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To determine whether state medical licensure application questions (MLAQs) about mental health are related to physicians' reluctance to seek help for a mental health condition because of concerns about repercussions to their medical licensure.
In 2016, we collected initial and renewal medical licensure application forms from 50 states and the District of Columbia. We coded MLAQs related to physicians' mental health as “consistent” if they inquired only about current impairment from a mental health condition or did not ask about mental health conditions. We obtained data on care-seeking attitudes for a mental health problem from a nationally representative convenience sample of 5829 physicians who completed a survey between August 28, 2014, and October 6, 2014. Analyses explored relationships between state of employment, MLAQs, and physicians' reluctance to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure.
We obtained initial licensure applications from 51 of 51 (100%) and renewal applications from 48 of 51 (94.1%) medical licensing boards. Only one-third of states currently have MLAQs about mental health on their initial and renewal application forms that are considered consistent. Nearly 40% of physicians (2325 of 5829) reported that they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure. Physicians working in a state in which neither the initial nor the renewal application was consistent were more likely to be reluctant to seek help (odds ratio, 1.21; 95% CI, 1.07-1.37; P=.002 vs both applications consistent).
Our findings support that MLAQs regarding mental health conditions present a barrier to physicians seeking help.
The prevalence of psychological distress among physicians is high.1,2 Unfortunately, their mood disorders often go untreated,1,3,4 contributing to a higher prevalence of suicide among physicians in comparison to other US workers.1,5 A third to half of physicians do not have a personal physician or regular source of health care,6-8 and physicians are less likely to have seen their personal physician in the past year than other US adults.9 Information regarding physicians' use of mental health services is limited, although data suggest that physicians frequently self-treat for depression and avoid seeking care for mental health conditions because of concerns that a mental health condition may affect their license to practice.1,3,4 For example, in a 2008 national study of 7905 US surgeons, 6.3% reported suicidal ideation during the previous 12 months.4 Among those with recent suicidal ideation, 26% had sought care, 16% had self-prescribed their antidepressant, and 60% reported that they were reluctant to seek care because of concerns that doing so could affect their licensure to practice.4
Many state licensing boards ask questions about mental health diagnoses or treatment. The fact that licensing boards inquire about these dimensions is believed to be a major deterrent to help seeking among troubled physicians, many of whom have treatable disorders.1,3,10-12 Such a concern is reasonable because a study published in 2007 found that greater than one-third of state licensure board executive directors reported that a diagnosis of mental illness was itself sufficient to sanction physicians.13 In addition, there are reports of disclosure of mental health conditions resulting in overt and covert discrimination (eg, restrictions on clinical practice, mandatory clinical proctoring, and mandatory psychiatric evaluation for the purpose of determining competence).1,3,10,13-15 There is also a real possibility of public disclosure of physicians' personal health information.1,14,16
State medical licensure boards serve to protect the public through licensure, surveillance, misconduct investigations, and disciplinary actions.17 The Federation of State Medical Boards advises that medical licensure boards not ask physicians about history of mental illness18 and indicates that doing so could violate the Americans with Disabilities Act of 1990.19,20 The American Psychiatric Association has also specifically stated that impairment and potential risk of harm to patients cannot be inferred from a diagnosis or treatment alone.10,21 Indeed, many have called for medical licensure applications to include only questions about current functional impairment of professional performance1,19,21-25 and for decisions regarding licensure to be based solely on professional performance.22,26 In response, some state licensing boards have modified their questions in regard to mental health14; however, many may remain in violation of the Americans with Disabilities Act,19,21 and the prevalence of licensure questions about physicians' history of mental illness appears to be increasing.20
It remains unknown whether physicians who are licensed by medical boards that inquire about current or past diagnosis or treatment of a mental health condition are more reluctant to seek care for a mental health concern than those who are licensed by medical boards that inquire only about current impairment. In this study, we evaluated the relationship between state medical licensure application questions about mental health and whether physicians endorse reluctance to seek help for a mental health condition because of concerns about repercussions to their medical licensure.In this national study of nearly all (94.1%) medical licensure board applications, only one-third of states (16 of 48 [33.3%]) had questions on their initial and renewal application forms that were congruent with the American Medical Association,25 American Psychiatric Association,21 and Federation of State Medical Boards18 polices and recommendations or in clear compliance with the Americans with Disabilities Act of 1990.19,20 Nearly 40% of physicians reported they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure, and physicians working in a state in which neither the initial nor the renewal application was consistent were more likely to be reluctant to seek help.
Large population studies have found attitudes toward mental health help-seeking are associated with actual mental health care service use.28,29 If, as observed in large previous national studies,4 6% of the more than 800,000 US physicians have experienced suicidal thoughts in the past 12 months and 40% of those with such suicidal ideation do not seek care because of concerns that it may have repercussions for their medical licensure, this would imply that licensure concerns may be a factor in 20,000 US physicians not receiving the professional help they need for mental health concerns.
Because the lack of seeking professional help is thought to contribute to the elevated risk of suicide among physicians in comparison to the general US population,1 barriers to help-seeking should be removed when identified. In this regard, it is notable that physicians who worked in states with medical licensure questions consistent with national recommendations18,19,21,25 were less likely to report that they would be reluctant to seek formal medical care for treatment of a mental health conditions because of concerns about repercussions to their medical licensure than physicians who worked in states not classified as consistent. This relationship between the way state medical licensure boards inquired about mental health conditions was independently related to whether the physicians in that state reported a reluctance to seek mental health care after adjusting for sex, age, relationship status, practice settings, and specialty. Physicians working in states in which neither the initial nor the renewal application was consistent had a 21% increase in the odds of reluctance to seek help for a mental health concern. Even physicians working in states/territories in which only the initial licensure application was not consistent had a 22% increase in the odds of reluctance to seek help for a mental health concern independent of age. This observation suggests that the questions on the initial licensure application may leave a lasting impression on physicians.
The finding that male and younger physicians were more reluctant to seek help is consistent with findings from studies of the general US population reporting that younger individuals and men are disproportionately deterred by stigma about mental illness, which is associated with reduced help-seeking.28 The observation that physicians in private practice had 25% to 50% greater odds of being reluctant to seek help for a mental health concern on multi-variate analysis warrants further study but may be due to greater concern over public disclosure resulting in current or future patients judging them negatively28 and choosing to go elsewhere for care.
Our study has several limitations. First, some medical licensure applications may have asked different questions about mental health in 2014 (the year the cohort of physicians were surveyed) than at the time we collected licensure questions in 2016. Second, although analysis of early responders vs later responders (a standard approach to response bias) suggests that the sample was representative with respect to age, sex, and specialty, it is possible that the sample may not be representative with respect to attitudes about seeking care for mental health conditions. The rate of reluctance to seek formal medical care because of concerns about repercussions to medical licensure in our study, however, was similar to what has been previously reported in the literature.4,30
Our study has several important strengths. First, we were able to obtain the initial and renewal licensure application forms from all but 3 states. Second, the designation of medical licensure application question category (both consistent, initial consistent, renewal consistent, or neither consistent) was determined independent of the data on physicians' self-reported attitudes about whether concerns for licensure impacted whether they would seek help for mental health conditions. Third, 2 investigators independently coded each medical licensure application question pertaining to mental health using an evidence-based approach.18,19,21,25
The results of this study suggest that the way in which medical licensure questions regarding mental health conditions are asked may impact whether physicians are reluctant to seek help for a mental health condition. Physicians working in states in which medical licensure application questions inquire broadly about current or past diagnosis or treatment of a mental health condition, past impairment from a mental health condition, or presence of a mental health condition that could affect competency were 21% to 22% more likely to be reluctant to seek help. In contrast, physicians who worked in states in which questions on medical licensure applications asked only about current impairment from a mental health condition or included no question pertaining to mental health were less likely to endorse such reluctance and thus may be more likely to seek and receive care if the need arose.28,29 These findings support continued efforts to develop regulations and policies that encourage physicians to seek help, as suggested by others.1,19 They also support universal use of consistent licensure questions across the US states. In this regard, the American Psychiatric Association has already developed and recommended the following language for state licensing boards to use on licensure applications: “Are you currently suffering from any condition that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical and professional manner? (Yes/No).”21 Such a question encourages physicians to consider any physical or mental health issue that could impair their performance and helps to destigmatize mental illness. In addition, it also enables state medical boards and their members to protect the public while being consistent with the Americans with Disabilities Act of 1990. Although there are concerns that the very nature of some illnesses could impede physicians' abilities to recognize their own limitations, a history of a medical or psychiatric disorder has little predictive value for present impairment of functioning, and there is no evidence that the risk to patients is sufficiently great to require disclosure of private medical records for public scrutiny.