Layout 1 [Qualitative Research in Medicine & Healthcare 2019; 3:8649] [page 107] Introduction Could a pediatrician in marriage counseling 10 years ago be mandated to disclose her therapy records to the state board? Yes. Could a dermatologist with postpartum depression 3 years ago be required to defend her compe- tence before the board? Yes. Should a medical student worry that a licensing board might read his psychological evaluation for test anxiety? Yes. State medical boards may access applicants’ confiden- tial health records and require that all 3 individuals defend their competence to practice medicine. Are medical boards injuring physicians by violating their rights? Many, like this physician, say yes. Why are mental health questions still allowed to be on there? I have had postpartum anxiety/de- pression three times now and I feel like it is none of their damn business. So, I have lied about it on my applications. Also, I feel these questions could contribute to doctors not seeking help, es- pecially for serious problems that could require a mental health hospitalization. Do these ques- tions have an adverse effect on doctors and med- ical students presenting (or not) for care they may desperately need? We all desire competent, healthy doctors who deliver excellent patient care. State medical boards exist to pro- tect the health, safety, and welfare of patients through li- censing, investigating, and disciplining physicians. Their mission is to protect the public from impaired physicians, yet medical boards may be impairing physicians’ access to confidential compassionate health care by subjecting doctors to mental health questions that violate United States law. One doctor reports: After reading an article about one woman’s jour- ney through hell after being honest on those ap- plication questions, I sought care an hour away. I drove an hour in another direction to nervously fill prescriptions for antidepressants. I required several meds to stop thinking of suicide all day every day. My suicidal thoughts were 100% work- related. Suicide is an occupational hazard of the medical pro- fession.1 Though students enter medicine with their men- tal health on par with or better than their peers, they are 3 times more likely to kill themselves, according to the Physician-Friendly States for Mental Health: A Comparison of Medical Licensing Board Applications Pamela Wible,1 Arianna Palermini2 1Family Physician, Founder Ideal Medical Care, Eugene, OR, USA; 2Medical student ABSTRACT Do medical boards undermine physician mental health by breaching physician confidentiality and privacy? We analyze the initial medical licensing process in each state to determine if qualified applicants who report mental illness experience discrimination. We then identify the most favorable states for physician mental health. Correspondence: Pamela Wible, P.O. Box 5225, Eugene, OR 97405, USA. Tel.: +1.541.345.2437. E-mail: roxywible@comcast.net Acknowledgments: the authors thank all physicians who submitted their lived experiences with medical boards and physician health programs. Dedication: The article is dedicated to our brothers and sisters in medicine who lost their lives to suicide in pursuit of healing others. Contributions: AP performed the majority of research to acquire initial licensing applications from all state medical boards. PW drafted manuscript that was edited by both authors. Conference presentation: portions of prior draft manuscript were presented at Psych Congress in San Diego, California, on October 6, 2019. Key words: Physician mental health; physician suicide; physician depression; medical boards; physician health programs. Disclosures: authors report no financial disclosures or conflict of interest. Funding: research project was unfunded. Authors were unpaid vol- unteers. Received for publication: 31 October 2019. Accepted for publication: 14 November 2019. This work is licensed under a Creative Commons Attribution Non- Commercial 4.0 License (CC BY-NC 4.0). ©Copyright: the Author(s), 2019 Licensee PAGEPress, Italy Qualitative Research in Medicine & Healthcare 2019; 3:107-119 doi:10.4081/qrmh.2019.8649 Qualitative Research in Medicine & Healthcare 2019; volume 3:107-119 No n- co mm er cia l u se on ly American Medical Student Association. In some resi- dency programs 75% of interns meet criteria for major de- pression.2 Suicide risk increases with untreated mental illness. Physicians who die by suicide are less likely to be receiving mental health care compared with non-physi- cian suicides. Physicians are more likely to self-medicate for anxiety, depression, and suicidality - with tragic out- comes. Doctors are reported to have the highest suicide rate of any profession - even higher than the military-accord- ing to findings presented at the 2018 American Psychiatric Association annual meeting.3 What is causing our physician mental health crisis? Physicians are routinely exposed to tragedy and death resulting in occupationally induced anxiety, depression, and Post-Traumatic Stress Disorder (PTSD). Yet doctors receive no routine on-the-job support. Instead, they risk punishment when asking for help. State boards, hospitals, even health plan and malpractice insurance companies in- terrogate doctors about their mental health, read their con- fidential medical records, and then deny health plan participation, medical liability coverage, hospital privi- leges, and state licensure. Doctors with occupational dis- tress may be referred to Physician Health Programs (PHPs) where they are required to participate in 12-step addiction recovery with witnessed random urine drug screens - even when they have never used drugs as this psychiatrist reports: I’m amazed at the punitive terms I’ve had to face in recovering professionally from a depressive episode for which I was hospitalized last year. One of my requirements is to be urine tested for sub- stance abuse, despite multiple demeaning assess- ments that have rendered the clear verdict that I don’t have a substance use problem. I’ve had to at- tend costly treatments for ‘professionals’ in which I am the only female in a group of male physicians who have had sex with their patients or have be- come assaultive with staff. Any efforts on my part to point out that I don’t quite ‘fit’ are taken as fur- ther evidence of my pathology. I’m a single parent as well, so that each of these ‘treatments’ I’m re- quired to attend takes me away from my two chil- dren for extended periods of time. Throughout all of this, nobody has told me how common my feel- ings are - that a large number of doctors feel de- pressed and suicidal at times. Rather, I’ve been told that my actions are unheard of for someone in mental health and may preclude me from ever pro- viding therapy again since ‘we tell patients to never give up hope, but you did’. Hopefully, in the near future this won’t be a taboo subject, and there will be places for those like me to seek responsible and confidential care. While PHPs have been effective for some physicians with substance abuse, physicians have also died by suicide under the care of these programs.4 PHPs hold a monopoly in the provision of state-board-sanctioned physician as- sistance services in most states. To avoid punishment by PHPs and boards (that may restrict licensure and publish doctors’ mental health diagnoses online) physicians drive hundreds of miles out of town, use fake names, and pay cash for off-the-grid care. One doctor reports: I’ve been in practice 20 years and have been on antidepressants and anxiolytics for all of that time. I drive 300 miles to seek care and always pay cash. I am forced to lie on my state relicensing every year. There is no way in hell I would ever disclose this to the medical board - they are not our friends. Results from a 7-year investigation of 1300 physician suicides reveal that doctors (and medical students) die by suicide due to fear of seeking care that would be disclosed on their applications for residency, hospital privileges, and state licensure. Fear of seeking treatment leads to delayed diagnoses thereby increasing anxiety, depression, sub- stance abuse, and suicide.5 One doctor shares: Do you know what really hurts? The fact that any- one can look me up on the Internet and read my dirty laundry. I’m publicly shamed (by my medical board), punished for being ill. I will only know peace when I am gone. The American Medical Association (AMA) Code of Medical Ethics upholds the right of confidentiality for all seeking health care. A therapeutic alliance requires trust to allow full disclosure of sensitive and personal informa- tion. Individuals receiving care believe their medical records will be safeguarded and only released with their consent. Physicians hold confidentiality sacred and take an oath to preserve it at all costs. Physicians are under- standably shocked when their own personal health infor- mation is accessed by employers, hospitals, and medical boards under the pretense of public safety. Health Insurance Portability and Accountability Act (HIPAA) provides data privacy and security provisions to safeguard medical information for all US citizens. Infor- mation about health status, provision of health care, or payment for health care that is collected by a covered en- tity (such as a doctor or health center) and can be linked to an individual is Protected Health Information (PHI) under federal law. Though physicians must uphold patient HIPAA rights or face harsh penalties, physicians are ex- pected to waive their own HIPAA rights to medical insti- tutions such as state boards. The Americans with Disabilities Act (ADA) of 1990 states: No covered entity shall discriminate against a qualified individual on the basis of disability in regard to job application procedures, the hiring, advancement, or discharge of employees, employee compensation, job training, and other terms, conditions, and privileges of employment.Yet competent physicians suffer repeated in- vasion of privacy and discrimination by medical institu- tions in violation of the ADA. [page 108] [Qualitative Research in Medicine & Healthcare 2019; 3:8638] Article No n- co mm er cia l u se on ly Materials and Methods We queried via social media and emailed 6000 US physicians: Have you ever faced discrimination, limitation of license, or delay/denial of your medical license due to mental health issues? A selection of de-identified submis- sions is published with permission. We analyzed mental health questions on medical board initial licensing appli- cations from all 50 states and the District of Columbia. Most applications were accessed online or by portable document format. When only available through a portal, a login was created. When an application was unavailable or no mental health question was identified, the board was contacted by email and/or phone to confirm the absence or presence of mental health questions and verify wording when present. All mental health and impairment questions were organized on a spreadsheet to compare quantity and quality of questions. Substance use queries were removed. The focus of this research is on non-drug-related endoge- nous mental health conditions and corresponding ques- tions by medical boards. We italicized key mental health phrases for ease of reading and graded states based on in- vasiveness of mental health questions into 5 categories A through F. Grade A: States with no mental health questions or one or 2 straightforward current impairment question(s) that do not mention mental health. Grade B: States with progressive mental health question(s) linked to current impairment. Grade C: States with mental health question(s) spanning the last 5 years. Grade D: States with have-you-ever questions related to mental health, mental health questions beyond 5 years, or a requirement for peer reference on applicant’s mental health. Grade F: States with highly invasive mental health ques- tions unlinked to current impairment that contain con- fusing, punitive, or adversarial language. Results Grade A: States with no mental health questions or one or 2 straightforward current impairment question(s) that do not mention mental health. 9 States: Connecticut, Hawaii, Kentucky, Maine, Michigan, Nevada, New York, Pennsylvania, Wyoming. Connecticut, Hawaii, Michigan, and New York are the most physician-friendly of all states with no mental health or impairment questions. Kentucky asks: Are you currently suffering from any con- dition for which you are not being appropriately treated that impairs your judgement or that would oth- erwise adversely affect your ability to practice medi- cine in a competent, ethical and professional manner? Maine asks: Are you physically and mentally able to per- form all the essential functions or services necessary to exercise the privileges or services applied for with or without reasonable accommodation? Are you able to perform these functions without significant risk or injury to yourself or others? Nevada asks: Do you currently have a medical condition which in any way impairs or limits your ability to practice medicine with reasonable safety and skill? If you currently have a medical condition which in any way impairs or limits your ability to practice medicine, is that impairment or limitation reduced or ameliorated because of the field of practice, the setting, the manner in which you have chosen to practice, or by any other reasonable accommodation? Pennsylvania asks only about drug-related impairment: Do you currently engage in or have you ever engaged in the intemperate or habitual use or abuse of nar- cotics, hallucinogens, or other drugs or substances that may impair judgement or coordination? Wyoming has no direct mental health questions, though reference must answer: Does the applicant’s health allow for the safe and competent practice of medicine? Grade B: States with progressive mental health ques- tion(s) linked to current impairment. 14 States: California, Illinois, Indiana, Iowa, Maryland, Missouri, New Jersey, New Mexico, North Carolina, South Carolina, Tennessee, Vermont, Virginia, Wisconsin. California asks: Do you currently have any condition (in- cluding, but not limited to emotional, mental, neuro- logical or other physical, addictive, or behavioral disorder) that impairs your ability to practice medicine safely? Illinois asks: Do you now have any disease or condition that presently limits your ability to perform the essen- tial functions of your profession, including any disease or condition generally regarded as chronic by the med- ical community, i.e., i) mental or emotional disease or condition; ii) alcohol or other substance abuse; iii) physical disease or condition? If yes, attach a detailed statement, including an explanation whether or not you are currently under treatment. Indiana asks: Do you now have any disease or condition that presently limits your ability to perform the essen- tial functions of your profession, including any disease or condition generally regarded as chronic by the med- ical community, i.e., i) mental or emotional disease or condition; ii) alcohol or other substance abuse; iii) physical disease or condition? Iowa asks 5 current impairment questions. The first is: Do you currently have a medical condition which in any way impairs or limits your ability to practice with rea- sonable skill and safety? Follow-up questions: Are you receiving ongoing treatment or participating in a mon- itoring program that reduces or eliminates the limita- tions or impairments caused by either your medical [Qualitative Research in Medicine & Healthcare 2019; 3:8649] [page 109] Special Issue on Physician Mental Health No n- co mm er cia l u se on ly condition or use of alcohol, drugs, or other chemical substances? Does your field of practice, or the setting or the manner in which you have chosen to practice, reduce or eliminate the limitations or impairments caused by your medical condition or use of alcohol, drugs, or other chemical substances? The final 2 ques- tions relate to current drug use. Medical condition is defined as any physiologic, mental or psychological condition, impairment or disorder, including drug ad- diction and alcoholism. Maryland asks: Do you currently have any condition or impairment (including, but not limited to substance abuse, alcohol abuse, or a physical, mental, emotional, or nervous disorder or condition) that in any way af- fects your ability to practice your profession in a safe, competent, ethical, and professional manner? Missouri asks the same questions as Illinois though adds sexual disorder: Do you currently have any condition or impairment which in any way affects your ability to practice in a professional, competent and safe man- ner, including but not limited to: i) a mental, emo- tional, nervous or sexual disorder, ii) an alcohol or substance abuse disorder or iii) a physical disease or condition? States such as Missouri have updated their questions to avoid discrimination against physicians with mental illness reports one psychiatrist: I have experienced discrimination and delay in getting my Missouri medical license due to my mental illness. I have bipolar disorder in remis- sion for years. Never affected my ability to prac- tice (my only mental illness which has affected my ability to practice has been my PTSD secondary to being a physician). Years ago, the Missouri ap- plication asked whether you were diagnosed with a psychotic disorder, and it had schizophrenia and bipolar disorder in parenthesis. So, of course, I had to answer yes. As a result, I had to undergo an additional yearly evaluation by my psychiatrist and he had to write a letter to the board saying that I was safe to practice medicine even though I have a psychotic disorder. My license was al- ways delayed and it was a nightmare renewing every year. Now the Missouri board has removed that question so they must have caught some heat. But I felt very violated and targeted with that question. New Jersey asks 4 impairment questions. The first is: Do you have a medical condition which is any way impairs or limits your ability to practice medicine with reason- able skill and safety? The next 2 are related to current use of chemical substances and the final question asks about any diagnosis of pedophilia, exhibitionism, and voyeurism. The entire section on Medical Conditions is preceded with a statement about an applicant’s Fifth Amendment right against self-incrimination. New Mexicoasks: Do you have a physical or mental con- dition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essen- tial functions? North Carolina asks: Do you currently have any medical, chemical dependency or psychiatric condition that might adversely affect your ability to practice medi- cine or surgery or to perform the essential functions of your position? An emergency physician reports: I was sued. Overwhelmed with grief and fear, I took antidepressants and saw a psychiatrist. I paid cash and considered using a false name. I had already seen the North Carolina Medical Board send a physician to 6 weeks of inpatient alcohol treatment due to a complaint without any proof he was drinking. That saved his li- cense but he owed an astronomical bill. South Carolina asks: Are you currently being treated for any physical, mental or emotional condition that might interfere with your ability to competently and safely perform the essential functions of practice as a physician? Tennessee asks: Do you currently have any physical or psychological limitations or impairments caused by an existing medical condition which are reduced or ameliorated by ongoing treatment or monitoring, or the field of practice, the setting or the manner in which you have chosen to practice? Tennessee also asks: Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism, voyeurism or other diagnosis of a predatory nature? (Reference Grade B Section end note on predatory/criminal behaviors). Vermont has a section entitled: Medical condition, treat- ment, use of chemicals or illegal substances. It begins with definitions: The ability to practice medicine is a term that includes: i) The cognitive capacity to make and exercise reasoned medical judgments, and to learn and keep abreast of medical developments; ii) The ability to communicate those judgments and medical information to patients and other health care providers, with or without the use of aids or devices, such as voice amplifiers; and iii) The physical capacity to per- form medical tasks and procedures, with or without the use of devices, such as corrective lenses or hearing aids. Medical conditions include physiological, mental or psychological conditions with a non-comprehen- sive list that includes emotional and mental illnesses, learning disabilities, drug addiction, and alcoholism. Currently means recently enough to have a real or per- ceived impact on one’s functioning as a medical pro- [page 110] [Qualitative Research in Medicine & Healthcare 2019; 3:8649] Article No n- co mm er cia l u se on ly fessional. ‘Chemical substances’ means alcohol, drugs (legal and illegal), and prescribed medications. This section has 3 main questions, each with a follow-up question and place to upload relevant documents. All focus on current impairment. Two relate to substance use and the other reads: do you have a medical condi- tion that in any way impairs your ability to practice medicine in your field of practice with reasonable skill and safety? Virginia asks: Do you currently have any mental health condition or impairment that affects or limits your ability to perform any of the obligations and respon- sibilities of professional practice in a safe and compe- tent manner? Currently means recently enough so that the condition could reasonably have an impact on your ability to function as a practicing physician. Wisconsinhas 5 impairment questions: do you have a med- ical condition, which in any way impairs or limits your ability to practice medicine with reasonable skill and safety? Follow-up questions are: If yes, are the limita- tions or impairments caused by your medical condition reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring programs? If yes, are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the set- ting, or the manner in which you have chosen to prac- tice? The fourth question is related chemical substance impairment and final question: Have you ever been di- agnosed as having or have you ever been treated for pe- dophilia, exhibitionism, voyeurism? Note: New Jersey, Tennessee, and Wisconsin have a similar question on criminal/predatory behavior (pe- dophilia, exhibitionism, voyeurism) as do Alabama, Ohio, Minnesota, Mississippi, and Washington. Medical boards must protect patients from criminal behavior and we do not penalize states for these questions. Grade C: States with mental health question(s) span- ning the last 5 years. 10 States: Arizona, Colorado, Minnesota, Montana, North Dakota, Ohio, Oklahoma, Oregon, Texas, Utah. Arizona lists mental health questions in Confidential Questions. The primary question: Have you received treatment within the last 5 years for use of alcohol or a controlled substance, prescription-only drug, or dan- gerous drug or narcotic or a physical, mental, emo- tional, or nervous disorder or condition that currently affects your ability to exercise the judgment and skills of a medical professional? If so, provide the following: i) A detailed description of the use, disorder, or condi- tion; and ii) An explanation of whether the use, disor- der, or condition is reduced or ameliorated because you receive ongoing treatment and if so, the name and contact information for all current treatment providers and for all monitoring or support programs in which you are currently participating. iii) A copy of any pub- lic or confidential agreement or order relating to the use, disorder, or condition, issued by a licensing agency or health care institution within the last 5 years, if applicable. Colorado asks: Within past 5 years, have you engaged in any conduct or exhibited any behaviors that resulted in an impairment in your ability to practice in a safe, competent, ethical and professional manner? Minnesota asks: Have you within the past 5 years been advised by your treating physician that you have a mental, physical, or emotional condition, which, if left untreated, would be likely to impair your ability to practice medicine with reasonable skill and safety? An affirmative answer requires 5 additional questions re- garding current treatment, compliance, and name of treating physician. Minnesota also asks: Have you ever been diagnosed as having or have you ever been treated for pedophilia, voyeurism, or other sexual be- havior disorders? We strongly feel that sexual behav- ior disorders are too broad as focus should be on criminal/predatory conduct only. Montana asks: Have you been diagnosed within the past 5 years with a physical condition or mental health dis- order including potential health risk to the public? North Dakota asks: Within the last 2 years have you been treated for any physical, mental or emotional condi- tion which impaired or could be said to impair your ability to practice medicine safely and competently? Ohio asks 4 mental health questions. The first 3 are: In the past 5 years, have you been diagnosed as having, or been hospitalized for a medical condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety? Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing treatment or received treatment in the past (with or without med- ication) or participate in a monitoring program? Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the setting, or the manner in which you have chosen to practice? If you receive such ongoing treatment or participate in such monitoring program the board will make an individualized assessment of the nature, severity, and duration of the risk associated with an ongoing medical condition. Have each treating physician submit a letter detailing the dates of treat- ment, diagnosis, and prognosis. A final question is: Have you ever been diagnosed as having, or have been treated for, pedophilia, exhibitionism, or voyeurism? (Reference end note Grade B section on predatory/criminal behaviors). Oklahoma asks: Do you currently have or have you had within the past 2 years any mental or physical disorder or condition, which, if untreated, could affect your ability to practice competently? [Qualitative Research in Medicine & Healthcare 2019; 3:8649] [page 111] Special Issue on Physician Mental Health No n- co mm er cia l u se on ly Oregon has 3 mental health questions. The first: Within the past 2 years, have you participated in a program (other than the Oregon PHP) for evaluation, monitor- ing, or treatment for any issue in lieu of or as a condi- tion of resolving a matter before a health care program or facility or a regulatory or licensing board or has such action been pending or proposed? Issue includes, but is not limited to, substance use, communication, or boundary issues. (if yes provide full details and dates to include the name and location of the diversion program, regulatory Board, healthcare program or fa- cility, and/or court, and reasons for and results of en- tering the program). The second: Do you currently have, or have you had within the past 2 years, any physical, mental, or emotional condition which im- paired or does impair your ability to practice your health care profession safely and competently? The final question: Within the past 2 years, have you been admitted to any hospital or other treatment facility for any physical, mental or emotional condition or sub- stance use disorder which impaired or does impair your ability to practice your health care profession safely and competently? (If yes to either, provide full details and name of healthcare professional providing treatment. Request the healthcare professional send di- rectly to the Board a statement regarding the ability to safely practice medicine). Texas has a Mental and Physical Health section with 5 questions with mandatory submission of another form for any affirmative answer. The first 3 relate to self- referral to the Texas Physicians Health Program, sub- stance use within past 5 years, and physical/neurologic condition impairments within 5 years. The mental health question is: Within the past 5 years, have you been diagnosed with or treated for any: psychotic dis- order, delusional disorder, mood disorder, major de- pression, personality disorder, or any other mental health condition which impaired or does impair your behavior, judgment, or ability to function in school or work? If you answered Yes are the limitations caused by your mental condition or substance abuse/depen- dency problem reduced or ameliorated because you receive ongoing treatment (with or without medica- tion) or because you participate in a monitoring pro- gram? One internist reports: I am applying for my Texas license and I feel my rights are being violated. I have well-managed de- pression. I was asked do you have a mental con- dition - yes, and then I was asked does it affect how you function at work - no. I thought that would be the end of it, but now I need a treating physician statement, a statement from my pro- gram director, and I need to justify why I said no to it not affecting how I function at work. I’m re- quired to list all my medications from the past 5 years and all physicians who have treated me. How is this not a HIPAA violation? Why are they still allowed to do this? My application has been flagged as impaired and needs to go before the board and people who have never met me will de- cide if I am a danger to my patients. I have no money for a lawyer. If I fight this it can delay my license and my being able to work. My friends with no medical issues were approved months ago and here I am still waiting. Utahasks: If you are licensed in the occupation/profession for which you are applying, would you pose a direct threat to yourself, to your patients or clients, or to the public health, safety, or welfare because of any cir- cumstance or condition? Have you ever been declared by any court or competent jurisdiction incompetent by reason of mental defect or disease and not restored? Utah’s one have-you-ever question is far less invasive than those in Grade D section. Grade D: States with have-you-everquestions related to mental health, mental health questions beyond 5 years, or a requirement for peer reference on applicant’s mental health. 10 States: Arkansas, District of Columbia, Georgia, Idaho, Kansas, Louisiana, Nebraska, New Hampshire, South Dakota, West Virginia. Arkansas asks: Are you currently suffering from any con- dition for which you are not being appropriately treated that impairs your ability to practice medicine or to perform professional or medical staff duties in a competent, ethical, and professional manner? If yes, explain. Are you currently, or have you ever been monitored by a Physician Health Committee in any state? If yes, explain, and ask the Physician Health Committee to send documentation of your status. Non-impaired physicians have been mandated to im- paired practitioner programs as retaliation. These pro- grams (PHPs), governed by the Federation of State Physician Health Programs, exist under private con- tracts in all states except California, Nebraska, and Wis- consin. An occupational medicine physician explains: PHPs remain largely non-compliant with ADA laws and regulatory guidelines in assessing medical and psychiatric fitness of physicians. They receive revenue from contracts with physi- cian employers and residency programs plus re- ferred medical students/physicians who pay costly out-of-pocket fees or risk career destruc- tion. Physician employers liberally refer to PHPs for virtually any reason. PHPs even en- courage third-party referrals. Aggrieved spouses, jilted lovers, market competitors have all successfully required PHP evaluations of physicians. District of Columbia is a federal district with its own med- ical licensing board that asks 2 non-drug-related im- [page 112] [Qualitative Research in Medicine & Healthcare 2019; 3:8649] Article No n- co mm er cia l u se on ly pairment questions: Do you have a medical condition or have you become aware of any medical condition that impairs or limits your ability to practice your pro- fession? Have you ever engaged in any conduct that either indicated an impairment, or actually impaired, your ability to practice your profession? Two addi- tional questions are: Have you ever entered into a monitoring program for purposes of monitoring your abuse of alcohol, drugs, or other controlled sub- stances? Have you ever entered into a monitoring pro- gram for purposes of monitoring your professional behavior including recordkeeping, billing, boundaries, quality of care or any other matter related to the prac- tice of your profession? We find referrals based on any other matter related to the practice of your profession to be broad and subjective given that one anonymous and unsubstantiated complaint can lead to a physician PHP referral and undermine a doctor’s career. Georgia has no impairment or mental health questions though requires 3 peer references to answer: Does this physician have, or has this physician had in the past, any mental or physical illnesses or personal problems that interfere with his/her medical practice? Unlike the single Wyoming (Grade A) peer reference, Georgia re- quires multiple colleagues to reveal any mental health issue at any time in the life of a physician peer includ- ing past personal problems. Such questions pose barriers to seeking mental health care and create collegial distrust when physicians fear revealing their struggles with peers who may report them to boards. Two physicians explain: Isn’t it more appropriate to ask a reference about a physician’s knowledge, reliability, integrity- performance? Mental health questions have a chilling effect that I admit have kept me from seeking mental health support when it would have been wise to do so. Stigma is so severe that I have heard many physicians state that it would be better to die from suicide than be admitted to our hospital’s psychiatric unit. My psychiatrist requested I report to the Georgia Medical Board my inpatient care for a major de- pressive disorder. They stamped a 5-year private consent order on me whereby I had to submit to random urines (though there was no history of substance abuse). If I knew what I would be sub- jected to over the next 5 years and the expense of hundreds of urines, I would not have fulfilled his request. The toughest challenge was getting through the red tape with hospital privileges when they found out I had been treated for de- pression. I know dozens of physicians under psy- chiatric care for depression. They dare not relay such to the Board secondary to what I endured. Idaho asks: Have you ever been diagnosed and/or treated for any mental, physical, cognitive condition including substance use disorder that may affect your ability to practice medicine with reasonable skill and safety? Kansas has 4 impairment questions. The first: Within the last 2 years have you been diagnosed or treated for any physical, emotional or mental illness or disease, in- cluding drug addiction or alcohol dependency, which limited your ability to practice the healing arts with reasonable skill and safety? The second on self-med- icating: Within the last 2 years have you used con- trolled substances, which were obtained illegally or which were not obtained pursuant to a valid prescrip- tion order or which were not taken following the di- rections of a licensed health care provider? The third: Have you ever practiced your profession while any physical or mental disability, loss of motor skill or use of drugs or alcohol impaired your ability to practice with reasonable safety? Given widespread sleep-de- privation impairment (and use of stimulants) during residency, nearly all physicians (if responding hon- estly) would admit yes. The final question: Do you presently have any physical or mental problems or dis- abilities which could affect your ability to competently practice your profession? One doctor reveals: I used samples of Paxil and had my spouse write me prescriptions for Lexapro, Buspar, Paxil, and sleeping pills over the years. I did not trust other doctors. I did not want any of this stuff in my records as I did not want to be seen as crazy (this is how many doctors refer to psychiatric pa- tients). Louisiana asks: In the last 10 years prior to this applica- tion have you had any physical injury or disease or mental illness or impairment, which could reasonably be expected to affect your ability to practice medicine or other health profession? Nebraska asks: Do you currently, or have you had, any physical, mental, or emotional condition which im- paired, or does impair your ability to practice your health care profession safely and competently? Within the last 5 years, has any licensing agency or creden- tialing organization initiated any inquiry into your physical, mental or emotional health? As we noted previously, inquiries can be retaliatory and the ques- tion posed by Nebraska would imply physician guilt for having psychological needs. New Hampshire asks: Have you ever had any physical, emotional, or mental illness which has impaired or would be likely to impair your ability to practice med- icine? A physician with postpartum depression decades ago must answer yes leading to invasion of privacy unlinked to current impairment. South Dakota asks 4 questions. Two are related to drug use and the other 2 are: Do you have a physical, men- tal or emotional condition which may adversely affect your practice? Have you been treated for or do you have a diagnosis for any Mental Health condition? (If [Qualitative Research in Medicine & Healthcare 2019; 3:8649] [page 113] Special Issue on Physician Mental Health No n- co mm er cia l u se on ly yes, please ask your treating provider to send a status letter to the Board office). Phrasing indicates that a physician must reveal any lifetime mental health con- dition to the board which is invasive and unlinked to current impairment. West Virginia asks: Have you had any interruption in your practice of medicine which might reasonably be ex- pected by an objective person to currently impair your ability to carry out the duties and responsibilities of the medical profession in a manner consistent with stan- dards of conduct for the medical profession? Have you ever had anything occur which might reasonably be ex- pected by an objective person to currently impair your ability to carry out the duties and responsibilities of the medical profession in a manner consistent with stan- dards of conduct for the medical profession? Though West Virginia mental health questions focus on current impairment and are preferable to the wording of all other states graded D, we have placed West Virginia in this category due to have-you-ever questions. Grade F: States with highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language. 8 States: Alabama, Alaska, Delaware, Florida, Massa- chusetts, Mississippi, Rhode Island, Washington. Alabamaasks 3 mental health questions. The first: Within the past 5 years, have you ever raised the issue of con- sumption of drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral disorder or condi- tion as a defense, mitigation, or explanation for your actions in the course of any administrative or judicial proceedings or investigation; any inquiry or other pro- ceeding; or any proposed termination by an educa- tional institution; employer; government agency; professional organization; or licensing authority? The second: Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibition- ism, or voyeurism? Final question: Are you currently engaged in the excessive use of alcohol, controlled substances, or the illegal use of drugs, or received any therapy or treatment for alcohol or drug use, sexual boundary issues or mental health issues? The application explains: The term currently does not mean on the day of, or even in the weeks or months pre- ceding the completion of this application. Rather it means recently enough so that the condition referred to may have an ongoing impact on one’s functioning as a physician within the past 2 years. We wonder why the application did not instead read within the last 2 years. The final question suggests that applicants must reveal if they have ever received any therapy for mental health issues in their lifetime regardless of current im- pairment. For this reason, Alabama is graded F. Alaskaranks worst of all states with 25 yes-or-no questions related to mental health, many invasive have-you-ever- had questions unlinked to current impairment. The first: Has your ability to practice medicine in a competent and safe manner ever been impaired or limited by any condition, behavior, impairment, or limitation of a physical, mental, or emotional nature? Alaska also asks: Since completing your postgraduate training, have you ever been physically or mentally unable to practice medicine for a period of 60 days or longer? The most invasive mental health question we found on any appli- cation is: Have you ever been diagnosed with, treated for, or do you currently have: followed by a list of 14 mental health conditions including depression, seasonal affective disorder, and any condition requiring chronic medical or behavioral treatment (Figure 1). One hospitalist reports: In residency, I had to do a rotation in Alaska. The application asked if I had ever been on psy- chotropic medications or in counseling. I had taken Zoloft 12.5 mg for 90 days due to anticipa- tory anxiety about starting intern year. Fortu- nately, my fears weren’t realized, so I stopped the medication when the prescription expired. I had also gone to counseling in my fourth year of med- ical school for a separate relationship issue. So, I answered both questions affirmatively. This re- sulted in my having to defend myself to a panel of people on the Alaska medical board over the phone. They granted my license, but it was a hu- miliating experience - and definitely created bar- riers to my seeking care moving forward-both because I have not wanted to be in a position to have to answer those types of questions affirma- tively, and due to financial barriers because I will not use insurance to defray costs of counseling since that may be discoverable. What a horrible culture of shame those questions create! Delaware begins with the same question as Alabama: Within the past 5 years, have you ever raised the issue of consumption of drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation, or explanation for your actions in the course of any administrative or ju- dicial proceedings or investigation; any inquiry or other proceeding; or any proposed termination by an educa- tional institution; employer; governmental agency; pro- fessional organization; or licensing authority? Two follow-up questions include: Are such current conditions or impairments reduced or ameliorated be- cause of ongoing treatment (with or without medica- tion) or participation in a monitoring program or because of the field of practice, the setting, or the man- ner in which you have chosen to practice medicine? Do you have a mental or physical disability that limits your ability to practice medicine in a fully competent and professional manner with safety to patients? If yes, are you willing to accept a conditional or limited [page 114] [Qualitative Research in Medicine & Healthcare 2019; 3:8649] Article No n- co mm er cia l u se on ly license to practice medicine if it is possible to accom- modate such disability? Final question: Do you agree to submit to an exami- nation at your own expense if the Executive Director of the Board of Medical Licensure and Discipline deems it necessary to determine whether your physical and/or mental impairment presents a significant risk to the health or safety of patients or otherwise causes you not to be fully qualified to practice medicine in a competent and professional manner with safety to pa- tients without limitations or accommodations? If no, submit a signed, notarized statement fully explaining your answer. Delaware’s application makes an anticipatory request that physicians waive their confidentiality/HIPAA rights and submit to an impairment exam at their own expense before the board reviews the application or meets with the physician. Florida has 6 questions. Three relate to substance use and one to physical impairment. Two mental health ques- tions are: In the last 5 years, have you been admitted or referred to a hospital, facility or impaired practi- tioner program for the treatment of a diagnosed mental disorder or impairment? During the past 5 years, have you been treated for or had a recurrence of a diagnosed mental health disorder that has impaired your ability [Qualitative Research in Medicine & Healthcare 2019; 3:8649] [page 115] Special Issue on Physician Mental Health Figure 1. Alaska image (from public document Alaska Medical Board Licensing Application 2019; https://www.commerce. alaska.gov/). No n- co mm er cia l u se on ly to practice medicine? Neither of these questions focus on current impairment. An affirmative answer to any question requires: A self- explanation providing accurate details that include names of all physicians, therapists, counselors, hospi- tals, institutions, and/or clinics where you received treatment and dates of treatment. A report directed to the Florida Board of Medicine from each treatment provider about your treatment, medications, and dates of treatment. If applicable, include Diagnostic and Sta- tistical Manual of Mental Disorders (DSM) DSMIII R/DSM IV/DSM IV-TR Axis I and II diagnosis(es) code(s), admission and discharge summary(s). Two Florida physicians report: When I applied for my Florida license it was de- layed by months. I was required to have a psych evaluation by an approved doctor due my history of depression which was treated and well man- aged. It fell under the impaired physician pro- gram and definitely was stigmatizing. To this day I don’t answer those questions honestly anymore and am hesitant to seek treatment as needed. After the unexpected death of a patient, I sought counseling. By a stroke of (bad) luck, I picked the only one in town in charge of impaired physi- cian monitoring. He told the board (though sta- ble) I should be monitored. I had to defend myself in front of the Florida board. They laughed in my face and then posted in the local newspapers that I was sentenced to 5 years of monitoring. I had mandatory Wednesday group therapy. Though I was an exemplary physician, my employers had to be told why I was unavail- able for call every Wednesday. Each time I (re)credential with hospitals, I must explain the whole thing again. HIPAA for me does not exist. I have never missed a single day of work for mental health. Massachusetts previously ranked an A with one straight- forward question: Do you have a medical or physical condition that currently impairs your ability to practice medicine? Now Massachusetts asks 2 additional im- pairment-related questions related to substance use in- cluding: Have you ever refused to submit to a test to determine whether you had consumed and/or were under the influence of chemical substances? This sec- tion is preceded by a convoluted definition of cur- rently meaning within the past 2 years (similar to Alabama). Following these questions is a large box ti- tled ‘Important note regarding physician wellness’ with 4 paragraphs promoting the Massachusetts Med- ical Society’s Physician Health Services (PHS) culmi- nating with a statement that their state’s physician health program is designed to assist physicians with the following: alcohol misuse; substance use disorder; behavioral or mental or physical health issues that cur- rently impair the ability to practice medicine; stress including administrative burdens; financial pressures; and work-family balance issues. Recruiting physicians with occupational stress into the state’s PHP on a medical licensing application is mis- placed and predatory given the adverse impact of these health programs on the careers of physicians detailed in this report. Mississippi application forces physicians to waive all con- fidentiality and HIPAA rights plus consent to a mental exam at applicant’s expense. Similar to Delaware, Mississippi has this additional paragraph: By submis- sion of an application for licensing to the Board, an applicant shall be deemed to have given his or her con- sent to submit to physical or mental examinations if, when and in the manner so directed by the Board and to waive all objections as to the admissibility or dis- closure of findings, reports or recommendations per- taining thereto on the grounds of privileges provided by law. The expense of such examination shall be borne by the applicant. Mississippi also asks: Have you ever been diagnosed as having, or have you ever been treated for, pe- dophilia, exhibitionism, or voyeurism, bipolar disor- der, sexual disorder, schizophrenia, paranoia or other psychiatric disorder? Given the forced breach of confidentiality, forced con- sent to exam, and have-you-ever been diagnosed with mental health conditions such as bipolar disorder un- linked to current impairment, Mississippi is graded F Rhode Island has no current impairment questions; how- ever, there are 2 questions that may preclude a physi- cian who suffered retaliation for a mental health condition during training from receiving a medical li- cense. The first: During any Professional/Medical Ed- ucation were you ever dismissed, suspended, restricted, put on probation, or otherwise acted against or did you take a leave of absence for medical rea- sons? The second: During any Post Graduate Training, were you ever dismissed, suspended, restricted, put on probation, or otherwise acted against or did you take a leave of absence for medical reasons? Having to defend a leave of absence for medical reasons that may have happened decades ago re-victimizes physicians who have experienced punishment/retalia- tion for occupationally induced mental health condi- tions. One anesthesiologist explains: When I became overwhelmed with abuse I was facing in residency, I begged my program direc- tor with tears running down my face for emer- gency mental health care. I spent the next few days isolated, confused, exhausted on my couch. I saw a counselor. I started an antidepressant for the first time in my 30 years of existence. By the weekend I felt refreshed with a glimmer of hope. When my program asked to meet with me on [page 116] [Qualitative Research in Medicine & Healthcare 2019; 3:8649] Article No n- co mm er cia l u se on ly Monday, I was sure it was to see if I was okay, to ensure I had no thoughts of self-harm or sui- cide. I was wrong. The meeting was to let me know I was placed on 6 months’ probation for being unprofessional. I was flabbergasted, my mouth literally fell open. I couldn’t believe I was sitting in front of the people I trusted with my ed- ucation and they were able to look at me in my greatest time of need and anguish knowing I was now in counseling and on medication and re- spond only with punishment. Washingtonhas Personal Data questions that cover mental health, substance use, and criminal/predatory behavior with a list of impairing medical conditions that match the Vermont application (Figure 2). Though Washington asks about medical conditions linked to current impairment and rightfully screens physicians for predatory/criminal behavior, we find the threatening language in the black box to be con- cerning including forced breach of an applicant’s con- fidentiality and privacy. Discussion The Federation of State Medical Boards (FSMB) de- fines impairment as a physical, mental, or substance-re- lated disorder that interferes with a physician’s ability to undertake professional activities competently and safely.6 The FSMB focus is the individual impaired physician. But what causes the impairment? Has the impairment been fixed? One psychiatrist explains: Taking medication for Attention Deficit Hyperac- tivity Disorder (ADHD) is analogous to wearing [Qualitative Research in Medicine & Healthcare 2019; 3:8649] [page 117] Special Issue on Physician Mental Health Figure 2. Washington image (from public document Washington Medical Commission Licensing Application 2019; https://wmc. wa.gov/). No n- co mm er cia l u se on ly glasses for my nearsightedness. My state licensing question asks: Do you have a condition that could impact your abilities? As long as I am wearing my glasses I can see. As long as I am taking my ADHD medicine I can keep fairly focused. What business is it of theirs? Normally I feel guilty for lying about the slightest thing. I was counseled behind closed doors by a faculty who knew of my struggles with ADHD to simply put no on the form and leave it at that. This proved to be good advice. I was raised to be extremely honest about everything. When it comes to completing these questions for licensing I believe I am being honest because I was in- structed by my respected faculty member to look at the questions in this light: Are you impaired by your condition? No. Then the answer on the appli- cation is NO. Many states treat illness as impairment. According to the FSMB: Some regulatory agencies equate illness (i.e., addiction or depression) as synonymous with impairment. Physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years. This is a critically important distinction. Ill- ness is the existence of a disease. Impairment is a func- tional classification and implies the inability of the person affected by disease to perform specific activities.6 FSMB believes illness precedes impairment and that physicians may at any point fall into the continuum of in- ability to practice medicine competently and safely. Medical board intervention is always directed at the physician, not the system. But what if the system causes physician impairment? Case in point: Resident physicians are legally forced to work 28-hour shifts (or longer due to unenforced caps).7 Working just 17 hours is equivalent to the cognitive and psychomotor impairment of a 0.05% blood alcohol content (illegal to drive in Utah and most Western European countries). Working beyond 24 hours is equivalent to a 0.10% blood alcohol content (exceeding the 0.08% legal limit to drive in 49 states and District of Columbia). Impairment escalates along a continuum and is noted even at 10 hours.8 Sleep-deprivation-related cog- nitive and psychomotor impairment leads to medical mis- takes and fatal car accidents after long hospital shifts.7 Professional boards are tasked with protecting the public. To prevent pilot fatigue resulting in impairment- related plane crashes, the National Transportation Safety Board (NTSB) limits maximum flight time to 9 hours dur- ing the day or 8 hours at night. Why force physicians to work 3 times that amount? As guardians of public safety, medical boards (like transportation boards) must address hazardous work con- ditions that currently impair more than 130,000 US resi- dent physicians.9 Given our physician shortage, boards should protect physicians from sleep-deprivation-related seizures, hallucinations, psychosis and death inside our hospitals. We cannot afford to lose one more doctor. Beyond sleep deprivation, physicians are injured by chronic violations of their human rights in hospitals due to overwork (80-100 hours work week is equivalent to 2 to 3 full-time jobs), food/water deprivation, bullying, ha- rassment, discrimination, and punishment when sick (in- cluding lack of confidential mental health care).5 Late-stage effects of these violations are substance abuse and mental illness. Rather than address the systemic causes of physician im- pairment, medical boards too often sanction physicians - thereby re-victimizing victims. Some board questions seem more voyeuristic and predatory than helpful, exploiting vulnerable physicians for profit. Fine-print warnings threaten hefty fines for in- tentional or inadvertent non-disclosure leading naively honest physicians to answer ADA-noncompliant ques- tions by sharing intimate confidential information when they present no danger to patients. Sanctioned physicians risk public disclosure of their mental health conditions. One affirmative answer creates a cascade effect in which non-impaired physicians are further traumatized and may be mandated to multi-year addiction recovery programs (even though they have never used drugs). When one state denies or limits licensure, others mirror the action. One positive response to a mental health question may follow an applicant for life. Conclusions Medical boards do undermine physician mental health by breaching physician confidentiality and privacy. Qual- ified, competent applicants who disclose mental health conditions do suffer discrimination by medical boards. Many state medical boards ask questions about physical and mental health in violation of Title II regulations of the Americans with Disabilities Act of 1990, nearly 30 years after enactment of the law. In their search for criminal be- havior among physicians, medical boards must not be- come criminal in their own behavior. By breaking federal law, physicians’ civil rights, and the AMA Code of Ethics, boards have weaponized mental health diagnoses against physicians. Recommendations for all medical boards: i) Remove mental health questions from medical licensing applications. Replace with current functional impairment questions such as: Do you currently have a condition that impairs your ability to practice medicine safely? Comply with federal law by following best practices of Grade A states. Move criminal/predatory conduct such as voyeurism queries to the criminal section; ii) Address im- pairment from hazardous working conditions.Rather than focus on individual victims, engage in high-yield activi- ties that resolve hazardous conditions impairing physi- cians en masse. To truly protect patients, align with all other industries invested in public safety that have legis- lated and enforced maximum 16-hour shifts, 60-hour work weeks, with minimum 30-minute breaks every 8 [page 118] [Qualitative Research in Medicine & Healthcare 2019; 3:8649] Article No n- co mm er cia l u se on ly hours; iii) Encourage non-punitive 100% confidential mental health care. Physicians require safe, accessible mental health care to be well-adjusted human beings. Most physicians enter medicine as humanitarians with noble intentions. Help them be well. After all, how can physicians give patients the care they’ve never received? One surgeon summarizes: Physicians are treated as criminals and tracked more closely than Level 3 sex offenders. Answering all these questions on applications, the subtle, un- spoken lesson is you had better be squeaky clean, mentally, morally and physically! If you step off the shining path, bad things will occur. I have known 7 male physicians who died by suicide. Most with a happy exterior. Why? They cannot confide in colleagues for fear that their colleagues will turn them in to hospitals and boards - and there goes their privileges and livelihood. They cannot confide in their spouses because during rough patches mentally, their marriages are al- ready in trouble. If they share psychological prob- lems, they probably fear that the wife may use this as ammunition in any future divorce. So, they keep on smiling - right up to the hour they die. Even until their last breath, physicians retain their work ethic. Some doctors are completing chart notes, re- turning lab results, and checking in on hospitalized pa- tients in the hours before their suicides.5 By injuring physicians, we are not protecting the public. Let’s end the physician mental health witch hunt. References 1. Vogel L. Has suicide become an occupational hazard of practicing medicine? CMAJ 2018;190:E752-3. 2. Pereira-Lima K. residency program factors associated with depressive symptoms in internal medicine interns: a prospective cohort study. Acad Med 2019;94:869-75. 3. Anderson P. Doctors’ Suicide Rate Highest of Any Profes- sion. American Psychiatric Association annual meeting 2018. Available from: https://www.webmd.com/mental- health/news/20180508/doctors-suicide-rate-highest-of-any- profession#1 4. Wible P. Do physician health programs increase physician suicides? Medscape 2015. Available from: https://www. medscape.com/viewarticle/850023 5. Wible P. Human Rights Violations in Medicine: A-to-Z Action Guide. Pamela Wible, M.D. 2019. 6. Federation of State Medical Boards. Policy on Physician Im- pairment. Available from: https://www.fsmb.org/siteassets/ advocacy/policies/physician-impairment.pdf 7. Wible P. Sleep-deprived doctors disclose hospital horrors. Pamela Wible, M.D. 2017. Available from: https://www.i dealmedicalcare.org/sleep-deprived-docs-disclose-hospital- horrors/ 8. Dawson D, Reid K. Fatigue, alcohol and performance im- pairment. Nature. 1997;388:235. 9. Association of American Medical Colleges. Physician Spe- ciality Data Report. [Internet]. ACGME residents and fel- lows by sex and specialty, 2017. Available from: https://www.aamc.org/data-reports/workforce/interactive- data/acgme-residents-and-fellows-sex-and-specialty- 2017?fbclid=IwAR21ckjgb8UedW11y3l3lw9B5Qv0ysZR wXlvfguaba6tgo53St4_d3SLjXo [Qualitative Research in Medicine & Healthcare 2019; 3:8649] [page 119] Special Issue on Physician Mental Health No n- co mm er cia l u se on ly