Physician burnout is rampant, and every seat was taken at a workshop on physician burnout and depression at this year’s APA annual meeting in San Diego.
In his book, “Why Physicians Die By Suicide” (Amazon, 2017), Michael F. Myers, MD, describes “burnout.”
“It is a state of emotional exhaustion, depersonalization (a lack of feeling for others), and a diminished sense of personal accomplishment. Put another way, doctors who are burned out complain that they are used up emotionally and have nothing left to give their patients, medical colleagues, and staff. They are running on empty. They have become numb and feel detached from the symptoms and the suffering of their patients.”
Myers notes that there is no stigma to having burnout, as there is to having major depression – a condition that may have remarkably similar symptoms.
What stops physicians from getting help? It’s a complex question – especially in a group that has the means to access medical services – but one factor is that most state licensing boards specifically ask about mental illnesses and substance abuse in intrusive and stigmatizing ways. States vary both with their questions and with their responses to a box checked “yes.”
Katherine Gold, MD, MSW, MS, a family physician at the University of Michigan, Ann Arbor, has studied the topic extensively. Her review of licensing questions from all 50 states revealed that most states ask for information about mental health, and there is tremendous variation as to what is asked ( Fam Med. 2017 Jun;49[6]:464-7 ).
“Some states are very specific and very intrusive,” Gold noted. “They may ask if a physician has a specific diagnosis, a history of treatment or hospitalization. The questions may ask about current impairment, or they may ask about mental health conditions back to age 18 years. There may be very specific questions about diagnosis that are not asked about medical conditions, such as whether the applicant has kleptomania, pyromania, or seasonal affective disorder.”
Gold conducted an online survey of physician-mothers. Nearly half believed they had met criteria for an episode of mental illness at some point during their lives. Of those who did have a diagnosis, only 6% of physicians reported this on licensing forms, though she was quick to say that not all states ask for this information, and some may just ask about current impairment. “The people who are self-disclosing are probably not the physicians we need to be worrying about,” she said.
There is no research that supports the idea that asking physicians about mental illness improves patient safety. Not every state licensing board asks about psychiatric history, but many do ask these questions in a way that violates the Americans with Disabilities Act ( Acad Med. 2009;84[6]:776-81 ). This is not a new issue: In 1993, The State Medical Society of New Jersey filed an injunction against the New Jersey medical board ( Medical Society vs. Jacobs et al .) and questions asked on the licensing forms were changed.
Dr. Gold noted that if a physician checks yes to a question about a mental health history, the board response also varies. The doctor can be asked to provide a letter from his physician stating he is fit to work, or can be required to release all of his psychiatric record, or even to appear before the board to justify his fitness to practice.
Chae Kwak, LCSW-C, is the director of the Maryland Physician Health Program for Maryland MedChi. In the fall 2016 Board of Physicians newsletter, Kwak wrote , “An applicant has to affirmatively answer this question only if a current condition affects their ability to practice medicine. Diagnosis and/or treatment of mental health issues such as depression or anxiety is not the same as ‘impairment’ in the practice of medicine.”
Kwak was pleased that the board published his letter. “We want physicians to get the help they need. But this is not just about licensing boards, it’s an issue with hospital credentialing and applications for malpractice insurance as well.”
“We need to advocate on the level of the Federation of State Medical Boards on this subject, and there is a sense of increasing awareness that this is a problem, said Richard Summers, MD, who cochaired the American Psychiatric Association workshop on physician burnout and depression. “The increased salience and awareness of physician burnout, and its relationship to stigma might help this organization and the various state boards become more sympathetic and open to questioning the stigmatizing element of their questions. So, we’ve got to work on this situation both nationally and at the level of the state boards. Hopefully, some successes will stimulate others and will begin to help to change the culture of secrecy and shame.”
Nathaniel Morris, MD, is doing his psychiatry residency at Stanford (Calif.) University. He wrote about this issue in a Washington Post article, “Why doctors are leery about seeking mental health care for themselves” (Jan. 7, 2017). Morris wrote, “When I was a medical student, I suffered an episode of depression and refused to seek treatment for weeks. My fears about licensing applications were a major reason I kept quiet. I didn’t want a mark on my record. I didn’t want to check “yes” on those forms.”
Questions about mental health on licensing board applications were recently addressed by the American Medical Association’s House of Delegates meeting as part of Resolution 301 . The AMA concluded with a suggestion that state medical boards inquire about mental health and physical health in a similar way and went on to suggest that boards not request psychotherapy records if the psychotherapy were a requirement of training. This is a profoundly disappointing and inadequate response from the AMA, and my hope is that the APA will move ahead with both words and actions that condemn stigmatizing inquiries.
Questions that differentiate other medical disabilities from psychiatric disabilities need to be stricken from licensing and credentialing forms. Our treatments work, and the cost of not getting care can be catastrophic for both physicians and for their patients. Why ask intrusive and detailed questions about mental illness or substance abuse, and not about diabetes control, seizures, hypotension, atrial fibrillation, or any illness that may cause impairment? It would seem enough to simply ask if the applicant suffers from any condition that impairs ability to function as a physician. Furthermore, it is unreasonable to ask for a full release of psychiatric records following an affirmative statement if detailed records of other illnesses are not required to confirm competency to practice and may prevent psychiatrists from being honest with their therapists. Self-report has limited value on applications, and questions about past sanctions, employment history, and criminal records are more likely to identify physicians who are impaired for any reason.
Dr. Miller, who practices in Baltimore, is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).
