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EARLIER this year beyondblue conducted a national mental health survey of doctors and medical students. The results should be a wake-up call for all medical organisations.
Doctors have a higher reported rate of mental health problems than the general population and yet we are far less likely to seek medical help.
Those working in oncology are affected the most, with 33.9% having a minor psychiatric disorder and 5.5% experiencing very high psychological distress. Excessive alcohol use is also alarmingly prevalent, with 17.2% of emergency medicine doctors drinking at moderate risk levels.
Experiencing psychological distress must inevitably have an effect on patient care — it could lead to unprofessional behaviour and preventable errors.
The mental distress experienced by doctors can only be increased by the regulatory mechanism under which we operate. In that context it is interesting to see that the UK’s General Medical Council (GMC) has recently been under the spotlight for the pressure its complaints process puts on doctors.
Reports from the UK say the GMC has announced a review of its processes after revelations that since 2004, 96 doctors have died while being the subject of fitness-to-practise complaint proceedings.
There were concerns that a number of these deaths were due to suicide, with the GMC now conducting an internal inquiry into the handling of complaints.
The complaints process in the UK is very similar to the Australian Health Practitioner Regulation Agency (AHPRA) notification process.
An Australian study has also found that doctors experiencing a current medicolegal matter are at increased risk of psychiatric problems and hazardous alcohol use.
We all appreciate the day-to-day pressures of working in medicine, so imagine the additional stress for any doctor going through a complaints process (regardless of the final outcome). This must have an impact, not just on their current job, but on their career and their personal life.
Having invested so much time, money and effort into our training the fact that we could lose our career if we are subject to a complaint is frightening. So “confessing” to a problem may not seem like an option to junior doctors struggling with all our profession throws at them.
Doctors are under immense pressure in the workplace — hours worked, antisocial work times, variety of patients, fear of complaints and the stigma of “confessing” to errors.
When doctors do slip up, or are thought to be acting unprofessionally, the process of going through fitness-to-practise-style proceedings will take a further psychological toll.
More should be done. Some hospitals may be conscious of the need to offer support and guidance to doctors in these matters but the beyondblue results show that doctors are often reluctant to seek help. Perhaps it should be routine practice for every doctor to meet with a councillor once a month. That might help to overcome the stigma of talking about mental health problems.
AHPRA must release its statistics on deaths during the notification process, and we need further information from the GMC about how many of the 96 doctors’ deaths in the UK were from suicide, as this would indicate the scope of the problem.
All regulatory bodies must be acutely aware of the potential impact on the mental health of doctors during complaints proceedings. The tone, nature and frequency of communication need to be investigated; and there should be support in place for doctors during these times.
Doctors feel emotional and responsible when their patients die. We feel exhausted working night shifts and antisocial hours, and we feel pressure to project a good image to our patients and colleagues.
With this amount of stress, it is no wonder that doctors make mistakes.
Sometimes doctors do make mistakes that are more than simple human error. In these cases we must be held accountable to our regulatory authorities, and through them to the public.
But we are still human. Doctors should have support and guidance during our normal working week, but even more so during any complaints process.
Dr Tessa Davis is a paediatric emergency medicine trainee originally from Glasgow and now living in Sydney.
Mentoring should be wthin our profession, for doctors and medical students, by colleagues whom we choose, and who should be remunerated.
VMOs are entitled to be paid by the health service for meeting with colleagues regarding hospital business-this should be available regularly without the presence of health service managers.
The failure of hospitals to provide residential accommodation for doctors and medical students adds to our stress- not only to we have a dangerous walk to our cars, we then have to drive when we are exhausted, and have no peer support. Despite the fact that we may be on-call for unlimited hours, days and nights, we have no access to hospital accommodation provided for nurses who usualy work only 8 hours per day. Health service managers get cars provided to drive to work from other towns. We do not even get a parking spot.
No wonder that our profession is at risk of mental or any other illness-we are like George Orwell’s workhorse in “Animal Farm” -all animals are equal, but bureaucrats are more equal than doctors.
Health professionals are incredibly exposed to vexatious and even malicious allegations made against them by jealous collegues, litigous patients or bullying managers. I know of one DOH here in Australia who don’t even bother with investigation; they just send everything to AHPRA with the reasoning that the clinician will get their natural justce there.
My colleague was falsely accused by a manager of being the last clinician to see a child before he had a respiratory arrest. She was duly reported to AHPRA six months ater the alleged event. Except, that she wasn’t even working that day. 7 months on from the notiication she has a major depressive disorder and cannot be left alone. Freedom of information releases reveal that the manager knew one day after the event that the allegation was wrong. That did not stop the manager from writing a dishonest memo the CE of the organisation.
13 monhs later her career in tatters, she says she wil never return. Her depression caused the only action taken thus far by AHPRA – they stuck condiions on her registration, rather than speed up the investigation.
She will be cleared, christ knows when, but she will. I pesume she will sue. And years later, win. However, the trauma of it will mean she will never practice again.
The system has to change.
The argument here is not why this set up has been accepted by the profession. Indeed their raison d’être is a very noble one. It has been accepted in the hope of stopping the courts or politicians from getting involved in professional matters. The issue however, is that now the goal posts have shifted so much that the argument for their power is hard to sustain.
It seems that the end of a disciplinary enquiry may not be the end of a story for a medical mishap. Indeed the end of a disciplinary enquiry maybe the precursor for start of a legal enquiry. There are numerous examples for this.( Dr Jayant Patel’s case is but one ).
It seems the concept of double jeopardy i.e. “The act of trying someone twice for the same offence especially after an acquittal for the first trial “is very live and true in these circumstances which would be considered unfair in any fair legal system.
The unfortunate fact here is that while the medical boards have most of the powers of legal courts, when it comes to defense from double jeopardy, there is no protection for the ones already questioned by them in length.
The real question though is the absence of our professional representatives in coming up with any stance in these scenarios, perhaps even suggesting some modernizing of AHPRA itself. Unfortunately the largest of these representative groups (AMA) seems to be busying itself making statements on “ Heatwave Health Warning ”!!! 1).This is a complete fiasco indeed.
There have been many who have suffered mental illnesses after appearing before medical disciplinary bodies. Many have suffered life long depression requiring long term counseling. Indeed most of the medical defense unions have dedicated services just for this kind of common eventuality. This is the power of medical boards. They can investigate you, summon you and question you in length. They can actually deregister you which sometimes can mean destruction of livelihoods that can lead to destruction of entire families. In short, they can change a professional’s life 180 degrees. The only thing they can not do compared to courts is to jail you. Their powers of coercion have presumably been accepted by the medical profession in return for the promise of “self regulation” and hope of not involving the courts in every incidence of medical mishap. And for this reason every medical practitioner actually contributes to their very existence. By tradition, for many centuries, the medical boards consisted only of medical professionals. This was fair enough because it was supposed to be a professional self regulatory body. More recently however without any reaction from the profession, it was deemed to be necessary to involve some“ lay persons” in the composition of the Australian boards.
Ironically the recent beyondblue study of stress in the medical profession and the commentary in the MJA actually added to my allostatic load as it reminded me just how little is being done to reduce the stress experienced by medical students and doctors. As an oncologist this extra burden may well have ‘tipped me over the edge”. Thankfully however, like so many colleagues in medicine, I have found my own means to mitigate stress without any help from “the establishment” (hospitals, colleges, the AMA, psychiatrists). In my case mindfulness-based strategies have worked and could easily be applied widely. The beyondblue study added to innumerable studies over decades of stress in medicine notably by Jenny Firth-Cozens in the UK, Liselotte Dyrbye in the USA and Simon Willcock in the MJA. In oncology one can recall a seminal article by Vachon et al in the journal Death Education in 1977. Even William Osler discussed the topic. What is disappointing is the near-universal lack of action by responsible organisations, who knowingly place medical students and doctors of all ages at significant risk of intolerable stress that in turn may lead to errors, medico-legal consequences, substance abuse and suicide. There are many evidence-based means to prevent or mitigate stress – for example the randomised study of mindfulness in medical students by Emma Warnecke in Hobart, but many others also assessing other techniques (such as Ronald Epstein’s work in medical humanism). It is vital that clinical schools, hospitals, community health organisations, colleges and the AMA begin to seriously support such measures and ideally to evaluate the success (or otherwise) academically.
Thank G-d, a breath of fresh air. I agree with you Bill. We need an assertive professional body. MDO’s: I have had MD only because from the registration requirements expressed it seems one is obliged to do so. The question, Why is there this link between registration Boards and MDO’s?, awaits an answer. What is even more sinister is that Boards feed off one another, to effect reason for greater control, greater self promotion and self justification and greater reason to protect the public, which is a scam, a portrayal of doing good, while motives and actions are to do harm under the duplicitous guise of doing good. Their creed need to be replaced, as does anyone who recommended internal audit of this body as the mode of accountability, review and redress. Professor Murtagh described their actions as Stalinesque. Doing something positive will save us, the public good and our patients, as it is the only way to provide guidance as well as support to doctors, the profession and our grateful and needy patients and to weed out the rest. A System of Evaluated Decisions is required to objectively and prospectively review judicial decisions. A Health Commissioner needs to be appointed to review all health related decisions. One or more is needed as complaints are on the rise. So is mandatory reporting, while resolution has become a hijacked and disappearing option. I believe we need to sign a petition to good effect. Internal audit is wholly unacceptable, and it surprises me that the UK would permit it.
The regulators have a lot to answer for,but the HCCC is answerable to no-one. AHPRA has its own ombudsman-i wonder how much influence it has.
They have the vaguest of charges—-unprofessional conduct,non-conciliatory behavior,arrogance
The people complaining against doctors should themselves be subjected to a bit of a check,as there is mostly an obvious second agenda.
GP’s are expected to be everyones friend and advocate. How can they simultaneously be gatekeepers to the system?
doctors are simply not allowed to be sick,or to suffer adversity,or to have family problems.
I do not know how overseas doctors can be expected to cope with the dragons AHPRA and HCCC.
I just wish that Mr Abbott would cast an eye on them,when he is pruning dead wood from goverment institutions.
Me thinks this discussion is a continuation of last weeks discussion following Georgie Haysom’s article on ‘Mates Mistakes’. It seems to me that when it comes to protecting our interests our profession might be politically (and financially) effectivebut pretty hopeless at protecting our pastoral and legal interests. It seems that it is every person for themself when these challenges arise. (There are some exceptions such as the VDHP) Disillusioned docs experiences are an excellent example of this.If ‘law reform” means changing the current laws then I am doubtful that this is the right approach and I would not “hold my breath” for this to happen anyway. Good law reform takes years to happen, I think that most laws made in haste turn out to be bad and then judicial interpetation comes into play and this seems to be a bit of a lottery.
I think that a better approach would be to have a profession that is much more assertive and proactive with respect to pastoral care AND in assisting (not exclusively financially) with handling the (vexatious) aspects of legal matters.[ at least some of the MDOs say that this is their responsibility but do they do this well enough?].
Thanks for great content on a sensitive and important topic. Doctors with much to offer can suffer painful stress, loss of confidence, time income and health at the hands of vexacious complainants. Suicide, the worst outcome is far too prevalent in our profession. We need to cease being a profession that watches with shadenfrued, and support our peers, even when things are going well in a tough grind.
SO TRUE TESSA.
Disgruntled patients can use the law and lawyers to torment a doctor for many years. Innocence does not protect the victim (doctor) from this process. Vindictive or even psychopathic patients have unfettered use of the courts and legal system. Law reform is urgently required. “Due process” amounts to protracted hell while a doctor tries to function normally and care for her patients.