Medicine is grappling with rising levels of physician burnout, one of the factors driving high rates of depression and suicide in the profession. But physicians who suffer from mood disorders are often reluctant to seek treatment - in part because it might jeopardize their license to practice. For instance, in one survey, around 1 in 15 surgeons said they'd recently had suicidal thoughts, but more than 60 percent were reluctant to seek help because of concerns that it might affect their license.
Now, a new study shows, those concerns break down along geographic lines - and in those states whose licensure applications ask the most sweeping questions about mental illness, physicians are most likely to be reluctant to seek treatment.
The problem lies in how they ask, said Mayo Clinic professor and internist Dr. Liselotte Dyrbye, who led the study.
"In some states, the question is really broad, as in, ‘Have you ever been treated for a mental health condition?'" she said. "It's simply not a fair question."
Instead, Dyrbye said, licensing "should be based on your ability to perform your job today. Rather than asking, ‘Are you currently diagnosed with a mental health condition?' they can ask if you are currently suffering from any condition, mental or physical, that keeps you from doing your job. Asking about that is a reasonable question."
But, her team's research found, two-thirds of U.S. states ask the broader form of the question - despite the fact that groups including the American Medical American, American Psychiatric Association, and the Federation of State Medical Boards recommend against it - and that could be causing physicians to forego treatment.
‘I just crashed'
In 1994, Dr. Steven Miles was a well-respected gerontologist and professor of biomedical ethics at the University of Minnesota Medical School.
"I was at the peak of my career, getting awards and all that jazz, when I just crashed," he said. He sought help from a psychiatrist, who diagnosed him with bipolar II disorder.
Miles continued his clinical work while receiving treatment. He also spoke openly about it while teaching at the University of Minnesota, particularly one time after the suicide of a medical student.
"I said to the class, ‘Look, illness happens, and I'm proof that a physician can have a mental illness and function really well,'" he recalled.
Several months later he was filling out the annual renewal form for his state medical license. Among other things, the questionnaire asked if he had ever been diagnosed with one of several psychiatric conditions, including bipolar disorder. "I didn't think much of it when I said yes," Miles said.
He had no reason to. There hadn't been any patient complaints, and his name appeared regularly on lists of the state's "Top 100 doctors."
But the Minnesota Board of Medical Practice began an investigation, demanding a letter from his psychiatrist and full access to the records of his psychotherapy sessions.
Miles refused, arguing that the board's request was overly invasive and served to deter physicians from seeking help for mental health disorders. After a four-year standoff and threats of legal action, the board backed off. Miles still sees patients and teaches, and his bipolar disorder is well-controlled with medications and therapy. Minnesota remains, however, one of 24 states without the recommended wording in either its initial or renewal licensing forms.
Hands are tied
Revoking licensure or otherwise preventing a physician from working due to mental disorders is actually illegal under the Americans with Disabilties Act. Covered conditions include mental illnesses such as depression, bipolar disorder, and schizophrenia. The law defines as a form of discrimination "employment tests or other selection criteria that screen out or tend to screen out an individual with a disability or a class of individuals with disabilities."
Yet medical licensing boards get away with it.
"Boards' hands are often tied in terms of what state legislatures will let them do," Dyrbye said, adding that states are caught between protecting the public from impaired doctors and a physician's right to make a living.
"The ironic thing is that the unfair question defeats the boards' purpose," she pointed out. "If a doctor is impaired but is discouraged from seeking help, the patients are not being protected. We want doctors to get help before they are unable to do their jobs."
Dr. Beth Baxter, a Nashville psychiatrist who has bipolar disorder, has been open about her illness for years. But, she says, that's never hindered her license renewal in Tennessee - despite that state being one of three (Iowa and Wyoming are the other two) whose renewal forms do not contain recommended wording.
"It helps to be open about it" with colleagues, Baxter said. "So it's not a surprise when there is a time when you can't work."
Dyrbye is hoping to make that kind of openness the norm - starting with paperwork that asks about mental health in a better way. She presented her study's findings to the Federation of State Medical Boards earlier this year. Her next step, she said, is getting the word out to state legislatures that there are numbers to back up recommendations against broad questioning about doctors' mental health.
"Medical license boards are often controlled by the state legislature, so they are the ones that need to step up and get these questions fixed," she said.