Opinion | Mental Health Is a Slippery Slope When It Comes to Physician Well-Being

I applaud the efforts of several states that have enacted legislation to make it easier for physicians to get mental health treatment without incurring the wrath of physician health programs (PHPs). PHPs, while well-intended, are notoriously disruptive to the lives and careers of physicians struggling with depression, substance use disorders, and other mental health conditions. PHPs have a reputation for implementing unreasonable requirements and being coercive, sometimes worsening physicians’ underlying psychiatric status.

New laws in Virginia, South Dakota, Indiana, Delaware, and Arizona give doctors an option to receive truly confidential peer support. These states have enacted laws specifically intended to protect physicians seeking help for career fatigue and wellness, and more states are likely to follow.

In reality, these new programs are a wolf in sheep’s clothing.

The hitch is that to get the help they require, physicians must seek counseling for “career fatigue and wellness” rather than “burnout” — let alone depression or substance use. Also, because states’ medical societies run these peer-support programs, the process amounts to a classic case of the fox guarding the henhouse.

It is important to note that career fatigue and burnout are not recognized as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. In the World Health Organization’s International Classification of Diseases (ICD-11), burnout is included in the chapter titled “Factors influencing health status or contact with health services.” By all accounts, “career fatigue,” “wellness,” and “burnout” are not conceptualized as medical conditions; rather, these terms are specific to the occupational phenomenon.

Why is it important to make this distinction? For one, burnout is commonly recognized as a term that describes what ails more than 50% of physicians in practice today. Second, what good is legislation that only covers fatigue and wellness and does not afford confidentiality to treat more serious conditions that affect the health and welfare of physicians and, by extension, their patients? Third, given that generations of physicians have been taught that treatment follows diagnosis, how good will the treatment be if the diagnosis is masked or incorrect or camouflaged under the guise of wellness?

The symptoms of burnout and depression overlap to such a degree that the two conditions are sometimes indistinguishable. Moreover, what begins as “burnout” often seamlessly eventuates in clinical depression. Excluding depression and other psychiatric disorders from the category of “career fatigue and wellness” puts psychiatric nomenclature on a slippery slope. Diagnostic imprecision inherent in “career fatigue” overlooks seriously ill physicians in desperate need of help — all for the sake of compromising on legislation designed to help physicians, but instead has the potential to create further barriers to treatment or delay it.

Why would any physician take advantage of a confidential peer support system that could possibly expose them once a clinical diagnosis becomes apparent? These new laws are supposed to assist physicians who may avoid seeking help in other programs because of the fear of negative repercussions. But they do not provide crisis intervention services, and confidentiality and civil immunity protections go away if there is an obligation to report criminal charges or behavior or unprofessional conduct or if it is determined that the physician is not able to safely practice medicine.

My previous experience as a disability claims reviewer for an insurance company sheds further light. On occasion, I reviewed the medical records of physicians applying for short-term disability due to stress. Invariably, these physicians would be characterized as burned out. They were frequently denied short-term disability benefits on the grounds that occupational stress is ubiquitous and not tantamount to a disability, and burnout is not a clinical diagnosis. To be disabled, the physician would truly need to show impairments, limitations, and performance deficits substantiated by a bona fide mental health diagnosis (usually major depressive disorder) in the medical records.

In this scenario, the physician would be deemed temporarily unsafe to practice medicine and, therefore, denied access to confidential peer treatment under the recently passed legislation. But confidential treatment is precisely what is needed for physicians who face mounting work stress, burnout, and depression. That is why private therapy was — and still is — the best route to pursue. New legislation is meaningless if it only allows confidential peer support to address career fatigue and wellness. How many of us will actually step up if we cannot be guaranteed a safe haven for our more pressing mental health concerns?

Let’s not sugarcoat serious mental health problems as wellness initiatives. Let’s not pussyfoot around psychiatric diagnoses. And let’s stop penalizing troubled physicians for coming forward for treatment. Questions that are part of the physician licensure and credentialing process are threatening and continue to contain stigmatizing language, acting as a deterrent to mental health treatment. Is there no middle ground for physicians seeking voluntary support for career fatigue and those seeking services that might be required when there is a concern about impairment?

In many cases, it’s simply not possible to determine where career fatigue and wellness end and burnout and depression begin. States must enact broader legislation to ensure physicians receive confidential and non-judgmental treatment for mood and substance use disorders without putting their medical licenses and livelihood on the line. Otherwise, physicians will be driven further underground — literally and figuratively.

Arthur Lazarus, MD, MBA, is a psychiatrist.

This post appeared on KevinMD.