What Happens When Regulators Ask About Mental Health?
Regulators have good reason to ask about mental health. But some questions do more harm than good, encouraging clinicians to hide the truth and avoid treatment.
All but four state medical boards ask license applicants about their mental health and use of controlled substances. It’s not surprising. Practitioners were already suffering alarming rates of burnout before the pandemic hit and the psychological stress load they are now trying to cope with can be overwhelming. Meanwhile, the nation’s other health crisis, opioid abuse, is still raging out of control. Under such conditions, it would be a dereliction of duty for boards not to probe areas that might impair a practitioner’s ability to provide competent and professional care.
But as every clinician knows, if you want to get reliable information you have to ask questions in a way that elicits honest answers. For example, if a patient feels unduly challenged or threatened during an appointment, they are all too likely to hide just the data you are looking for. That in essence is one of the concerns experts are raising about how boards approach clinicians about sensitive topics like mental health and substance abuse.
Other experts go further, suggesting that some boards are asking irrelevant and overly intrusive questions with devastating, if unintended consequences. Still others point to court rulings that render certain questions not just inappropriate but possibly illegal as well.
Questions Should Focus on Current Impairment
A recent study comparing licensing board applications from all 50 states and the District of Columbia found some reaching back decades for information. One application asked, “Have you ever been diagnosed with, treated for, or do you currently have…?” A list of 14 mental health conditions, including depression and seasonal affective disorder, followed.
According to a white paper on Physician Wellness and Burnout from the Federation of State Medical Boards (FSMB), such questions are misguided.
“While information about a physician’s health status (both mental and physical) may be essential to a state medical board’s solemn duty to protect the public,” says the report, “the FSMB has previously noted that a history of mental illness or substance use does not reliably predict future risk to the public.” (1)
Even questions that limit their time horizon to five years are considered off limits by the FSMB. “Applications must not seek information about impairment that may have occurred in the distant past and state medical boards should limit the time window for such historical questions to two years or less, though a focus on the presence or absence of current impairment is preferred.”
Broad historical questions are not just inappropriate. Based on court rulings over the years, they may also violate applicants’ rights under the Americans With Disabilities Act (ADA). Again, according to the FSMB: “The ADA requires licensure application questions to focus on the presence or absence of current impairments that are meaningful in the context of the physician’s practice, competence, and ability to provide safe medical treatment to patients.”
To accurately gauge current impairment, boards also need to ask applicants how they are managing their condition. A person suffering from depression may be incapacitated if their illness goes untreated, but once they receive the care they need, they can function safely and appropriatly. That’s why a number of states include questions about treatment on their applications. One such question asks, “Are you currently suffering from any condition for which you are not being appropriately treated (emphasis added) that impairs your judgement or that would otherwise adversely affect your ability to practice medicine in a competent, ethical and professional manner?”
Treatment is not the only mitigating factor, of course. Practitioners can also take practical steps to limit an impairment, whether it is physical or emotional. Someone working with a therapist to resolve issues around sexual harassment might effectively protect themselves and their patients by limiting their practice to a specific gender or by arranging to have a trained chaperone in the room at all times. Some boards explore this possibility by asking if a current impairment or limitation is “reduced or ameliorated because of the field of practice, the setting, the manner in which you have chosen to practice, or by any other reasonable accommodation?”
Too Often Questions Discourage Treatment and Encourage Deception
It is in everyone’s best interest for providers to get professional help when they need it so they can continue practicing safely or return safely to practice as soon as possible. Yet licensing questions about mental illness often discourage applicants from seeking out appropriate care. In part, this is a societal problem. Given the stigma society attaches to mental illness, individuals in all walks of life tend to deny problems when asked.
But when a question on a medical licensing application sounds as if it is being asked by a prosecutor, the stigma looms much larger. One question mentioned in the nationwide review of applications reads, “Are you currently, or have you ever been monitored by a Physician Health Committee in any state?” The tone a question like this could be interpreted to have is that mental illness is something shameful that people may try to hide. As a hospitalist told the researchers, “Mental health questions have a chilling effect that I admit have kept me from seeking mental health support when it would have been wise to do so. Stigma is so severe that I have heard many physicians state that it would be better to die from suicide than be admitted to our hospital’s psychiatric unit.”
Practitioners worry that simply seeking help jeopardizes their license. Once they are being treated, they reason, they will have to respond positively to questions asking if they have been diagnosed or treated for a mental illness. If they avoid treatment they feel they can honestly answer no and avoid raising any red flags. A 2016 survey of female-physician-parents found that nearly half who suffered from mental illness never sought help. One of the primary reasons was “fear of reporting to a medical licensing board.” The title of the research paper captures the fear these physicians reported: “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting (2).
Providers who do seek help are often so fearful of revealing their treatment that they go out of their way to hide what they are doing. Some travel long distances to see therapists and fill prescriptions, hoping no one they know will see them. Others medicate themselves using pharmaceutical samples or ask a colleague to write them a prescription off the books. Then they lie on their applications, intentionally violating ethical and professional standards they have sworn to uphold simply to avoid the stigma of mental illness and the implied threat of losing their license.
Reframing Can Make Questions More Effective
One way applications can help reduce the stigma is by treating psychological disorders the same way they treat physical ailments. That is exactly what the FSMB recommends. “Questions that address the mental health of the applicant should be posed in the same manner as questions about physical health, as there is no distinction between impairment that might result from physical and mental illness that would be meaningful in the context of the provision of safe treatment to patients.”
This simple suggestion can make a significant difference. As the following example illustrates, referring to physical and mental illness in the same question eliminates the implication that one is more shameful than the other:
“Do you now have any disease or condition that presently limits your ability to perform the essential functions of your profession, including any disease or condition generally regarded as chronic by the medical community, i.e., i) mental or emotional disease or condition; ii) alcohol or other substance abuse; iii) physical disease or condition?”
Answers Should Be Put to Good Use.
Honest answers can lead to productive outcomes when boards treat applicants as trained professionals worth supporting. When this does not happen, when the practitioner who answered truthfully is treated as an offender, no one benefits. The stigma around mental illness grows, the individual is traumatized, and their story increases distrust in colleagues who fear similar treatment.
A psychiatrist told researchers that when she informed her board about a serious depressive episode the year before, she was required “to be urine tested for substance abuse, despite multiple demeaning assessments that have rendered the clear verdict that I don’t have a substance use problem.” She also had to attend a remedial education course designed for practitioners with boundary violations. What she found most distressing was the total lack of support. “Throughout all of this,” she said, “nobody has told me how common my feelings are, that a large number of doctors feel depressed and suicidal at times. Rather, I’ve been told that my action are unheard of for someone in mental health and may preclude me from ever providing therapy again.”
The FSMB report suggests a better way, encouraging boards to “emphasize the importance of physician health, self-care, and treatment-seeking for all health conditions by including a statement to this effect on medical licensing applications, state board websites, and other official board communications.”
In addition to the suggestions already mentioned, the FSMB recommends that state medical boards…
• Consider offering “safe haven non-reporting” to applicants for licensure who are receiving appropriate treatment for mental health or addiction. This allows physicians who are in “good standing” with a Physician Health Program to apply for medical licensure or a license renewal without having to disclose their diagnosis or treatment to the board.
• Work with their state legislatures to ensure that the personal health information of licensees related to an illness or diagnosis is not publicly disclosed as part of a board’s processes. Information disclosed must relate only to impairment of professional abilities, medical malpractice, and professional misconduct.
Additional Related Articles
September 17 is National Physician Suicide Awareness Day. Visit their website at NSPAday.org to learn the vital signs and how you can help prevent physician suicide.
- The New England Journal of Medicine. (2021). Physician, Heal Thy Double Stigma — Doctors with Mental Illness and Structural Barriers to Disclosure
- Federation of State Medical Boards. (2018). Report and Recommendations of the Workgroup on Physician Wellness and Burnout. https://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf
- Katherine J. Gold, Louise B. Andrew, Edward B. Goldman, Thomas L. Schwenk, “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting, General Hospital Psychiatry, Volume 43, 2016, Pages 51-57, ISSN 0163-8343 (https://www.sciencedirect.com/science/article/pii/S0163834316301281)
- Pamela Wible, Arianna Palermini. Physician-Friendly States for Mental Health: A Comparison of Medical Licensing Board Applications. Qualitative Research in Medicine & Healthcare 2019; volume 3: 107-119.