Avedas Donabedian, recognized as one of the thought leaders of the modern quality movement, characterized a quality system as one that has alignment of structures, processes, and outcomes.1  Without such alignment, a healthcare system is destined to have both untoward variation and undesired outcomes.

In the current issue of JMR, Giddings and colleagues2  report the results of their literature review regarding how medical licensing systems query physicians regarding their health and potential impact on patient safety to determine whether that impairs reporting the health issue on licensure applications. The manuscript is timely and impactful in both its results and as an example of misalignment of structures to desired outcomes.

Surprisingly, or perhaps not, only 9 published and peer-reviewed articles addressed the subject according to the authors. As they note, there are published evidence-based guidelines about how to ask questions about self-reported health issues and their (again self-reported) potential impact on safe clinical practices. The review highlights often significant medical licensing system variation from these guidelines. As a result, the authors cite evidence that physicians are hesitant to self-report or seek therapeutic care. From a quality system perspective, the structure (questions that query health conditions) and processes (providers to seek help or recognizing a patient safety issue) are misaligned to the outcome desired, which is physician well-being and patient safety. A system that shows misalignment needs to be adjusted, but a system that may also unintentionally promote bad outcomes needs to be changed.

Approximately 57% of physicians are reporting symptoms of burnout2 ; physician suicide, substance abuse, and divorce rates are alarming. Feeding the stress fire have been all the burdens and strains of the current medical system that have been discussed without resolution ad nauseum. While the COVID-19 pandemic has highlighted these issues, the pandemic has also highlighted and accentuated an issue that has been brewing but still relatively taboo as a discussion for decades.

The authors conclude that there should be a review and rewording of how the health conditions are self-reported on license applications. This should be more than an exercise in wordsmithing. Those who suffer mental health and other forms of psychological strain are prevalent and pervasive. If not addressed early and thoroughly, physical and mental strains can only worsen and negatively impact outcomes. Would any physician hesitate to refer a patient for mental health or counseling if that patient presented to them?

Physicians are patients also. The licensing system should look at novel approaches that support and encourage not just physician reporting of physical and mental health issues that may have already affected patient care but rather promote and align the application structures, so the early recognition, support, and treatment, if appropriate, occur without hesitancy. Desired outcomes can then occur. Waiting until impairment becomes flagrant, as may be occurring with current licensure questions, does no good for anyone.

“Evaluating the quality of medical care”: Donabedian’s classic article 50 years later
Milbank Q.
Do medical licensing questions on health conditions pose a barrier to physicians seeking treatment? A literature review
J Med Regul