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Physician Mental Health and Substance Abuse
What Are State Medical Licensure Applications Asking?
Randy A. Sansone, MD;
Michael W. Wiederman, PhD;
Lori A. Sansone, MD
Arch Fam Med. 1999;8:448-451.
ABSTRACT
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Objective To summarize and characterize the questions on initial applications for medical licensure (nonosteopathic) as they relate to applicants' mental health and substance abuse.
Design Collection and analysis of applications for initial medical licensure (nonosteopathic) from 50 states and the District of Columbia.
Participants Nonosteopathic medical licensure applications of 47 states and the District of Columbia (N=48).
Intervention None.
Main Outcome Measures Number of questions per application relating to mental health problems and substance abuse, in addition to time qualifiers (eg, current difficulty, specified number of years in the past, ever) and impairment qualifiers (eg, functional impairment, treatment, hospitalization) per question or set of questions for each area.
Results Of 48 applications analyzed, 41 (85%) inquired about mental health problems and 43 (90%) inquired about substance abuse. Most explored periods between the past 10 years and the present; functional impairment was the most common inquiry.
Conclusions Applications for nonosteopathic medical licensure most often inquire about physicians' recent history of mental health and substance abuse problems as well as related functional impairment. Variation of items across state applications may have important implications for some physician applicants.
INTRODUCTION
THE ETHICAL dilemma regarding a state medical board's duty to protect the public vs the physician's right to privacy is a complex one. This dilemma recently surfaced in a controversy involving a physician with bipolar disorder, type II, and the Minnesota State Medical Board.1 When the physician acknowledged receiving treatment for bipolar disorder, an investigation was initiated by the state medical board, including a request for treatment records. As of this writing, the case is still under litigation.
Historically, one important role of state medical boards has been to protect the public from impaired physicians.2 However, the prevalence of physicians with past or current emotional problems or substance abuse remains unknown. It is estimated between 8% and 12%3 but remains the subject of ongoing study.4 Anecdotal estimates from state medical boards indicate that one third to one half of physician-related complaints involve allegations of substance abuse.5 However, of the documented disciplinary actions taken by the Florida State Medical Board between August 1990 and March 1992, only 3.8% were related to emotional problems, including substance abuse.6
Although not documented, state medical boards may routinely inquire about mental health or substance abuse concerns on initial applications as well as renewals for licensure. Therefore, most physicians may be confronted with inquiries about their personal history; failure to provide accurate information on the application may result in the revocation of a license to practice medicine. Acknowledgment of a history of mental health problems or substance abuse may precipitate a more detailed inquiry by the state medical board.
Inquiries by state medical boards can be potentially problematic for physicians. First, board actions may be distributed among state medical boards through the Federation of State Medical Boards7 and, in almost all states, may be available to the public.8 In addition, the National Practitioner Data Bank maintains records of physicians' personal diagnoses and treatment9 when they are related to medical liability actions, and, although these records are not currently accessible by the public,10 such access is under review by Congress.7 Second, questions on some state licensure applications are phrased, "Have you ever . . . ," suggesting that past impairment from emotional problems or substance abuse, even in the remote past, correlates with one's current competency to practice medicine, a hypothesis that remains unproven.6 Finally, there is a realistic concern that these types of inquiries on state licensure applications may cause some physicians to avoid or postpone treatment6 because of fears of stigmatization.8 This might result in self-treatment with drug samples, which is potentially compromising.
The purpose of the current study was to examine state medical board licensure applications (initial application request, nonosteopathic) and characterize questions relating to mental health and substance abuse (eg, number and types of questions, presence of qualifiers). We are unaware of any previous empirical studies examining this issue.
SUBJECTS AND METHODS
Letters requesting initial applications for medical licensure were sent to nonosteopathic state medical boards in all 50 states and the District of Columbia, hereafter referred to as states. The initial letter simply requested an application for licensure. When a preapplication and/or application fee was requested (n=14), a follow-up letter was sent. The follow-up letter stated that the application was being requested for a research project exploring mental health and substance abuse inquiries of applicants. Data were solicited and collected over a 3-month period during the winter of 1997-1998. Two states (Louisiana, Mississippi) did not respond to multiple requests, and the state of Kansas indicated that the application could not be provided. The final sample consisted of 48 applications (from 47 states and the District of Columbia), representing a 94% response rate.
Following the receipt of the applications, those questions relating to mental health and substance abuse were selectively summarized and reviewed by investigators. Two of us (R.A.S. and M.W.W.) independently coded each item pertaining to mental health and substance use/abuse; discrepancies were resolved by discussion.
Items in each application that related to mental health issues were coded as a set with regard to time qualifiers and impairment qualifiers. Time qualifiers were coded according to whether the set of mental health questions asked about current problems, those experienced within a specified period (eg, "within the past 2 years"), or those ever experienced by the applicant. In coding a set involving multiple questions or multiple time qualifiers, the most broad time qualifier was coded (ie, "ever" was considered most broad, followed by a specified period, followed by currently).
Impairment qualifiers were coded according to whether a single question or set of mental health questions (applications with multiple questions) included a statement regarding the applicant's treatment for a disorder, hospitalization for a disorder, functional impairment (typically with regard to professional duties), or no such impairment qualifier. Again, in cases involving multiple qualifiers, the most broad qualifier was coded (ie, functional impairment was considered most broad, followed by treatment, followed by hospitalization). Finally, items on applications specifically inquiring about psychotic symptoms or conditions (eg, bipolar disorder, schizophrenia, paranoia, "any other psychotic disorder") were coded.
The application items pertaining to substance use/abuse were coded similarly to the mental health items. However, none of the applications asked only about hospitalization for substance abuse; therefore, this category was not used. Instead, items asking only about legal encounters (ie, legal problems caused by substance use) were coded. To determine whether functional impairment was indicated by the question, we coded questions that included references to dependency, addiction, problems with drugs, or excessive drug use as implied functional impairment. The same decision rule (ie, the most broad qualifier) used with the mental health questions was also used in coding the substance use/abuse items.
RESULTS
Of the 48 applications analyzed, only 7 (15%) did not include specific questions pertaining to mental health conditions. Four of these 7 states (Connecticut, Hawaii, New York, and Rhode Island) also did not include questions pertaining to substance use or abuse. Indiana, Michigan, and Pennsylvania asked about substance use/abuse but not about mental health conditions. All remaining 41 states surveyed asked specifically about both mental health conditions and substance use/abuse. Among the states asking such questions, the number of items pertaining to mental health ranged from 1 to 9 (mean [SD], 2.2 [1.6]), whereas the number of items pertaining to substance use or abuse ranged from 1 to 7 (mean [SD], 2.1 [1.5]).
Qualifiers associated with the mental health questions are shown in Table 1. It was most common for the application to inquire about current mental health conditions or impairment. Along these lines, the question in the Arizona state licensure application was typical: "Do you have any medical condition that in any way impairs or limits your ability to safely practice in any field of medicine?" The term medical condition was defined to include "mental or psychological conditions or disorders," "emotion [sic] or mental illness," "specific learning disabilities," "HIV disease," "drug addiction," and "alcoholism."
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Table 1. Mental Health Inquiries on Licensure Applications (Nonosteopathic) as a Function of Impairment and Time Qualifiers (N = 41)*
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Only 6 of the applications (12%) asked specifically about psychotic conditions or diagnoses in which psychotic experiences are likely, and 5 of these specifically asked whether such conditions had been experienced "within the past 10 years." Interestingly, each state asking about psychotic conditions also included a question or questions pertaining to other mental health conditions. Typically, however, these applications asked about current mental health conditions, followed by a question pertaining to psychotic conditions experienced within the past 10 years.
Qualifiers associated with the substance abuse questions are shown in Table 2. Unlike inquiries about mental health conditions, it was equally common for the application to inquire about current and past substance abuse. Most included a qualifier with regard to functional impairment. The following question in the Iowa state licensure application was typical: "Does your current use of alcohol, drugs, or other chemical substances in any way impair or limit your ability to practice medicine with reasonable skill and safety?"
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Table 2. Substance Use/Abuse Inquiries as a Function of Impairment and Time Qualifiers (N = 43)*
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Interestingly, 7 states inquired about applicants' histories of pedophilia, exhibitionism, and voyeurism. One state inquired about compulsive gambling and another asked whether the applicant had ever been verbally, physically, emotionally, or sexually abusive.
COMMENT
These data summarize the mental health and substance abuse questions on state applications for initial medical licensure. They do not address applications relating to reciprocity or the renewal of licenses. Most states inquire about mental health conditions (n=41 [85%]) and substance use (n=43 [90%]). Of those states that inquire about mental health issues, 28 (68%) specify somewhere between the present and the past 10 years and most are concerned about functional impairment. Of those states that inquire about substance abuse, 22 (51%) specify somewhere between the present and the past 10 years, and most states that ask about substance abuse are also concerned about functional impairment. Only 5 states (12%) inquiring about mental health specifically ask about psychotic symptoms or mental health conditions potentially associated with psychosis. One could summarize these applications by noting that few states explore applicants' lifetime histories of mental health or substance abuse problems; however, there is obvious variability among the states regarding these inquiries.
Consider some hypothetical cases that illustrate the implications of these findings. Suppose 2 applicants had both experienced major depression 4 years earlier, with equal and significant levels of impairment during the episode. However, the first applicant (recipient of treatment) received treatment with antidepressants and the second did not. Both are currently symptom-free. As the application questions are worded, the first applicant would have to indicate a mental health problem in 21 states, whereas the second applicant would have to admit such a problem in only 17 states (Table 1). If a third applicant had an experience identical to that of the first applicant, except that the episode had occurred 2 years earlier (ie, 6 years ago), that applicant would have to indicate a mental health problem in only 14 states. Similar implications are apparent for the questions exploring substance abuse.
With substance abuse, a dilemma arises when the question is based on the applicant's assessment of whether there is or was impairment caused by the substance use. Suppose one applicant is currently using marijuana on the weekends and does not believe that such use affects professional functioning. A second applicant abused alcohol during a discrete period 3 years earlier, during which time there was impairment of professional duties, but currently the applicant does not drink. The first applicant would have to indicate substance use in 5 states, whereas the second applicant would have to indicate a substance use problem in 23 states.
Physicians with histories of emotional problems or substance abuse do have some protections. First, every jurisdiction in the United States has a mechanism to deal with chemically impaired physicians,3 and if a physician self-reports11 and/or cooperates with treatment, the state medical board may not pursue a disciplinary action.5, 11
Second, the Americans with Disabilities Act (ADA) may or may not protect physicians with regard to disclosure. Shellow and Coleman6 argue that the relationship between physicians and state medical boards fulfills the requirements of the ADA, a position supported by some courts.1, 12 Because the ADA protects those who have recovered from a disability,12 questions about current or past emotional problems or substance abuse on licensure applications may be interpreted as discrimination based on disability.13 It is unclear how the ADA's protection of individual rights will be reconciled with the need to protect the public.13
In a different professional arena, that of bar examiners, the issue of disclosure of a personal history of emotional problems or substance abuse has been challenged and the position of the examinees has been supported by courts in Maine12 and the District of Columbia.14 Similar cases have either been threatened or emerged in Arizona, Connecticut, and Texas.12
Do states fairly and reasonably inquire about mental health and substance abuse issues when physician applicants seek initial licensure? These data only summarize the types of questions on state medical licensure applications. They do not necessarily provide a sense of fairness and reasonableness regarding, for example, the process that unfolds when such inquiries are endorsed by applicants, the attitudinal climate of the individual state medical boards when confronted with an endorsement, or the frustrations of state medical boards as they attempt to resolve practice concerns related to these issues. In addition, these data do not measure physician candor or willingness to reveal previous treatment, nor do they indicate the prevalence of concern about avoiding treatment because of the fear of stigmatization. The licensure applications for osteopathic medical boards were not examined in this study and represent another area of future investigation. Medical licensure issues clearly warrant further research and broach some uncomfortable professional questions.
AUTHOR INFORMATION
Accepted for publication October 22, 1998.
Corresponding author: Randy A. Sansone, MD, Sycamore Primary Care Center, 2115 Leiter Rd, Suite 3, Miamisburg, OH 45342.
From the Department of Psychiatry, Wright State University School of Medicine, Dayton, Ohio (Dr R. Sansone); the Department of Psychiatry Education, Kettering Medical Center, Dayton (Dr R. Sansone); and the Department of Psychological Science, Ball State University, Muncie, Ind (Dr Wiederman). Dr L. Sansone is a family physician with Kettering Medical Center Physicians Inc, Dayton.
REFERENCES
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1. Miles S. Do state licensing procedures discriminate against physicians using mental health services? one physician calls for reform. Minn Med. January 1997;80:42-46.
2. Trado CE. A North Carolina medical board member looks at the North Carolina Physicians Health Program. N C Med J. 1996;57:230-232.
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3. Blondell RD. Impaired physicians. Prim Care. 1993;20:209-219.
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4. Corsino BV, Morrow DH, Wallace CJ. Quality improvement and substance abuse: rethinking impaired provider policies. Am J Med Qual. 1996;11:94-99.
5. McIntyre BW, Hamolsky MW. The impaired physician and the role of the Board of Medical Licensure and Discipline. R I Med. 1994;77:357-358.
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6. Shellow RA, Coleman PG. Fitness to practice medicine: a question of conduct, not mental illness. J Fla Med Assoc. 1994;81:101-105.
7. Marwick C. State medical boards discipline more, want role in health system reform. JAMA. 1994;271:1723-1724.
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8. Peyser HS. Self-incrimination on medical board and licensing applications. Hosp Community Psychiatry. 1993;44:517.
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9. Ankney RN, Coil JA, Kolff J, Esper E. Physician understanding of the National Practitioner Data Bank. South Med J. 1995;88:200-203.
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10. Wolfe SM. Questionable doctors: lots of them! Revolution. Summer 1996;6:20-22, 85.
11. Jones TL. The road to recovery: new law removes one barrier to rehabilitation for impaired physicians. Tex Med. August 1995;91:22-24.
12. Struthers MS, Ulrich LM. Are medical licensing questions discriminatory? Minn Med. May 1994;77:27-29.
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13. Kopelman LM. Ethical assumptions and ambiguities in the Americans with Disabilities Act. J Med Philos. 1996;21:187-208.
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14. Reischel CL. The constitution, the disability act, and questions about alcoholism, addiction, and mental health. Bar Examiner. August 1992;61:10-23.
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