Last month, a prominent Manhattan emergency room doctor, Lorna Breen, died by suicide after describing the horrific events she had witnessed while fighting covid-19, the disease caused by the novel coronavirus. Her death highlighted what some of us in the mental health community have known since the start of the crisis: that the psychological impact of what is happening in American hospitals will stay with us long after the immediate crisis subsides and that among those most affected will be health-care workers. All agree that we should focus on how to help them seek the care they may need, but little has been said about the barriers that can discourage them from reaching out — or that a significant barrier is medical licensing.
The pandemic has provoked fear in doctors and nurses. They’re scared, not just because they so often can’t save the lives of covid-19 patients, but because they can’t always protect themselves and their families from infection. Those like Breen who lead a hospital department probably feel most the additional burden of having to keep their colleagues safe and fight for protective equipment. National shortages, coupled with the highly contagious nature of this virus, have resulted in workers and vulnerable relatives getting sick and, in some cases, dying. No doctor imagines having to treat a colleague; confronting our own mortality and safety in the workplace on a daily basis is something none of us were taught in medical school. It makes the mundane experience of going to work terrifying and even traumatic.
The toll that trauma and post-traumatic stress puts on the body is well-established. We’ve also known for some time that trauma can change the structure and chemical makeup of the brain. It hijacks the ability to reason and activates our most primal emotional responses. It should come as no surprise, then, that there is a proven link between trauma and suicide. While we do not know the specific circumstances of Breen’s challenges — she had also contracted the virus herself — we do know that her experience in the hospital, as relayed by her father and sister in the news media, is the experience of countless other health-care workers who remain on the front lines and, consequently, face the same risk. Common symptoms of trauma include avoidance of reminders of the traumatic event, nightmares with similar themes, flashbacks and intrusive memories, critical self-evaluation, guilt, negative mood, anxiety, panic attacks and detachment or dissociation. When these symptoms go untreated, sufferers become vulnerable to post-traumatic stress disorder (PTSD), other serious disorders and, yes, suicide.
Early treatment is essential to the prevention of a potentially debilitating, if not deadly, outcome, but physicians, in particular, face elevated levels of scrutiny when disclosing any form of mental health treatment to state licensing boards. For many doctors, the repercussions they may face introduce a significant obstacle. About 90 percent of state licensing applications include a question about a physician’s mental health, and some even ask questions about past diagnoses, such as depression or anxiety, that may have occurred before medical school. This goes against the recommendation of the American Medical Association and has been cited in studies as a significant reason that physicians are reluctant to seek mental health care.
Although there is no reason to believe that psychiatric diagnosis or treatment poses a risk to patients unless the physician has very serious ongoing symptoms, answering yes to these questions often leads to further questions. The state licensing board can require all of your medical and mental health records, including intimate details about your upbringing, your family and your spouse that you may have divulged in private psychotherapy sessions. Your license may be contingent upon sharing these records. Moreover, after sharing your records, the board can then dictate further evaluation and possibly send a physician to a physician health program (PHP). Initially started to assist physicians through tough times, some PHPs have earned a poor and even malignant reputation over the years, partly because they have financial arrangements with select treatment institutions across the country. PHPs reportedly send physicians to these institutions — at their own expense — for costly cash-only evaluations that sometimes last weeks. After the evaluation, the PHP may require supervision of the physician’s practice of medicine — through a workplace monitor whose job it is to report back to the PHP about the “troubled physician" — or order random check-ins even without any specific evidence of current impairment.
Once a PHP requires this evaluation, the physician is trapped. If you don’t enter into a contract with the PHP to fulfill whatever requirements have been outlined, you risk permanently losing your medical license. Many physicians caught in what some believe to be a corrupt PHP system have written about their experiences. One neurologist described quitting medicine after she sought help from a PHP for trauma and anxiety and felt as if she were under arrest: “All of my belongings except my clothing and a couple of books were taken from me,” Melissa J. Freeman wrote in a health-care journal. “My phone was taken and I had no means of contacting family or friends. I was isolated in a locked psychiatric facility for a forensic evaluation that nobody warned me about. I was not allowed an attorney; I was not read any rights; there was no due process. I was emotionally battered by psychologists, psychiatrists, and a chaplain. This made me physically ill — especially the religious part.”
Others who know how this system works have advocated for these doctors, but PHPs still exist and physicians still fear them.
The consequences can be dire. A 2016 survey of female physicians showed that half believed that they had met criteria for a mental illness but had not sought treatment in part due to fear of reporting to state licensing boards. In 2011, a survey of surgeons found that 1 in 16 had thought of suicide; of those, more than 60 percent had concerns about losing their medical license. This pattern of fear and avoidance of treatment contributes to a shocking statistic: One physician commits suicide each day in the country, twice the rate as in the general population.
Despite this and the numerous studies on physician mental health, as well as advocacy by the American Medical Association and the Federation of State Medical Boards, some states continue to prop up barriers that stigmatize seeking help for mental illness at a time when it should be encouraged most. Required mental health disclosures don’t eliminate mental illness; they reduce the treatment of it. Covid-19 is an international crisis that has led to the deployment of thousands of physicians who are desperately needed in the fight. Licensure applications should be amended to remove broad questions regarding mental health history and focus on a clinician’s ability to function. Licensure should not be contingent upon intrusive access to a physician’s most personal medical records or costly and lengthy evaluations and demoralizing contracts that, as psychiatrists ourselves, we would never require of our patients.
These requirements should be lifted so that health-care workers who risk their lives daily can be allowed the opportunity to seek mental health care without fear of forfeiting their right to privacy. Only then can they feel comfortable enough to seek early treatment for the ongoing trauma they endure to save the lives of others — and the helplessness they may feel when there are so many they can’t save. Covid-19 has killed more Americans than the Vietnam War. With that somber milestone observed, and as deaths continue to mount, there is no doubt that health-care workers are experiencing something only those serving on a battlefield can understand. They deserve the opportunity to heal their psychological wounds without the fear of losing their careers.