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Do US Medical Licensing Applications Treat Mental and Physical Illness Equivalently?

Katherine J. Gold, MD, MSW, MS; Elizabeth R. Shih, MD; Edward B. Goldman, JD; Thomas L. Schwenk, MD

Background and Objectives: State medical licensing boards are responsible for evaluating physician impairment. Given the stigma generated by mental health issues among physicians and in the medical training culture, we were interested in whether states asked about mental and physical health conditions differently and whether questions focused on current impairment.

Methods: Two authors reviewed physician medical licensing applications for US physicians seeking first-time licensing in 2013 in the 50 states and the District of Columbia. Questions about physical and mental health, as well as substance abuse, were identified and coded as to whether or not they asked about diagnosis and/or treatment or limited the questions to conditions causing physician impairment.

Results: Forty-three (84%) states asked questions about mental health conditions, 43 (84%) about physical health conditions, and 47 (92%) about substance use. States were more likely to ask for history of treatment and prior hospitalization for mental health and substance use, compared with physical health disorders. Among states asking about mental health, just 23 (53%) limited all questions to disorders causing functional impairment and just
6 (14%) limited to current problems.

Conclusions: While most state medical licensing boards ask about mental health conditions or treatment, only half limited queries to disorders causing impairment. Differences in how state licensing boards assess mental health raise important ethical and legal questions about assessing physician ability to practice and may discourage treatment for physicians who might otherwise benefit from appropriate care.

(Fam Med. 2017;49(6):464-7.)

Like all individuals, physicians may experience physical or mental illnesses over the course of their professional career. These illnesses may or may not impact how well a physician is able to function in their duties and patient care. The American Medical Association defines physician impairment as “when failing physical or mental health reaches the point of interfering with a physician’s ability to engage safely in professional activities.”1 Impairment is typically overseen by state medical boards responsible for licensing medical professionals in training and practice.

Physicians with mental health issues are often reticent to seek external treatment.2 With high levels of burnout and depression among students, residents, and practicing physicians along with increased risk of physician suicide compared to the general population, it is worrisome that many physicians avoid the same help and treatments which they routinely advise to patients.3-6

Prior research has examined compliance of state licensing applications with the 1990 Americans with Disabilities Act (ADA).7 Three prior studies (last using data from 2006–7) evaluating mental health or substance abuse questions, reported concern that licensure questions were overbroad, leading physicians to avoid mental health treatment.8-10 We queried how medical licensing applications had changed over time and if mental health and physical health were treated equitably.

 

Methods

 
 

We evaluated “new applicant” licensing forms for the allopathic medical boards of all 50 states and the District of Columbia in 2013 (henceforce referred to as “states”) to match the samples from prior studies by Sansone (1999) and Schroeder (2009).9, 10 We obtained applications online from state web sites, the centralized web site for the Universal Application (Federation of State Medical Boards), or by requests to individual states. The project was deemed “not regulated” as human subject research by the University of Michigan Institutional Review Board. We extracted questions on mental health, substance use, and physical health, focusing on diagnosis, treatment, impairment, and reporting timeframe. We recorded questions asking whether an applicant currently or ever had the problem and whether some, all, or none of the questions were limited to disorders causing impairment.

Two authors (ERS and KJG) independently abstracted data and compared coding. If there was disagreement, they re-evaluated the application and reached resolution through discussion and consensus decision-making. Data are provided as summary statistics. To compare proportions of questions asked for different topics (e.g. treatment for mental health versus physical health), we used the Exact McNemar’s test. We used Stata/IC 13.1 (College Station, TX) with p<0.05 as level of significance.

 

Results

 
 

 

Of 51 applications, 43 (84%) asked questions about mental health, 47 (92%) substance use, and 43 (84%) physical health; differences were not statistically significant (Table 1). However, states were significantly more likely to ask about past or current treatment for mental health or substance abuse vs. physical health disorders (28 vs. 16, P=0.0005 and 33 vs. 16, P=0.0002). Hospitalization for mental health problems was queried more often than for physical problems (10 vs. 4, P=0.031). There was a nonsignificant trend in asking about hospitalization for substance use vs. physical problems (6 vs. 4, P=0.625).

table1

Many states asked about prior conditions or treatment (Table 2). Overall 35% of states inquired whether applicants ever had a mental health disorder compared to 23% for a physical health problem (P=0.063). For substance abuse disorder, 28% of states ask questions versus 23% asking about physical health problems (P=0.453). Fewer states restricted all questions to current problems or treatment for mental health or substance abuse compared with physical health conditions (6 vs. 15, P=0.004 and 8 vs. 15, P=.039).

table2

Bipolar disorder and schizophrenia (nine states), psychosis (eight states), and paranoia (seven states) were the most common disorders assessed. One state inquired about delusional disorder and personality disorder while another included depressive neurosis, hypomania, dissociative disorder, kleptomania, pyromania, delirium, and seasonal affective disorder. Queries about these specific diagnoses were not limited to whether or not such diagnoses had caused impairment. One asked about lifetime hospitalization for any mental health condition (but not physical health or substance abuse conditions). Of states assessing mental illness, just 23 (53%) limited all questions to conditions or symptoms causing impaired functioning, versus 9 of 47 (19%) states asking about substance abuse and 35 of 43 (81%) states asking about physical health.

 

Discussion

 
 

There are substantial variations in how state medical boards assess mental health, physical health, and substance abuse with mental health being evaluated with more scrutiny than physical health with less focus on function or impairment. Our findings lead to important questions about the ethics of requiring disclosure of conditions which are not current or are stable with treatment and well-controlled. Compared with previous studies, particularly the most recent data from Polfiet (2008), we found surprisingly little change in the number of states asking about mental health diagnoses, those limiting questions to current illness, those asking about treatment, hospitalization, specific mental health diagnoses, or sexual behaviors.8, 10 While prior review of 2006 applications noted that eight states limited mental health questions to both the current time period and functional impairment, we identified just six states meeting both criteria in 2013.8

Mental illness includes a heterogeneous set of diagnoses, which may vary by severity among different patients and vary over time in any single individual.11 Prior history does not necessarily predict current functioning or risk.12 For example, although depression may cause significant distress for the suffering physician, the diagnosis does not implicitly pose risk to patient care.13, 14 Many depressed physicians report that, despite higher professional stress and lower work productivity and satisfaction, they work harder to combat their illness.2

Despite efforts to integrate medical and behavioral health in primary care, mental health diagnoses among physicians still carry enormous stigma, causing significant barriers to treatment.15-17 Many physicians use self-prescription of antidepressants, benzodiazepines, and other psychotropic medications.18-20 Physicians may seek informal (“off-the-books”) treatment from a colleague or pay cash for visits.2, 21

Despite these concerns, it is unknown if these broad, time-unlimited medical board questions protect patient safety.7, 14, 22 Questions not focused on current impairment violate an applicant’s right to privacy and the ADA which was noted in a recent ruling by the US Department of Justice for a state bar application.10, 23 We are concerned by the continued widespread use of similar questions in our analysis.10, 14, 24, 25 In a recent study, we showed that just 6% of surveyed physicians who acknowledged a history of a mental health diagnosis or treatment reported that they disclosed this to a state medical board.26

Our study is limited by its cross-sectional nature. State applications may have changed since our analysis as our applications were obtained in 2013. We do not have access to how individual physicians respond to these questions nor how different licensing boards manage physician responses and decisions about practice.

The majority of states continue to ask physicians applying for a medical license about a wide range of mental illness diagnoses, treatment, and hospitalizations. Mental health receives far greater scrutiny than physical health in many states, particularly regarding past history that may no longer be relevant to current function. This approach may well discourage physicians from seeking appropriate, and often effective, treatment that would, in fact, enhance their professional function, and additional research should evaluate the impact of these questions on help-seeking and protection of patient safety.

Acknowledgements: The authors are immensely grateful to Ms Katie Grode for her support in preparation of this manuscript.

No direct financial support was provided for this research. Part of Dr Gold’s salary was covered by a K23 grant from the National Institute of Mental Health. NIMH had no role in the design, analysis, interpretation, or publication of this study.

No author has any conflicts of interest to declare.

Previous Presentation: Some data from this manuscript was presented at the Joint Professional Development Conference of the American Association of Medical Colleges: CFAS/CDI/ORR. Salt Lake City, UT. March 5, 2016.

 

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From Department of Family Medicine, University of Michigan (Drs Gold and Shih); Department of Obstetrics & Gynecology, University of Michigan Law School, University of Michigan (Dr Goldman); University of Michigan Depression Center (Dr Gold); Institute for Healthcare Policy and Innovation, University of Michigan (Drs Gold and Goldman); Division of Health Sciences, University of Nevada School of Medicine
(Dr Schwenk)


Copyright 2018 by Society of Teachers of Family Medicine