Why a group of U of M med school residents pushed to get Minnesota to change its medical licensure language

Inspired by tragedy, Brianna Engelson launched a push to make lasting change that supports the mental health of her fellow med students. 

After the suicide of a classmate,  Engelson, a psychiatry resident at the University of Minnesota Medical School, worked in close collaboration with fellow residents Jennifer Zick and Sameena Ahmed-Buehler to start a campaign at the medical school aimed at creating a more open, accepting culture around mental health. “Medical students are way more likely to suffer from depression, suicidal ideation and anxiety than the general population,” Engelson said. 

A cultural norm of “toughing it out” and bottling up mental health struggles only contributes to that, she believes.  

After news spread about their classmate’s death, a number of med students reached out to Engelson to report feelings of depression, anxiety and suicidal ideation. She decided to hold a small focus group centered on the mental health pressures of medical school — and the culture that encourages med students to keep their struggles to themselves.  “We wanted to tease out what is unique about medical students,” Engelson explained. 

This fall, insights from the focus group led to real-world change, when the Minnesota Board of Medical Practice voted to change key questions involving mental health treatment in its medical license form. 

In the past, the form required physicians to disclose all mental health conditions. Now, they are only required to state if they have a health condition that is not being appropriately treated and could impair their ability to practice medicine.

Engelson, 31, is pleased that her work inspired this change and believes the new wording, though subtle, will help physicians feel more comfortable seeking treatment for mental health concerns.

For this Q&A, I spoke to Engelson, the Minnesota Psychiatric Society’s 2021 Eric Brown Scholarship Award recipient, about her research, her commitment to supporting the mental health of med students and her hopes for her future.

MinnPost: Can you tell me more about the events that ultimately inspired you, Ahmed-Buehler and Zick to go to the Board of Medical Practice and ask for changes in the licensure language?

Brianna Engelson: One of our medical school classmates had died by suicide. He wasn’t a close friend, but I knew him, and right away, all kinds of classmates — people I know well — were texting me, saying, “I’ve thought about suicide, too,” or,  “I’m worried about my friend,” or, “This was bound to happen to one of us.” 

I was well known in my med-school class as someone who is interested in mental health. I had been vocal, advocating for mental health parity. I think my classmates felt like I was safe, like I wasn’t going to judge anybody if they told me about their mental health. They knew I get it. These are not uncommon feelings. I was struck by how few people who could benefit from psychiatric care were actually accessing it because they were worried that if anyone knew they’d sought out that kind of help it could have a negative impact on their career.

MP: What made you decide to gather classmates for the focus group? 

BE: I thought it would be a good way to hear from other medical students, to talk about mental health in a safe place, to gather themes to support the idea of changing the licensure language. We were limited financially in this research, but I found a group of six third-year and one fourth-year medical students who answered the call to participate in a focus group. 

MP: What were some of the most important things you learned? 

BE: The one thing that was unanimous across all participants was the theme of discrimination, the fear that they could be discriminated against if they came out and told others that they were seeking psychiatric care. In the medical community, there is a perceived weakness if you need to take time away from your rotation or your clinic for a mental health appointment. This fear of discrimination leads many medical students to avoid seeking mental health care. 

Interestingly, it was also unanimous among participants that they would support a friend or colleague in seeking out mental health care. They also supported the idea that individuals who are being treated for mental illness should be able to continue to practice medicine. But if you turned the question around and asked, “What if you were the one seeking mental health  care?” they’d say, “I’d be really nervous about disclosing that.” 

They were holding themselves to a different standard.

Another thing that I was hoping would come up in these focus groups was the disclosure requirement on licensing and credentialing. I had an ulterior motive in doing this research: I wanted to see if medical students were concerned about the wording of the licensing application and if that played a role in how they thought about mental health treatment. I wanted to find out about their thinking and get that information out to the state’s medical community. 

MP: Once you held the focus group and compiled the information, what was your next step before meeting with the Board of Medical Practice? 

BE: We went to the Minnesota Academy of Family Physicians and the Minnesota Medical Association and said, “This is what we found out. Can you make this a priority? Can you help us advocate? Can you put pressure on the board?” They both agreed to help.

MP: After you’d gathered support from physician groups, it seems like the next step went fairly smoothly. The Board of Medical Practice agreed to change the language and it was made official on Sept. 11, 2021. Were you surprised at how quickly your goal was met? 

BE: In some ways it felt like we were taking on this huge thing. I remember saying, “I hope I can take this on in my career.” I was thinking that it would be a long-term goal. The fact that we changed it as quickly as we did makes me wonder if we can’t actually change the entire medical school culture. Look at what we just did: Maybe little by little we can change the culture and make medicine a safer place to be for everyone.

MP: The license-form wording change might have been made pretty quickly, but you invested a lot of up-front energy in getting it done. Medical residency is a busy time. How did you motivate yourself to add such a daunting task to your schedule? 

BE: A  lot of my activism on this topic rose out of grief. Getting it done was part of my grieving process. And I kept going because I kept  hearing from med students, from residents, from people who l look up to. They’d say, “This is important work and it impacts me personally.”  

I heard so many shocking stories. It was a theme of, “Me Too.” 

MP: Let’s talk a bit more about the actual wording of the medical license form and how the changes you advocated for could inspire more medical students and residents to seek out mental health care when they need it.

BE: When you apply for your medical license there is a question that you have to answer. Until last month the wording was, “Have you in the past five years been advised by a physician that you have a medical or behavioral illness that if untreated could impair your ability to practice safely?”

I had heard anecdotally people saying, “I am afraid to seek out care for my mental health because that would give me a medical record. It would get disclosed when I apply for my license that I have a mental health condition and that could make it difficult for me to get a job.” Given the time and the effort and the sacrifice that people put in to go to medical school, it is really scary to think what could go wrong if you answer that question the “wrong way.”

MP: So how has the wording changed, and why is that change important? 

BE: The new wording is, “Do you have a condition that is not being appropriately treated which is likely to impair or adversely affect your ability to practice medicine?” What changed was instead of, “Have you within the past five years” to  “Do you currently have a condition.”  Instead of separating out “mental, physical or emotional conditions,” they changed it to “a health condition.”  Rather than saying, “which if untreaded,”  they ask basically, “Do you currently have an untreated condition?”  

These changes seem small but they’re actually pretty big.

MP: All states have medical practice boards. Do other states’ medical license forms include similar questions? 

BE: It varies by state. Some states are better than others. Some are worse. Minnesota isn’t the worst. It isn’t the best, either. But I’m pleased with this language change. I would like to see that we have more consistency in terms of disclosure of treatment forms state to state.

MP: You worked on this project with two classmates, but you alone won the Psychiatric Society’s scholarship award. Why was that? 

BE: I won the award because I am trying to take this work a step further. I think we’ve made great progress in getting the Board of Medical Practice to accept this language change. But I think there is still room for improvement. I would like to take this momentum nationwide. 

MP: How will you do that? 

BE: I’m hoping that if I can take some of the themes that turned up in our original focus group, do additional focus groups, create a broader survey, that we can highlight more specific items and advocate and make some changes nationally. 

MP: You seem comfortable talking about mental health in a way that many other physicians might not. Why is that? Did you grow up in a family that was open about their mental health? 

BE: Not at all. I grew up in a stoic Scandinavian family in Two Harbors. We didn’t talk about emotions very much. Even though we weren’t talking about it, mental health is all around you, especially living in a rural area like I did. I was raised in a community where you know people who’ve died by suicide, where you have neighbors who die by suicide. Just because you aren’t talking about it doesn’t mean that it isn’t going to happen. We’d be  whispering about it after the fact — but  not figuring out how to help ahead of time. As I’ve gotten older, I have become more open about mental health.

Because I grew up in a small town, I thought stigma around mental illness is a small-town thing. We don’t have the same access to care as people has in the city. But when I got to medical school I realized that it’s an issue everywhere. I realized, “We need to take on this issue from the top. If all of my classmates don’t feel safe talking about their mental health, how are we going to expect our patients to feel safe seeking mental health care?’ 

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MP: When you got into medical school, did you know what type of physician you’d like to be?

BE: At first my plan was to figure out how I could open a small-town family practice, focus on mental health and meet people’s mental health needs in a sneaky way. In retrospect I think I was caving to the stigma around mental health by finding workarounds instead of tackling it head on. Now I’m like, “Let me talk about it, be loud about it, break down the stigma.” I want to treat mental health like any other kind of health.

MP: I hear you using the word “stigma” when you talk about mental health. Some people tell me they’re offended by the use of that word. Where do you stand on that issue? 

BE:I think that I still use “stigma” out of habit. It’s the way we’re used to talking about mental health. But the word “discrimination” is also a good option.  I do think that almost always you can replace the word “stigma” with “discrimination” and your sentence will still be accurate. 

Plus, using the word “discrimination” gets people to pay more attention. These days, we’re almost comfortable with things being stigmatized. It doesn’t get your attention. It goes in one ear and out the other. But if you say people with mental illness are discriminated against, it gets more attention. And that’s important.

MP: Once you’ve finished your residency, do you plan to move ahead with your small-town practice plans? 

BE: I’ve totally changed. At this point I see myself working in a city in academic medicine where I am able to work with all sorts of medical trainees and medical students. I’d do research and work to change the culture of medicine.