Physicians have an increased rate of depression and suicide compared with nonphysician peers. State medical licensure questions about mental health deter physicians from seeking mental health care. Several previous studies have examined state medical licensing board compliance with the Americans with Disabilities Act (ADA) of 1990, but none have included osteopathic licensing boards.
To evaluate compliance of state osteopathic medical licensing boards with ADA requirements regarding mental health.
State medical licensing applications for 51 states, including the District of Columbia (DC), and 16 states with osteopathic licensing entities were reviewed for ADA compliance in questions about mental health. In states where both osteopathic and allopathic applications were available, questions and compliance were compared.
Fourteen of 51 states (including DC) were grossly out of compliance with ADA statutes. In states where osteopathic and allopathic licensing were both available, 7 of 16 asked different mental health questions of osteopathic physicians than their allopathic physician counterparts. Of those 7 states, 6 of the osteopathic boards were out of compliance with ADA, while their allopathic counterparts were either compliant or intermediately compliant.
To improve physician wellbeing, corrective action must be taken to create ADA-compliant language in medical licensing so physicians can seek treatment for mental health conditions without discrimination by licensing boards. Osteopathic physicians should be aware that there is a discrepancy in state licensure compliance compared with allopathic requirements in some states.
In an era when workplace burnout affects approximately half of the physician workforce, understanding the implications of burnout (which include anxiety, depression, and suicide) is imperative.1 Physicians face a higher rate of depression and suicide than their nonphysician peers.2 Mehta et al3 showed that depression among providers is associated with a lower quality of patient care. Compounding the issue, barriers for physicians seeking treatment abound; among them are state licensure requirements for reporting of mental illness. Multiple physician surveys and studies have shown that many physicians are reluctant to seek mental health care due to concerns about how that might affect their ability to obtain state licensure.4-6
Unfortunately, state medical board license applications are not uniform across the country; questions about mental health vary from state to state. Studies have found a relationship between physicians’ reluctance to seek mental health care and how mental health questions were worded on licensing applications.5,6 States with more probing questions about mental health history were linked to a higher level of reluctance by physicians to seek mental health treatment.4
The Americans with Disabilities Act of 1990 (ADA), in an attempt to address discrimination against people with certain qualified conditions, including mental health conditions,7 legislated how those medical conditions could be queried. In 2014, the Louisiana Supreme Court Settlement Agreement established the legal way to inquire about mental health questions on an application. After judicial challenge in an application for law licensure, the courts deemed that the only question reasonable to ask a candidate for licensure is: “Do you currently have any condition or impairment (including, but not limited to, substance abuse, or a mental, emotional, or nervous disorder or condition) that in any way affects your ability to practice (medicine) in a competent, ethical, and professional manner?”8
While the US had 16 states with separate licensing applications for osteopathic physicians as of this report, a study reviewing state licensing processes for discriminatory language has yet to include osteopathic licensing bodies. To investigate the degree of ADA compliance by state medical boards regarding mental health questions, we conducted a review of all state medical licensing applications, comparing both osteopathic and allopathic applications where available.
Initial state licensure applications were obtained from all 50 states and the District of Columbia (N=51) through state licensing board websites, by individually emailing state boards and requesting an application file, or through osteopathic medical school website links. Each state application was examined and found up-to-date for 2019.
Using a previous study8 and position statements from the Federation of State Medical Boards (FSMB)9 and the American Psychiatric Association (APA)10 as a basis for evaluation, each state medical license application was assessed for ADA compliance. To be ADA compliant, application questions should focus only on medical conditions (physical or mental) that cause current functional impairment.8,10 Based on the recommendations of FSMB,11 “current” impairment should be limited to a window of 2 years or less. State applications that met these guidelines were considered compliant. State applications with hypothetical phrasing or with compliant phrasing but a longer timeframe (2 to 5 years) for impairment were considered intermediately compliant. States applications asking mental health questions without mention of current impairment (or phrasing impairment questions within a timeframe of 5 to 10 years), without mention of impairment at all, or with multiple probing questions regarding physical or mental health conditions were considered non-compliant with ADA. In states with both allopathic and osteopathic state licensing agencies, compliance questions were compared side by side.
In the United States, as of 2019, there were 16 states with separate agencies granting osteopathic physician medical licensure (Figure 1). Seven of the 16 states (43.7%) had different osteopathic and allopathic applications. In 6 of those 7 (85.7%), the osteopathic board application was not fully compliant (either intermediately compliant or noncompliant) with ADA requirements, while the allopathic application was, at a minimum, intermediately compliant (Figure 1). Notably, of these 16 states, there were also 7 states (43.7%) where the wording on osteopathic and allopathic applications was the same, and these states were all compliant with the ADA guidelines.
There are 24 states, including the District of Columbia, that had applications compliant with the ADA; 7 of those have separate osteopathic applications and questions for osteopathic physicians. These states either did not ask any questions about mental health or asked only about current impairment, most using the format recommended by FSMB.11 Of these 24 states, 9 states (37.5%) had no questions about physical or mental health. These states included Connecticut, Hawaii, Indiana, Michigan, Mississippi, New York, Pennsylvania, Rhode Island, and Wyoming (Figure 2).
Fourteen state applications were grossly noncompliant with ADA-recommended language (Figure 2). Six of those were from states with separate application forms for osteopathic and allopathic physicians. These states asked questions about physical and mental health conditions without mentioning current impairment, asked questions probing into mental health diagnoses, or required documentation about diagnosis and treatment despite the absence of current impairment. One state listed 14 different diagnoses (including seasonal affective disorder) and asked the applicant to check any for which he or she has ever been diagnosed or treated. Another state asked for a list of all prescription medications, reasons for use, prescriber and pharmacy information, and permission for said prescriber and pharmacy to release records to the board upon request.
Thirteen states were not ADA compliant, but were very close; small changes in wording or phrasing could easily correct the erroneous language, thereby achieving complete ADA compliance (Figure 2). Among those 13, 7 states (53.8%) applications contained noncompliant, hypothetical questions. The court system has deemed that hypothetical questions are not permissible, as they require the applicant to have insight into a topic that is not reality.8 Impermissible questions force the applicant to make a judgment based on what could happen, not what has happened; an example is, “Do you presently have any physical or mental problems which COULD affect your ability to practice with reasonable safety?” Other applications in this group contained questions about impairment dating back 5 years, outside of the reasonable timeframe for current impairment as outlined by the FSMB.11
Fundamentally, the 4 tenets of osteopathic medicine state that the person is a unit of body, mind, and spirit; the body is capable of self-regulation, self-healing, and health maintenance; structure and function are reciprocally interrelated; and rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.12 Understanding these truths, osteopathic physicians have an opportunity to be particularly self-aware when an element (body, mind, or spirit) is out of balance. This modern self-awareness to obtain mental health services should be honored even in licensing processes, not judged or scrutinized. The FSMB encourages all state medical boards and licensing boards to view improved mental health of the physician through the lens of burnout, acknowledging that when physicians are supported, a positive downstream effect is improved patient safety.13
As discussed earlier, physicians may not seek mental health treatment for various reasons, including fear of reporting on state medical licensing applications. In a 2016 survey of 2100 female physicians,13 50% felt they met criteria for mental illness, but had not sought treatment; of these women, 40% did not seek treatment due to having to report to a licensing board. Only 6% of women with a diagnosis of mental illness reported it to their state board agency. The fear of stigma physicians feel may be justified for physicians practicing in the 14 states with gross noncompliance and even the 13 states with partial compliance.
The differentiation between illness and impairment on licensure applications is important. The FSMB discussed this distinction in a policy statement on physician impairment.9According to that paper, impairment is a “functional classification” and physicians with an illness “may or may not have evidence impairment.”9 A physical or mental health diagnosis does not cause functional impairment solely by existing. Furthermore, history or presence of mental illness does not predict a future risk of harm to the public.11 Rather, when an illness is left untreated, it can lead to impairment. Therefore, it would benefit patients and society for the physician to seek timely treatment for the illness. Physicians should not be discouraged from pursuing treatment for fear of professional stigma and disciplinary action. Armed with the data that probing questions about mental health history on licensure applications is actually a deterrent to a physician seeking mental health treatment,3,4,13 medical licensing boards should encourage physicians to seek the help they need without regulatory board oversight and focus on the identifying and helping impaired physicians. A troubling finding of our study was the differences between osteopathic and allopathic licensing board applications in states with dual licensing bodies. It is discouraging that in some states, osteopathic boards lag behind their allopathic counterparts in updating their licensing applications to include less intrusive (and more compliant) mental health questioning.
Since medical licensure applications fall to the purview of individual states, each state holds the power to modify its application process. To that end, it is important to shine a spotlight on the 24 states in ADA compliance. Seven of these states choose not to include any mental health-related questions of the initial application for medical licensure, which allows physicians the right to privacy when they have identified an illness and sought appropriate treatment.
Since 2014, there have been ADA compliance improvements by state boards regarding mental health questioning.4,9 While it is difficult to make a direct comparison between similar studies given the different methods with which they were conducted (particularly in this case, as this is the first study to our knowledge to include osteopathic boards), overall, there seem to be more states in compliance with the recommendations of the FSMB and APA than ever before. For instance, Jones et al8 reported only 7 licensing bodies asking no mental health questions, whereas our study noted 9 states without mental health questions. As more light is shed on state licensing applications’ discrepancies, state medical boards will hopefully make appropriate changes toward compliance.10-12 State medical licensing applications should also be uniform and collectively follow standards set by the ADA, particularly in the context of the single Graduate Medical Education accreditation system for both osteopathic and allopathic medical students.
There is significant discrepancy between US states regarding mental health-related questions on state medical licensure applications, and many remain noncompliant with ADA guidelines. Further, there are significant differences between mental health questions and levels of ADA compliance for osteopathic and allopathic applications in states that offer both licensure options. Although medical board licensure is overseen by each state, efforts should be made toward standardization and compliance so as not to deter applicant physicians from seeking mental health treatment and from answering related questions honestly. In the osteopathic medical community, health of the body, mind, and spirit are all paramount, and our licensure applications should reflect our commitment to the health of physicians and patients alike in a time when increased physician burnout, depression, and even suicide are all increasing.
Both authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; both authors drafted the article or revised it critically for important intellectual content; both authors gave final approval of the version of the article to be published; and both authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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