Issue 4 / 7 February 2011

THE doctor who treats himself has a fool for a physician.

Enter that phrase into Google and you’ll get about 147 000 hits.

There are variations, such as “A physician who treats himself has a fool for a patient” attributed to Sir William Osler.

Why, then, should a group of NSW doctors who are retired or nearing retirement want to write prescriptions and referral letters for themselves and their families?

For decades, responsible medical organisations have been urging doctors to have their own GP — and not to treat themselves or their families.

Doctors’ fallacious reasons for not having a GP are legion, including “Taking a health problem to another doctor lays me open to professional ridicule for not recognising, myself, that the problem is a) trivial or b) serious.”

Other reasons given can be found on various websites, including that of the Australian and New Zealand College of Anaesthetists.

But the problem now has the potential to get worse as the number of retired doctors expands exponentially with the baby boomer generation reaching retirement age.

Some doctors retire to enter other fields; others because of illness, infirmity, old age or burn-out.

Some were in clinical medicine, others were non-clinical or in administration.

Some doctors have been out of practice for two or more decades.

All were “registered to practise medicine”.

Whether clinicians, or in laboratories, or in administration, we all had the same registration privileges.

NSW instituted “non-practising registration” a few years ago for those who had retired and who charged no fees for services rendered to their families.

This curious form of registration has been deemed inappropriate by the new Medical Board of Australia:

For the purposes of this registration standard, practice is not restricted to the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession.

Medical practitioners with non-practising registration cannot undertake any practice as defined above. They are not permitted to prescribe or refer, regardless of whether they are being remunerated.

This would accord with the dictum “The doctor who treats himself has a fool for a physician”.

Doctors who wish to treat themselves or their family must now have full registration, indemnity insurance and continuing education  — as well as a higher registration fee.

Surely this approach is sensible and logical.

Alas, many do not see it like this.

Led by some current and former leaders of the AMA, NSW is opposing this commonsense approach.

They maintain that an annual 2-day seminar is sufficient for retired doctors — some of whom have never practised clinical medicine requiring prescribing and referral to specialists — to keep abreast of current practice.

Some have expressed “outrage” that doctors could go from “valued competent professionals” to “nothing but retirees”.

Some wish to maintain the “dignity [sic] of writing the occasional script or referral”.

Is this a logical, rational approach?

Or is it inflated professional pride, seeking to preserve status when, in truth, claims to that status have expired?

Can’t we be like ordinary people who, when they retire from their jobs or professions, do just that?

They retire to pursue other interests and don’t hold out to be still competent in their erstwhile field of practical expertise.

To treat oneself and one’s family when in clinical practice is foolish — to do so when no longer in clinical practice is not only foolish, but foolhardy.

Let’s hope that the Medical Board of Australia does not give in to this irrational attack from NSW.

Dr Peter Arnold is a former Deputy President of the NSW Medical Board, former chairman of the Board’s Professional Standards Committee and a former member of the Medical Tribunal of NSW.

Dr Arnold has submitted this article on the condition that anonymous comments in response are not accepted. MJA InSight has agreed to this condition.

Posted 7 February 2011

23 thoughts on “Peter Arnold: Avoid the foolish physician

  1. Anonymous says:

    Would Dr.Peter Arnold please contact me as a Wits dental graduate whose father taught me Anatomy in 1952.
    I look forward to his communication.
    Geoffrey Sperber

  2. Serge Liberman says:

    What has happened to evidence-based medicine in discussing this issue?
    Is there any hard and fast data derived from, say, trials comparing the success and/or failure or complications resulting from treatment of doctors’ families managed by the doctor within the family and an external GP to justify such a blanket hand-me-down bit of comic lore that Dr Arnold feels so attached to? Since when does another’s clever aphorism make a convincing case for anything?
    Is there any hard and fast data that a doctor loses all his knowledge and expertise of prescribing and/or appropriate referral the instant that he/she retires?
    Is there any hard and fast data that a retired doctor, if he wishes to retain at least some of the privileges of helping others with advice, scripts and referrals, cannot keep up to date with new developments in medicine, given the plethora of available books, journals and the web, which, with the manipulation of a few keys can bring him precisely the information he requires which his life of work in the field should enable ready assimilation of all the new material?
    I have for many years treated myself, family and friends both when called upon and even on a continuous basis, some in excess of 25-30 years and up to the natural ends of their lives, in keeping with the same principles of approach and care that I have used with my clinical patients – referring myself and them for pathology, radiology and to specialists as warranted, and knowing full well my limitations, there having been no mishaps along the way. To my mind, the whole issue is overblown
    Why I – along with some 80-90% of other doctors who wish to retain certain rights upon retirement – should, with one bureaucratic stroke, be totally delegitimised from advising, prescribing and referring, is beyond my understanding when other doctors in active practice would have to deal with extra loads of ex-doctor patients and families who could very simply manage their specific needs for themselves.
    Dr Arnold’s piece is, in short, merely an exercise in emotive rhetoric empty of any objective substance which, in sum, amounts to opinion, and opinion only – and rigid, dogmatic, soap-box opinion at that. Here, I have merely asked questions. Bring me the evidence for your opinion, Dr Arnold, and I, for one, might take your doctrinnaire pontifications seriously.

  3. David Cox says:

    Agree with Ian Bernadt.
    The patronising reason given by the new Medical Board is not valid, because retired doctors can still write prescriptions and refer, provided they pay the extortionate amount required for full registration, and undertake CPD. The CPD will in most cases be of little value to retirees, who no doubt keep reading in their areas of interest in any case.
    In my view, it’s not about the principle, it’s about the money!

  4. Ian Bernadt says:

    Since Federation retired doctors have, until now, maintained their professional status and self-esteem by remaining a board registered medical practitioner albeit in a non-practising capacity.
    In the absence of any evidence of malpractice, misprescribing or medical malfeasance over this period there is no reason to withdraw this privilege and token of respect to the doctors of Australia.

  5. Dr Michael Claxton says:

    I cannot agree with Peter Arnold. I have been retired from anaesthetic practice for 6 years and have maintained limited registration which allows me to write repeats scripts but not initiate treatment, and to write referrals to specialists – and I only write subsequent referrals. My wife and I both have a multitude of problems and writing our repeat scripts take a significant load off our personal overworked GPs who only charge us refund only, and nothing for scripts without a consultation. This does not mean that we avoid seeing our doctors at the appropriate intervals.
    I do not believe that suddenly overnight a doctor goes from being fit to totally unfit to practise. I read the BMJ every week – the best all-round journal I know – and the MJA fortnightly. I do not think that I am out of date and senile!
    I fully support the comments of Drs. Geoffrey Miller and David Cunningham.
    Dr Michael Claxton FAMA
    Former Federal Councillor

  6. Graham Row says:

    Peter Arnold is showing signs of “medicalboarditis”. I have never treated any family member in my professional life. I have written many prescriptions and renewed referrals. There is a very clear distinction between medical care and administrative facilitation. A junior house officer authorises a hell of a lot of medication and investigations resulting from the executive clinical decisions of more senior doctors.
    Much more sophistication is required in this area

  7. sue ieraci says:

    Celine, the title of Peter Arnold’s piece is clearly meant to be attention-grabbing, but it reflects his opening quote, attrubted to Willian Osler “A physician who treats himself has a fool for a patient.”
    Peter isn’t saying that retired doctors are fools – he was saying that all doctors – active or retired, should have their own doctors, avoid treating self or family. Sounds reasonable to me.

  8. Celine Aranjo says:

    Dear Sue, I wish we could be reassured by your kind words about retired doctors, but what prompted my comments in the first place is the title of the story and its contents ‘Avoid the foolish physician’.

  9. sue ieraci says:

    I’m not aware of anyone who looks upon retired doctors with “scorn” – unless, of course, they earned that scorn while they still practised…
    Nobody I know would equate retirement with deregistration for offences or drug convictions – both the general community and the medical community understand what retirement is, and most of us would think that, after a long and busy career, most retirees have earned that status.

  10. Celine Aranjo says:

    Dr Sue Ieraci has tried to simplify the issue of retired doctors and the Medical Registration Board of Australia, and rightly so, from her perspective of specialist emergency physician, her interest in policy development and health system design, medical regulation and management, as well as her running the health system consultancy SI-napse.
    On my part, being struck off the register for none of the previous reasons for being struck off, apart from the situation that I have retired and no longer practising, is unfair.
    Should not doctors like myself be on a special register for retired doctors, that is until the rules are changed again?
    By the way, I and my family have had our own personal doctors for many years, so it doesn’t matter whether or not I can legally prescribe from the PBS within Australia, nor whether or not I can legally refer within Australia (for reimbursement from Medicare).
    The fact that I will be looked upon with scorn within Australia for not ‘making it’ on this Australian medical register should irk me, but I am broad-minded enough not to be irked. BUT, is the medical and allied medical fraternity as broad-minded to accept this without a hint of scorn given the mind-set within Australia, that those who do not have their names kept on the register are either incompetent or convicted of offence, or alcohol/drug addicts, or HIV +, etc?

  11. sue ieraci says:

    There are two aspects to this issue – not just the ability to maintain clinical currency with increasing age and decreasing exposure, but also the pitfalls of treating self or family members.
    How would all the GPs commenting on this issue feel if their own patients bypass them by getting some other family member or friend to prescribe or refer for them? What if you have no idea that one of your patients was referred to some other consultant who doesn’t write back to you? What if that BP check or blood test you had planned to do at the next prescription renewal doesn’t actually happen because they wrote their own script? What if they kept on renewing their own script when you had planned to review or cease that particular medication? What if that elderly doctor patient of yours slips gently into early dementia but you don’t realise that they are still presecribing for themselves?
    This is not about diminishing respect for retired professionals – it’s about trying to extend the same safety principles to our esteemed elder colleagues as we would extend to any of our patients.

  12. Celine Aranjo says:

    I agree with these comments posted by retired/near retired doctors in General Practice. Dr Peter Arnold, in his folly, asks ‘Can’t we be like ordinary people…..’ but, in all humility, we are NOT ordinary people. We are unique in that we have been family doctors all our working life, and only such family doctors can understand what this means not only to themselves and their immediate families, but also the community and society at large. I have worked hard firstly to get my name on the medical register, and then onwards to keep myself on this register, and now I have updated to many important 2000-onwards text-books (paid for by non-taxable income), journals, conferences (albeit these are sponsored mainly by pharmaceutical companies). Perhaps the federal government and the Medical Board of Australia feel the need to get more income from us, and also to get more members for the medical indemnity companies!

  13. Ian Bernadt says:

    A retired doctor after long years of study and decades of devoted practice is entitled to the continued respect of his or her peers, professional colleagues, patients and the community in general.
    To unceremoniously remove his or her professional status by bureaucratic edict is historically a grave insult to all Austalian medical practitioners since Federation.
    We must not allow this to happen.

  14. Malcolm Stumer says:

    Compulsory Indemnity Insurance is not for the benefit of physicians, but for the lawyers and their clients. Compulsory Indemnity Insurance just makes all physicians the targets of frivolous claims made against them by “sickos” with the connivance of their lawyers, many of whom do know better. You cannot get water out of a stone, and compulsory medical indemnity just provides a “milking cow” for the disgruntled.

  15. R Johnston says:

    I cannot believe the rubbish I am reading! The reason a GP referral is required to see a specialist, is I believe, to ensure that it is appropriate and necessary. If you are not up-to-date in terms of current diagnostic and management practice, how can you know that you are making clinically appropriate decisions, and in fact not giving second rate management to the relative or to self? As a rural GP for 35 years (who does have his own GP), I am still astounded at the numbers of my colleagues still practicing, who fool themselves into believing it is safe, much less appropriate, to manage their familiy’s or their own medical care when they cannot be objective. To consider that one can safely do so when no longer practicing, suggests ego is overwhelming common sense!

  16. David Knight says:

    There are many doctors who have retired from active practice but who continue to attend conferences and read medical journals. I have met several at the conferences which I attend. These doctors are keeping up to date but are not seeing patients. Are they really fools for wanting to write referrals to specialists or repeat prescriptions which have been prescribed by “practising” doctors? I believe the new Medical Board of Australia is being short sighted as is Peter Arnold.

  17. Dr Julian Fidge says:

    Why the fuss about anonymous comments?
    As a pharmacist, I keep “non-practising” registration, just in case one of these crazy medical boards goes mental on me again and takes away my registration. It allows me to re-enter the profession with some re-training.
    Can’t the medical board offer something similar? There is clearly a gradual decline in our skills as we get older and frailer, but in between full practice and senility there could be a few things we could do safely.
    And some of it is about dignity and respect. I have worked and continue to work very hard to get where I am, and I deserve to be treated appropriately.
    It is not surprising that when the boards treat doctors with contempt they take umbrage.
    The solution is to find a middle path, something the boards have never excelled at.
    Dr Julian Fidge

  18. David Cunningham says:

    The phrase “Power tends to corrupt, absolute power tends to corrupt absolutely” comes immediately to mind. Why is it that the powers to be imagine that when retire we become mental pygmies. Many retirees and their wives suffer from chronic diseases, eg, arthritis, diabetes, mildly elevated blood pressure, dermatitis, random mild infections, etc. Of course one should have GP but it appears to be nonsensical to have to run to him/her for every prescription or to obtain referrals to a specialist that one has been attending for years. Often doctors who have retired to country areas know more about their complaint than anybody within a hundred kilometers. We still read our journals and consult the internet. We are certainly more competent to write our prescription than memnbers of the nursing profession. Won’t somebody rid me of this irritating big brother?

  19. Phil Chalmers says:

    Butt out Arnold. Sick of your opinionated bullshit.
    Echos of tall poppy syndrome, in Australia freedom is compulsory, tyranny of the majority … etc that we have been hearing from you for years.
    You and your ilk have brought medicine into disrepute, have hamstrung practitioners of the arts of medicine by bureaucratic balls and chains, aided and abetted tyranny through syncophant “official” “representative” bodies passed off as such aiming to bring the spectrum of real medical professionals into some bland, homogenous mass using recipies to diagnose and treat patients and made to cower in fear of Medicare, PSA, Tribunals more like star chambers conducting show trials.
    Could be it’s better to have the fool you know than the fool you don’t as your physician

  20. A.R.Clifford says:

    As a recently retired anaesthetist, I can fully appreciate that prescribing medication requires a full knowledge of the side effects and possible interaction with other drugs (both prescription and over the counter medication). This obviously needs continued education and I don’t have a problem with the need for full registration to continue prescribing. I also agree that every physcian requires their own general practitioner who can give an objective and dispassionate disgnosis and examination, investigation and referral prn.
    What I have a major problem with is why a retired physcian cannot refer a member of the family, friend or collegue to another registered doctor without being fully registered themselves.
    Where is the harm in this and what special registration is required to make a simple decision to refer?

  21. Dr M. Geoffrey Miller says:

    Ms Todd asks “why should one small group be able to self treat, potentially without review?”
    The answer is that they are not self treating. The prescription for the chronic disease was given by another doctor with the understanding that the chronic disease remained stable. Retired clinicians, who have spent a lifetime in treating diseases, would be able to recognise a change in a once stable chronic disease and attend their GP.

  22. A Todd says:

    I have to disagree with Dr Miller’s sugestion – you can’t have your cake and eat it too. If the majority of GPs expect every other patient to attend to renew their prescription for chronic conditions or be charged a “service” fee for prescriptions without a consultation, why should one small group be able to self treat, potentially without review? Why not make all scripts for chronic conditions open ended? (the PBS arm of Medicare would hate that but the MBS arm might be delighted!) Over the years as a pharmacist I have dispensed many a script from a “retired” doctor where I have had to advise changes not just because they are no longer aware of PBS restrictions but because the script seems clincally inappropriate.

  23. Dr M. Geoffrey Miller says:

    Dr Arnold wrote:
    Why, then, should a group of NSW doctors who are retired or nearing retirement want to write prescriptions and referral letters for themselves and their families?
    Dr Arnold, the reason why so many retired doctors wish to write prescriptions for themselves, or their families, is that the prescriptions have been prescribed for them for chronic diseases over the years and they do not wish to have to go to their GPs every time the prescription runs out!

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