Recognizing that invasive mental health questions in credentialing applications might prevent her colleagues from seeking the care they need, Annabella Salvador-Kelly, MD, deputy chief medical officer and senior vice president of medical affairs at Northwell Health, was on a mission.
“I felt like I had the opportunity to really make a difference for our physicians and our credentialed clinicians’ well-being by changing these questions,” she says.
She proposed rewriting applications to remove inappropriate questions and found universal support from her colleagues in Northwell Health’s medical staff office and system leadership team. “There was no question about it,” she says. “Everyone was ‘let’s do it.’ ”
In September 2023, Northwell Health — New York’s largest health system with 21 hospitals and more than 12,000 physicians — became one of the first 12 health systems in the country to earn a Wellbeing First Champion Challenge badge from the ALL IN: Wellbeing First for Healthcare coalition, which is led by the Dr. Lorna Breen Heroes’ Foundation, affirming that the health system’s applications and credentialing forms are free of intrusive mental health questions and stigmatizing language.
The badge program is one of many ways in which government agencies, professional medical societies, healthcare organizations, and others are trying to address the mental health crisis among physicians and other healthcare workers.
The crisis, building for years, was exacerbated by clinicians’ fears that if they disclosed mental health diagnoses or treatments as required by many state licensing and hospital credentialing forms, they might lose their jobs.
More than 75% of physicians, residents, and medical students responding to the Physicians’ Foundation’s annual survey this year agreed that a stigma surrounds mental health and seeking mental healthcare among physicians. About half of the respondents said a colleague or peer has indicated they would not seek mental healthcare, and about 40% said they were afraid or knew someone who was afraid to seek mental healthcare because of questions in medical licensure, credentialing, or insurance applications.
Salvador-Kelly says changing the wording on those documents is one step in making clinicians feel safe in seeking mental health services. “Physicians struggle with it because we are so used to taking care of others that we often don’t look at taking care of ourselves,” she says. “The more we’re able to do for individuals to find the help they need, the better we will all be.”
THE JOURNEY SO FAR
Clinician well-being was already a well-known industry-wide problem before the COVID-19 pandemic erupted in early 2020. Lorna Breen, MD, an emergency physician at Allen Hospital in New York City, was one of hundreds of U.S. physicians who died by suicide that year.
Salvador-Kelly, an emergency physician who knew Breen, was struck by the news. “If you knew Lorna, she was a beautiful, intelligent, amazing clinician with such life and spirit in her,” she says. “For me, it really hit home because if we can lose somebody like Lorna to suicide, there’s so many others out there who are suffering and we have to make it easier for them to seek help.”
After her death, Breen’s family realized that one of her fears — that she would lose her medical license or be ostracized by her colleagues because she needed mental health care — is shared by physicians and other clinicians across the country. Her sister, Jennifer Breen Feist, and brother-in-law, J. Corey Feist, established the Dr. Lorna Breen Heroes’ Foundation to focus on clinician well-being.
In that way, Breen’s death triggered action that many organizations, including the Federation of State Medical Boards, the American Medical Association (AMA), and others, had been advocating for, says Stefanie Simmons, MD, the foundation’s chief medical officer.
The foundation developed toolkits to help licensure boards, hospitals, health systems, and insurance companies ferret out and remove inappropriate questions and stigmatizing language from their applications, forms, and addendums. And it brought together a coalition, ALL IN: Wellbeing First for Healthcare, including the American Hospital Association, American Nurses Association, AMA, and many others, to challenge licensing boards and health systems to do better.
Simmons says it’s working. As of September 1, 2024, she found 29 state medical licensure boards had verified that their licensing applications do not include inappropriate mental health questions, up from 17 before the challenge was issued. In addition, four nursing licensure boards and one dental licensure board have updated their application forms.
Beyond that, 375 hospitals — up from 75 last year — verified that their credentialing applications avoid intrusive mental health questions. Other organizations are also stepping up: One health plan, one locum tenens firm, and a national hospital-based physician practice have verified that their applications and forms have met the ALL IN challenge.
Momentum is building for more progress. Seven states have a mandated state credentialing application. “Two of them are now consistent with best practices: Texas and, because of the advocacy of an individual within that state credentialing process, Iowa as well,” Simmons says. “That impacts dozens of hospitals and hundreds of thousands of healthcare workers all at once.”
In some states, the state insurance department must approve any changes to hospital credentialing forms if the hospital credentialing application is also used for insurance credentialing.
“Departments of Insurance and payers have also gotten on board with this change in multiple states,” Simmons says. “In fact, in Massachusetts, where the Massachusetts Health and Hospitals Association led work for all of the hospitals to make this change, they worked with the payers to get this work done.”
MENTAL HEALTH CHECKUP
Of course, all the document-editing in the world will not improve the well-being of the healthcare workforce unless clinicians who need help are seeking it.
Lisa MacLean, MD, director of physician wellness at Henry Ford Health, thinks progress is being made there as well, with younger physicians leading the way. When she spoke to Henry Ford Health’s incoming residents this summer, she made her pitch: “If you’re currently in treatment and need to continue treatment, contact me.” She got six referrals within the week.
“The younger clinicians seem to be more open to seeking care than when I was going through training years ago,” she says. “I think it is because these things are being discussed more at the residency level and even medical school level.”
MacLean, a psychiatrist, runs a physician specialty clinic that gives Henry Ford Health physicians fast-track access to behavioral health services if they need it. She and another psychiatrist do all the medication evaluations, working with a psychologist who only sees physicians.
Because finding time for a behavioral health visit can be a major barrier for a physician to receive care, MacLean and her behavioral health colleagues dispensed with a set clinic schedule. Rather, they schedule their physician patients when it works for the patient — during their administrative hours, their lunch period, after their work hours. “We may say ‘Let’s do it at 8 o’clock when your shift ends,’ ” she says. “This kind of custom scheduling makes it a lot easier to get people to where they need to be.”
In another bid to reduce stigma associated with mental health services, Henry Ford Health embedded a therapist specifically for physicians in its employee assistance program. “People who don’t necessarily need medication and maybe just need a few sessions have a person that they can see for free without anything being documented in their medical record,” she says.
There are tentative signals that America’s mental health crisis among physicians may be abating. The 2024 Medscape Physician Burnout & Depression Report, based on an online survey with 9,226 physicians responding in mid-2023, revealed that 49% of respondents were experiencing burnout, down from 53% in the previous year. Also, 20% of respondents said they were suffering from depression, down from 23% a year earlier.
The rates of burnout and depression among physicians in 2023 were still higher than pre-pandemic levels, but any decline is a reason to be “cautiously excited,” Breen says. “We should be excited about that because that’s a trend in the right direction after a trend in the wrong direction for several years,” she says.
The AMA survey of physicians also suggested a possible tipping point in the mental health crisis. Its analysis of more than 12,400 responses gathered in calendar year 2023 from physicians working in 81 health systems in 31 states found that 48% experienced at least one symptom of burnout, down from 53% in 2022.
TIPS FROM THE FRONTLINES
Select the right leader. The champion for these changes needs to have passion for the task. “I’d be very shocked to find individuals who would be against it, but it takes work,” Hall says. “Somebody has to push it forward.”
Follow-through is essential. When MacLean approached Henry Ford Health’s vice president of quality and safety with the idea of updating the system’s credentialing questionnaire, she got immediate buy-in.
The idea sailed through the system’s credentialing committee, medical executive committee, and legal review. Thinking the work was done, MacLean was surprised to learn, several months later, that no documents had been changed. The decision had not been communicated to the individual authorized to actually make the changes.
“This work may feel like it’s simple and straightforward, but you have to double-check everything,” she says. “And it’s not done until you actually see it in print.”
Typically, that means it must be in print on a lot of documents. Every hospital in a health system will likely need to change multiple documents.
“Some of these questions may exist not just on your initial credentialing questionnaire or your re-credentialing questionnaire, but on things like the peer review form that you send out to check references,” MacLean says.
At Northwell, Salvador-Kelly also found the work did not end with changes to the credentialing questions. After the initial forms were changed, she and other leaders started finding stigmatizing language in other documents, including bylaws that require medical board and board of trustees approval.
“So we’ve been slowly going through the organization to update our bylaws, rules, and regs,” she says. “When we looked at our employee health services questionnaires, we realized there were opportunities there, so we changed those questions as well.”
Make sure all clinicians know that it is professionally safe to seek mental healthcare. “If this change happens in a vacuum, nothing has changed,” Breen Feist advises. “The communication piece of this is so important.”
Hospitals and health systems that earn the Wellbeing First Champion Badge receive a communications toolkit to help them educate their workers about the policy changes that eliminate barriers to seeking care.
WHAT TO DO NOW
The task of updating an organization’s applications and credentialing documents can be seen as tedious and time-consuming — or as a gift to the physicians and others who are devoting their lives to patient care.
By officially destigmatizing mental health treatment, healthcare leaders signal that they value their colleagues.
“This really matters to healthcare workers,” says Simmons, of the Dr. Lorna Breen Heroes’ Foundation. “This is not administrative. It lets people know they are allowed to be human; they are allowed to take care of themselves, and in fact, that makes them better doctors, not damaged doctors, not worse doctors, not unworthy doctors.”
The Impact Wellbeing Guide, published by the foundation in conjunction with the National Institute for Occupational Safety and Health, is a good starting point. The guide offers step-by-step guidance to help hospital leaders improve professional well-being within their organizations.
One step is the auditing and updating of hospital credentialing questions to remove intrusive and stigmatizing questions that may prevent physicians and other healthcare workers from seeking help.
The audit reviews all credentialing, peer reference, and application forms to identify problems, including:
Questions that ask about a history of mental health diagnosis or treatment.
Questions that ask about an individual’s history of “time off” or “breaks in practice.”
Questions that ask about past substance use or experiences with mental healthcare.
Questions that include overly broad language and unnecessary specifications such as “current impairment can be any time in the last five years.”
The guide suggests three options to update problematic language in the forms:
Ask a single question that addresses all mental and physical health conditions as one without adding explanations or asterisks.
This language is recommended by the Federation of State Medical Boards: “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner? (Yes/No)”Do not ask any probing questions about an applicant’s health.
Use an attestation model, which affirms that clinicians’ self-care is patient care. This wording from the Federation of State Medical Boards is used in North Carolina:
“The Board recognizes that licensees encounter health conditions, including those involving mental health and substance use disorders, just as their patients and other healthcare providers do. The Board expects its licensees to address their health concerns and ensure patient safety. Options include seeking medical care, self-limiting the licensee’s medical practice, and anonymously self-referring to the NC Physicians Health Program, a physician advocacy organization dedicated to improving the health and wellness of medical professionals in a confidential manner. The failure to adequately address a health condition, where the licensee is unable to practice medicine within reasonable skill and safety to patients, can result in the Board taking action against the license to practice medicine.”