Reducing Mental Health Care Barriers for Hospitalists

Clinical vignette 

MB is a 36-year-old woman who completed her residency three years ago. She has practiced as a hospitalist at a community hospital since that time. Throughout her time in medical school and residency, MB often experienced periods of depressed mood, insomnia, and lack of energy. She was able to access resources for therapy through her medical school, however, she was never given a formal diagnosis of a mood disorder. Now, she feels that her symptoms have returned and continue to worsen. In addition to her depressed mood, she has lost interest in activities she previously enjoyed and has had difficulty focusing while working on the inpatient general medicine service. She has become increasingly concerned that her symptoms will contribute to her making a serious medical error. She feels guilty because of this and has been experiencing passive suicidal ideation for the first time in her life. When she considers reaching out for mental health support, she remembers that her hospital credentialing and state medical licensure applications both ask questions about mental health disorders. She also remembers reading about other physicians experiencing costly legal battles and harmful ramifications from mental health disclosures. For these reasons, she is hesitant to speak with colleagues or access the care she needs. 

Discussion

While the above vignette is fictional, it highlights an all-too-common problem that occurs among our friends and colleagues. It has been shown that physicians are more susceptible to and have higher rates of depression than non-physicians.¹ This applies to medical trainees as well, with 15% to 30% higher rates of depression in medical students and residents compared to the general population.² Unfortunately, this trend is also reflected in rates of physician suicide. Combined studies have shown that the suicide rate of male physicians is 40% higher than in the general population.¹ Staggeringly, the rate of female physicians completing suicide is 130% higher than in the general population.¹ The increasing rate of burnout also highlights the importance of mental health for physicians. A recent survey of 2,440 U.S. physicians revealed that 62.8% of physicians had some manifestation of burnout, which was an increase of almost 20% when compared to four years prior.³

When it comes to medical licensing, physician mental health is a topic that is often asked about on applications. State medical boards have licensing authority over physicians in each state and act to protect public safety by ensuring that physicians can safely practice health care. The questions included on the physician-license applications vary from state to state. A recent audit revealed that 33 states included questions about mental health conditions on their physician-license applications.⁴ The questions tended to be time-specific, but this was also variable, ranging from current to no time limit. If physicians responded “yes” to inquiries about mental health, they were often requested to provide written explanations, the contact information of treating psychiatrists, or access to personal medical records.⁴  

Given the information above, it is unsurprising that physicians are hesitant to get the care they need for mental health conditions. A survey of more than 7,000 U.S. surgeons revealed that 60% were reluctant to seek care for mental health issues due to fears that it would affect their medical licensure.5 Furthermore, an association has been shown between questions on the medical-license application and physicians’ willingness to seek care. In states where questions about mental health were not consistent with the recommendations of the American Psychiatric Association and the Federation of State Medical Boards (FSMB), physicians were significantly more reluctant to seek medical care for a mental health condition.⁶ 

Further advancing this discussion is that, in a recent study, depression was not tied to medical errors, but burnout was, raising additional questions about why questions about mental health are being asked so often.⁷ Perhaps in part due to this, several professional medical organizations have given recommendations on how to approach questions about mental health on medical-license applications. The American Psychiatric Association released a position statement on the matter in 2018 where it concluded that “General screening inquiries about past diagnosis and treatment of mental health disorders are overbroad and discriminatory and should be avoided altogether.”⁸ Instead, it recommends that questions should focus only on conditions that currently impair a physician’s capacity to practice medicine.⁸ The FSMB also released a report in 2018 where it made a similar recommendation that questions focus only on current impairment “which may be more meaningful in the context of a physician’s ability to provide safe care to patients in the immediate future.”⁹ SHM published an open letter in support of the FSMB recommendations in 2020, citing the increased urgency to address concerns for physician mental health in light of the COVID-19 pandemic.¹⁰ Similarly, the Joint Commission strongly encourages organizations not to ask about the history of mental conditions or treatment and supports the removal of any barriers to mental health care access for physicians.¹¹ It’s therefore reasonable to extend these recommendations to credentialing applications as further recommendations and studies emerge.

Conclusions and our ‘ask’ of hospitalists

As we turn our focus back to our clinical vignette, what efforts can we take to help MB and clinicians like her feel more comfortable accessing the mental health resources they likely need? We can reassure her that medical boards have drastically changed their approach to physicians seeking mental health care. One meaningful change would be for all state medical boards and hospital credentialing committees to heed existing recommendations and have questions on current impairment rather than on mental health. How these questions are worded has been shown to have a significant impact on physicians’ openness to seeking mental health care. Instead, questions should be framed in a non-punitive manner and include language that supports those who are receiving mental health care.¹² Hospital medicine groups can request their credentialing committees remove such questions from applications and replace them with language that doesn’t deter help-seeking. Individual hospitalists can also share mental health resources, such as employee assistance programs, within their groups. Additional support and resources for generating change can be found through the Institute for Healthcare Improvement and specifically the Help Health Care Heal Coalition.¹³ 

Moving forward, hospitalists are uniquely positioned on the frontline of health care and quality improvement to advocate for positive changes. Through education, policy making, and organizational advocacy, hospitalists can help increase access to mental health for physicians. These efforts will benefit not only physicians currently practicing, but also future generations of physicians to come. 

Dr. Gaskill

Dr. Wardrop

Dr. Allen-Dicker

Dr. Barrett

Dr. Gaskill is a resident at the Cleveland Clinic Foundation in Cleveland. Dr. Wardrop is a program director, vice chair, and staff physician at the Cleveland Clinic Foundation in Cleveland. Dr. Allen-Dicker is an associate attending at Memorial Sloan Kettering Cancer Center in New York. Dr. Barrett is a faculty member of the Institute for Healthcare Improvement, where they’re working to remove mental health questions from medical license and credentialing applications.

References

1. Schernhammer E. Taking their own lives—the high rate of physician suicide. N Engl J Med. 2005;352:2473-6.
2. Center C, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289(23):3161-6.
3. Shanafelt TD, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. 2022;97(12):2248-58.
4. Saddawi-Konefka D, et al. Consistency between state medical license applications and recommendations regarding physician mental health. JAMA. 2021;325(19):2017–8.
5. Shanafelt TD, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.
6. Dyrbye LN, et al. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017;92(10):1486-93.
7. Menon NK, et al. Association of physician burnout with suicidal ideation and medical errors. JAMA Netw Open. 2020;3(12):e2028780. doi:10.1001/jamanetworkopen.2020.28780.
8. Bonnie RB, et al. American Psychiatric Association position statement on inquiries about diagnosis and treatment of mental disorders in connection with professional credentialing and licensing. American Psychiatric Association. https://www.psychiatry.org/getattachment/e8c96a1e-3858-496d-920b-503290bb3561/Position-2018-Inquiries-about-Diagnosis-and-Treatment-of-Mental-Disorders-in-Connection-with-Professional-Credentialing-and-Licensing.pdf . Published 2018. Accessed February 5, 2023.
9. Hengerer AS, et al. Physician Wellness and Burnout. Federation of State Medical Boards. https://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf. Published April 2018. Accessed April 14, 2023.
10. Scheurer D. Letter to the Federation of State Medical Boards regarding mental health disclosures and state licensure. Society of Hospital Medicine. https://www.hospitalmedicine.org/policy–advocacy/letters/Mental-Health-Disclosures Published August 10, 2020. Accessed February 5, 2023.
11. The Joint Commission. Statement on removing barriers to mental health care for clinicians and health care staff. The Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/covid19/statement-on-removing-barriers-to-mental-health-care-for-clinicians-and-health-care-staff.pdf . Published May 12, 2020. Accessed February 5, 2023.
12. Loehrer S, et al. The connection between credentialing and physician mental health: a call to action. Modern Healthcare. https://www.modernhealthcare.com/opinion-editorial/connection-between-credentialing-and-physician-mental-health-call-action. Published January 12, 2022. Accessed February 5, 2023.
13. IHI Leadership Alliance Help Health Care Heal Coalition. Institute for Healthcare Improvement. https://www.ihi.org/Engage/collaboratives/LeadershipAlliance/Pages/Help-Health-Care-Heal-Coalition.aspx. Published 2022. Accessed February 5, 2023.