“Are you now or have you ever engaged in the illegal use of controlled substances? ... Have you within the past five years been treated for any mental, emotional, and nervous disorders?”
For decades, such questions were standard on the forms that doctors and other medical professionals filled out every year to maintain their credentials.
Yet doctors who sought help for past mental health or substance use problems faced a dilemma: Lie about their medical histories or risk not being able to obtain a medical license. Those struggling with trauma or depression avoided seeking treatment due to fear they might have to disclose it in the future, according to physician groups.
Now, in an effort to combat stigma and burnout among medical professionals, Massachusetts has become the first state to eliminate questions about providers’ mental illness and addiction throughout the health care system. In roughly two dozen other states, professional boards that license doctors have stopped the practice. Yet Massachusetts has gone further: scrubbing the questions from credentialing forms used by virtually every hospital, health system, insurer, and medical licensing board in the state.
“This is a monumental step forward,” said Dr. James Baker, president of the Massachusetts Society of Addiction Medicine and a physician at a hospice care facility in Haverhill. “The power of this new policy is that it opens the door for physicians who are struggling with depression, anxiety, and substance use disorders to get the help they need without fear.”
The questions stem from the idea that medical professionals should be held to a higher standard, and because lives hang in the balance if they are under the influence of alcohol or drugs on the job.
Yet studies have found that questions about mental health history and past drug use have long had a chilling effect on doctors seeking professional help. In a 2017 survey, nearly 40 percent of American physicians said they would be reluctant to seek treatment for a mental health condition because of concerns about repercussions to their medical licensure. In a separate study, almost half of female doctors said they met the criteria for mental illness but had not sought treatment partly for fear of reporting to a medical licensing board.
The push to root out questions about drug use and mental health gained momentum during the pandemic amid rising rates of burnout and mental distress among physicians. Forty-six percent of health workers nationwide reported frequently feeling burnout in 2022, up from 32 percent in 2018, according to a survey published last fall by the Centers for Disease Control and Prevention. Each year, an estimated 300 to 400 physicians kill themselves, and the suicide rate within the profession is more than double that of the general population, according to an American Psychiatry Association analysis.
Yet it was the high-profile death of a New York physician in the early days of the pandemic that galvanized hospital and medical professional associations to address the issue.
In April of 2020, Dr. Lorna Breen, an emergency room physician at New York Presbyterian Hospital in Manhattan, became overwhelmed by the relentless number of sick patients, many of whom were dying in the hospital’s waiting rooms and hallways, her family said. After working a string of 12-hour shifts, Breen called her sister to say that she couldn’t get out of her chair at home. Concerned, family and friends drove Breen to her childhood home of Charlottesville, Va., where she checked into an in-patient psychiatric unit.
While in the psychiatric unit, Breen repeatedly told relatives that she feared losing her medical license and hospital credential because she sought mental health treatment, according to family members.
Days after expressing those fears, Breen took her own life.
“Those questions absolutely contributed to [Breen’s] death,” said J. Corey Feist, who is Breen’s brother-in-law and cofounder of a national foundation that advocates for removing stigmatizing questions from the medical credentialing and licensing process. “Much of her self-identity was inextricably linked to being a doctor. ... When you threaten to take away that lifelong pursuit, that can result in suicide.”
In recent years, medical boards in at least 26 states have changed the language of their licensure applications to remove questions related to physicians’ mental health — changes affecting 673,000 doctors nationwide, according to the Dr. Lorna Breen Heroes’ Foundation.
It took more than a year of meticulous work to find and remove the language. The Massachusetts Health & Hospital Association began collecting credentialing forms from every hospital, health insurer, and medical licensing board in the state. Staffers at the association then carefully combed through the scores of forms — many numbering 20 pages or more — to identify potentially stigmatizing questions about past treatment or diagnosis of a mental illness or substance use disorder.
Many of the forms had not been updated in decades and reflected outdated views on the nature of addiction and mental illness, the association found. Some placed questions about past mental health and substance use treatment in the same category as questions about criminal convictions. Many of the hospitals and health insurance plans had been using a standard form that had not been updated since 2004.
Dr. Steve Defossez, a neuroradiologist at Tufts Medical Center and vice president of clinical integration at the state hospital association, said the questions were a “huge disincentive” to doctors seeking help for mental health and substance use problems. In hospitals, such credentialing forms are shared with up to three dozen hospital staff and administrators, from the hospital credentials committee up to the board of trustees, Defossez said.
“If someone has a condition which is still stigmatized, there’s no reason for them to bare that to dozens and dozens of strangers and colleagues they work with,” Defossez said. “The alternative is for doctors to hide it and not get the help they need.”
A combination of high stress levels, long hours, and repeated exposure to trauma can make health care workers especially prone to burnout, according to physician groups. Across the state, there are confidential peer support groups designed for health care workers; and the Massachusetts Medical Society offers a program, known as Physician Health Services, that provides therapy and monitoring of doctors with substance use and mental health problems.
Baker is not ashamed that he sought psychiatric counseling for his grief after losing his 23-year-old son, Max, to a heroin overdose seven years ago. But he has resented having to disclose this fact every two years when he renews his credentials. Typically, he jots an asterisk next to the question and scribbles in a short explanation, noting that he sought psychiatric care “due to a family tragedy.”
“What happened to my son was a horrible tragedy, but the fact that I sought care for it should be my private business,” Baker said. “Those questions don’t improve patient care. All they do is stop physicians from seeking care for themselves.”