Mental Health

ADA-noncompliant state licensing boards are a barrier to mental health treatment for physicians, DOs write

Many state osteopathic medical licensing boards do not comply with ADA requirements regarding mental health, according to recent research in The JAOA.

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.”

Related reading:

ACEP Now: Emergency physician with depression chronicles her 10-year fight to keep her license
This personal account won an AM&P Excel award last year for best editorial/opinion piece in a magazine.

Fearing license issues, depressed doctors don’t get help

My victory over burnout: How leading a sustainable life changed everything for me

7 comments

  1. As someone who struggled with depression during residency, I sought out the help that I would encourage any of my patients to seek. I saw a therapist and take medication. I was never a danger to anyone and in fact am much better for it. In doing so, however, I accepted that there were states in which I would never practice due to the prejudice of the boards. But in a profession with a shockingly high suicide rate, it is absolutely unconscionable that a job licensing board can flagrantly violate our civil rights in this way. And because we’re physicians, we’re expected to tolerate that abuse as part and parcel with practicing medicine. It is well past time to name and shame state medical boards into respecting the rights of physicians.

  2. Behavioral health is a broad field that includes mental health for organic and nonorganic disorders as well as substance use disorders and sobriety. I am concerned with any ADA-inappropriate questions that might deter physicians and other health professionals from seeking their own care for fear of discovery or reprisal. As a DO physiatrist who cares for people with physical, mental and substance use recovery and resilience, my career has extended from clinical practice to serve pro bono for 12 years on my state’s Doctors Diversion Panel before becoming president of the Utah Osteopathic Medical Association. Leading up to the establishment of an osteopathic medical school in Utah, UOMA worked at the Governor’s directive to help revise legislative language to accord parity to MD and DO colleagues in practice and training. Actions to protect individuals applying for licensure are essential when the inquiry infringes on privacy and requires nonessential or compromising information.
    Given the obvious or hidden stresses that every undergraduate and graduate doctor encounters in the course of study, training, career and life, it is only reasonable to anticipate and offer supportive services rather than penalize osteopathic physicians and colleagues. Our compassion for patients should be at least equal to what we give ourselves.

  3. Great article, thanks for posting, I really appreciate Dr Lincoln and Dr Wagner’s insight on this topic. I hope to share some insights on the issue as I treat several physicians and medical professionals as patients and have come across this issue a number of times. Fortunately, the state I live in and am licensed does not ask mental health questions on applications. Some of my medical professional patients have moved or gotten additional licenses in other states that do ask them these types of questions and the best piece of advice I give to them is to lie on the application. I don’t mean to sound controversial or pessimistic, but in my experience the cost of being honest is too high and then benefit none. Protecting a medical/professional license of upmost importance, and we know that the programs that physicians are often enrolled into when they answer honestly are not evidence based, are often punitive, not even run by physicians, and are often treated homogenously despite the underling medical condition. For example, someone with alcohol use disorder and multiple DUI’s can be treated in the same program/ protocol as a physician with underlying depression that is well controlled. Lying on a medical license application is not generally a good idea, but in this line of questioning I think it the best option for those in mental health treatment. I do not see how a medical board could prove you are lying. (part 1 of 2)

  4. Sure, if something terrible happened and the legal system mandated a subpoena of records then you are out of luck, but I imagine in this situation there are far more problems than this. Otherwise no medical board can obtain medical records without your consent or a subpoena. I have been in mental health treatment for years on and off and I would never check the “yes” box on any of these application question and would not think twice or feel bad about it. There should be no barriers for anyone, physician or not, from obtaining evidence based mental health treatment. Just my 2 cents. (part 2 of 2)

  5. Thank you for the article and comments. The punitive and shaming nature of probing mental health a treatment inquiries are invasive and of a paradigm that does not allow for fluidity of healing, adaptations to stress and contribute, in fact to stress. I am with you, I would never check yes on any box. It was in medical school that my depression was ignited and persists as I continue to work in a broken system. Praise to counseling, medication and resiliency. May we support one another during sick and sickening times.

  6. I appreciate this article and the awareness it creates. I’m currently chairing our state’s medical association’s Committee on Physician Wellness. Our state only recently changed the licensing question for our physician (MD & DO) applications. I was not aware that historical questions were not ADA compliant. I believe we should institute policies starting in medical school, extending into residency, and eventually into practice in which physicians are required to participate in mental health wellness programs. The questions should be changed to read, “Why haven’t you been seen and evaluated by a mental health professional?”

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