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Eliminate Mental Health Questions on Applications for Medical Licensure

      The 2010s saw “an unusual number of public calls to change privacy rules to permit or require greater disclosure of individuals’ mental health information. . . . Typically, safety concerns are invoked.”
      • Mathis J
      Mental health privacy: do inquiring minds really need to know?.
      Though some states have removed bar and medical licensure application questions requiring disclosure of applicants’ mental health information,
      • Jones JTR
      • North CS
      • Vogel-Scibilia S
      • et al.
      Medical licensure questions about mental illness and compliance with the Americans with Disabilities Act.
      ,
      • Jaffe D
      • Stearns J
      Conduct yourselves accordingly: amending bar character and fitness questions to promote lawyer well-being.
      “the majority [of state medical boards continue to] ask questions that are unlikely to meet [Americans with Disabilities Act (ADA)] standards.”
      • Jones JTR
      • North CS
      • Vogel-Scibilia S
      • et al.
      Medical licensure questions about mental illness and compliance with the Americans with Disabilities Act.
      Recently amended questions still unfairly single out applicants with physical or mental health illness or conditions without appropriate justification, and they should be removed from applications for medical licensure. One such recently amended question, from New Mexico's application, was approvingly decribed by Barrett et al in the Annals of Internal Medicine, and reads as follows:
      Do you have or have you been diagnosed with an illness or condition which impairs your judgment or affects your ongoing ability to practice medicine in a competent, ethical and professional manner?
      • Barrett E
      • Lawrence E
      • Waldman D
      • Brislen H
      Improving how state medical boards ask physicians about mental health diagnoses: a case study from New Mexico.

      Why State Medical Boards Should Remove Mental Health Questions on Licensure Applications

      All but a handful of states continue to ask medical licensure applicants mental health questions, and the overwhelming majority also use terminology similar to New Mexico's (ie, impair or impairment and affect).
      • Jones JTR
      • North CS
      • Vogel-Scibilia S
      • et al.
      Medical licensure questions about mental illness and compliance with the Americans with Disabilities Act.
      These questions should be removed from licensure applications because the presence of these illnesses and conditions does not predict clinical competence. They are especially likely to result in unwarranted disciplinary scrutiny and exclusion of these physicians in the context of misunderstanding within the medical community about mental disorders, the meaning of terms such as impair or affect, and the appropriate application of important ADA rules that protect all physician-employees from unwarranted mental health inquiries.

      Lack of Connection Between Mental Disorders and Clinical Competence

      There is no appropriate justification for these questions because there is no evidence that experts or medical board examiners can predict inappropriate professional behavior on the basis of a person's physical or mental health. Study after study, in fact, indicates the opposite. One recent analysis of 280 cases of serious ethical violations in medicine from 2008 to 2016, found serious mental illness such as major depression, bipolar, or schizophrenia in only 1% of cases, and only 5.4% involved a wrongdoer with a suspected substance use disorder.
      • DuBois JM
      • Anderson EE
      • Chibnall JT
      • et al.
      Serious ethical violations in medicine: a statistical and ethical analysis of 280 cases in the United States from 2008-2016.
      A 2005 study
      • Khaliq AA
      • Dimassi H
      • Huang CY
      • et al.
      Disciplinary action against physicians: who is likely to get disciplined?.
      found “[o]nly 3.8% of 371 cases involved substance abuse,” and a 2001 study of psychiatrists found “drug or alcohol impairment” in 69 of 584 (12%) of medical board violators and “mental or physical impairment” in 29 of 584 (5.0%) of violators.
      • Morrison J
      • Morrison T
      Psychiatrists disciplined by a state medical board.
      Past performance, and not health conditions or disabilities, are the most reliable predictors of future behavior.
      • Mathis J
      Mental health privacy: do inquiring minds really need to know?.

      Misunderstanding About Mental Disorders and Definitional Terms

      Questions such as New Mexico's are especially likely to subject licensure applicants with these conditions to burdensome supplemental investigations because of poor understanding on the part of state medical boards
      • Hendin H
      • Reynolds C
      • Fox D
      • et al.
      Licensing and physician mental health: problems and possibilities.
      and physicians in general
      • Agaronnik ND
      • Pendo E
      • Campbell EG
      • et al.
      Knowledge of practicing physicians about their legal obligations when caring for patients with disability.
      about mental disorders, relevant terms, and ADA rules. Members of the medical community are frequently told that mental disorders are reliable predictors of clinical incompetence, ethical violations, medical errors, and poor patient care. Some physicians may assume that terms like impair or impairment refer to the dictionary definition of “being in a less than perfect or whole condition.”
      Merriam-Webster's Collegiate Dictionary.
      Yet while all physicians are imperfect, not all are impaired (incompetent or unprofessional) physicians. Some may confuse the word impairment with the way it is used in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      in which it forms part of the definition of many mental disorders. Yet almost all physicians with a DSM-5 mental disorder have impairments in the DSM-5 sense, although very few are impaired physicians. Another point of confusion is that impairment is a legal term of art under the ADA that simply refers to the presence of a disability. By definition, all persons with disabilities have impairments, but this does not mean that all physicians with disabilities are impaired physicians. Similar problems exist with the word affect, which has the dictionary definition of “influence.”
      Merriam-Webster's Collegiate Dictionary.
      Some physicians may have mental disorders that affect or influence their performance but simply make an already exceptional physician just a little less exceptional.

      The Problem of Institutional Policies

      Application questions such as New Mexico's also leave determinations as to whether an illness or condition “impairs” a physician to state medical boards, employers, and institutions, many of which have greatly expanded their policies on mental health inquiries and referrals of physician-employees. “In order to demonstrate concern and provide evidence of intervention, some residency programs require all trainees be evaluated by psychology and psychiatry services.”
      • Balon R
      • Morreale MK
      The madness of mandated wellness.
      In 2017, the Accreditation Council for Graduate Medical Education (ACGME) defined resident “well-being”

      Accreditation Council for Graduate Medical Education's (ACGME). Common program requirements. Available at:https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. Accessed April 29, 2020.

      (ie, wellness or health) as a component of resident competence in its Common Program Requirements. Yet “[f]raming wellness as a competency may perpetuate stigma against learners with disabilities . . . by labelling them as ‘not competent,’”

      Stergiopoulos E, Hodges B, Martimianakis MA. Should wellness be a core competency for physicians?[e-pub ahead of print]. Acad Med. doi: 10.1097/ACM.000000000000328. Accessed June 1, 2020.

      with “profound implications for evaluation and licensure.” These requirements also “encourage residents and faculty members to alert the program director or other designated personnel or programs when they are concerned that another resident, fellow, or faculty member may be displaying signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence.”

      Accreditation Council for Graduate Medical Education's (ACGME). Common program requirements. Available at:https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. Accessed April 29, 2020.

      They advise that “personnel and the program director should be familiar with the institution's impaired physician policy and any employee health, employee assistance, and/or wellness programs within the institution”

      Accreditation Council for Graduate Medical Education's (ACGME). Common program requirements. Available at:https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. Accessed April 29, 2020.

      and not the ADA. And they advise that “[i]n cases of physician impairment, the program director or designated personnel should follow the policies of their institution for reporting.”

      Accreditation Council for Graduate Medical Education's (ACGME). Common program requirements. Available at:https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. Accessed April 29, 2020.

      By leaving so much discretion to institutions to define physician “impairment,” state medical boards effectively defer to these problematic institutional policies that ignore the ADA's rules.

      Future Directions and Recommendations

      State medical boards should remove mental health questions on applications for medical licensure. These questions will not improve patient safety or protect future patients because the presence of a physical or mental health illness, condition, or disability is not a predictor of incompetence or unethical physician behavior. Accordingly, these questions single out licensure applicants with these conditions and disabilities without appropriate justification. Especially in the context of misunderstanding within the medical community about mental disorders and appropriate legal protections under the ADA, these questions will likely result in inappropriate disciplinary scrutiny and exclusion of these physicians from the profession. State medical boards should get rid of these mental health questions on licensure applications altogether.

      References

        • Mathis J
        Mental health privacy: do inquiring minds really need to know?.
        Human Rights. 2014; 41: 10-13
        • Jones JTR
        • North CS
        • Vogel-Scibilia S
        • et al.
        Medical licensure questions about mental illness and compliance with the Americans with Disabilities Act.
        J Am Acad Psychiatry Law. 2018; 46: 458-471
        • Jaffe D
        • Stearns J
        Conduct yourselves accordingly: amending bar character and fitness questions to promote lawyer well-being.
        Professional Lawyer. 2020; 26 (Available at:)
        • Barrett E
        • Lawrence E
        • Waldman D
        • Brislen H
        Improving how state medical boards ask physicians about mental health diagnoses: a case study from New Mexico.
        Ann Intern Med. 2020; 172: 617-618
        • DuBois JM
        • Anderson EE
        • Chibnall JT
        • et al.
        Serious ethical violations in medicine: a statistical and ethical analysis of 280 cases in the United States from 2008-2016.
        Am J Bioeth. 2019; 19: 16-34
        • Khaliq AA
        • Dimassi H
        • Huang CY
        • et al.
        Disciplinary action against physicians: who is likely to get disciplined?.
        Am J Med. 2005; 118: 773-777
        • Morrison J
        • Morrison T
        Psychiatrists disciplined by a state medical board.
        Am J Psychiatry. 2001; 158: 474-478
        • Hendin H
        • Reynolds C
        • Fox D
        • et al.
        Licensing and physician mental health: problems and possibilities.
        J Med Licensure Discipline. 2007; 93: 6-11
        • Agaronnik ND
        • Pendo E
        • Campbell EG
        • et al.
        Knowledge of practicing physicians about their legal obligations when caring for patients with disability.
        Health Aff (Millwood). 2019; 38: 545-553
      1. Merriam-Webster's Collegiate Dictionary.
        11th ed. Merriam-Webster Inc, 2003 (Available at:)
        https://merriam-webster.com
        Date accessed: April 29, 2020
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders.
        5th ed. American Psychiatric Association, Washington, DC2013
        • Balon R
        • Morreale MK
        The madness of mandated wellness.
        Ann Clin Psychiatry. 2019; 31: 81-82
      2. Accreditation Council for Graduate Medical Education's (ACGME). Common program requirements. Available at:https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2019.pdf. Accessed April 29, 2020.

      3. Stergiopoulos E, Hodges B, Martimianakis MA. Should wellness be a core competency for physicians?[e-pub ahead of print]. Acad Med. doi: 10.1097/ACM.000000000000328. Accessed June 1, 2020.