Dear Pamela,
Question for you in regards to disclosure about mental illness. In every job that I have applied for, as part of the credentialing process, there are questions about felonies, treatment for drug/alcohol abuse and mental illness. Why are mental health questions still allowed to be on there? I have had postpartum anxiety/depression three times now and I feel like it is none of their damn business. So I have lied about it on my applications. Also, I feel like these question could contribute to doctors not seeking help, especially for problems that could require a mental health hospitalization. I would be so interested if there were a survey out there or a study looking at whether these questions have an adverse effect on doctors and medical students presenting (or not) for care they may desperately need. If somebody answers that question as a no, but lies, are these places able to access medical records to find out if somebody is truthful? How much weight does that question even have? Do we as docs worry too much about mental health questions unnecessarily?
Sincerely,
Concerned Physician
Dear Concerned Physician,
Mental health questions on job applications are more than just an invasion of privacy. These questions are against the law. According to the Americans with Disabilities Act—a law enacted by the U.S. Congress in 1990—employers are prevented from discrimination based on mental or physical health. It’s illegal to ask applicants disability-related questions. Furthermore, accommodations must be provided for employees with medical conditions. Case closed.
Yet on physician insurance credentialing, state board licensing, and employment applications, mental health questions persist. In addition, these personal health questions are grouped with questions on criminality (such as felonies and DUIs) which would suggest that a doctor who seeks mental health support is committing a crime, further stigmatizing those who need support—not punishment.
Why are there no questions about diabetes, stroke, or other physical conditions that could potentially impair a physician’s ability to care for patients? Why is the singular focus on mental health? And why are these questions allowed to be on there at all when they are against the law? Medical boards exist to protect the public. Employment applications protect the needs of employers. Insurance credentialing applications protect the needs of insurance companies. So who’s protecting doctors? Nobody.
These illegal questions have remained unchallenged by medical students and physicians for far too long. Do we really need a survey to prove these questions have a detrimental effect on doctors and medical students who may delay/avoid care?
It’s none of their damn business if you’ve had postpartum depression. I agree. If you are not impaired and your physician has released you to work then you shouldn’t need anyone else’s permission or approval to do your job.
Those who tell the truth about seeking mental health care have suffered delays in licensure and ridiculous levels of added scrutiny. A physician friend of mine had a 6-month delay in obtaining her state license when she revealed that she had sought counseling during a divorce ages ago. The board mandated that she provide her counseling records. But her counselor had retired. So they forced her to get a psychiatric evaluation before declaring her safe to practice in the state. Doesn’t everyone need therapy during a divorce? Why the hell is it anyone else’s business?
This is exactly why a friend of mine, an excellent psychiatrist, drives 200 miles out of town, pay cash, and use a fake name to receive mental health care.
Some doctors do lie on applications. Can the board, insurance companies, and employers gain access to your medical records? Not unless your records are easily accessible on an electronic medical record system and they can find out who provided your care. Though I’m no legal expert, I believe they can still subpoena your records. So do docs worry too much about these questions? I believe concerns are justified. Physicians have faced discrimination and major career ramifications by revealing the truth.
Fear of seeking treatment due to these antiquated, punitive, and illegal questions leads to increased physician depression, anxiety, substance abuse—and ultimately may result in suicide. I know of several medical students who have died by suicide for fear of seeking mental health care that would be disclosed on their official school records and in future applications for residencies, hospital privileges, state licensure, and insurance credentialing.
We enter medicine with our mental health on par with or better than our peers, yet anxiety, depression, substance abuse, and suicide are all occupational hazards of our profession. Here’s why. We’re steeped in a profession full of human drama, suffering, and death. Yet we have no on-the-job emotional support then we’re punished if we seek mental health care. How can we care for others if we can’t get the care we need as human beings—without fear, stigma, and discrimination?
Seeking mental health care is the responsible thing to do for one’s own health and I believe regular mental health support makes one a better doctor. In fact, I believe all medical students and doctors require mental health care to be well-adjusted human beings. We should be far more concerned about physicians who don’t receive mental health care.
Pamela Wible, M.D., is the author of Physician Suicide Letters—Answered. She enjoys answering questions from doctors and medical students. Dr. Wible is the founder of the Ideal Medical Care Movement and teaches popular biannual retreats to help other docs open their ideal clinics too.
There are legal distinctions here which are important. Medical boards are allowed to ask whatever they want; they’re not bound by the ADA. They’re given extraordinarily wide leeway in what they do and whether or not they approve people for licenses. So, they can ask for medical records if they want to. They can’t subpoena them but they don’t have to; if you refuse to provide what they want, they’ll simply reject you. But if you don’t tell, they’ll never know.
Employers of any kind aren’t allowed to ask on job applications. They are allowed to ask on credentialing forms once you’re hired, but not to discriminate on the basis of them. So I heard one doctor talk at the APA about how she always expects this long wait in the hallway with other doctors before being called in for the perfunctory interview by the approval committee when she’s getting privileges at a new hospital; that’s how she knows she’s the next one up for the interview. She knows they’re trying to think of reasons to turn her down, but they can’t. Credentialing committees are considered to be an arm of your employer — they can’t ask for things of you that they don’t require of all employees. So they can’t even ask for your medical records, let alone subpoena them. If you request accommodations, they can ask for medical verification that you need them, but they are strictly limited in what they can ask for.
Of note, most credentialing committees and medical boards do ask whether applicants have any physical OR mental conditions that may interfere with ability to practice. I’ve simply never heard of a case where the Board or anyone else cared about the physical stuff. I do know of at least one case where a doctor who lied about having a significant history of mental illness on a medical license application was sanctioned by the Board after becoming impaired on the job, and it was mentioned in their decision as part of the reason for a five-year supervision plan. However, I’ve never heard of anyone being sanctioned purely for lying about a history of mental illness, likely because they’d never find out. Medical Boards don’t have enough money or time to even investigate the cases they should look into, let alone a case where a doctor hasn’t had any complaint filed against them.
If you have an illness of any kind, a consultation with an employment lawyer can be worthwhile when considering how to answer questions on licensing or credentialing applications, if they are vague in any way.
By the way — I do agree with your general point, that mental health issues shouldn’t be treated any differently than medical ones. But don’t contribute to the hype!!! Physicians are MUCH more afraid of getting mental health help than they should be. You will essentially NEVER lose a license or be denied a license simply because of a history of treatment, no matter how backwards the medical board is. At most you will be required to have an independent exam, or potentially ongoing visits with a psychiatrist to verify you’re fit to practice. It’s discriminatory and unfair, but it won’t keep you from practicing medicine.
Thanks for your thoughts on this topic. I am no legal expert as I stated in the article. Simply reporting what I have witnessed and been told by others based on their experiences. Appreciate your input.
You’re welcome. As a public figure on the topic of physician suicide, though, if you’re going to try to answer a question which has a legal component to it, it’s vitally important for you to do more than just speculate in a way that makes people more afraid to get help. You need to learn about the legal aspects and make sure you’re not making misinformation worse. When doctors feel trapped between a rock and a hard place — they’re depressed but also think they can’t get help for a mental illness without losing their license — they become even more hopeless, and turn to suicide as the “only way out.” Physicians considering suicide will find your column, and you don’t want the folks who have depression and read your column to feel even more hopeless than they did before they read it. The truth is that it’s OK to get help, and it’s OK to use your own insurance to pay for it! There are thousands of doctors out there who have done it and are now happily practicing medicine. So anyone who is suffering rather than getting help should put these particular fears aside.
Thank you for your comment Julie. I am no expert on legal matters and my essay is based on 100s of letters and conversations I have had with struggling physicians. They have told me that they’ve faced delays and had to meet with the board over issues such as seeking marital counseling. Certainly it would be great to have more data than just my sampling. There seem to be wide variation between how physicians are handled state by state and it would be wonderful to have more uniformity and transparency so physicians won’t have to wonder what will happen to them if they tell the truth.
Of related concern are the PHPs (Physician Health Programs) to which physicians suffering from mental health issues are often referred/mandated for monitoring. These PHPs also lack uniformity and transparency in how they deal with physicians and that creates a great deal of fear that again deters physicians from seeking care. Please see my book Physician Suicide Letters (and I will quote from a letter below): http://www.physiciansuicidelettersanswered.com
October 11, 2014
Dear Pamela,
I’m amazed at the punitive terms I’ve had to face in recovering professionally from a depressive episode for which I was hospitalized last year. One of my requirements is to be urine tested for substance abuse, despite multiple demeaning assessments that have rendered the clear verdict that I don’t have a substance use problem. I’ve had to attend costly treatments for “professionals” in which I am the only female in a group of male physicians who have had sex with their patients or have become assaultive with staff. Any efforts on my part to point out that I don’t quite “fit” are taken as further evidence of my pathology. I’m a single parent as well, so that each of these “treatments” I’m required to attend takes me away from my two children for extended periods of time. Troughout all of this, nobody has told me how common my feelings are—that a large number of doctors feel depressed and suicidal at times. Rather, I’ve been told that my actions are unheard of for someone in mental health and may preclude me from ever providing therapy again since “we tell patients to never give up hope, but you did.” Hopefully, in the near future this won’t be a taboo subject, and there will be places for those like me to seek responsible and con dential care.
Sincerely,
Amy
I think transparency on the part of the board and PHPs and proper treatment of physicians with a true advocacy group overlooking these programs and agencies would do a a lot to clear the air. As you can imagine, I have received 100s of letters from physicians who feel they have been mistreated by these agencies. Obviously, I have not received the same amount of correspondence from physicians who have had positive experiences.
Hi Julie.
I wish I knew about the legal distinctions you’ve outlined a few years ago. It’s good to know the law, but having been through the legal process of which you speak; it’s also good to know that the law doesn’t always work the way it should.
Physicians seeking mental health care should certainly do so, but my advice is to proceed with caution. It’s hard if we’re in a small town, but we really need to be as private as possible because any public knowledge of it can only hurt us. Most of the time it won’t, but it can. And if it ever becomes a legal issue, our ADA rights won’t even be discussed.
And Pamela is correct about some state licensing boards, especially NC. The confusion is made worse by the FSPHP, which seems to lobby for more business. It recently described mental health conditions as “potentially impairing” and “requiring evaluation and treatment” under their terms and by one of their approved providers (i.e. not your physician), usually on a frequent basis and for a lengthy contractual period.
Again, you are correct. It IS ok to get help and fear should not prevent us from doing so. But we all need to keep this conversation going so that there is no reason for any of us to be fearful for taking care of ourselves.
I believe this all speaks for those of us who are EMTs and firefighters as well. I lost a job at my first department for a suicide attempt and getting mental health care afterwards. None of my brothers stood up for me. I was just thrown away!
Tragic. I thought it was better with firefighters. I thought you all were like a big family.
Great points, Pamela! Mental Health Care is highly stigmatized throughout our society, but it can disproportionately affect physicians because of those questions. I also find it interesting that all of the questions for recredentialing only focus on mistakes we might have made or problems we may have had, but not one asks about the good things we have done, or for positive patient reviews.
Avoiding documentation is always important, so important that avoiding treatment is usually the only way for us to keep our job which often is the main stressor. State medical boards give lip service to treatment but Maine has a physician whose license is suspended for “mental health problems”.
Thank you for addressing these problems. I don’t know that I trust the system but it won’t change until we make it change.
Most application do have a question of this nature, “Do you have any physical limitations, that would impact your ability to preform the privileges requested?” or something similar. So question about physical fitness are asked. I guess I don’t find these questions excessively invasive or intimidating. I am aware of situations where surgeons still tried to operate even though they were so ill they could barely stand up. Additionally, it is my experience that the questions are phrased in such a why, that they are only asking if the problem impacts you ability to practice.
I have been under treatment for depression for years. I work ata small multispecialty group practice, I am not embarrassed about admitting this. So many of colleagues know, even though only a handful of them have actually be involved in my medical care.
This is the same crap that happens in the of dentistry. Mental health records should never be published by medical and dental boards.
So the questions remains, how can we find out what will be revealed when they run an employment check? How do we access the same information?
The State of Texas licensing board asserted that I had mental health problems as evidenced by the fact my patients were being sent for polysomnograms to an extent the board considered unreasonable. My practice had mostly adults of an age where the research had already established them so affected by undiagnosed obstructive sleep apnea and/or periodic limb movement disorder. The board, after admitting the forensic psychiatrist on the board had no expertise whatsoever on sleep apnea, wanted me to limit the number of polysomnograms I ordered to an unreasonable extent. So, now I had to send my patients to doctors experienced enough to recognize the wisdom of my concerns for my patients’ health for them to get the poysomnogram ordered.
I did have brain damage because my own physicians had repeatedly missed the obstructive sleep apnea I had as a result of an undiagnosed craniofacial syndrome. I was followed by a neurologist boarded in sleep medicine and neurorehabilitation and a boarded neuropsychologist who both vouched for my abilities to practice medicine. The forensic psychiatrist on the board however, wanted me to go see a neuropsychiatrist, as the credentials of the physicians following me were apparently deemed inadequate.
Eventually, I took a supplement called ubiquinone and my brain damage reversed appreciably leaving me with measured intellectual abilities higher than the mean for physicians. The board however did not want to relent on their harassment. I decided to sue the board using the Americans with Disabilities Act and the person contracted to do this supposedly died suddenly and their website was inaccessible. I was stalked out of my homestead in Texas. No lawyer has been willing to touch this case.
Excellent points! It is time we start seeing mental health as a part of the larger picture anyway . . . not in isolation of the rest of the body and certainly not equal to criminal activity! Love your emails.
Angela, OR RN
Hello Pamela,
I’ve always said that it requires a high degree of self awareness, emotional maturity, and humility to admit that one needs help, professional or otherwise. Such personal attributes lay the foundation for successful therapeutic outcomes, which requires the ability to endure or to change painful personal realities, without fleeing the therapeutic relationship. Such traits should be fostered, not used as a cause for scrutiny.
Exactly!
Physicians are in marked distress.Applications for state boards, malpractice carriers, commercial insurance companies,hospitals, and job applications are full of these types of questions. Also, your reference sources are asked the same kinds of questions about you. This is completely wrong and holds physicians to ridiculous standards. That is when you start withholding the truth. Hiding the fact you got treatment, or took medicine, or were addicted to alcohol & drugs from everyone.
Isolation, lies, shame, guilt, and fear. A seriously bad combination for physicians who certainly will consider suicide.
reiki helped me with tremendous psychological trauma =it may help others too
From Nancy: As regards the recent question about what to do when an application for privileges or licensing specifically asks if you have ever had “mental illness”, why not just leave that question blank? If the agency responsible questions why you did that, just remind them that the question is not legal. If all doctors, regardless of their own mental health history consistently refused to answer this inappropriate question, these agencies may get the message and change their application, or at least mark that question “optional.” Most of us have forgotten the effectiveness of good passive-aggressiveness.
My reply to Nancy above: I believe the application may not be accepted with a blank (though who knows if they even pay attention in big bureaucracies).
Per my friend and pilot (Vince Czaplyski) on Facebook: Good to hear from you. Pilots too get asked those kind of questions on our required 6 or 12 month FAA physicals (more a screening for problems than a real in-depth physical.). It’s been 33 years since I interviewed for a flying job so I’m not up to date on what is asked of applicants nowadays. 1. No doubt pilots lie about these things too on medical applications (here’s the FAA form we fill out for every physical). I don’t know very many pilots who would report experiencing ‘anxiety’ for example on their medical application. That would be inviting trouble from an agency that has the power to end your career for a perceived issue (up to you to prove them wrong).
Vince the pilot continues: 2. On the other hand I don’t feel pilots experience as a group the same kinds of pressures that you and your fellow physicians experience in terms of hours, life and death decisions etc. Yes we pilots have a lot of responsibility and in a general sense each flight is ‘life or death’ in terms of our professionalism and how we approach the career. But I don’t put in the kinds of hours you’ve alluded to, nor do I (speaking for myself) feel the kinds of stresses that physicians as a group experience based on our conversations.
Flying for a major airline, I have a pretty good schedule with federally mandated time off, lots of vacation and quite honestly for me a low stress work environment. For me every time I go to work it’s like I’m in for a real treat on many levels. I enjoy the people, the technology, the travel, cultures, food etc. Honestly it’s a great gig and over a three decade plus career I’ve known personally of very few pilots who ended their lives by suicide, as opposed to the relatively large numbers of doctors who have ended their lives that way, based on what you’ve told me.
So while I don’t like the questions about mental health and I suspect they are largely blown off by most pilots, I don’t think we’re dealing with the same situation your profession is in terms of overall stress levels. Of course that is just one pilot’s impression, based on my own career.
Finally (I know this is a long post!) we have well established and successful programs at the major airline level for addressing alcoholism and substance abuse issues among pilots. There is a lot of help available for pilots experiencing major mental health issues in their lives. It helps too that we have a powerful and effective national pilots union (ALPA) that has been involved in these kinds of issues.
The German Wings suicide accident obviously points to the need to keep pilots dealing with serious mental health issues out of the cockpit until such time as they are healthy enough to fly. In that case he should have been grounded but was not reporting an obviously serious mental health condition to his employer.
Yes, that was very unfortunate for the passengers, crew who have lost their lives.
Why, I am asking, could it be, that nobody picked-up on symptoms? (Their should have been a few).
Of course, the German System with “Schweigepflicht” concerning patients, does not end with death, so we might never know, what this person might have had, to act like that.
It’s so sad, but the families, who lost loved-ones are now grieving forever.
The life’s are put on hold, or are no longer enjoyable (I just saw a good documentation on German TV). I am German, and I was told, that in the USA, such a thing, won’t be possible – maybe they should all work and trade experiences? Maybe the US approach towards screening works far better, than the standard, that is right now in Germany?
Post by Michelle Grenier MD:
Mental health issues are prevalent in our society, and are likely only exacerbated by the stress of practicing medicine (long hours, lack of attention to normal bodily function and needs, the omniscience of holding another’s life in one’s hands). Certainly, any hospital or organization has the right to know if an individual will be more susceptible to these stressors based on their background and general health. It is important to provide the best care for the patient (the ultimate goal).
If the intent of asking these very personal questions was to support the physician with confidential and compassionate resources during their time of need, then questions regarding mental health would be better tolerated. However, many times these questions are used as tools to exploit the perceived “weaknesses of others”. In fact, third party counseling has been used to control outspoken physician behavior on more than one occasion.
In summary, we need to re-assess the intent of obtaining very personal information in an age where medicine is heavily controlled by hospital administrators with MBA/MHA who are no longer or never have been “in the trenches”. What is the intent? To protect the patient? To protect the hospital from frivolous litigation? To protect the administrator because they were taught during their MBA program that “their physicians need to dress appropriately and keep themselves in line” (an actual quote overheard from a young hospital administrator)?
We physicians, for the most part, are extremely caring, intelligent people who give the best part of our lives to care for others. Henry David Thoreau said it best: “The cost of anything is the amount of life you pay for it.” Let us start recognizing this, and using the information reaped on mental health questionnaires to help, rather than harm our physicians.
Hi Pamela, I offer very discrete mental health care for professionals with vicarious trauma and/or compassion fatigue. I’m in the state of CA and I offer online therapy so any physician or “helper” seeking treatment in CA can see me without even leaving their home. In addition, I do home visits in the LA County area. You can find me on Psychology Today near Monrovia, CA. I’m here to help! No insurance and therefore no third party involved in treatment planning.
Sincerely,
Janel Grobes
Awesome Janel! Thanks for writing. We need more folks like you! <3
I am a graduating resident who took 3 weeks off to get help for my depression – I did an intensive outpatient program because its hard to get the time to get help in residency. And now I am applying for my Texas Medical License and I feel like my rights are being violated. I was asked do you have a mental condition – yes, and then I was asked does it affect how you function at work – no. I thought that would be the end of it but now I need a Treating physician statement, a statement from my Program director, and I need to justify why I said no to it not affecting how I function at work. I’m also required to list all of the medications I have been on in the past 5 years and all physicians who have treated me. How is this not a HIPPA violation? Why are they still being allowed to do this? My application has to go before the board and people who have never met me have to decide if I am a danger to my patients. I have no money for a lawyer and if I fight this then it can delay my getting my license and thus delay my being able to work. In all honesty this is probably going to delay my getting a license regardless because my husband with no medical issues has already been approved months ago and here I am still waiting.
Kyndra – just so you know several states such as Hawaii and New York have NO mental heath questions on their licensing applications. These questions are illegal according to the Americans with Disabilities Act and are also a confidentiality breach of your HIPAA-protected rights. Texas, Alaska, and Florida have the most invasive licensing questions.