Since May, physicians in 21 states are no longer being asked broad mental health or substance abuse questions when they apply for a medical license. That's a major shift that could ease doctors' concerns about seeking treatment, according to the Dr. Lorna Breen Heroes' Foundation, a physician burnout prevention group that tracks such changes.
The foundation was named in honor of Lorna Breen, MD, an emergency medicine physician in New York City who died by suicide in April 2020 as the pandemic unfolded. The rate of suicide among physicians is twice that of the general population.
"The issue is not whether a physician may have had a serious or a mild mental illness...but whether they have any disabilities that may affect their current work," said Peter Yellowlees, MD, distinguished professor of psychiatry at the University of California, Davis. "Asking about any past mental illness episodes, which may have occurred years previously...is simply discriminatory and is an example of the stigma associated with mental disorders."
The Breen Foundation has been working with state medical boards and hospitals to remove stigmatizing mental health and substance abuse questions from licensing and credentialing applications.
Breen had told her sister and brother-in-law shortly before her suicide that she was afraid she could lose her license and the career she loved if the medical board found out that she had received inpatient mental health treatment, said J. Corey Feist, JD, MBA, her brother-in-law and co-founder and president of the foundation.
She wasn't aware that New York was a state that didn't ask physicians questions about their mental health, said Feist.
"That's why we want to make it very clear to physicians which states continue to ask these questions and which ones don't," Feist said.
Many physicians share Breen's concern about professional consequences.
Four in 10 physicians said that they did not seek help for burnout or depression because they worried that their employer or state medical board would find out, according to the Medscape 'I Cry but No One Cares': Physician Burnout & Depression Report 2023.
One Oregon emergency department physician said that informing her state medical board about an episode of mania resulted in public disclosures, a 4-month long investigation, lost income, and poorer work evaluations. Looking back on her decision to be transparent with the board, Susan Haney, MD, said that she was naive. "The board is not your friend."
Fearing for her career, now-retired ob-gyn Robyn Alley-Hay, MD, never disclosed on licensing applications that in the 1990s, she had been hospitalized and treated for depression. She stopped practicing medicine in 2014 and now works as a life coach.
"I hated those questions because I felt I could never tell the whole truth," Alley-Hay said. "But I could always truthfully answer 'no' to questions about impairment. That was a line that I wouldn't cross ― if you're impaired, you shouldn't be practicing."
Does the Focus on Current Impairment Protect the Public?
New York, Texas, California, Montana, Illinois, and North Carolina are among the 21 states that either ask no health-related questions or ask only a single question to address physical and mental health, said Feist.
Most of these changes align with the 2018 Federation of State Medical Boards (FSMB) recommendations, said Joe Knickrehm, FSMB vice president of communications. "Application questions must focus only on current impairment and not on illness, diagnosis, or previous treatment in order to be compliant with the Americans With Disabilities Act," states the FSMB.
Mental health questions were often added to licensing and credentialing applications out of a "misplaced desire to protect patients and families from clinicians who might not be fit to give care. Yet there is no evidence they serve that function," said Feist.
Marian Hollingsworth, a patient safety advocate in California, says medical boards have a responsibility to ensure that doctors pose no risk or a negligible risk to the public. She questioned whether the medical boards can adequately protect the public if they only ask about medical conditions rather than mental illness or substance abuse.
"There's a fine line between privacy and right to know for public protection. I would want to see the approving medical board have assurance from a treating professional that this physician is stable and is doing well with continued treatment," said Hollingsworth.
Legislation Requires That Mental Health Questions Be Removed
In March, Virginia became the first state to enact a law that requires all healthcare profession regulatory boards, including medical boards, to remove or replace mental health questions on licensing, certification, and registration applications.
The law requires that boards use the following wording if they replace mental health questions: "Do you have any reason to believe you would pose a risk to the safety or well-being of patients?" "Are you able to perform the essential functions of your job with or without reasonable accommodations?"
The Illinois General Assembly passed a more limited bill in May that requires medical boards to remove or replace mental health questions on its licensing applications. Gov. J. B. Pritzker (D) is expected to sign the bill.
The Virginia Healthcare and Hospital Association, which represents more than 100 hospitals and health systems in the state, partnered with the Medical Society of Virginia and the Virginia Nurses Association to advocate for the new legislation.
"The reason that the Virginia coalition pushed for the law was because the state's medical boards weren't acting quickly enough. Although state laws vary about what medical boards can do, legislation isn't necessary in most states to change licensing questions," said Feist.
Virginia hospitals began working last year with the foundation to change their mental health questions on credentialing applications. About 20% of Virginia's hospitals have completed the process, including four large health systems: Inova, UVA Health, Centerra, and Children's Hospitals of King's Daughters, said Feist.
The foundation also challenged Lisa MacLean, MD, a psychiatrist and chief clinical wellness officer at the Henry Ford Medical Group in Detroit, to review their credentialing application for any stigmatizing mental health questions.
MacLean told the American Medical Association (AMA) that she had found one question that needed to be changed but that it took time to get through the hospital's approval process. Ultimately, the wording was changed from "a diagnosis or treatment of a physical, mental, chemical dependency or emotional condition" to "a diagnosis or treatment of any condition which could impair your ability to practice medicine."
National Medical Organizations Back Changes
The Joint Commission, which accredits hospitals, has emphasized since 2020 that it doesn't require hospitals to ask about an applicant's mental health history.
"We strongly encourage organizations to not ask about past history of mental health conditions or treatment," the Commission said in a statement. "It is critical that we ensure health care workers can feel free to access mental health resources."
The Joint Commission said it supports the FSMB recommendations and the AMA's recommendation that questions about clinicians' mental health be limited to "conditions that currently impair the clinicians' ability to perform their job."
More than 40 professional medical organizations, including the American Academy of Family Physicians and the American Psychiatric Association, signed a joint statement in 2020 calling for changes in disclosure rules about mental health.
"The backing of major organizations is helpful because it's changing the conversation that occurs within and outside the house of medicine," said Feist.
Should Doctors Answer Mental Health Questions?
Many states continue to ask questions about hospitalization and mental health diagnoses or treatment on their licensing and credentialing applications.
Yellowlees advises doctors to "be honest and not lie or deny past mental health problems, as medical boards tend to take a very serious view of physicians who do not tell the truth."
However, the questions asked by medical boards can vary by state. "If it's possible, physicians can give accurate but minimal information while trying to focus mainly on their current work capacity," said Yellowlees.
He also suggested that physicians who are uncertain about how to respond to mental health questions consider obtaining advice from lawyers accustomed to working with the relevant medical boards.
Christine Lehmann, MA, is a senior editor and writer for Medscape Business of Medicine based in the D.C. area. She has been published in WebMD News, Psychiatric News, and The Washington Post. Contact Christine at email@example.com or via Twitter @writing_health.
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Cite this: Mental Health Questions Cut From MD Licensing Applications in 21 States - Medscape - Jul 10, 2023.