THE PANDEMIC LAID WASTE to many things, including clinician wellbeing. Once a closeted subject that could jeopardize their jobs and licenses, physicians’ need for mental health resources during the pandemic became a clear and national crisis.
So much so that, in 2022, Congress passed the Dr. Lorna Breen Health Care Provider Protection Act, mandating federal grants to promote mental health programs for clinicians. Tragically, the law was named for an emergency physician in New York City who took her own life during the pandemic’s first months.
But a lack of funds is only one barrier to clinicians getting help. For years, questions about any history of mental health diagnoses or treatments on state licensing and hospital credentialing applications stopped doctors from seeking treatment. While physician advocates have for years called for removing such questions, advocacy efforts have accelerated since the pandemic—and are now making some progress.
“A lot of physicians either lied on applications or didn’t get care.”
Richard Wardrop III, MD, PhD
That’s according to hospitalist Richard Wardrop III, MD, PhD, program director, vice chair and staff physician at Cleveland Clinic. Dr. Wardrop is also a member of the Help Health Care Heal Coalition, an Institute for Healthcare Improvement (IHI) collaborative dedicated to removing obstacles that stop physicians from seeking mental health care.
“It ends up being almost a cognitive bias”—that doctors, or anyone for that matter, who seek out mental health care are professionally impaired—”and it isn’t borne out in data,” Dr. Wardrop explains. “Doctors, hospitals and state medical boards are data-driven and willing to look at evidence, and that’s why we’ve begun making inroads.”
Defining best practice
Dr. Wardrop’s own career has been a window into how far medicine has come in normalizing mental health needs.
While training in the mid-2000s, he realized that colleagues suffering from even garden-variety depression and anxiety “didn’t have any outlet to talk about it,” he says. “I found out later that colleagues on antidepressants or anxiety medications would huddle together, afraid they wouldn’t be promoted or even graduate. A lot of physicians either lied on applications or didn’t get care.”
Dr. Wardrop also believes that “we probably have a non-self-care mechanism in most of our practice patterns where ‘I don’t have time for that because I have all these patients.’ We needed to become more willing to admit we had problems.”
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Research found that doctors have higher rates of depression and suicide than the general population and that intrusive questions on licensing and credentialing applications discouraged those who needed help from seeking it. Studies also indicated that it was burnout—not mental health diagnoses or treatment—that adversely affects patient safety.
And in the 2010s, courts (as well as the Justice Department) began ruling that licensing or credentialing questions about mental health diagnoses violated applicants’ rights under the Americans with Disabilities Act.
Those factors led the Federation of State Medical Boards (FSMB) in 2018 to issue 10 recommendations to further physician wellness including that licensure questions should focus only on a physician’s current impairment. Advocates including the IHI’s Help Health Care Heal Coalition have been working ever since to align state licensing and hospital credentialing applications with those FSMB recommendations, which are now considered best practice.
A long way to go
With active licenses in four states, Dr. Wardrop sees how far some licensing applications have evolved.
“There is now much softer language than even five years ago,” he points out. “Now, that section of the application says something to the effect that, ‘We recognize that physicians have mental health and/or substance misuse issues. Physician health programs are a resource. Check this box if you read and understand this statement.’ The language now focuses much less on past problems and instead on getting help for any current impairment.”
But there is still a long way to go. In 2020, researchers looked at initial state licensing applications to see how well those reflected FSMB recommendations. According to results published in JAMA in 2021, “in most states, recommendations from the FSMB have not yet been fully adopted. Consequently, medical license applications may continue to deter physicians from seeking mental health care.”
State specialty chapters, as well as state medical societies and academic institutions, are pushing to change licensing application language.
But getting state boards to change “is very complex,” Dr. Wardrop cautions. Does a state have the physician health programs it needs to handle behavioral and substance use issues, for instance? Does the board have the support of that state’s legislature to remove care-access barriers for clinicians, and what is the state culture? “It’s a long process for a lot of states.”
Importantly, the pandemic—which ushered in interstate licensing and a dramatic increase in telehealth— helped push state boards toward a more regional approach.
“It’s become clear that there is a benefit to aligning the treatment of mental health issues across states,” he says.
Working with hospitals
While advocates have made some progress among state boards, “changing questions on hospital credentialing is the next level,” Dr. Wardrop points out. As with state boards, working with hospitals on credentialing applications can’t be “calling them out or accusatory. Instead, you have to give them the data and base any requests for changes on evidence and best practice”—and expect change to be a drawn-out process.
At Cleveland Clinic, “we have one of the best employee assistance programs I’ve ever seen. It’s very nuanced, and it completely destigmatizes accessing mental health care.” But other hospitals may struggle to provide any mental health resources.
“If you change your credentialing without an employee assistance program, you’ve just created a problem for yourself within your health care system,” he points out. “Or you may not have the expertise you need in the C-suite to change those questions legally.” In its toolkit of online resources, the IHI’s Help Health Care Heal coalition has talking points for advocating for application changes as well as a sample e-mail to send to a privileging or credentialing office.
Dr. Wardrop also notes that the members of ACP’s Virginia chapter are now writing every hospital in their state, requesting changes on credentialing applications. Other state chapters are following suit. Because hospitalists play such key roles in their institutions, hospitalists leading such requests “can have an enormous impact,” he says.
At the same time, Dr. Wardrop adds, “there is still a cultural stigma to mental health and to past substance misuse, which is applied to doctors and other health care professionals. That somehow means you are damaged and you can never be good.” While advocates continue to work to reduce that stigma, “we can certainly remove these obstacles to treatment. Otherwise, people won’t seek help.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the July/August 2023 issue of Today’s Hospitalist.