Barriers to mental health care: Removing invasive questions, removing stigma

Applications for employment and credentials may include potentially invasive questions about physicians’ mental health. Having to reveal diagnoses or treatments is what stops many physicians from seeking mental health help if they need it. Daniel Saddawi-Konefka, MD, MBA, and Christine Yu Moutier, MD, are co-authors with Jesse M. Ehrenfeld, MD, MPH, of the special communication, “Reducing Barriers to Mental Health Care for Physicians: An Overview and Strategic Recommendations,” published in JAMA. Here they discuss what a change in questions can do for changing doctors’ ability to seek assistance.

Medical Economics: The Dr. Lorna Breen Heroes’ Foundation and other organizations have pushed for substantial change toward limiting disclosure of mental health treatment for licensing and credentialing purposes. You've already touched on stigma in our conversation. How important are those efforts and what needs to continue to happen for additional success on that in the future?

Christine Yu Moutier, MD: I really think this is one of the linchpins that is changing, thankfully, and must change in order for stigma to actually have a chance at really coming down more dramatically. Now the laws changing and the questions that physicians and nurses are being asked on licensure forms and recertification forms are really critically important to treat mental health just like physical health, not make assumptions of impairment. The questions should either not be there at all or they should center around impairment related to any health cause, and rather than singling out mental health because there's really some loaded assumptions built in there. I think the thing is, that effort is important and must continue to get to all of the states. Hospitals also need to change their privileging questions along those same lines, and that's kind of a separate advocacy effort that, again, the Lorna Breen Heroes’ Foundation has been very effective at creating a toolkit that's simple enough to actually make those changes happen. I think the next stage that really needs to happen is a communication strategy so that physicians who are in various hospitals and states understand what their conditions are, and if they are in an environment where it will not even be probed if you go into treatment. And of course, that's back to the self-prescribing and the informal curbside stuff — that is, in part, because of this great fear. So we do need to know that that era is over. So we have some ways to go with that yet, but it's a very, very critically important part of this work.

Daniel Saddawi-Konefka, MD, MBA: I couldn't agree more. One of the sort of landmark articles, as I see it, that came out in 2018-ish, was that in states that ask those questions, physicians are 21% more reluctant to seek care. So, it's not just a hypothetical or something that we postulate. They're less likely to seek care. And I'll also echo that, I think it's sort of a critical first step, because we if that, if that culture in these applications persist, that sort of gives life to all the stigma that follows. Now I will say that even if all of the licenses and credentialing applications and malpractice insurance and commercial — even if all of those were were fixed today, we would still have issues with stigma, issues with fear of getting jobs or getting into different residency programs. We'd still have the culture of stoicism and and we'd still have logistical barriers. So there's still a lot of work to be done, but it's such a critically important first step that it's just fantastic that so many groups have been focused so intently on making sure that that's taken care of.