March 18, 2022 was a memorable day for graduating medical students. It was Match Day, the day they learned which residency training program they will attend as they begin their careers as physicians.
March 18, 2022 was even more memorable for the approximately licensed to practice medicine in the U.S. It was the day President Biden signed into law the Dr. Lorna Breen Health Care Provider Protection Act, legislation designed to promote the mental health of medical professionals. Yet, the day went by with hardly a whimper. Let's revisit the significance and challenges of the legislation.
Lorna Breen, MD, was an emergency physician working at a frenetic pace at the height of the coronavirus pandemic in New York City in 2020. She contracted COVID-19, returned to work early out of a sense of duty, and after struggling with psychiatric challenges took her life a few weeks later. She had no previous psychiatric history before this. Her only known risk factor for suicide was being a physician.
The legislation enacted in her honor was sponsored by Sen.Tim Kaine (D.-Va.), and its core tenets were promoted tirelessly by Breen's sister and brother-in-law, Jennifer Breen Feist and Corey Feist, both lawyers, who also established a to decrease healthcare professional burnout, improve job satisfaction, and reduce mental health stigma so that seeking psychiatric care will be viewed as a sign of strength for healthcare professionals.
Among its many , the "" seeks to identify "barriers to seeking and accessing mental health care for health care professionals, which may include consideration of stigma and licensing concerns, and actions taken by State licensing boards, schools for health professionals, health care professional training associations, hospital associations, or other organizations, as appropriate..."
And therein lies the rub. The Act does not provide a blueprint for expanding access to mental health resources or ensuring that states don't force doctors to disclose whether they've received or are seeking mental health counseling. As it became clear that Breen needed psychiatric help, her main fear was that she would lose her license to practice medicine for accepting treatment. (Other physicians do not seek help is their concern that colleagues will find out or they will be shunned by the medical profession.)
Disclosing whether or not physicians have a mental health or substance use history has become a standard and ill-fated requirement asked on applications by most state licensing medical boards and hospitals' and health systems' credentialing committees. The American Medical Association licensing bodies to remove questions on their applications, but to no avail. A past or current psychiatric diagnosis raises a red flag. It is a serious deterrent to treatment. How do we overcome such an impasse?
The Act recognizes licensing issues as barriers to mental health services, but it stops short of a proclamation or solution that would remove any sanctions for unwell physicians seeking treatment. Licensing and privileging authorities still retain the right to set the ground rules, acting as gatekeepers to practice, even dictating extracurricular activities when deemed necessary -- for example, onerous including "fitness-to-practice" evaluations for physicians who wish to return to practice after a period of absence. For sure, coercion is not a satisfactory way for well or unwell physicians to retain or regain their professional standing.
Rules and regulations governing practice and hospital privileges vary widely by state and even locale. In Florida, for instance, physicians are only granted a medical license if they have been in active practice two of the previous 4 years. North Carolina, on the other hand, requires physicians to be in active practice for the previous two consecutive years. The variability in healthcare licensing across the country is remarkable -- not to mention .
Make no mistake about it, contribute to mental health stigma by persisting in probing licensure applicants about their history of treatment and fostering public disclosure of mental health problems. I used to view state licensing boards as the enemy. Now I realize, as did the great comic strip character Pogo, "We have met the enemy, and he is us." Why is the issue essentially ours to deal with?
Ask, who actually deliberates on state medical licensing boards? Who decides whether hospital privileges should be granted? Who controls medical schools' admissions committees? Who determines the disposition of recovering physicians enrolled in diversion programs (and who reports physicians that seem impaired)? Physicians do -- in virtually all instances. It's unfathomable that doctors who struggle may be especially reluctant to ask for help from the people best positioned to intervene -- their own colleagues.
Not until we -- physicians -- eliminate implicit biases and view our troubled colleagues through a wide psychological aperture of human fallibility will we begin to shed some of these archaic and unnecessary barriers to treatment and begin to embrace "treatment without consequences." If doctors could be guaranteed there would be no repercussions to their state licenses or medical staff privileges, wouldn't more of them voluntarily seek mental health services?
Physicians opposed to such a policy usually beat the quality drum. They claim impaired physicians are a risk to the public -- and of course they are, when acutely ill. However, have shown that recovered physicians pose less discipline problems to state medical licensing boards than the average practitioner. Successful mental health and substance use treatment improves many aspects of physicians' lives in addition to stopping the use of illicit drugs or recovering from deep depression. Interventions directed at physician wellness also improve patient care, and we know the converse is certainly true: .
Unfortunately, Breen's life was cut short before she could benefit from therapy. However, the Act that bears her name makes provisions for grants, education, and research related to burnout and the overall well-being and mental health of health professionals. The bill is designed to bolster the mental health infrastructure and, by tackling stigma, send a message to physicians that their reputations and medical standing will not suffer for seeking help, nor will they be viewed pejoratively if they succumb to stress and enter treatment.
April 26, 2022 marks the second anniversary of Breen's death. The Dr. Lorna Breen Health Care Provider Protection Act the legacy of her memory -- "an extension of her caring for her colleagues in the deepest possible way." A puzzling and troublesome question remains, however. How could have voted to veto the bill given Breen's ultimate sacrifice in the service of others, not to mention the loss of per year to suicide? Perhaps the enemy is not entirely us.
If you or someone you know is considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board, a 2021-2022 Doximity Luminary Fellow, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.