‘Safe Haven’ Integral to Physician Wellness

Abstract

Back to table of contents Previous article Next article Ethics CornerFull Access‘Safe Haven’ Integral to Physician WellnessClaire Zilber, M.D.Claire ZilberSearch for more papers by this author, M.D.Published Online:14 May 2019https://doi.org/10.1176/appi.pn.2019.5b22AbstractA psychiatry resident is treated for anorexia nervosa in a state that doesn’t offer “safe haven.” She discloses her illness to the licensing board, which publishes details about her illness on its website. What she thought was her private, protected health information is now available to the Googling public.Claire Zilber, M.D., is a psychiatrist in private practice in Denver, a faculty member of the PROBE (Professional Problem Based Ethics) Program, and chair of the Ethics Committee of the Colorado Psychiatric Society. She is the co-author of Living in Limbo: Creating Structure and Peace When Someone You Love Is Ill.A growing number of medical licensing boards (MLBs) are forging agreements with their corresponding physician health programs (PHPs) to provide “safe haven” to licensees who are in psychiatric or substance abuse treatment and whose treatment is monitored by the PHP. This column details the history of safe haven agreements, explains their importance for physician wellness, and describes the experience with safe haven in one of the first states to implement this innovation.Following the 1990 passage of the Americans With Disabilities Act (ADA), MLBs have been encouraged to modify their broad questions on licensure applications, such as, “Are you now, or have you ever been, diagnosed with or treated for mental illness?” The Department of Justice has deemed that questions about history of mental illness, rather than impairment, are a form of discrimination because they foster assumptions about a person’s functioning based on a diagnosis—similar to categorizing people based on race or gender.In 1997, APA proposed guidelines to help MLBs comply with the ADA by narrowing their questions to reflect current functional impairment. Despite the ADA’s and APA’s guidelines, a study by Sarah Polfliet, M.D., reviewing MLB questions from 1993, 1996, 1998, and 2006 application forms found that licensing boards asked more questions about past diagnoses and treatment of mental illness in 2006 than in the 1990s.Equally concerning were the results of a survey by the Federation of State Medical Boards (FSMB) in 2007, in which MLBs were asked about licensing applications.Thirteen of the 35 (37%) responding boards indicated that a mental health diagnosis by itself was sufficient to sanction physicians, regardless of occupational functioning. Over one-third of responding state boards admitted that they treat physicians receiving psychiatric care differently from those receiving other forms of medical care.Given societal stigma about psychiatric illness and some MLBs’ apparent discriminatory practices, it is no surprise that medical students and physicians often avoid seeking mental health treatment. This likely exacerbates the high suicide rate among physicians and the epidemic rates of burnout.In the 1990s, some PHPs negotiated safe haven agreements with MLBs to encourage physicians to proactively seek assistance for mental or physical illness by ensuring confidentiality from the medical board. This was an attempt to preserve physicians’ ability to receive confidential treatment while honoring the duty of the licensing boards to protect the public from impaired physicians. Under safe haven agreements, applicants for licensure are allowed to answer “no” to questions about mental illness as long as they are being treated under the supervision of their state PHP. The PHP reports physicians to the MLB only when they are deemed dangerous or are not following the program’s recommendations.A direct, linear relationship exists between the extent to which the clients of a PHP must be reported to the licensing board and the number of clients in that PHP: The less confidentiality exists for treatment, the fewer physicians enrolled in a PHP. Amid growing concern about physician burnout and its impact on patient care, the AMA in 2016 and the Federation of State Medical Boards in 2018 each advanced a policy that discourages probing questions about psychiatric illness or substance abuse on licensing applications and promotes safe haven for physicians who seek treatment as long as they are not impaired in their ability to treat patients competently.Colorado was one of the first states to adopt a safe haven agreement. Under the agreement, which has been in effect since 1990, a physician or physician assistant applying or reapplying for licensure can reply “no” to application questions about psychiatric illnesses as long as the applicant has had a voluntary evaluation by the Colorado Physician Health Program (CPHP). Prior to safe haven, referrals to CPHP came primarily through the MLB and were complaint driven, usually after something bad had happened. After safe haven, the majority of CPHP encounters were voluntary referrals, unknown to the board; and interventions were early, before impairment occurred. Within five years of implementing safe haven, voluntary referrals increased by 195%. In 2019, the Colorado Medical Board took a further positive step to reduce stigma by changing its application questions to ask only about impairment by a medical or psychiatric condition.As MLB policies adapt to changing societal expectations, organized medicine and PHPs must remain vigilant to inadvertent erosion of protections that afford physicians and trainees confidential health treatment. Nobody deserves to have his or her psychiatric history available to the public simply for choosing to seek treatment.Without safe haven, rather than voluntarily presenting to a PHP for evaluation and referral to treatment, depressed, anxious, suicidal, or otherwise suffering colleagues may try to tough it out on their own with no treatment. Or they may attempt to self-medicate, a solution fraught with medical and ethical risks. Their illness may become known to the PHP and the licensing board only after a bad outcome, such as poor work performance, behavioral problems, adverse patient care, or a suicide attempt.APA district branches and state PHPs can work with their state MLBs to ensure that safe haven is available to physicians in their state. ■“AMA Adopts Policies to Support Physician Wellness, Mental Health” can be accessed here. “Report and Recommendations of the Workgroup on Physician Wellness and Burnout” by the Federation of State Medical Boards is available here. APA’s policy on the diagnosis and treatment of mental disorders in connection with professional credentialing and licensing is posted here. ISSUES NewArchived