In an essay last year in the New York Times, Aaron E. Carroll, MD, wrote about his depression during residency and his reluctance to acknowledge it, even after peers and loved ones told him he needed help.
Why the hesitancy? Dr. Carroll asserts that the problem with physician depression is made worse by “a profession in which admitting a problem carries a stigma that can have more impact than in others.”
In fact, a recent survey of 2,100 female physicians on a closed Facebook group found that almost 50% of the respondents believed they had met the criteria for mental illness at some point in their careers but had not sought treatment. Two-thirds reported that fear of stigma drove them to keep their worries quiet. The 2016 report on the survey concluded that “licensing questions, particularly those asking about a diagnosis or treatment rather than functional impairment, may contribute to treatment reluctance.”
Empowering physicians to seek care
“The question is, ‘How do we get across to doctors that you’re human?’ ” said Humayun J. Chaudhry, DO, president of the Federation of State Medical Boards (FSMB). “It’s perfectly OK to have an issue in your life, and it’s also OK to seek care. We are exploring ways in which state boards may be helpful toward this goal.”
State medical boards play a crucial role in breaking the culture of silence around physician depression.
“Physicians experiencing depression or any mental health challenge do not feel their confidentiality would be protected if they were honest about what they are experiencing,” wrote Arthur Hengerer, MD, past chair of the FSMB, in a perspective piece for the National Academy of Medicine. In the essay, Dr. Hengerer goes on to wonder whether licensing requirements are actually causing physicians to hide their own burnout.
This is a question Dr. Hengerer and others hope to explore as part of an FSMB wellness and burnout work group that is looking at the licensure application process and asking how best to handle questions about mental health. Their findings will be reported in April 2018.
Mental health questioning
The passage of the Americans with Disabilities Act (ADA) in 1990 prohibited employers from asking broad questions about illnesses when people apply for jobs. But most state medical licensing boards—which must balance their roles of protecting the public from physicians too physically or mentally impaired to practice medicine with the physician’s right to privacy—still ask specific questions about mental health.
The broadness of licensure questions on mental illness directly corresponds to physicians’ willingness to seek treatment, a new study in Mayo Clinic Proceedings has found.
“Physicians who worked in states where the medical license application questions were overly broad (for example, asked about current or past diagnosis or treatment of a mental health problem) were 20% more likely to be reluctant to seek care for a mental health problem,” wrote lead researcher Liselotte Dyrbye, MD, in an email to The DO. “This is due to concerns that doing so could affect their license to practice.”
Two-thirds of U.S. states ask the broader form of the question, the study’s researchers discovered.
Rather than asking physicians if they have ever been diagnosed with a mental health condition, the study authors suggest questions should ask if doctors are currently suffering from any condition—mental or physical—that keeps them from doing their job.
A call for change
“With data clearly demonstrating the problem … it is now time to address the manner in which physician mental health is queried on hospital privileging and medical licensing forms,” wrote Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention, in a publication of the Federation of State Physician Health Programs. “Hospitals and medical boards are encouraged to put the focus on competence and impairment rather than illness and treatment, as outlined in the ADA.”
A number of licensing boards are beginning to heed this call for change, Dr. Chaudhry notes.
“Some states are offering ‘safe haven’ to doctors, which translates to no reporting of mental illness on licensure applications,” he says. “That’s one example of something that other state boards might want to consider.”
A kinder, gentler approach
In North Carolina, for example, the annual license renewal process no longer asks physicians to disclose whether they are in treatment for any medical condition that might limit or impair their ability to practice safely. Instead, it now offers an advisory statement of its expectation that licensees address personal health conditions, including mental health issues, without disclosing details.
Doctors with depression are not required to report their condition to the medical board, says Thomas Mansfield, chief legal officer of the North Carolina Medical Board.
“There is an obligation for physicians to take care of themselves. We want to get the message out to physicians that if they need help, they should get it. Changing the wording on the annual license renewal to this advisory message was part of the process,” he says.
Dr. Dyrbye, who on top of leading the Mayo Clinic study, also directs its Department of Medicine Physician Well-Being Program, agrees.
“There is a high prevalence of psychological distress among physicians, and often their mood disorders go untreated, contributing to the higher prevalence of suicide among physicians than other U.S. workers,” Dr. Dyrbye says. “To reduce barriers to care and help physicians receive care for treatable mental health problems, medical license application questions in many states need to change.”
North Carolina’s medical board is working toward reducing those barriers to seeking help.
“By being willing to be self-reflective and question existing processes,” says Mansfield, “we are always looking to improve and have common-sense regulation.”
Read on for more about barriers to physicians seeking mental health care and the dangers of depression: