Remove stigma from licensure, credentialing applications

Many physicians will struggle with their mental health at some point in their career, but few will seek care.

To help remove one barrier to access, physician advocates across the country are working to revise intrusive mental health questions on medical licensing and credentialing applications, one state at a time.

"We know that [health care workers] have unique occupational hazards that increase the risk for trauma that can lead to increased risk for mental health disorders," said Kristin Jacob, MD, FACP, medical director for the office of physician and advanced practice provider fulfillment at Corewell Health West in Michigan. "But at the same time, despite those high risks and this high-risk natured profession, these clinicians … have lower rates of seeking help for mental health disorders, and that's due to a number of unique barriers."

One of these barriers is the fear of losing their medical license. Licensing and credentialing applications often include vague questions about applicants' mental health diagnoses and treatment history, such as whether an applicant has ever received treatment for a mental health condition that could impair their ability to practice medicine.

This language can deter people from seeking care, according to research. In a survey of over 9,100 physicians carried out last year and published by Medscape, 41% said they have not sought help for burnout or depression because they are afraid the medical board or their employer will find out. A similar proportion have not sought care because they worry "people will think less of my professional abilities."

While some applicants are afraid to answer truthfully about their mental health history for fear of being considered unfit to work, others who need help do not seek it to avoid lying on the applications. These probing questions also create a perception, albeit unintentional, that the institutions doing the asking "negatively perceive supporting your mental health," said Dr. Jacob.

Perpetuating stigma

The questions were originally included on the applications to identify physicians unable to safely practice medicine, said Eladio Pereira, MD, MACP, a general internal medicine physician who practices in Arizona. The problem is, "over the years, there has been no data to show that those questions are effective and there is no data that they protect the public," he said.

These questions don't help distinguish between who provides good versus bad care, and they are, to some extent, performative, added Eileen D. Barrett, MD, MPH, MACP, a hospitalist and Immediate Past Chair of ACP's Board of Regents. "People less commonly have diagnoses that affect their ability to provide safe, ethical, competent, professional care," she said, but the questions as usually written do not identify those individuals and can put applicants in a position where they feel as if they have to lie. Dr. Barrett, who began researching this topic around 2017, noted that the questions appeared on licensure applications as early as the mid-1990s.

Notably, a cross-sectional study of attending and postgraduate trainee physicians surveyed from November 2018 to February 2019, published in JAMA Network Open in December 2020, showed that among physicians, depression is not associated with medical errors, though burnout is.

Applicants who do report a diagnosis or past treatment may be subject to subsequent unnecessary medical history reviews, experts say. And although these can be carried out appropriately, "at times, they're not, and people's lives have really, really been upended" as a result, Dr. Barrett said.

The notion of self-sacrifice is often instilled in medical students throughout their training and can persist as they begin their careers, explained Dr. Jacob.

"We are trained in an environment that honors this, and the idea of reaching out for help can make us feel like we might be failing; it might be perceived that it's a weakness," she said. That pressure, coupled with an expectation of perfectionism, can make it hard to "admit that something's wrong, and that you need to be the one cared for."

Overly broad questions on mental health perpetuate stigma and make it even harder to take the first step of seeking care, Dr. Jacob stressed.

Progress made

"The reality [is] that at some point, all of us will feel overwhelmed and we may need help," said Dr. Pereira, who presented on reducing barriers to physicians receiving mental health care at last month's Internal Medicine Meeting 2024, with Richard Wardrop III, MD, PhD, FACP, and Ankita Sagar, MD, MPH, FACP. Getting that help will not only reduce medical errors but will help keep physicians in the field and prevent suicide, he said.

With these goals in mind, several states have updated the language on their licensing applications or removed questions on mental health altogether. In 2018, the Federation of State Medical Boards (FSMB) issued a report on physician wellness and burnout that listed recommendations for updating application language. These included considering whether it is necessary to include probing questions about a physician's mental health at all, and if doing so to solely ask about conditions that result in impairment, asking questions pertaining only to the last two years, and including supportive language on seeking mental health care. They also include listing a safe-haven nonreporting option that allows physicians who are monitored by and in good standing with state Physician Health Program recommendations to apply for their license or renewal without having to disclose their diagnosis or treatment to the board. However, the FSMB notes this option should only be offered "when treatment received is commensurate with the illness being treated and has a reasonable chance of avoiding any resultant impairment."

By October 2023, 26 states had audited and changed intrusive language in licensure applications, and 11 were in the process of doing so, according to data collected by the Dr. Lorna Breen Heroes' Foundation. The foundation identified these states as those that either asked a single question consistent with the FSMB's recommended language addressing mental and physical health conditions as one, refrained from asking probing questions about an applicant's health altogether, or implemented a model that uses supportive mental health language and offers safe-haven nonreporting options for physicians.

The foundation is named after an emergency medicine physician who died by suicide in 2020. In the weeks prior to her death, Dr. Breen expressed fear of being stripped of her medical license should she seek out mental health care.

Dr. Breen's death helped bring the issue of intrusive licensing questions to the forefront during the pandemic, said Dr. Barrett. In May 2020, The Joint Commission issued a statement strongly encouraging organizations to not ask physicians about their history of mental health conditions or treatment and noted that inquiries should instead be limited "to conditions that currently impair the clinicians' ability to perform their job."

"Even in the last three years, we have seen this rapid acceleration" in change, Dr. Barrett said.

Several other organizations have taken up the cause. The American College of Physicians offers an advocacy toolkit on modernizing application language, while the American Medical Association has pushed for officials to eliminate or reword intrusive questions. The Dr. Lorna Breen Heroes' Foundation also developed the Wellbeing First Champion Challenge, where organizations can verify that their applications have been changed and are awarded a badge to publicly recognize their efforts.

Whether updating the application language goes far enough to achieve the goal of ensuring patients' safety without needlessly deterring physicians from receiving care remains to be seen. Some places that were early adopters of asking about current impairment instead of diagnoses "are still seeing physicians deterred from seeking care and still not identifying the small numbers of physicians who are problematic for patient safety or professionalism," Dr. Barrett said. "So, more work should be done."

Next steps

States that have not updated their language may be unaware of the questions' impact on applicants, experts say. Medical boards might also be too busy dealing with other demands, like managing an influx of new license applications following changing telehealth rules, addressing the consequences of misinformation, or handling situations where physicians do have impairing conditions that need to be addressed, said Dr. Barrett.

But the questions don't appear only on state licensing applications, and more work is needed at the hospital and health care system levels, since these types of questions are asked there as well, experts note.

"Some states are creating coalitions where everyone is opting into this [effort to change language] and doing it as one. I know here in Michigan, it's been a little bit more piecemeal, that hospital system by hospital system it's been changing," said Dr. Jacob.

Intrusive mental health questions can be found on credentialing applications for health plans and commercial insurance too, along with malpractice insurance, added Dr. Pereira. However, even if questions are adjusted or removed, there has to be a culture of wellness in place to support physicians and make the change worth it, he stressed.

"Each institution must verbalize and create the systems to support that language ... If that culture of wellness, of well-being, to support the doctor doesn't exist, then these items will not work," he said.

Workplace interventions could include flexible schedules so physicians can access mental health care during the workday. Institutions could waive mental health co-pays or institute opt-out mental health check-ins. This has the added benefit of the institution signaling they support students and physicians receiving mental health care, Dr. Barrett said.

"We also have an opportunity to add, any place that we have an application, a statement supporting physicians receiving mental health care" and highlighting available mental health services, she added.

Something as simple as checking in with a colleague can help, too. If, for instance, a colleague's behavior has changed—maybe they're arriving late to work or expressing cynicism—asking if they'd like to talk or if there's anything you can help them with can really save someone's life, Dr. Pereira noted.

"Those connections are critical," he said. "We, colleagues, should have a responsibility with each other to be aware that mental illness is all around us."