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IN 2013, a beyondblue study showed that one in 10 doctors had experienced suicidal thoughts in the previous 12 months.
The study also showed substantially higher rates of psychological distress and attempted suicide for doctors, compared with both the general Australian population and other Australian professionals.
Doctors face a huge amount of stress in their careers. Balancing personal life with large workloads, long hours and the responsibility for others’ lives can create a pressure cooker situation.
Among surgeons, the transition from study to work may be a difficult time for trainees. They spend extended periods of time in the operating theatre and long hours on call, while at the same time studying for the examinations that will determine their future progress.
Surgical trainees spend a maximum of 6 months on a surgical unit before rotating to a new speciality with new senior staff and, at times, a new hospital. This constant change contributes to the stress that they experience.
Men are particularly at risk. In 2010, men accounted for more than three-quarters (76.9%) of deaths from suicide, but an estimated 72% of Australian males don’t seek help for mental disorders.
A survey of members of the American College of Surgeons suggests surgeons were less likely than those in the general population to seek help for mental health problems. One in 16 surgeons reported suicidal thoughts in the preceding 12 months, yet only one in four sought psychiatric or psychological help. Depression, burnout and the perception of making a major medical error are closely linked to suicidal ideation.
Doctors should be encouraged to seek professional help if they experience any symptoms of psychological distress.
However, a potential impediment to seeking help is mandatory reporting of “notifiable conduct” by health professionals, which is now required by the Australian Health Practitioner Regulation Agency. This applies to not only health practitioners but also their employers, and for students, to their registered training organisation.
Is this resulting in better patient care or preventing health professionals from looking after their own mental health?
A recent article suggested that the spectre of mandatory reporting may impact on the “therapeutic relationship between a treating doctor and doctor-patient”. If doctor-patients perceive they could be reported, they may not access care when needed.
A review undertaken in New Zealand more than a decade ago found that true cases of incompetence may actually be less likely to be exposed through mandatory reporting.
Apart from reluctance to make a mandatory report about a colleague, there is uncertainty about what is classified as “notifiable conduct”. The grounds for notification include drug and alcohol abuse while practising, sexual misconduct, a departure from accepted professional standards and, notably, any “impairment” which places the public at risk of substantial harm.
While the misuse of drugs and alcohol or sexual misconduct during practice are clear indications for notifiable conduct, whether a person’s mental health poses a risk to their patients can be much more difficult to gauge. The Medical Board of Australia defines “impairment” as a person who has “a physical or mental impairment, disability, condition or disorder (including substance abuse/dependence) that detrimentally affects or is likely to detrimentally affect the person’s capacity to practise the profession”.
Western Australia is the only jurisdiction where a health practitioner can legally keep confidential a consultation with a colleague on mental health issues. This is granted through a special statutory exemption, which experts recently argued should be considered for adoption across Australia.
Perhaps it is time we revisited this aspect of mandatory reporting to ensure all Australian health professionals do not face real or perceived barriers to seeking help.
Doctors have a right to confidential care without being concerned that they will be reported, or stigmatised by their colleagues, while recognising mutual professional duties to uphold high standards of patient care.
Doctors who need help or advice can contact beyondblue, a confidential 24-hour referral, advice and support service, as callers do not need to provide their names. Visit beyondblue’s website — www.beyondblue.org.au.
Dr Mary Langcake is the chair of the Royal Australasian College of Surgeons NSW Regional Committee, and a trauma surgeon in NSW.
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I fear there are a multiude of reasons medical practtioners are reluctant to reach out for help. In my experence shame and fear of the consequence of disclosing what they perceive as a weakness is more of a deterrent to asking for hep than the fear about mandatory reporting.
Further to the comments from Dr Gordon the Medical Benevolent Association of NSW also provides confidential support to doctors and their families in NSW and ACT.
Dr Gordon’s concern that one of my colleagues might be causing actual harm to a patient is an everyday issue. In my field of hand surgery, there are publications which show that surgery by the registrar has a much higher complication rate compared with surgery by the consultant, eg a 40% compared with a 20% recurrence risk for volar wrist ganglions. Similar technical failures have been published in other areas eg a higher rate of recurrent laryngeal nerve injury in thyroid surgery. There are far more difficult to quantify areas, such as poor judgement in selecting the operation, which may further prejudice the results of registrar surgery.
We routinely consider the trainee as some sort of special case. We all seriously risk harm to another person, every time we give the trainee the scalpel, or our P-plate teenager the car keys.
But what of the senior surgeon whose skills are declining? His eyes are failing, his tremor is increasing, and his judgement is not what it used to be. He is doing inappropriate operations, poorly. His attention wanders and a few times the RMO has warned him not to cut a nerve. Still, by objective measures, his results are no worse than the registrar. At what stage do we report him? When he becomes worse than the senior registrar, or when his outcomes are below that of the junior trainee?
And of course, the poor GP is on the spot – lacking access to the hospital’s audit figures, what does he do when his doctor/patient tells him he is not operating as well as he used to? How does a GP separate the worried well from the seriously impaired? Surgery is far more complex than assessing fitness to drive – should the GP mandatorily report all his doctor/patients?
The problem with mandatory reporting is that it takes discretion away from the reportng doctor, and discourages doctors from seeking help. A senior clinician should be allowed to make the call as to whether one of his colleagues/Dr patients can be treated without APHRA involvement and inevitable loss of confidentiality. Some leeway is needed.
It’s not just about surgeons although they might have certain personality traits that increase their risk. Having a brother who is a medically impaired practitioner I know all too well that confidentiality delayed him accessing help until he lost his mind and at that time mandatory reporting didn’t exist.
I have been the victim on two occasions of vexatious mandatory reporting. I believe there is a real need to make it a professional offence to use the current system to report a colleague in a vexatious way with no plausible evidence. This is particularly the case when the accusations are found to be false,. Such a report is cowardly, causes great distress and means that under the guise of ” in good faith” a good doctor is required to defend outrageous claims. I know personally know of other cases where anonymous reporting has caused harm to ill doctors and where the system has been abused. There is a real need to ensure our colleagues cannot misuse the current sytem. AHPRA knows this is occurring but assumes every report needs to be investigated without first checking the motives of the report.
All doctors should read the clear, concise mandatory reporting guidelines and ask themselves this question: “If I had a serious concern that one of my colleagues might be causing actual harm to a patient, would I ignore the situation, or would I feel a moral obligation to act?”
Would any of us seriously risk harm to another person, with or without the existence of mandatory reporting?
It is a pity that Dr Langcake hasn’t mentioned the role of doctors’ health advisory services around Australia (http://www.adhn.org.au) which provide advice for doctors, their colleagues, their bosses, their juniors, their staff members and/or their families about issues of concern.
Doctors who work in these services are volunteers who provide confidential, anonymous support via helplines around the country. Contrary to hearsay reports, the Doctors’ Health Advisory Service in NSW has not experienced a reduction in calls to the helpline in the wake of mandatory reporting. This is a beat up.
Dr Jill Gordon, President DHAS NSW