are more or less split on the issue. According to a recent survey, 43% oppose random testing for doctors and 39% support it. Proponents said testing would protect patient safety and is already required for some other professions, such as airline pilots. But opponents thought random testing was demeaning, and they questioned where it was accurate, fair, or even necessary.

Doctors Dodged the Bullet This Time

However, even physicians who support random testing would agree that passage of the ballot measure would have been an unmitigated disaster, said Yul David Ejnes, MD, a Rhode Island internist.

"Some random drug testing may be necessary," he said, "but this ballot measure was flawed in so many ways."

Dr Ejnes noted that according to the wording of the proposal, drug testing would have applied only to physicians, and there would have been scanty protections for innocent physicians who tested positive. Even if they had a legitimate prescription, their licenses would have to be suspended, pending investigation.

It's not clear when random testing for doctors will come up again for a vote. Right now, the issue seems to lack a powerful advocate. According to reports, plaintiffs' attorneys were the major force behind Prop 46, and they were mainly interested in raising the cap on noneconomic damages and viewed random testing as a "sweetener."

But Dr Ejnes is concerned that an issue that resonated so well with the public might come up again, without much notice, and the medical profession would be unprepared to deal with it. When he searched for policies on random testing of doctors on the websites of some of the leading medical groups, he found virtually nothing on the topic. "Professional societies need to develop some type of policy in this area," he said.

He added that many individual doctors just dismiss the issue, hoping it will go away. "I've heard such things from doctors as, 'There's no way, no how, that we need to do this,'" he said. "We need to step up and take it on, so that the public doesn't see us as circling the wagons and protecting our own."

Dr Ejnes said he still isn't convinced that random testing should happen. He doesn’t agree with several physicians in the poll who said that if pilots are tested, then physicians ought to be, too. "What makes us better than someone else?" one doctor wrote. But Dr Ejnes thinks doctors are in a very different situation. "The pilot is one of two people in the cockpit, whereas the surgeon, for example, is part of a larger team," he said.

Before any decisions on random testing are made, Dr Ejnes said, "we need to have a dialogue about it, and there needs to be more research on whether it is effective in increasing patient safety and on how to carry it out."

Physicians' comments to the poll could be seen as a first step in the dialogue. But although there were many trenchant insights, these physicians also revealed a variety of misconceptions about how random testing works, how test results are handled, and the extent of random testing today.