The primary role of state medical boards is public safety. This involves protecting the patient, the doctor-patient relationship, and assessing and monitoring a physician’s competence and fitness for duty, including medical illness, mental illness and addictive disease. Recent tragedies involving medical students, residents and practitioners have raised the level of concern and further inquiry. It’s about time.
I have worked with Impaired Health Professionals as a researcher since Yale. But, in my tenure as a Florida professor, researcher and department chair, I have witnessed anesthesiologist overdoses as well as physician and medical student impairments. I have seen first-hand how hyper-stress and the formidable challenges of medical education and clinical practice have impacted my students, fellows and colleagues, at all stages of their careers.
Stressors left ignored nearly always intensify, due in part to a culture that discourages acknowledgment of high stress, mental illness and Substance Use Disorder (SUD).
As much as we have learned about the role of age of onset or genetic contributions to psychopathology, the tipping point of professional impairment is usually not a single stressor; nevertheless, the emotional and physical demands inherent in medical education are well known. Given the well-documented success of specialized intervention and recovery programs for physicians impaired by SUD and mental illness, we can certainly address stressors within the academic culture. We can also buttress the assessment and treatment process. To wit, a recent investigation by Gold, et al., (2013) reviewed a cross-section of applications for licensure from all 50 states and the District of Columbia.
The results revealed numerous disparities in how states approach the identification of impaired evaluation process. For example, 43 states asked questions about mental health conditions, 43 asked about physical health conditions and 47 about substance use. Additionally, states were more likely to ask for history of treatment and prior hospitalization for mental health and substance use, compared with physical health disorders. This is most likely a result of the increased liability associated with impaired physicians and patient risk.
Among the states that queried candidates about their mental health, 23 states limited their query to a physician’s knowledge of disorders that cause functional impairment, whereas six states limited their assessment to current problems only.
Why Does This Matter?
While most state licensing boards ask about mental health conditions or treatment history and outcomes, half limited queries to disorders that cause impairment. This of course erroneously insinuates that SUD is a secondary condition caused by another. This archaic belief kept untold masses of addicts from getting the “primary” treatment they required. Moreover, large disparities in how state licensing boards differ in their assessment of mental health issues raise important ethical and legal questions about when and how to evaluate a physician’s ability to continue his/her education or practice. As a result, some states inaccurately diagnose impairment caused by SUD, mental illness or both.
Missed diagnosis leads to inadequate treatment and ultimately failure, posing a real threat to the physicians themselves, their patients and the public. Lastly, stigma has kept thousands of doctors and medical students from seeking the help they require. When a treatment opportunity is missed, the results are often disastrous. Remember that the mortality rate for untreated depression and SUDs is at unprecedented levels. Between 15-20% of U.S. adults with untreated depression kill themselves. Certainly, chronic stress is a proven predictor of suicidality.
A Sliver of Hope
The Federation of State Medical Boards (FSMB) has recently stated that licensure events offer a golden opportunity to help physicians who may be sick, emotionally overwhelmed, at risk or currently impaired. Yet because of the stigma associated with mental illness and SUD, most are fearful of seeking help. Standardizing at least part of the process by using evidenced evaluative approaches can save careers and, more importantly, save lives.