On July 1, 2020, I started my career as a newly minted, internal medicine resident amid the ongoing global COVID-19 pandemic and international crisis. None of us could have anticipated the challenges to come. Weeks went by where I would lose a patient every day to COVID complications. I spent hours on the phone updating family members who could not visit their loved ones. Our medical teams went days reusing the personal protective equipment we needed to stay safe.
Having just graduated from medical school, the bags under my eyes and tension in my neck were stressors to which my body had become accustomed. What shocked me were the nightmares and flashbacks: sudden fits of tearfulness or palpitations, and dreams and images of desaturating patients or patients coding.
Amid the pandemic, I realized that the personal narratives of human experience I sought in pursuing medicine — and even my own narratives — were marked by sorrow, pain, and suffering. It was in the midst of such suffering that I took my oath to serve for the good of humanity to the utmost of my capabilities. While physician workplace burnout has been a rising topic of concern for years, in the setting of the recent and ongoing coronavirus pandemic, health care worker mental health has developed into a growing crisis.
Now in my second year of residency, I have seen the rippling effects of the pandemic from the perspective of a treating psychiatrist. Through treating health care workers, I learned that my experience with COVID-19 was not unique. Studies have shown that health care workers have experienced extreme levels of anxiety, depression, and posttraumatic stress symptoms over the past 2 years, throughout the pandemic.
In a comprehensive 2021 survey, more than 40% of physicians reported workplace burnout, 70% of whom reported symptoms that seriously affect their lives — both within and outside the workplace setting.1 More than 50% of surveyed health care workers met the threshold for a clinically significant mental health disorder, including posttraumatic stress disorder, generalized anxiety disorder, and depression.2 This is a staggering number, given that mental illness in the general public throughout the pandemic was found to be around 20%.3 Shockingly, 14% of physicians surveyed reported suicidal thoughts or actions.1 Again, this number is staggering as compared to a range of 4% to 8% of suicidal thoughts within the general public.4
Extensive studies of physician wellness in 2021 and 2022 consistently showed that the majority of physicians surveyed did not seek professional treatment for mental health and reported fear of disclosure as a primary reason for withholding treatment.1.5 A comprehensive 2019 study found that nearly 70% of physicians reporting workplace burnout identified fear of reporting mental health treatment to licensure renewals as a barrier to care.6
Health care workers’ fear of disclosure regarding mental health is a reality born from the systems in which we work. It may seem surprising that mental health stigma continues to be seen within health care. A major consequence of mental health bias in medicine remains that the majority of state medical licensure applications require physicians to disclose information regarding their current or history of mental illness and / or mental health treatment. Professional organizations have an obligation to protect the public from physicians who may be impaired by any medical condition that would impact their ability to treat patients.
Professor of law, James TR Jones, JD, identifies the duty for public safety may seem to conflict with the Americans with Disability Act (ADA), which protects individuals from discrimination based on disabilities including psychiatric and medical illness.7 Jones goes on to identify that under ADA guidelines, specific questions regarding a physician’s current fitness or impairment to complete clinical responsibilities are appropriate, while vague or nonspecific questions about mental health history, hospitalizations, treatment, or diagnoses without specific questions regarding fitness are often illegal under ADA precedence.
It is demonstrated that questions regarding health care worker mental health on medical licensing applications are based not in best practice or public safety, but in mental health stigma. Nevertheless, in 2018, 32 licensing bodies were found to have questions regarding physician mental health that could be found to be illegal under ADA.7 In a 2021 study, 41 state licensing boards continued to ask questions regarding current mental health conditions, with 39 states asking specific questions regarding physician impairment and only 8 states using supportive language regarding mental health.8
The increasing burden of physician wellness has not gone unnoticed by the public or the government. In response to multiple health care worker deaths by suicide since the start of the pandemic, the Biden Administration has recently signed into law the Dr. Lorna Breen Health Care Provider Protection Act.9 The bill seeks to develop and disseminate policies that improve mental and behavioral health of health care providers, remove barriers to accessing mental health treatment, and identify resiliency strategies.
An obvious and immediate remedy to remove barriers to accessing mental health treatment is to end the practice of illegal and unjust questions regarding mental health and mental health treatment in medical licensure applications. Years of evidence suggests that such questions are not only intrusive and unlawful, but maintain a dangerous culture in which health care providers are in fear of losing their medical license if and when they seek treatment.
Recommendations for ways medical licensure can ask about mental health while promoting a culture of health care worker wellness and maintain legal precedence under ADA exist. The Federation of State Medical Boards (FSMB), an organization that oversees and advises individual state medical boards, published recommendations in 2018 for licensing applications as it relates to health care worker wellness and burnout.10
As an immediate action of the Dr. Lorna Breen Act, all medical licensure organizations should be expected and required to uphold the FSMB recommendations for any and all questions regarding mental health. Procedures to regulate state licensure questions should be swiftly implemented to ensure all medical licensure organizations are promoting health care worker wellness and a culture of safe treatment for mental health. Furthermore, due to overwhelming fear among health care workers regarding seeking treatment for mental health and ramifications for their medical license, implemented regulations should be widely publicized.
With an ongoing mental health crisis growing among health care workers, the time is imminent to implement changes to medical licensure questions regarding mental health. Health care workers should never have to feel like they must choose between the profession to which they have devoted their lives and their mental well-being. It is time we make the steps to dispel stigma against mental illness within health care and support health care providers by making necessary reforms to medical licensure questions. The recommendations of best practice are available — it is imminent regulation and implementation that is needed.
Dr Athanasios is a psychiatry resident at Jersey Shore University Medical Center.
1. Kane L. 2021 physician burnout & suicide report. Medscape. January 22, 2021. Accessed April 4, 2022. https://www.medscape.com/slideshow/2021-lifestyle-burnout-6013456
2. Greene T, Harju-Seppänen J, Adeniji M, et al. Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19. Eur J Psychotraumatol. 2021; 12 (1): 1882781.
3. de Sousa GM, Tavares VDO, de Meiroz Grilo MLP, et al. Mental health in COVID-19 pandemic: a meta-review of prevalence meta-analyzes. Front Psychol. 2021; 12: 703838.
4. Ivey-Stephenson AZ, Crosby AE, Hoenig JM, et al. Suicidal thoughts and behaviors among adults aged ≥18 years – United States, 2015-2019. MMWR Surveill Summ. 2022; 71 (1): 1-19.
5. Yasgur BS. A tragedy of the profession: Medscape physician suicide report 2022. Medscape. March 4, 2022. Accessed April 4, 2022. https://www.medscape.com/slideshow/2022-physician-suicide-report-6014970
6. Arnhart K, Privitera MR, Fish E, et al. Physician burnout and barriers to care on professional applications. J Leg Med. 2019; 39 (3): 235-246.
7. 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 (4): 458-471.
8. Saddawi-Konefka D, Brown A, Eisenhart I, et al. Consistency between state medical license applications and recommendations regarding physician mental health. JAMA. 2021; 325 (19): 2017-2018.
9. United States, 117th Congress. Dr. Lorna Breen Health Care Provider Protection Act, HR1667. March 18, 2022.
10. Physician wellness and burnout. Federation of State Medical Boards. 2018. Accessed April 4, 2022. https://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf