hile the life of a physician can be extremely stimulating and gratifying, it often requires great personal sacrifice (1). The personalities of individuals entering medicine are often driven, perfectionistic (2), and highly self-reliant (3). Suicide rates in physicians are significant (4, 5). Compared to the general population, male physicians have an aggregate suicide rate ratio of 1.41 (95% CI=1.21—1.65), and female physicians have an aggregate suicide rate ratio of 2.27 (95% CI=1.90—2.73) (5). While data are limited (6), it is estimated that approximately 2% of physicians currently have an active substance abuse problem and another 8%—18% of physicians will be affected at some point in their lives (7). Cross-sectional rates of depression in medical students and residents range from 15%—30% and are higher than in the general population (8—10). Despite this reality, stigma attached to mental illness is greater within the field of medicine than it is in the general public (11). Its existence reinforces denial in physicians that they might become ill and contributes to delays in seeking care, unnecessary suffering, self-medication—increasing the risk for impairment—disruptive behavior in the work place, isolation from medical colleagues, medical errors, failed marriages, and dangerously heightens the risk of death by suicide (11). According to suicidologist Edwin Shneidman (12), three events converge for an individual to choose to end his or her life: 1) experiencing unbearable psychological pain and seeing no escape other than death; 2) having ready access to instruments of suicide such as guns, knives, or pills; and 3) being in a highly agitated state of discomfort and anxiety.

In the aftermath of a 12-month period with four physician related deaths including three suicides and one homicide in one medical community, substantial collective efforts were made to identify and reduce barriers to seeking psychiatric care. This state’s medical board still required full disclosure for any mental health treatment in its initial and renewal medical licensure applications. See Table 1 .

Careful review of 47 state licensure applications identified three states that contain this disclosure requirement (13). This disclosure occurs in a forum where confidentiality cannot be assured (board meetings are open to the public), undermining any progress toward decreasing the stigma of seeking help early in the course of illness to prevent impairment.

Following this cluster of tragic physician deaths, the President of the state’s Psychiatric Society met with the state’s medical licensure board requesting changes in disclosure requirements. The Medical Board extended its assurances that its members needed to know this information to protect the public and that they intended no harm to applicants who sought mental health treatment. They failed to comprehend that seeking mental health treatment does not necessarily imply functional impairment in the practice of medicine and that this violation of privacy served as a strong deterrent to physicians considering reaching out for help.

In an effort to educate the board, trainees and physicians were invited to share their anonymous views. An invitation was extended through the medical school e-mail list with the title, "Request for supportive information to change questions about mental health treatment."

The message read:

Responses were returned voluntarily and identifying information was immediately removed to protect the identity of the respondents. The results were compiled and submitted to the president of the State Psychiatric Society, who brought them to the meeting with the State Medical Board.

Anonymous Views of Trainees:

Reaction of the State Medical Board

The collection of responses opened discussions with the State Board of Medical Licensure. Next, stakeholders from the State Medical Society, the State Psychiatric Society, and the College of Medicine joined efforts to formulate recommendations for specific revisions of the licensure questions (Table 2 ). They chose questions that specifically identified impairment while protecting the confidentiality of physicians who appropriately seek mental health care to ensure their optimal functioning. The formal request for change is in process.

The State Medical Board approved the recommended modification in April, 2006.

Expert Recommendations

In 2003, leaders in the American Medical Association and the American Foundation for Suicide Prevention recognized the significant problem of physician suicide. They formulated a consensus statement encouraging a shift in professional attitudes and institutional policies to support physicians seeking help for the treatment of depression (14).

They identified a profile of a physician at high risk for suicide (Table 3). The Consensus Statement makes a strong recommendation to ensure that licensure regulations, policies, and practices are nondiscriminatory. They should require disclosure of misconduct, malpractice, or impaired professional abilities and NOT a psychiatric or medical diagnosis (14).

Improvements

Both the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education are leading efforts to require confidential primary prevention programs for medical students and trainees (14). These programs are designed to maximize the mental health and functioning of medical students (16) and residents in training (17) and are becoming readily accepted and utilized in many institutions (18). Trainees learn the signs and symptoms of stress related illnesses such as depression, anxiety disorders, substance use, and relationship difficulties, and are encouraged to seek early treatment to optimize their performance.

Discriminatory Practices

Unfortunately, some physicians in practice who have psychiatric disorders continue to encounter discriminatory practices. As far back as 1983, APA expressed concern that the licensing board questions inquiring about diagnosis or treatment of mental illness will deter physicians from seeking help (19).

One physician with bipolar disorder disclosed his diagnosis to his state licensing board. When mandated to provide his psychiatric records, he refused, pointing out that he was receiving effective treatment and his performance was not impaired. He also advocated that impairment could not be inferred from his diagnosis and that such policies are overly invasive and counterproductive because they deter physicians from seeking help, thereby posing greater risks to patients (19).

Discriminatory insurance practices are common where individuals who have a history of mental health treatment are either refused life or disability insurance coverage or are charged significantly higher premiums.

Unresolved Challenges

Changing medical licensure questions is one step toward encouraging physicians to seek mental health care, but many challenges remain. The personalities of physicians raise their risk for suicide. They are gifted (or cursed) with excellent organizational skills including perfectionism, a willingness to work long hard hours, often neglecting themselves and their closest relationships, and a competitiveness that fuels their need to appear highly competent and self-reliant (11). While in medical school, students often cope with the stress of medical school by self-medicating with alcohol (20). This stress reduction technique is unfortunately reinforced through a longstanding tradition of alcohol centered medical school events. The importance of changing this tradition is emphasized when taking into account that each of the recent physician deaths was associated with heavy alcohol intake. Twenty-five percent of all persons who commit suicide are intoxicated at the time of their deaths (21).

Monumental cultural change will be necessary to esteem highly the physicians who attend to their own feelings, live their values (22), strive for excellence (rather than perfection), and appropriately rely upon others. One innovative academic institution allows physicians to work less than full time in order to live their values. To their surprise, they discovered that these faculty experienced a significantly higher quality of life, were equally as productive as their full time colleagues, and their patient satisfaction surveys were superior (23).

Dedicated to our colleagues who didn’t reach out for help.

Web Resources: The American Foundation for Suicide Prevention (http://www.afsp.org/physician).