Nathaniel P Morris: US medical licensing applications ask too much about mental health

Asking about applicants’ mental health history risks driving physicians and trainees away from self care and deeper into distress

The mental health of US physicians has garnered increasing attention in recent years. Research suggests that nearly 30% of resident physicians and medical students suffer from depressive symptoms. Several studies have found greater than 10% of trainees have had suicidal thoughts in their last year. Suicide, burnout, and substance abuse among doctors has attracted national media coverage.

Despite public alarm about their mental wellbeing, physicians—like many Americans—are often reluctant to disclose mental illness or seek care for themselves. Some of this may stem from embedded cultural norms in medicine—a field in which resiliency is championed and the needs of patients are often put before those of providers. Other factors, like the challenges of navigating busy schedules and finding mental health providers outside their own professional circles, may also play a part.

But questions about mental health on medical licensing applications have been identified as a key factor in physicians’ hesitancy to get care for themselves. Surveyed physicians point to the fear of having to disclose mental illness on licensing applications and possible professional sanctions as reasons for avoiding care. And among doctors who do seek mental healthcare few are willing to disclose this fact: a 2016 survey found that only 6% of female physicians with prior mental health diagnoses or treatment had disclosed this history to a state medical board.

As a way of encouraging physicians to take care of themselves, organizations including the American Foundation for Suicide Prevention and the American Medical Association have recommended reforming these licensing questions; in particular, many in the medical community have called on state medical boards to limit questions about mental health to functional impairments, as opposed to asking about any history of mental health problems. Studies from the 1990s and 2000s reported that most state medical boards asked licensing questions about mental health and often asked about prior treatment.

A new study published in June 2017 suggests that little has changed over the past two decades—84% of state medical licensing applications from 2013 asked questions about mental health histories, and just half limited these questions to functional impairment. The authors compared these findings with questions about other medical issues and concluded that “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.”

These findings have profound implications for physicians and medical trainees. As a physician who has been open about my own experience with depression during medical school, I can say that I delayed seeking mental healthcare in part because of concerns about medical licensing applications. I worried that I would have to disclose treatment, and I double checked the language of licensing applications in states where I thought I might end up training. After seeking treatment, I repeatedly questioned my decision to do so because I feared that I might suffer professional ramifications down the road.

If I had been grappling with asthma or diabetes, I doubt I would have felt the same way.

State medical boards cite a duty to protect the public from impaired physicians as reasons for these questions. Yet licensing bodies haven’t produced evidence to support broad mental health screenings, especially when these questions are often more invasive than those about other medical ailments.

To protect patients, medical licensing boards should focus on functional impairments in physicians. Asking about any history of mental health problems is misguided: further stigmatizing mental illness, but also driving physicians and trainees away from self care and deeper into distress. It’s a disservice to the practitioners of medicine and to those who receive our care.

Nathaniel P Morris is a resident physician in psychiatry at the Stanford University School of Medicine.

Competing interests: None declared.