A recent article in The Journal of the American Osteopathic Association (JAOA) shines a light on many state physician licensing boards’ noncompliance with the American Disabilities Act (ADA) regarding mental health, as well as some compliance discrepancies between osteopathic and allopathic licensing.
Mayo Clinic Proceedings published a study in 2017 examining the impact that medical licensure questions about mental health histories have on physician reluctance to seek care, but Beth Wagner, DO, a family physician in Vermont, noticed that it only reported on allopathic licensing boards and didn’t examine their osteopathic equivalents (in states where there are separate boards).
Physician mental health has always been a topic of great interest to Dr. Wagner and her friend Katherine Lincoln, DO, another family physician in Pennsylvania. So the two of them set out to evaluate the compliance of state osteopathic medical licensing boards with ADA requirements.
Both the AOA and the Federation of State Medical Boards have policies urging boards not to ask applicants about their mental health history and instead focus on current impairments. But Drs. Wagner and Lincoln found that boards in 14 states were “grossly out of compliance.”
In this edited Q&A, Drs. Lincoln and Wagner (who were also featured in the JAOA’s Behind the Research podcast) discuss their experience reviewing licensing applications in all 50 states and Washington, D.C., why ADA compliance matters and the barriers that can prevent physicians from seeking mental health treatment.
Other than the Mayo Clinic study, what inspired you to start working on this article?
Dr. Wagner: “I did my residency in Alaska, and I remember filling out the forms for licensure there and being surprised by the questioning on mental health history. It asked if you’ve ever had any disorder, ranging from schizophrenia to seasonal affective disorder, which everyone in Alaska has.
“Even in residency, we talked about being afraid to go get our mental health issues treated, because we knew that there were these invasive questions on licensing applications.”
Dr. Lincoln: “Dr. Wagner and I heard from more than a few physicians, ‘if I go seek the mental health help that I need, I’m afraid if I start therapy or any sort of medication, I’m going to have to report that to my state board.’ Many physicians are the primary source of income in their families, so by not seeking help because they’re worried that their license will be somehow compromised, they don’t, and are then certainly at increased risk of burnout and suicide.
“It’s our job to look out for those behind us. We’re really thankful to be healthy and well so we can defend those brothers and sisters of ours who may not be able to do that for themselves.”
What are some examples of noncompliant questions on licensure applications that you found in your research?
Dr. Wagner: “The Federation of State Medical Boards (FSMB) recommends asking about the last two years in people’s histories, but beyond that, anything that says ‘in the last ten years,’ or ‘have you ever had any mental illness?’ or anything that doesn’t ask about any current impairments would be considered ADA noncompliant.
“Some places even ask if you’ve ever been hospitalized for mental illness. And that could include instances that were 20 years ago. One state’s osteopathic licensing board wanted you to give your list of medications, the pharmacy where you got them, who prescribed the medication, and what it was for. Then you have to sign a medical release form to authorize that they can get any of your medical records. It can be really probing.”
Did you expect to see differences in the licensing applications for allopathic and osteopathic physicians?
Dr. Lincoln: “We’re so far beyond the classification of DOs as being ‘others’ or ‘different,’ that we were pretty surprised to see some states ask more probing questions of osteopathic physicians seeking licensure. We definitely wanted to draw attention to that.
“I’m so thankful to be in this giant body of graduates who have come up in an era when everyone knows who DOs are, and knows what our backgrounds in medical education and patient care are like. So it’s not an issue generally when I’m practicing, but these old disparities appear still in these licensing applications.”
What message do you believe these noncompliant questions send to physicians?
Dr. Wagner: “If you’ve ever had any sort of mental or physical illness, or any hospitalization, particularly with physicians, there’s a stigma. We’re not supposed to get sick. We’re supposed to be the ones who are healthy, and treat everybody else before we treat ourselves.
“When we have these questions that feel almost punitive, then you might not want to answer it correctly, or you might not want to get treated, because it creates a record that someone could find. That’s one of the problems, that language and stigmatization go together. It’s a roadblock that keeps people from getting the treatment that they need.”
Dr. Lincoln: “The more knowledge we gain about mental health, we realize treating it is a disease process just like high blood pressure and diabetes. We would never be fearful to go to the doctor for a diabetes diagnosis, so oftentimes if our physician colleagues do get the care and treatment they need, it helps them be better doctors and community members.”
What can physicians do to raise awareness of these discrepancies and advocate for change?
Dr. Lincoln: “If you live in a state that has different licensing for DOs, advocate for transparency. But also advocate for making those questions ADA-compliant. As a starting point, we should all be part of our osteopathic medical association in our state. We have to be unified. Isolated letters from doctors aren’t as powerful as collective action.”
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This personal account won an AM&P Excel award last year for best editorial/opinion piece in a magazine.