Are State Medical License Applications Harming Clinicians?

My Uber driver studied me in the rearview mirror as we zipped across the open Colorado landscape.

“What brings you to Denver?” she asked. “You look too young to be here on business.”

Five stars.

I told her I flew here for my profession’s biggest conference and, for the next week, her city would be swarming with PAs. She considered this for a moment and then nodded.

Research in Action Presentation
at AAPA 2019 in
Denver, Colorado

“I like medical conferences,” she said. “They’re good for our economy.”

She was right, of course. What city wouldn’t want the occasional flood of clinicians? We bring disposable income and continuing education expense funds ripe for the city’s best hotels and restaurants. When it comes to career paths, healthcare has its perks.

But there’s another prominent feature of healthcare professions, one that nobody mentions at job fairs or in the pages of Forbes magazine. Just by entering this industry, healthcare workers have a higher risk of mental illness. And it’s one of the reasons I flew to Denver.

The statistics are staggering. Depression has a prevalence of about 8% across the entire US population. But for inpatient nurses, that number jumps to 18%. Medical students suffer depression at an annual rate of 27%; for resident physicians, that number climbs to 29%. And things don’t seem to improve after training is complete: 30% of practicing surgeons say they’re depressed.

Nurses and physicians also endure higher rates of suicidal ideation, as well as attempted and completed suicide. This effect is especially pronounced in female physicians, who are many times more likely to die from suicide than women in other fields.

The causes of these devastating rates of mental illness in healthcare workers are uncertain. The selection of high-performing, success-driven individuals may play a role. The stress and sacrifice of education and training may take a toll on clinicians and damage their interpersonal relationships and support networks. The work environment itself could represent a major factor, with routine exposure to high stress, long hours, futile care, frequent tragedy, and interpersonal abuse.

While there is currently no published data on the rates of mental illness in PAs, it is reasonable to suspect the rates resemble those of other healthcare professions. After all, PAs experience many of the same factors affecting nurses and physicians. It’s unlikely the PA career path is somehow protective.

Just by entering this industry, healthcare workers have a higher risk of mental illness.

Making a dire situation worse, healthcare workers are less likely than other professions to seek mental health care when they need it. While several reasons may exist to explain this, multiple research studies find a recurring theme: the fear of disclosing a mental health diagnosis to state medical boards.

State medical license applications ask broad and invasive questions about an applicant’s mental health. This screening process ostensibly exists to keep impaired or unqualified individuals from practicing medicine and putting the public at risk. But when it comes to mental health, these questions often stray beyond the mandate of public safety.

Many questionnaires, for example, do not ask applicants if they are impaired by a mental illness. They ask if applicants have received a mental health diagnosis or treatment. And they don’t necessarily focus on current or recent issues, either. They often pry many years into the past.

This sweeping line of questioning reinforces a dangerous myth: that licensed healthcare workers have a “permanent record,” one that could follow them for life and would be soiled by any mention of mental health treatment. I was shocked to learn that—despite no evidence that these broad, probing questions make patients any safer—the vast majority of physician license applications ask about applicants’ mental health histories beyond current, impairing conditions.

And I wanted to know if my profession had the same problem.

That’s how I found myself headed towards downtown Denver on a mission. I had performed the world’s simplest research study: I sat on my couch and spent countless hours reading all 51 state license applications for PAs. And I had my answer.

But the results did not reassure me.

State Medical Board License Applications for Physician Assistants
This map represents the mental health-related questions asked by medical boards for PA licensing in each state. Dark red states asked questions beyond conditions causing impairment and asked questions beyond current or recent conditions. Light red states violated one of these two criteria. Gray states either omitted mental health questions or violated neither criteria.

At the AAPA 2019 conference in Denver, I stood on stage and told the audience what I found: just like our physician colleagues, the majority of state medical boards ask PA license applicants about mental health issues that are neither current nor a source of impairment.

In fact, 65% of PA state license applications stray beyond the strict mandate of protecting the public. They ask questions about mental health problems that may be in the remote past, or they ask about diagnoses and treatment that may have never represented a danger to patients.

This practice may contribute to PAs avoiding the mental health care they need. If PAs are anything like physicians, they are deeply concerned about their ability to obtain a license and see mental health care as potentially career-damaging. Even if medical boards never deny a single license on the grounds of a mental health diagnosis, these questions and the perception they create present a danger.

We still face a mountain of unanswered questions. What is the rate of mental illness among PAs and what is our perception of how a diagnosis might affect our careers? Are states with medical boards that ask more invasive questions safer than those that ask narrow questions? What about states that ask no questions at all? And perhaps most important: would changing these applications shatter the stigma that seeking care tarnishes a career?

The biggest change in clinicians’ attitudes towards mental health probably won’t come from a medical board meeting or even a legislative battle.  It will require open, honest discussion about the problems we face. It will come from an understanding that burying our problems only make them worse.

And it will start with individuals reaching out to those around them, withholding all judgment, and offering unconditional support.

The vast majority of those who think about hurting themselves find help, get better, and are glad they did. If you have thoughts of harming yourself, there is hope and there is help. The first thing you should do is call The Suicide Prevention Lifeline at 1-800-273-8255.

We care about you and want you here.

Author: Harrison Reed

Harrison Reed is an emergency medicine and critical care physician assistant (PA-C) in Baltimore, MD. He is the Associate Editor of the Journal for the American Academy of PAs (JAAPA) and regularly contributes to the New England Journal of Medicine's In Practice blog. He is the creator and editor of The Contralateral.

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