While medical regulation supports the medical profession to fulfill its social contract with society, regulation for providers with serious mental illnesses is a particularly complex topic. Conventional framing describes medical regulation as protecting the public from incompetent and unfit providers. This framing of the public versus providers implies that providers do not belong to the public and therefore, do not need protection. Recognizing that physicians are humans with their own patienthood and illnesses, this article attempts to take a nuanced exploration into how disability may allow us to identify and address barriers for providers at risk of workplace impairment, such as those with serious mental illness. To date, physician impairment within medical regulation is largely understood through the medical model of disability which views disability as a problem inherent to an individual. This model neglects the ways in which unaccommodating or harmful work environments contribute to impairment. The author, a bipolar physician, provides personal narratives to unpack the duality of experience as a vulnerable member of the public and a provider deemed at risk for impairment. He proposes local and structural solutions to address some of the issues in medical regulation regarding providers with serious mental illness.

The medical profession fulfills a social contract with society: in exchange for a monopoly over the practice of medicine, autonomy, status, and financial rewards, society demands professional competence, integrity, and promotion of the public good.1  Regulation, the process by which physicians and other healthcare workers are evaluated on their competency to practice medicine safely, occurs on at least four levels: (1) by governmental organizations, (2) by professional organizations, (3) by employing institutions, and (4) by the physician themselves.1,2  Practices and procedures permitting entry to the profession have largely been built by the profession as opposed to externally overseeing agencies.3  In the United States, once a medical license is issued by a state medical board, evaluation of competence typically only occurs after a concern for incompetence has been raised. In assessing competence or fitness for practice, regulatory structures must determine when a person has—or is at risk of—violating the standards for the profession.

Medical regulation for providers with serious mental illnesses—defined as a mental, behavioral, or emotional disorder, which substantially interferes with or limits one or more major life activities—is a particularly complex topic.4  Mental health challenges are highly prevalent among providers5  and serve as a potential cause for impairment in physician performance. Overly punitive licensing, credentialling, assessment, and remediation processes with respect to mental health challenges may discourage providers with from seeking help for their own mental health, ultimately worsening public good.6  Insufficient guardrails for impaired providers simultaneously threatens public good. As a bipolar nephrologist, I argue that the current systems of medical regulation do not optimally balance the forces of safety and accountability for providers with serious mental illness.

A more nuanced understanding of disability may allow us to identify some of the individual and structural barriers facing providers as risk of workplace impairment, such as those with serious mental illness. Almost 12% of health care professionals identify as having a disability during residency training, with disability prevalence that likely increases over time but has never been measured.7  Disability is defined as an impairment in one or more key daily functions. It is important to distinguish disability from workplace impairment. Workplace impairment in medicine refers to an inability to provide care in a safe and reasonable manner.8  Many people with active disabilities are still able to provide care in a safe and reasonable manner. Discrimination may occur if an individual faces increased scrutiny simply because of a health diagnosis or illness exacerbation in the absence of other concerns around competence or fitness in the workplace.

While writing this piece I had the opportunity to speak with leaders in medical regulation at both state and national levels as well as one medical director of a state physician health program (PHP). While informed by these experts, the opinions presented here represent my ideas alone. I speak from the perspective of an individual who is actively involved in research, advocacy, and policy change for doctors with disabilities.

Medical regulation often distinguishes the ‘providers’ from the ‘public.’ I problematize this distinction. Physicians are indeed afforded special privileges based on the social contract. The regulator's perspective is predicated on the special privileges given to physicians that differentiate them in important ways from members of the public. But as opposed to being seen as members of the public with special privileges, physicians are largely discussed as not belonging to the public. This framing influences the meaning of public good. Physicians doff their white coats, sit in clinics, and lie on the operating table just as other members of the public. Those policies and procedures which improve the public good must therefore also positively influence physicians. This language of contrast health care professionals against the public engenders an antagonistic relationship in which providers understand that they are not on the same team as the medical regulators whose goal is to protect the public. Reframing this dialogue could shift from a perspective of providers versus public to one where everyone benefits from safe, non-impaired providers.

The physician charter, a document which aims to describe medical professionalism in the new millennium, has been endorsed by over 100 professional medical organizations.9  The first sentence of this charter says that professionalism, “demands placing the interests of patients above those of the physician.” In addition to differentiating physicians from patients, this statement can be interpreted to mean that physicians have an unequivocal duty to put the health and wellbeing of patients above the health and well-being of themselves. The physician charter lacks even a single statement about physician wellness or self-care as a core component of professionalism. Recognizing that physicians are humans with their own patienthood and illnesses, there are likely many instances in which the demands of the physician should be prioritized equally or above patient interest. Provider-patients face conflicting messaging about what it means to be a good doctor and a good patient.10,11  Imagine a provider who struggles with mental illness, who has a major life stressor, and feels at risk of decompensation. This individual could either make it through clinic to serve their patients or cancel clinic for the day for an urgent mental health appointment at the cost of patients, some of whom may have waited months for their appointment. True professionalism, in an alternative perspective would advocate to prioritize the provider's well-being and advocate against the short-term public good. Instead, it would recognize that conditions such as unmanaged mental illness could impair patient care in the long run. As members of the public, physicians’ physical and mental health would be seen as goals in and of themselves, as opposed to physician wellness solely being a goal because its benefit to others in society.

Physicians with serious mental illness often simultaneously face challenges as both a patient and a physician-patient with a stigmatized health condition. The following section draws on my personal narrative, as a licensed physician who openly discusses practicing medicine with bipolar disorder.12  I then examine opportunities to improve the current model of medical regulation.

There are few groups who are more multiply impacted by the policies and practices of medical licensing boards than the mentally ill physician-public. Only five years into physicianhood, I have been repeatedly caught in the crosshairs, harmed by the policies intended to protect me as a member of the public and failed by those intended to protect me as a provider.

I have been psychiatrically hospitalized multiple times over the last 15 years, each time for being a danger to myself due to depression. When involuntarily admitted, I am stripped of most of my decision-making agency. Those providers licensed by the medical board hold an enormous amount of power over my life. I cannot elect to leave; at times, medications can be given against my will. The word of providers is consistently believed above the word of patients. Problematic providers cause direct harm to patients. They have to me.

Once during an admission following a suicide attempt, my treating physician told my outpatient providers that I had not been taking my medications before I came to the hospital. This information was unequivocally false. I had blood lithium levels from my admission to disprove this. My outpatient doctors could not see this data. This and other information was wielded against me to demonstrate that I was not being truthful and therefore still ill and needed to remain in the hospital. In ways that are beyond the scope of this piece, this doctor pitted me against my outpatient providers. My psychiatrist and therapist who had both cared for me for years, did as most doctors do: they believed my treating clinician instead of me. This doctor leveraged their physicianhood and my patienthood and used it to confine me as an inpatient for longer.

Months later, my own therapist discovered that this clinician had recently been disciplined by the state medical board but was still allowed to practice. I searched their name and found the state medical bulletin listing their disciplinary action: “Physician has a condition affecting [their] ability to practice medicine safely. Probationary license issued, placed on three years’ probation with terms and conditions including, but not limited to, obtaining medical treatment, and prohibited from engaging in the solo practice of medicine.” Even in a large city, healthcare can be a small world: I happened to have colleagues who worked with them who told me about other problematic behavior from this physician. I have no desire to attack that physician. I do not know for certain that their previous impairment was the cause of my concerns. However, I did and still do feel failed by the state medical board and my own providers who were supposed to protect me as a vulnerable member of the public.

While physician patients such as myself have immense privilege, when psychiatrically hospitalized we too are incredibly vulnerable. If my state medical board knew that someone was unable to practice medicine safely, how could they allow this person to continue to practice medicine in such a high stakes environment where the patients have almost no agency to challenge their clinicians? My first response was anger. I wanted punishment and retribution for being harmed. I wanted them to never practice medicine again.

Soon after discharge, I would experience the contrasting side: a physician considered to be at risk of impairment because of my bipolar disorder. After being discharged from the hospital, I completed a partial hospitalization program. I was cleared by the program's therapist and psychiatrist to return to work. I assumed that my transparency about my illness, my strong work record, and my appropriately taking sick time when I felt that I would not best care for patients would be considered signs of good insight and judgement, of being reasonably capable of determining when my illness might result in unsafe care. My assumptions were wrong, I was assumed unfit until proven otherwise.

I was told I was being sent through fitness for duty to ‘protect me’ from the state medical board. By participating in a so-called diversion program, my institution claimed that they were preventing the more nefarious state medical board from jeopardizing my license. Despite being under constant psychiatric care for the preceding decade, I felt coerced into reliving dark experiences from my childhood with an evaluator who held my career in their hands. I completed the evaluation and the drug tests. There was never a single instance of concerning performance or behavior. Still, I was forced to agree to specific treatment recommendations if I wanted to return to work. Simply being bipolar seemed to warrant sanctions in medicine.

I believe I am a better kidney doctor because of my bipolar disorder. I question whether regulators consider how the presence of a condition can be an asset and not just a liability. It turns out that a lot of patients with kidney disease also have mental health conditions! Many people's kidney disease is directly due downstream consequences of uncontrolled mental illness. I disclose my bipolar disorder in moments where I feel it will add to my patients’ care. I draw on my bipolar experiences every day in my provision of care for the underserved.

Interestingly, despite my active mental illness, I have never interacted directly with any state medical board beyond applying for my medical license. I have worked in two states, have answered all licensing questions honestly, and have gotten full licenses both times with no issues. To my understanding, no supervisor, peer, or patient has ever been concerned that my mental illness has interfered with my ability to provide safe patient care. As someone who recognizes the reality of my health condition, I must always be vigilant of signs that I may not be safe to work. As someone who has learned how to appear ‘normal,’ I know that my personal community and I will notice my warning signs far before my workplace could. The lives of my patients and my own life are reliant upon my help-seeking.

Physician impairment within medical regulation is largely understood through the medical model of disability. The medical model of disability views disability as a problem inherent to an individual due to biologic, genetic, or physical factors within a person.13  Solutions aimed to address impairment in the medical model of disability focus on fixing the issue with the individual. The current medical model orientation is particularly true for providers with a history of substance use disorder. In contrast the social model of disability views disability as a feature created by an unaccommodating environment.13  The social model says that in an appropriately accommodated environment, disability would not exist. Solutions in the social model focuses on structural changes which can prevent disability or physician impairment

The dialectical model views disability from both the medical and social lens. This model acknowledges that certain individuals may possess some intrinsic factors which predispose them to disability and simultaneously that some environments mays worsen or provoke disability.14  Solutions aimed to prevent and address disability through the dynamic lens looks at interventions at both the individual and structural level. Medical regulation is currently strongly oriented to address workplace impairment via the medical model of disability. It is currently easier to remediate the problematic, impaired provider as opposed to the reforming of the system or institution that contributed to the provider resulting as such.

The Americans with Disability Act (ADA) should serve as the floor of protections, as opposed to the ceiling for physicians with disabilities. Some leaders at the state and federal level are pushing to acknowledge the social environment as a key determinant of physician mental health and physician impairment. In 2018, the Federation of State Medical Boards issued recommendations that medical licensing questions align with the ADA recommendations to ask only about current impairment as opposed to history of impairment. The movement gained significant momentum following the tragic suicide of Dr. Lorna Breen during the COVID-19 pandemic. Dr. Breen's death was not in vain as her family supported the creation of the powerful advocacy and lobby organization the Dr. Lorna Breen Heroes’ Foundation (https://drlornabreen.org/). In recent years, many states have changed their licensing questions (recent estimates suggest that over half of states now have ADA compliant licensing questions). The battle is not won: even in those states who now follow ADA recommendations for licensing questions, many employers and credentialing entities continue to ask credentialing questions which are in violation of the ADA.

Our system has made progress and still does not do enough to encourage help-seeking. Effective state medical boards rely on trusted and independent physician health programs. Trust and independence between the PHP and medical board are interrelated and essential. When a state medical board can rely on their PHP, they are able to offer autonomy to the program which allows treatment for impairment to be as decoupled as possible from licensing. To the extent possible, decoupling of treatment for impairment and licensing encourages help-seeking. For example, in some states the PHP may be required to report positive toxicology testing or return to substance use to the state medical board, whereas in other states, the PHP is trusted to manage these matters (while also protecting patient safety) within the reasonable degree of confidentiality of the program. The possibility of forfeiture of confidentiality in the event of a positive test or return to use discourages help-seeking and self-referral and almost guarantees that health professionals will only come forward for help when others have reported them, or they have no other potential solution. We must work to understand and mitigate the threats for identity groups who are potentially uniquely threatened by our medical regulation policies. For example, physicians who are international medical graduates on work visas may be hesitant to seek help because of the risk of losing one's visas if one's job status changes.

I, along with colleagues, have previous published recommendations for how to improve physician fitness assessments.6  These recommendations include limiting the scope of investigations, eliminating conflict of interests, ensuring clinical excellence of evaluators, creating a trauma-informed equitable process, mandating external oversight, and ensuring continuous quality improvement. Medical regulators should have a responsibility to encourage individuals to seek care outside of the medical regulation pathway whenever possible. Haunting stories of negative experiences should be taken seriously as they may illuminate untapped opportunities for improvement.15 

To my knowledge and the knowledge of our informants, state medical boards and institutions do not provide publicly accessible recommendations for accommodations that providers may adopt to prevent impairment. Actively publicizing accessible resources encourages individuals who are struggling to request work accommodations without having to disclose their underlying condition. Accommodations (such as leave for work for medically necessary treatment) may help prevent individuals arriving at the point of workplace impairment. It is not the mere presence or absence of illness that matters, but also the individual capacity for self-assessment as well as accessibility of support structures that are in place. When the physician has reasonable accountability measures in place there is often little need for the regulator to be involved. PHPs can and do serve as an interim accountability measure during the period when physicians are also building an autonomous accountability structure.

The activities of state medical boards are guided by the executive and judicial branches of government: this is beyond our scope. However, the concept of transparency and visibility is critically important and likely influences lobbying and legislation around these topics. In the United States, medical regulation is made of a network of interconnected state medical boards. Many physicians are licensed in multiple states. Medical regulators are only as strong as their weakest link: policies in one state intended to encourage help-seeking may be neutralized by other states with policies which discourage help-seeking. Anecdotally, as I have presented across the country, changes to licensure questions are largely unknown by the physicians in those states. Transparency about the process of evaluation of impairment creates trust for those considering reporting and decreases distress for those being evaluated. Patient advocacy groups should demand medical regulators report complaints within their processes and how these structures have improved. Finally, public stories of those who have benefited from physician health programs are needed. This will challenge the stigma of impaired providers and notion of recovery.

It has been over four years since my last psychiatric hospitalization. I continue to live with bipolar disorder. I am fortunate to now work in a space where I can ask for help, increase my mental health support, change my medicines, and adjust my schedule in the moments where I begin to struggle. In this environment, I think I am a good doctor. I had a patient who struggled with his mental health which was influencing his ability to take his kidney medications. I shared that I too struggled to take medicines each night because they reminded me of my own past attempts to harm myself but said that the impact of not taking my meds was worse for me. I reflected after the appointment, unsure if I had shared too much. The next time I saw this patient, he said to me, “I knew there was something about you that was different, and I couldn't put my finger on it until you shared last time.” He told me he appreciated having a doctor who actually understood what he was going through. I appreciated having a patient who understood what I was going through too.

The author would like to acknowledge the three directors of state medical boards, two individuals from the Federation of State Medical Boards, one director of a state physician health program who he spoke to in gathering information for this piece. He would like to specifically identify Dr. Christopher Bundy, Mr. David Johnson, and Dr. Lisa Meeks for their feedback on versions of this article. The thoughts presented in this article do not represent the individuals herein acknowledged and instead solely represent the thoughts of the author.

1.
Cruess
SR
,
Cruess
RL.
Professionalism and medicine's social contract with society
.
Virtual Mentor
.
2004
;
6
(
4
):
185
188
.
doi:
10.1001/virtualmentor.2004.6.4.msoc1-0404
2.
Madara
JL
,
Burkhart
J.
Professionalism, self-regulation, and motivation: How did health care get this so wrong?
JAMA
.
2015
;
313
(
18
):
1793
1794
.
doi:
10.1001/jama.2015.4045
3.
Nasca
TJ.
Professionalism and its implications for governance and accountability of Graduate Medical Education in the United States
.
JAMA
.
2015
;
313
(
18
):
1801
1802
.
doi:
10.1001/jama.2015.3738
4.
National Institute of Mental Health: Mental Illness
. Published 2024. Accessed October 12, 2024.
5.
Rotenstein
LS
,
Ramos
MA
,
Torre
M
, et al.
Prevalence of depression, depressive symptoms, and suicidal ideation among medical students a systematic review and meta-analysis
.
JAMA
.
2016
;
316
(
21
):
2214
2236
.
doi:
10.1001/jama.2016.17324
6.
Bullock
JL
,
Kimberg
LS
,
Meeks
LM.
Trauma-informed transformation of evaluation and licensure for physicians with mental illness
.
J Hosp Med
.
2021
;
16
(
7
):
434
437
.
doi:
10.12788/jhm.3648
7.
Pereira-Lima
K
,
Meeks
LM
,
Ross
KET
, et al.
Barriers to disclosure of disability and request for accommodations among first-year resident physicians in the US
.
JAMA Netw Open
.
2023
;
6
(
5
):
3
11
.
doi:
10.1001/jamanetworkopen.2023.9981
8.
Physician Illness, Disability, and Impairment: Differentiation and Responsibility
.
Federation of State Physician Health Programs
.
https://www.fsphp.org/assets/docs/2023/FSPHP Physician Illness Disability Impairment APPROVED ON JULY 19.pdf. Published 2022
. Accessed September 1, 2024.
9.
Medical Professionalism in the New Millennium: A Physician Charter
.
ABIM Foundation
.
doi:
10.7326/0003-4819-138-10-200305200-00012
10.
Stergiopoulos
E
,
Fernando
O
,
Martimianakis
MA.
Being on both sides”: Canadian medical students’ experiences with disability, the hidden curriculum, and professional identity construction
.
Acad Med
.
2018
;
93
(
10
):
1550
1559
.
doi:
10.1097/ACM.0000000000002300
11.
Stergiopoulos
E
,
Martimianakis
MA.
What makes a “good doctor”? A critical discourse analysis of perspectives from medical students with lived experience as patients
.
Med Humanit
.
2023
:
613
622
.
doi:
10.1136/medhum-2022-012520
12.
Bullock
JL.
Suicide – Rewriting my story
.
N Engl J Med
.
2020
;
382
(
13
):
1196
1197
.
doi:
10.1056/NEJMp1917203
13.
Jain
NR.
Frameworks for Inclusion: Toward a Transformative Approach
. In:
Disability as Diversity
. Vol
1
.
Cham: Springer International Publishing
;
2020
:
1
13
.
doi:
10.1007/978-3-030-46187-4_1
14.
Einbinder
J.
The Dialectical Model of Disability: Society Impacting Conditions, and Vice Versa
. . Accessed October 12, 2024.
15.
Hill
AB.
Breaking the stigma – A physician's perspective on self-care and recovery
.
N Engl J Med
.
2017
;
376
(
12
):
1103
1105
.
doi:
10.1056/NEJMp1615974

Funding/support: The author receives funding support from an NIH training grant, #TL1DK143270.

Other disclosures: The author is the co-director of the Docs with Disabilities Initiative.