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NAVIGATING the tensions between protecting public safety and maintaining the intrinsic professionalism of medical practitioners is a continuing challenge for health regulators, says the chair of the Medical Board of Australia, Dr Joanna Flynn.
“There are fundamental tensions in terms of the way … regulation can actually decrease professionalism”, Dr Flynn told MJA InSight. “We want regulation to create an environment in which professionalism can flourish because, ultimately, it’s when people are intrinsically motivated to behave professionally that you get the best quality practice. The Medical Board is very well aware of that tension.”
Dr Flynn’s comments came after the release of a report earlier this month into the UK’s medical regulatory body, the General Medical Council (GMC), which found a “culture of complaint” had developed in the UK. (1)
The report, by an independent consulting group Civitas, stated that it was “disturbing” that the GMC appeared to “give no serious consideration to the impact of its own activity (and deficiencies) on either doctors or patients”.
“Doctors who feel ‘guilty until proven innocent’ will practise defensive medicine, which is both costly for the NHS and worse for patient care. Furthermore, regulatory models that are designed to promote confidence at the expense of trust can create a false expectation of certainty within the uncertain practice of medicine, and drive out morality,” wrote Dr Tony Hockley, head of the Civitas Health Unit, in a foreword to the report.
The UK report comes as a 3-year review into the Australian Health Professionals Regulation Agency (AHPRA) begins, after the terms of reference were announced in April. (2)
Ms Georgie Haysom, head of advocacy at Avant, said the review’s terms of reference were sufficiently broad to explore the impact that complaints handling was having on medical practitioners.
Ms Haysom said many of the issues raised in the UK report resonated in Australia. She said while most of the matters referred to bodies handling complaints in which Avant was involved were dealt with fairly and efficiently, there remained instances where doctors were adversely affected.
“There are cases that aren’t dealt with well”, she said. “Particularly concerning is the impact the process can have on practitioners’ personal and professional lives.”
The UK report also pointed to a GMC acknowledgement of a lack of evidence that its fitness to practise processes improved the quality of medical care. The UK also introduced a revalidation system in 2012, which is being considered for introduction here. (3)
Dr Flynn said it was too early to determine if the UK’s 2012 introduction of revalidation would improve public safety, however, the case for its introduction was sound.
“Wherever you look you can find reports of a percentage of doctors who are underperforming and we know that engagement in ongoing education, peer review and reflection on practice are really important things and that’s really what the GMC is requiring people to do, albeit in a somewhat complex system”, she said, adding that strong evidence for the effectiveness of engaging in continuing professional development was also “pretty thin”.
“It’s hard to find [evidence] and yet I think it’s sensible enough on the face of it that people need to keep their knowledge up to date”, Dr Flynn said.
Last week in the UK, a report analysing the reasons behind the steep rise in the number of complaints made to the GMC was also released. (4)
It showed complaints about doctors’ fitness to practise in the UK more than doubled in the 5 years to 2012 when there were 10 347 notifications.
The report identified several trends that had contributed to the rise in complaints, including patients’ higher expectations of their doctors, increased public awareness and social media’s role in encouraging patients to speak out about issues.
Dr Flynn said notifications were also increasing in Australia, by about 20% per year, although many did not meet the threshold for board action. (5)
She said many of the same factors, such as the changing doctor–patient relationship, were driving the upward trend in complaints.
Ms Haysom said Avant, which had also seen a rise in complaints, had recently launched a website aimed at helping doctors better manage their health more generally and cope with the stresses associated with the complaints handling process. (6)
Dr Flynn also pointed to the board’s funding of doctors’ health programs across Australia to ensure medical practitioners had ready access to assistance.
1. Civitas 2014; The General Medical Council: Fit to practise?
2. AHPRA 2014; Three-year review
3. GMC: Revalidation
4. Plymouth University 2014; Understanding the rise in Fitness to Practise complaints from members of the public
5. AHPRA annual report 2012-2013
6. Avant: Health and wellbeing
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While any patient can make any complaint against any doctor, no matter how trivial it may be, when the Regulator is asked whether the doctor can make a complaint about a particular patient, the Regulator said that it has no such avenue for the doctor to do so. So, is the Regulator there to protect the public but the Board itself has nothing in place to protect the doctor?? Simply to persecute doctors???
I agree with all the points made by Annonymous. I worked in the UK in the 1970s with a general registration and again in the 1990s with a specialist registration. I have experienced first hand the metamorphosis of the GMC into an Orwellian state controlled monstrousity whose sole function, despite all the cant to the contrary by its senior employees, is the deprofessionalisation of medicine. Without exception, every one of my UK specialist colleagues of a certain age were desperate to reach 55 to escape the NHS and its associated bureacratic enforcment monster the GMC. Every medical practioner in Britain was made to feel like a criminal in the late 1990s thanks to Shipman, Bristol, a virulent and despicable press, a self serving tranche of politicians and a willing phalanx medical bureaucrats looking to further their own careers. It is with horror that I have observed once again, the slavish way the health bureacrats of Australia follow the NHS. The only thing the NHS can teach is how to build a huge pyramid of expensive unelected power manipulating earnest paper shufflers who more than double your registration fees and then thoughtfully provide you with a help-line to deal with the stress they cause! Make no mistake the 252 page diatribe the suitably named “Regulating Medical Practitioners in the Public Interest” and the Archer Report should be read by every medical practitioner in Australia. Its very important. May I also suggest Samuel Butler’s “Erewhon” (Nowhere backwards) and a re-read of George Orwell’s works, 1984, Animal Farm etc. In Qld we now have á politically controlled Ombudsman with his star chamber as well.
I have read the above comments with interest. Clearly there is some angst out there about complaint procedures. APHRA needs to take this on board. My advice to those on the end of a complaint is , if possible, see it as a bureaucratic process that has to be gone through: the likely result , unless the complaint is serious and well founded, is that your practice will continue without restriction.
Revalidation has been shown to be a largely wasted exercise and does not necessarily weed out the duds, or the “bad guys” in the professions.
While there is no doubt that having a national registration body is great in terms of interstate movements etc it comes at the expense of local knowledge and easy ability to meet face to face, as one can do with State Boards. Also I believe that setting up one Board to cover all health professions was a mistake, no doubt a cost- minimising exercise, which means that none will be served really well.
AHPRA presumably must balance the public safety against fair treatment of health professionals. This means that AHPRA, HCCC and other such bodies should be completely and transparently fair and objective in all their decisions, hearings, etc, which appears not to be the case at present, judging by some of the earlier comments. We live and work in a democratic country; fairness, transparency and due process should be the right of all, and the media should be prohibited frompre-judging and reporting the names of people under investigation by government agencies unless and until they have been found guilty of a criminal offence.
My big concern is the issue of revalidation by AHPRA, which was raised for discussion earlier this year by Dr Flynn. This would be an unnecessary duplication of what is already handled effectively by the medical colleges. In the USA professional medical organizations are vigorously challenging the requirement for a major closed textbook re-examination every ten years as part of the recertification process. If AHPRA really wish to address the stress and bureaucratic red tape imposed on the medical profession, they should look no further than this proposal for revalidation in Australia.
I retired three years ago as a result of going through the process of a series of patient complaints. I felt that I was not given a fair evaluation of the situation, I could only follow the directives of the medical council. I believe I should have been given the option of mediation which is I believe available but was not offered to me. I have undertaken studies in Dispute Resolution at UTS in the Law School and have obtained a Gradate Certificate in Dispute Resolution. I am now able to be a mediator. I feel that complaints need more flexibility than the present system.
As a person who had experienced intimidation by a medical board for failing to yield to their interests which compromised patient care, I realize how heart wrenching the activity of these ‘regulatory’ agencies is. I believe we should have a forum like the Pilots (PPRUNE) to expose these atrocities anonymously. Free speech is the only solution.
My complaint is with AHPRA. My only practice is to provide repeat prescriptions and referral mainly for myself but sometimes for family. For that I have to pay $600 reg. fee and $200 med. defence, both annually! Where has good Aussie fairness gone?
KBO
Having been randomly audited for compliance with CPD/ CME by our Colleges, we now also face random auditing from AHPRA. This is unnecesssary duplication and adds to our bureaucratic burdens.
Many complaints made to Medical Boards by patients are vexatious or unfounded, and much time is wasted with a toll of dismay and emotional fatigue, and ultimately cynicism from doctors about the process, which in many ways is a sop to consumer groups and Govt Health departments . Medical Boards need to be given discretion to filter such complaints and prevent lengthy processes which achieve nothinng other than distress to the practitioner.
Recertification or revalidation will expend huge resources in trying, often unsuccessfully, to weed out a tiny minority of rogue practitioners. These are better targeted via peer groups and hospital accreditation committees.
Anonymous has made valid points in his letters.
The HCCC investigates all complaints on their face value without any enquiry into another agenda, or, indeed, the validity of the complaint,
the process is inquisitorial. One is guilty unless one can prove one’s innocence. How ? THEY HAVE NO REGULATOR. They self-report to a joint parliamentary committee.
Despite constant prating about patient confidentiality, they name, blame, and shame in press releases, revealing the innermost details of the doctors’ private lives. Inhuman and impossible personal standards are demanded of doctors.
Their reports on themselves read like a road kill tally–so many doctors deregistered, x number reprimanded, y number are fined. This is not improving the situation of medicine. And , in spite of the above statistics, they seem to miss some really big problems..
I asked for my documents , under FOA. It seems that HCCC has made itself an exception to FOA – it is not legally required to comply. AHPRA sent me some documents which I already had, telling me that any other documentation would compromise others. (It would compromise them, that’ s who.) These bodies have become a law unto themselves, and it is time to change the culture.
The medical insurance companies would rather do a quick payout than defend. This is implicit acknowledgment that the doctor is guilty.
I would feel happy if Dr. Flynn could show that the percentage of doctors who are underperforming is approaching or exceeding 50%. Otherwise revalidation merely punishes the majority of conscientious doctors in the (often) vain hope of forcing incompetent doctors to comply with a standard. I think every doctor knows of those who manipulate the present system to achieve the PDP/CME points necessary for registration. I have no reason to believe that those doctors will not work out how to achieve revalidation with the minimum of effort also.
The HCCC in NSW acts as a prosecuting body and some of it’s employees have been in the police force.
There is a culture within the organisation that the Dr is guilty even though the complaints are not sworn statements now matter how extreme they may be.
i am not sure who it was but a few years ago I met a psychiatrist who was looking into suicides that resulted from HCCC investigations. I am personally aware of some doctors who have been severely affected by investigations conducted by the HCCC. In spite of what the defence organisations may claim they are insurance companies and will try to minimise costs by suggesting a conciliatory (there must be something in the complaint) approach rather that ascertaining if it even falls within their terms of reference.
In our era of evidence based medicine it would be interesting to see if there is any evidence that the present complaints system has improved anything or caused serious problems to those complained about.
One of the problems is the way the regulator’s registration process actively promotes stigmatisation of medical practitioners with a past history of a mental health issue.
If a medical practitioner has a reactive depressive episode (say from a divorce) that required a period off work and, in good faith, agrees to “undertakings” to have a colleague help him re-enter the workforce the medical practitioner will always be require to disclose his prior “undertakings” during medical registration and hosptial credentualing for the rest of their career.
Once a doctor has been branded with the “crazy” label any ‘unusual’ behaviour is considered to be pathological until proven otherwise. You are no longer allowed to be human because you are no longer allowed to have a “bad day”. “Perfection” is an impossible burden to bear. Little wonder the rate of anxiety, depression and suicide is higher in the medical workforce that the general public.
There are medical boards where constituent members are involved in anti-competitive practices and unprofessional conduct themselves which goes unnoticed. They harass practitioners who provide quality care for their self-serving interests in the name of investigations, abusing their positions. These go unnoticed! I am wondering what mechanisms exist to check the growth of collectivism among some medical boards which are biased.
In the absence of such a mechanism to check corruption within, the projection of the AHPRA by itself as a neutral party (in this article) between patients and doctors should be seriously questioned. A self generated report suffices nothing. I believe this organisation should be subject to a third party auditing like the ACCC