Each state board application was given 1 point for consistency with each of the 4 evaluable Federation of State Medical Boards recommendations, for a total of up to 4 points. The Figure includes all 50 states in the US and Washington, DC. Three territories (Guam, the Northern Mariana Islands, and the US Virgin Islands) are not shown.
eTable. Coding Criteria for Each FSMB Recommendation
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Saddawi-Konefka D, Brown A, Eisenhart I, Hicks K, Barrett E, Gold JA. Consistency Between State Medical License Applications and Recommendations Regarding Physician Mental Health. JAMA. 2021;325(19):2017–2018. doi:10.1001/jama.2021.2275
Physicians have higher rates of depression, burnout, and suicide than the general population.1 Despite this, physicians infrequently seek mental health care, consistently citing fear of negative ramifications for licensing.2,3 State medical license applications often ask broad questions about mental health history or its hypothetical effect on competency, even though asking violates the Americans With Disabilities Act. In states with license applications that ask such questions, physicians are more reluctant to seek help.4
In 2018, the Federation of State Medical Boards (FSMB), an umbrella organization that advises state medical boards, published recommendations on physician wellness and burnout,5 some of which directly relate to licensing applications. We reviewed the consistency of medical license applications with those FSMB recommendations.
In July 2020, publicly available initial medical license applications from 50 states in the US; Washington, DC; Guam; the Northern Mariana Islands; and the US Virgin Islands (referred to as states hereafter) were obtained.
Of 10 FSMB recommendations to state medical boards,5 4 were evaluable in license applications (eTable in the Supplement). These recommendations included “only if impaired” (if mental health questions are asked, they are limited to conditions resulting in impairment), “only current” (if mental health questions are asked, they are limited to questions about conditions within the last 2 years), “safe haven non-reporting” (if mental health questions are asked, safe haven nonreporting is offered [ie, allowing physicians to not report diagnoses or treatment history if they are being monitored by and are in good standing with a Physician Health Program]), and “supportive language” (inclusion of supportive or normalizing language regarding seeking mental health care). If no questions were asked that could require disclosure of a mental health condition, the application was coded as consistent with the first 3 of these recommendations.
Data from each application were coded for consistency with each of these 4 recommendations by 2 authors (I.E. and K.H.), with discrepancies resolved by a third author (D.S.-K.). Each state received an overall score for consistency ranging from 0 (consistent with none of the evaluable recommendations) to 4 (consistent with all evaluable recommendations). Data related exclusively to substance use were excluded from our analysis.
Initial medical license applications from all 54 states were reviewed and included in the analysis. Thirty-nine (72%) were consistent with the “only if impaired” recommendation, 41 (76%) with the “only current” recommendation, and 25 (46%) with the “safe haven non-reporting” recommendation. Seventeen states (31%) asked no questions that could require disclosure of mental health conditions and thus were included in the consistency counts for these 3 recommendations. Only 8 states (15%) were consistent with the “supportive language” recommendation.
Scores ranged from 0 to 4. Five states were inconsistent with all recommendations. Only 1 state was consistent with all recommendations. The mean consistency score was 2.1 (SD, 1.1) (Figure).
State medical boards varied in their consistency with FSMB recommendations regarding physician mental health on initial license applications. Many states did not ask questions about mental health diagnoses or asked only about current impairment, which suggests improvement since previous reports. For example, in a 2017 report that examined 51 initial license applications, 21 states (41%) limited questions to current conditions with impairment.4
Despite this progress, in most states, recommendations from the FSMB have not yet been fully adopted. Consequently, medical license applications may continue to deter physicians from seeking mental health care. With the COVID-19 pandemic increasing the mental health care needs of physicians, barriers to help-seeking pose an even greater threat to physician wellness.6
The primary limitation of this study was that only initial license applications were assessed. Although prior work suggests that most states that are consistent with recommendations on initial applications are consistent on renewal applications,4 future work should include evaluation of these applications as well.
Corresponding Author: Ariel Brown, PhD, The Emotional PPE Project Inc, 15 University Rd, Arlington, MA 02474 (firstname.lastname@example.org).
Accepted for Publication: February 8, 2021.
Author Contributions: Dr Saddawi-Konefka had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Barrett and Gold are co–senior authors and have done equal work in creation and execution of this project.
Concept and design: Saddawi-Konefka, Brown, Barrett, Gold.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Saddawi-Konefka, Brown, Barrett, Gold.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Saddawi-Konefka, Brown, Eisenhart.
Administrative, technical, or material support: Saddawi-Konefka, Brown, Hicks, Barrett.
Supervision: Saddawi-Konefka, Brown.
Conflict of Interest Disclosures: Dr Brown reported being an employee and shareholder of Sage Therapeutics. No other disclosures were reported.