Do Medical Licensing Questions on Health Conditions Pose a Barrier to Physicians Seeking Treatment? A Literature Review

Physician health is strongly linked to patient health outcomes and safety. Unaddressed health problems may hinder a physician’s ability to function effectively in the workplace, which ultimately interferes with their capacity to engage safely in patient care.¹  The COVID-19 pandemic has had a substantial impact on physician physical health, mental well-being and livelihood.^2,3  The resulting impact of the pandemic, along with the short and long-term health implications for physicians, have uniquely highlighted both long-standing and novel barriers for physicians in accessing care. Now more than ever, it is important to understand and identify barriers that may reduce the likelihood of physicians seeking help when experiencing negative effects from health conditions. Addressing these barriers remains vital to optimizing physician health and improving the overall functioning of our healthcare system, especially during times of pandemic.

Regulatory bodies such as the College of Physicians and Surgeons of Alberta (CPSA) play a significant role in keeping physicians accountable and ensuring safe and effective medical care is provided to the public.⁴  In protecting public interest, CPSA must maintain and enforce appropriate standards that continually ensure physician competence. One of the ways this is currently achieved is through initial and renewal registration questions that ask physicians to self-report health issues that negatively impact their current or future ability to practice effectively. Below are the questions posed by CPSA on their 2021 registration and renewal forms.

• Do you presently have a physical, cognitive, mental and/or emotional condition that is negatively impacting your work, or is reasonably likely to negatively impact your work in the future?

• In the last ten years, have you had a physical, cognitive, mental and/or emotional condition that, were it to reoccur would, or would be reasonably likely to negatively impact your work in the future?

• Do you presently have a physical, cognitive, mental and/or emotional condition that is negatively impacting your work, or is reasonably likely to negatively impact your work in the future?

• Since you last completed an application or annual renewal form for CPSA have you had a physical, cognitive, mental and/or emotional condition that has not been previously reported to the College, and that were it to reoccur would, or would be reasonably likely to negatively impact your work in the future?

Concurrently, with the privilege of self-regulation and in keeping with the mission of guiding the medical profession to protect the public, the CPSA also has a responsibility to physicians to mitigate barriers to self-reporting. This includes promoting a culture that supports and responds effectively to physicians’ needs. Therefore, when a physician reports a condition, an assessment process is undertaken that determines if and what accommodations are needed to address the unique needs of the physician. It is rare that a physician’s work is impacted in a manner that requires removal from the workplace. Additionally, at the forefront of the process is the commitment to maintaining standards of confidentiality for all physicians’ health information. For this reason, not only is this information kept away from the public, but it is also fire-walled away from all other parts of the CPSA. The careful balance between ensuring physician competency to uphold public interest, and responsibility to the physician workforce, is a critical inflection point for medical regulatory agencies across Canada and internationally.

In 2012, the University of Alberta Faculty of Law’s Health Law Institute (HLI) released a report entitled “Physicians with Health Conditions: Law and Policy Reform to Protect the Public and Physician-Patients.” This report made recommendations to reduce barriers physicians may face in accessing treatment, and increase access to services while maintaining regulators’ legal, ethical, and professional obligations to the public.⁴  Although the report details the role of licensure questions in assessing and monitoring physician health to ensure public protection, it provides little insight as to whether these questions themselves serve as barriers to attending to physician health. The questions above were based on the recommendations contained in that report.

Growing evidence suggests that licensure questions may act as impediments to seeking necessary treatment due to fears regarding confidentiality and how disclosure may affect licensure.^{5, 6, 7}  This presents a gap in understanding how health questions on application and renewal forms may contribute to the range of barriers that continue to exist. With the health effects of the pandemic and the increased likelihood of physicians needing various health services, it is essential to consider whether these questions may compromise the ability to self-report and seek care. This paper aims to better understand how self-reporting questions influence physician health and their willingness to seek care.

The objective of this literature review is to determine if the inclusion of the annual renewal questions on health conditions confers any benefit to physician health, and so to patient care, and whether they act as an impediment to physicians seeking medical care. The main questions are: is the best practice to preserve or remove renewal questions moving forward? If the questions are to be preserved, what form should they take? Were they to be removed, what would replace them to ensure CPSA’s duty to the public interest?

A list of relevant search terms was developed to capture vital aspects of the objectives. Key terms included all applicable words describing the:

• Population (physicians)

• Intervention (licensure questions, self-reporting questions)

• Outcome (health, health-seeking behavior, etc.)

The following inclusion/exclusion characteristics were used to determine article eligibility for this review.

• A study population consisting of practicing physicians or medical trainees

• Papers published from 2011–2021

• Papers published in English

• Articles not including new data—eg: opinion-only pieces

The eligibility criteria were left intentionally broad with no limits on the study type and methodology as the available amount of relevant literature on the topic was expected to be limited. Publication date was limited to papers from 2011–2021 to focus on data published subsequent to the Health Law Institute paper⁴  that helped inform the current CPSA initial and renewal licensure questions.

To identify relevant articles, a structured search strategy was designed. Key concepts of the questions were combined using Boolean terms. Using the combined terms, searches were conducted on the following online databases: Scopus, APA PsychINFO, Web of Science, PubMed, and MEDLINE from June to July 2021.

Relevant articles were identified using a multi-part screening process. The initial search results displayed were screened by the relevance of their title and abstract, followed by a full-text review. Papers included either focused on the impact of licensure questions on health/health behavior or on how licensure questions can be modified to minimize negative health consequences. Articles for which the title and abstract did not provide sufficient information to judge its relevance were considered in the full-text review. The reference list of relevant publications selected for inclusion was hand-searched to further identify relevant studies. The screening process was corroborated independently by two other reviewers.

The gathered articles were read in full, and data were extracted into a spreadsheet for inclusion in the review. Extracted information consisted of the title, article type, objective, methodology, results, and authors’ conclusion.

Lastly, as this review utilized only publicly available and published peer-reviewed articles, and no new data were collected, no ethical approval was sought.

A total of 1303 articles were reviewed for potential inclusion in this review. In the first step, 1281 studies were excluded based on title and abstract, leaving 22 articles to be assessed via full-text review for eligibility. Eight studies were selected to be included based on a full-text review, and 1 additional study was found in the reference lists of the included studies. All 9 were primary quantitative studies that used surveys, questionnaires, or available information on application processes to determine the relationship between licensure questions and physician health-seeking behaviors^5–13  Six studies specifically sought to examine whether those experiencing mental health concerns were reluctant to seek treatment due to concerns of professional repercussions if required to report it on licensure applications.^5–10  The remaining 3 studies looked at the phrasing, uniformity, and compliance with non-discriminatory standards of licensure questions.^11–13 

Dyrbye et al looked at both initial and renewal application questions across 48 states in the US. Licensure application forms were coded on their consistency with policies and recommendations by the American Medical Association, American Psychiatry Association, Federation of State Medical Boards, and Americans with Disabilities Act (ADA).⁵  Questions were labelled as “consistent” if they did not inquire at all about mental health conditions or only asked about current impairments (within a period of 12 months or less) from a medical or mental health condition. Applications that asked about any previous history (ever) of impairment or mental health conditions that could affect or potentially impair one’s ability to practice medicine if untreated were not considered “consistent”⁵  Additional survey data on care-seeking behavior from a convenience sample of 5829 practicing US physicians was obtained. Results showed that reluctance to seek care was least prevalent among physicians practicing in states in which both applications were designated “consistent” (36.6%) compared with those practicing in states classified as only initial application “consistent” (43.2%), only renewal application “consistent” (41.0%), and neither application “consistent” (42.0%). A significant proportion reported reluctance even where questions were judged “consistent.”

In a similar study, 1058 New York physicians responded to a survey with questions that measured burnout levels and determined if reporting mental health on both initial and renewal applications would pose a barrier to seeking care.⁶  In survey responses, 57% of physicians were recognized as experiencing symptoms of burnout. Two-thirds of the physicians perceived being asked to report burnout on license applications as a definite barrier to receiving mental health care. Additionally, data showed that physicians experiencing symptoms of burnout were more likely to perceive reporting as a barrier to care (69%) compared to those not experiencing symptoms (64%). The same reluctance was reported in a third study that found only 6% of female physicians with a formal diagnosis or treatment of mental illness disclosed their state.⁷  When surveyed about personal care seeking behaviors, 75% agreed or strongly agreed that licensure questions asking whether a physician has ever had a mental health diagnosis or treatment impacted their decision to seek treatment.

This pattern was also identifiable in medical trainees. Aaronson et al sought to determine the barriers to seeking mental health treatment among residents across all specialties.⁸  They found that the primary professional concerns affecting residents’ and fellows’ decisions to seek mental health care were confidentiality (58%), the judgment of peers (55%), and licensure concerns (44%). Comparatively, another study found that 51% of medical students who perceived they had a mental health diagnosis stated they would not disclose this information on the state medical license application.⁹  Fletcher et al reported fear of stigmatization, fear of repercussions, and a belief that such disclosure was irrelevant were cited as the most common reasons for non-disclosure. Even with uncertainty as to whether their respective state licensing board requires mental health disclosure, 45% of medical students in a study conducted by Tamminga and Tomescu (2021) believed disclosing current mental health treatment or diagnosis could affect their license.¹⁰ 

Given the stigma associated with mental health issues, Gold et al examined whether medical licensing applications treated mental and physical health conditions differently and reviewed medical licensing applications for new applicants in the 50 states and the District of Columbia.¹¹  Questions about physical health, mental health, and substance use were identified and coded as to whether or not they asked about diagnosis and/or treatment or limited the questions to conditions causing physician impairment. Results showed that 43 of 51 states asked questions about mental health conditions, 43 of 51 about physical health conditions, and 47 of 51 about substance use. Though the differences in the type of questions asked were not significant, it was found that states were more likely to ask for the history of treatment and prior hospitalization for mental health and substance use, compared with physical health disorders. Among states asking about mental health, just 23 of 43 limited all questions to disorders causing functional impairment, and just 6 were limited to current problems.

Likewise, Jones et al examined medical licensure questions from each state and the District of Columbia pertaining to the mental health of applicants and discussed their validity under the Americans with Disabilities Act (ADA) standards.¹²  They found that only 18 of 51 questions from licensing bodies conformed with the ADA standards, while 32 of 51 questions fell outside the limits of those standards. Lincoln and Wagner did a similar study on state osteopathic medical licensing boards.¹³  They found 14 of 51 questions were out of compliance, 13 of 51 questions were of intermediate compliance (meaning not in compliance but close) and 24 of 51 questions were in full compliance with ADA criteria.

No studies were identified that sought to examine the impact of including health questions within the annual licensure application on the quality of patient care.

Physician professional regulatory bodies exist to protect the public by ensuring safe and competent medical practice through regulations, licensure applications, misconduct investigations, and discipline of physicians.⁴  The purpose of the questions posed in the initial and renewal application is to detect illnesses that can impair a physician’s ability to practice and treat patients effectively.⁴  Paradoxically, the findings of this review suggest that the very presence of health questions on applications for medical licensure or licensure renewal may influence the behavior of physicians suffering from mental and behavioral illnesses for which they might otherwise seek care.^5–10  This reluctance is seen as early as the medical school years and persists throughout residency to independent practice.^8–10  It was consistently observed in the reviewed studies that those experiencing higher symptoms of burnout are the least likely to disclose this.^5–7 

Mental health conditions are often associated with stigma, which may be further emphasized by any disparity in how mental health and physical health are treated in the medical licensing process.¹¹  The studies showing that many state licensing bodies did not meet the ADA standards when it comes to inquiring about mental health diagnosis also underscores this risk of stigmatization.^12,13  This presents a situation where questions meant to identify and support physicians with ill health or impairments may actually contribute to the exacerbation of those impairments.

Physician health is inextricably linked to patient outcomes, making imperative the appropriate and timely medical care for physicians. In their current form, the CPSA’s initial and renewal application questions do not meet the standards suggested in multiple reviewed papers.^5,12,13  According to Dyrbye et al ‘consistent’ application questions only asked about current impairment (within 12 months or less), or did not ask about mental health conditions at all.⁵  Lincoln and Wagner (2020) defined ADA-compliant questions similarly but with current impairment limited to a window of 2 years or less, while Jones et al (2018) added that “hypothetical impairment,” where physicians are asked about the potential for their illness to affect their future ability to practice, should be excluded.^12,13 

To address this, some jurisdictions are moving towards removing the health questions entirely from the annual renewal applications and simply including a reminder of the duty to self-report the relevant health conditions. Rather than removing the question, a modification to the question in a manner that fulfills a regulator’s duty to the public while minimizing any risk of harm caused to physicians could be considered. Following the standards highlighted earlier, new licensure questions that limit inquiries to current conditions could be phrased as such:

• Do you presently have a physical, cognitive, mental and/or emotional condition that is negatively impacting your work?

• Since you last completed an application or annual renewal form, have you had a physical, cognitive, mental, and/or emotional condition that has not been previously reported that is negatively impacting your work?

Rephrasing the questions as such changes it to be more congruent with the discussed standards. By placing the inquiry surrounding impairment in the context of patient care, focus is shifted away from mental health conditions themselves to competence and the capacity to provide care. Ultimately this should help reduce stigma associated with mental health and encourages treatment-seeking behavior among physicians. To determine the effectiveness of these questions, changes would need to be studied when implemented.

This review had several identifiable limitations. First, the limited availability of studies on medical licensing health disclosure questions resulted in a relatively small body of evidence to review. Second, all studies were performed on physicians or medical trainees in the US as there were no identifiable studies in the Canadian context. While there are some shared similarities with many state regulatory bodies, this still calls into question the adaptability of the proposed modifications to the licensure questions for Canadian regulators. Furthermore, many of the studies utilized in this report gathered data through surveys and questionnaires which, on its own, has several methodological limitations. Though many of the studies validated their survey questions, self-reporting can still be prone to numerous biases such as social desirability and recall bias. Additionally, there are limited data on the effectiveness of these questions in identifying truly impaired physicians and the protections they confer for patients. This gives rise to the question of whether the licensure process may be posing a barrier without knowing how effective it is in detecting how physician health influences risks to patients.

This review has identified medical licensure health disclosure questions as a barrier to accessing care for physicians. Further research examining the usefulness of the health licensure questions in identifying impaired physicians is needed to truly understand their relevance and impact. To reduce further stigmatization, medical regulatory bodies should consider modifying licensure questions to inquire only about functional impairments that currently affect a physician’s ability to practice safely. Doing so not only promotes patient safety and the delivery of quality health care but likely benefits the overall health of physicians, and the public.