Volume 9 Number 2
Health questions on medical licensure applications: effective or counterproductive? A systematic review
Quyen K. Lam, MD, and Jeremy Beach, MBBS, MD
KEY WORDS: health questions, medical licensure, physician health, medical regulatory authorities, stigma
Lam QK, Beach J. Health questions on medical licensure applications: effective or counterproductive? A systematic review.
Can J Physician Leadersh 2023;9(2):36-44
Objectives: Many medical regulatory authorities (MRAs) require their members and applicants to report information about their health on their medical licensure application and renewal forms. We wanted to determine whether this practice is effective in identifying physicians who have a health concern impacting their professional capacity and whether it influences members to seek treatment for their health concerns. Methods: A literature search was conducted in accordance with PRISMA publications standards. Results: From 7998 references found in all databases, after removal of duplicates and screening, five studies were included in this systematic review. None addressed the question of how effective health questions on licensure application forms are in identifying relevant health concerns. Stigma and fear of perceived ramifications of reporting mental health illness to MRAs were common reasons for physicians and medical students not seeking professional mental health care. Significance: MRAs who include health questions on their medical licensure applications should consider their effectiveness in identifying members who have health concerns that may impact their fitness to practise. Contrarily, these questions may deter members from seeking professional treatment for their own mental health. This is an important consideration, especially as burnout is prevalent among practising physicians and medical trainees.
KEY WORDS: health questions, medical licensure, physician health, medical regulatory authorities, stigma
Lam QK, Beach J. Health questions on medical licensure applications: effective or counterproductive? A systematic review. Can J Physician Leadersh 2023;9(2):
Medical regulatory authorities (MRAs) have a mandate to protect patients; this includes ensuring that their active regulated members are fit to practise medicine. As part of the process, some MRAs require reporting of information about certain aspects of physician health on licensure application forms. In the United States, concerns have been raised that asking these health questions might breach the Americans with Disabilities Act (ADA), as well as acting as a barrier to regulated members seeking treatment for their own health conditions.1,2 Similar concerns have been raised in other countries.3,4
Medicine is often considered a career with high expectations, attracting individuals who tend to be perfectionist, compulsive, and have a high drive.5 Occupational distress, including burnout and overwhelming exhaustion, is thought to be prevalent among practising physicians and medical trainees.6-9 Further, burnout, which comprises the core dimensions of exhaustion, depersonalization, and diminished professional efficacy,10 has been associated with self-reported medical errors11,12 and lower-quality patient care.13,14
Although several interventions have been suggested to reduce risk,15-17 it remains important for MRAs to identify physicians who have a health condition impacting their fitness to practise. However, it does not help protect the public if regulatory processes deter a regulated member from obtaining care for their own health conditions.
This paper aims to build on the work of a recent non-systematic review.4 We undertook a comprehensive systematic review to identify evidence about two issues: whether including health questions on licensure applications is effective in identifying physicians who may have a relevant health concern; and whether including such questions influences their decision to seek treatment for their own health concerns.
Figure 1. PRISMA flow diagram
A literature search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.18
Search strategy and study selection: A research librarian developed search strategies through an iterative process in consultation with the review team; it was then peer reviewed using the PRESS Checklist.19 Ovid MEDLINE ALL (including Epub Ahead of Print, In-Process and other non-indexed citations), Embase, APA PsycINFO, Web of Science (WoS) Core Collection, and Scopus were searched. The Ovid searches were performed on 22 Sept. 2021, and the WoS and Scopus searches on 23 Sept. 2021.
The search strategy used a combination of controlled vocabulary (e.g., “licensure, medical,” “physicians/lj [legislation and jurisprudence],” “disclosure”), and keywords (e.g., “medical permit,” “confidential,” “stigma”). Vocabulary and syntax were adjusted across the databases as needed. No search restrictions by time or language were applied. Results were downloaded and de-duplicated using EndNote version 9.3.3 (Clarivate Analytics, Chandler, AZ). An additional potentially relevant article was identified by reviewing the bibliographies of papers identified in the literature search. An update was performed on 26 April 2023, to ensure that no recent publications were omitted.
Publications were screened for relevance based on title and abstract (stage I) by two independent reviewers (QL, JB). The full text of retained articles was then reviewed (stage II) by the same two reviewers before selecting those for extraction. A third reviewer was available when required to resolve a tied outcome.
Inclusion criteria comprised: study population consisting of physicians, resident physician trainees, or medical students; considered initial or renewal MRA licensure forms; and included original data. Exclusion criteria comprised: non-medical professions; non-relevant focus of study (e.g., study not licensure-related, licensure questions not health-related); full text not available; or included no relevant original data (e.g., review articles, opinion statements, and editorials).
Ethical considerations: Because of the nature of the work undertaken, ethical approval was deemed not necessary.
Figure 1 illustrates the search process. The initial search resulted in 7998 references comprising 2422 from MEDLINE, 1579 from Embase, 135 from PsychINFO, 1399 from WoS, and 2463 from Scopus. After removal of duplicates, 5108 papers remained with titles suggesting they were potentially relevant.
Of these, 5025 were excluded after initial screening of titles and abstracts resulting in 83 full text articles for review. The full text of all but one of these was retrieved and reviewed. The reference for the article that could not be retrieved appeared to be incorrect and no links could be found to it elsewhere. Of the full-text articles reviewed, 77 were omitted as they did not meet the inclusion criteria or met the exclusion criteria, leaving five studies20-24 to be included in this systematic review (Table 1). Two articles were retrieved from the update completed in April 2023, but neither met the inclusion criteria.
All five identified studies20-24 were cross-sectional, based on research performed in the United States, and published between 2016 and 2021. Populations included medical students, physician mothers with an active medical licence within the last five years, and non-retired physicians who participated in a previously reported national survey. The overarching theme of all the studies was to determine what impact mandatory reporting of health conditions had on physicians’ or medical students’ self-reported reluctance to seek medical care. No studies attempted to address the question of how effective health questions were in identifying relevant health concerns.
Fletcher et al.20 invited 349 medical students enrolled in classes of 2019, 2020, 2021, and 2022 at the University of New Mexico to participate in a confidential electronic survey about their mental health throughout and before starting medical school; their willingness to seek mental health care; and whether they would disclose a mental health diagnosis on a licensing application to the New Mexico Medical Board (NMMB) or on the electronic residency application system. Half the students completed the survey and, of these, 36% reported a mental health condition before medical school. Of the respondents, 51% reported that they would not disclose a mental health condition on the NMMB licensure application, 21% said they would (28% were unsure). The top three reasons given for not disclosing to the NMMB were: fear of stigma (49.7%), belief that their condition was not applicable to performance or ability (46.3%), and fear of repercussions or inconvenience (45.7%).
Tamminga and Tomescu21 sent an anonymous survey to medical students at a private American medical school in Pennsylvania. Among other questions, they asked whether students had accessed mental health treatment before or during medical school, whether they believed that disclosing mental health care could affect their licence, and the degree to which concerns about medical licensing discouraged them from seeking health care. They received 327 completed surveys, and the results are as outlined in Table 1. Of note, respondents with a mental health history were less likely to believe that disclosing a mental health condition would not affect licensing (13% vs. 25%, p = 0.03).
Gold et al.22 surveyed physician mothers through the Facebook platform, and of the 2109 who completed responses, 33% indicated that they had been given a mental health diagnosis since medical school and nearly half reported receiving treatment for a mental health condition. Of the 1009 women who said they had received a diagnosis of, or treatment for, a mental health condition, 6% had disclosed this information on their licensure application. The most common reasons for not disclosing were “the respondent believed that: the condition did not pose any potential safety risk to patients” (75%); “the condition was not relevant to clinical care” (70%); and “it was not the business of the medical board” (63%). Qualitative responses with representative quotes about mental health stigma, treatment-seeking, and disclosure were also provided.
Dyrbye et al.23 surveyed a “convenience” sample of 5829 physicians, asking, “If you were to need medical help for treatment of depression, alcohol/substance use, or other mental health problem, would concerns about the repercussions on your medical licensure make you reluctant to seek formal medical care?” Nearly 40% replied yes. The authors also examined the initial and renewal medical licensure applications of 48 states and classified them as “consistent” with the ADA if they asked only about current (within 12 months or less) impairment or did not ask about mental health conditions. Physicians working in a state in which either the initial or renewal application form was not “consistent” indicated more self-reported reluctance to seek treatment for a mental health condition compared with those who worked in states where both applications were consistent (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.07–1.37, p = 0.002). Increased reluctance was also noted in states in which only the renewal application was consistent (OR 1.22, 95% CI 1.05–1.43, p = 0.011 vs. both applications consistent). Similar findings were found in the study by Roman et al.,25 which surveyed physician assistants, demonstrating that health professionals other than physicians also sometimes display a reluctance to seek medical care because of concerns about repercussions on their licensure.
Arnhart et al.24 compared New York state physicians with and without symptoms of burnout and asked whether they thought mandatory reporting of their health condition on their medical licence, malpractice, and hospital privilege credentialing applications and renewals would be a barrier to seeking mental health care. Their analyses showed that compared to physicians without symptoms of burnout (n = 456, 43% of respondents), those experiencing symptoms (n = 602, 57%) were significantly more likely to think that such mandatory disclosure for medical licensing (X2 =7.9, p<0.05), malpractice insurance (X2 = 16.3, p < 0.001), and hospital practice credentialing (X2 = 23.2, p < 0.001) would be a barrier to them seeking treatment. The authors noted that the New York State Board for Medicine does not have questions about mental health on its medical licensing application.
This review reveals the paucity of studies assessing the effectiveness of health questions on a licensure application or renewal form and the impact of such questions on health-seeking treatment by physicians and medical trainees. None of the identified studies included medical residents as part of their analyses. All studies used data that were self-reported by participants. Nonetheless, some trends are worthy of further discussion.
Health questions on medical licensure forms are intended to identify regulated members with health conditions that may affect their fitness to practise medicine to help ensure safe health care provision to the public. None of the reviewed papers reported simple measures of effectiveness of this practice in identifying relevant health concerns among physicians and trainee physicians. Thus, it appears that it is assumed to be effective.
A large proportion of participants responded that they would not disclose their mental health condition on medical licensure forms or they believed that it was inappropriate for MRAs to mandate such disclosure. In the study by Fletcher et al.,20 half the survey respondents reported they would not disclose a mental health condition to their medical board, while, in the Gold et al.22 study, only 6% of women who reported having had a mental health condition said they had disclosed that to their state medical board.
Including questions about health on licensure applications appears to increase self-reported reluctance of a physician or medical trainee to seek treatment for their own health. In Gold et al.,22 three-quarters of the respondents agreed or strongly agreed that questions about mental health diagnosis or treatment impacted their decisions about seeking treatment. Similarly, in Arnhart et al.,24 69% of participants believed that it would be a barrier for physicians to receive mental health treatment if reporting such treatment on licensing applications and renewals was mandatory. In Dyrbye et al.,23 reluctance to seek treatment for mental health conditions was more apparent when health questions were not considered compliant with the ADA.26
The main reasons why physicians and medical students are reluctant to seek treatment for their mental illness or report a mental health disorder to MRAs appear to be related to the stigma of having a mental health disorder and fear of ramifications regarding their licences. Weiss and Ramakrishna27 have defined health-related stigma as, “a social process or related personal experience characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group identified with a particular health problem.” Coupling the stigma surrounding mental health issues with the fear of perceived consequences of reporting a mental health condition to an MRA potentially magnifies the issue of physicians not seeking treatment for their mental health.
It is important to distinguish between an illness and a work impairment. Impairment is defined by the American Medical Association as “any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities.”28 Not all illnesses have that effect, especially when appropriate care is provided and accepted.
Although the culture of medicine is deep-rooted, regulatory organizations can take actions to mitigate the stigmatizing effects of asking health questions on their licensing applications. It would be legally and ethically sound to adhere to the principles of the ADA, anti-discrimination legislation in other jurisdictions, and the guidelines provided by the Federation of State Medical Boards, including only asking about current (within one year) health conditions, not dividing physical from mental health disorders, and focusing on any impairment to work function as opposed to diagnosis or treatment.5 A recent article by Stergiopoulos et al.29 discussed how policy regarding questioning physicians about their health on medical licensure applications should change in Canada.
There were limitations in our systematic review. Very few studies met our inclusion criteria. Included studies were all cross-sectional, and most relied on self-reported perceptions. Some of the reported reluctance to report to an MRA likely reflects the respondents’ intentions in a theoretical manner rather than actual outcomes, and the two may differ in some instances. Finally, selected studies were all based in the United States and, thus, caution should be used when extrapolating their findings to other jurisdictions.
Our systematic review revealed no studies reporting the effectiveness of health questions on medical licensure forms and only a handful of cross-sectional studies examining the effect that health questions have on physicians seeking treatment for their own health. Stigma and fear of perceived ramifications of reporting mental health illness to MRAs were common reasons for physicians and medical students not seeking professional mental health care. Prospective studies involving regulated members in different countries, and with collaboration among MRAs, medical associations, physician health programs, and educational organizations are needed.
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We thank Ms. Becky Skidmore, research librarian, for devising and undertaking the literature search, and the members of the Alberta Health Questions Working Group for their support and general insight. The working group comprised: Teresa Brandon, MD (clinical and program co-director, Physician and Family Support Program, Alberta Medical Association); Gary Goldsand, MA (clinical ethicist and assistant clinical professor, Faculty of Medicine and Dentistry and the John Dossetor Health Ethics Centre, University of Alberta); Kimberley Kelly, MD, CCFP (AM), FCFP (assistant executive director, Professional Affairs, Alberta Medical Association); Melanie Lewis, MD (chief wellness officer, Faculty of Medicine & Dentistry, University of Alberta); Florence Obianyor, MBBS, CCFP, MPH, CHE (physician medical advisor, Alberta Health Services); and Sharron Spicer, MD (associate chief medical officer, Physician Wellness, Diversity and Development, Alberta Health Services).
Quyen K. Lam, MD, is senior medical advisor at the College of Physicians and Surgeons of Alberta and clinical assistant professor in the Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary.
Jeremy Beach, MBBS, MD, is assistant registrar, College of Physicians and Surgeons of Alberta, and professor emeritus with the Faculty of Medicine, University of Alberta, Edmonton.
Funding disclosures: Funding for this work was provided by the College of Physicians and Surgeons of Alberta, where this was required.
Conflicts of interest: The authors have declared no conflict of interest.
Correspondence to: Quyenkim.Lam@ucalgary.ca
This article has been peer reviewed.