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“We cannot solve our problems with the same thinking we used when we created them.” Attributed to Albert Einstein
DOCTORS continue to have high levels of mental illness and suicide partly because a medical career has never been more challenging. It is unthinkable that most doctors believe they cannot disclose their distress to their treating doctor without fear for their career. But is this a justified fear about discrimination in the medical workplace, rather than an unjustified fear of a mandatory report to the Australian Health Practitioner Regulation Agency (AHPRA) for mental impairment?
In an Insight+ poll completed by over 2800 doctors to date, 59% of responders either strongly disagreed or disagreed with the statement that “doctors can disclose their mental illness to their doctor without fear for their career,” which suggests that many doctors are quietly suffering. Only 32% agreed or strongly disagreed, the rest were neutral, and these deeply worrying findings are consistent with other studies.
Two weeks ago, and against the strong advice and advocacy of many of our respected medical leaders, the relevant Parliamentary Committee recommended the new Health Practitioner Regulation National Law and Other Legislation Amendment Bill 2018 on mandatory reporting be passed in Parliament. There is no further recourse on the Bill because health consumer groups are unwavering in their belief that the new Law must “protect the public”.
With this reality in mind, how can we currently reassure doctors that they can disclose their mental health illness to their own doctor without fear for their career?
The threshold for mandatory reporting of doctors with mental illness is rarely met.
In 2017–18, there were a total of 343 mandatory notifications for medical practitioners to APHRA and the Health Professional Councils Authority for all causes. Of these, 241 were related to professional standards whereas 63 were related to impairment. Thirteen medical practitioners notified under mandatory reporting had their registrations cancelled or suspended. Nobody had their registration cancelled or suspended by AHPRA for mental impairment (Table 15). No action was taken in 61% of all mandatory notifications, which suggests that there was confusion about the high threshold for reporting in the past.
The Parliamentary Committee’s (4 February 2019) report emphasised the higher threshold in the new Law as follows:
“Reforms are aimed at ensuring health practitioners seek treatment for health conditions (such as a mental health issue or an alcohol or drug problem) without fear of being subject to mandatory reporting … only serious health conditions that are not being appropriately managed through treatment or mitigation strategies need to be reported — because they place the public at substantial risk of harm.”
In his submission to the Parliamentary committee, Mr Martin Fletcher, CEO of AHPRA, reiterated that doctors should be able seek mental health care without fear:
“There are crippling fears about what regulators will do when they get a mandatory report and there are distressing stories of doctors and other health practitioners being afraid to seek the care they need because of fear of losing their registration … These fears are the unintended consequences of mandatory reporting and are the biggest challenges we face.”
Treating doctors determine when to make a mandatory notification, not governments, the regulator or the legal profession.
Under the new Law, a treating doctor must have “sufficient grounds” and use their professional judgement and clinical expertise to form a “reasonable belief” that a doctor patient’s behaviour constitutes notifiable conduct. This clinical opinion is based on:
“The nature, extent and severity of an impairment, the steps a practitioner-patient is taking or willing to take to manage an impairment, the extent to which an impairment can be managed with appropriate treatment, and [any] other matter a treating practitioner considers is relevant to the [substantial] risk of harm the impairment poses to the public … [and] the effectiveness of treatment or engagement in treatment of an impairment by the practitioner-patient in deciding whether there is likely to be an ongoing [substantial] risk of harm to the public.”
The reality is that there are rarely “sufficient grounds” for mandatory reporting by a treating doctor because mental illness can be managed successfully. “Reasonable belief” requires the treating doctor to have evidence from a reliable source or a direct knowledge or observation of the behaviour of the doctor patient, placing the public at substantial risk of harm, which is also rarely the case.
There are no penalties prescribed under the National Law for failing to make a mandatory report; however, the treating doctor may have their clinical assessment reviewedif the doctor patient later causes harm to patients.
For all these reasons, it is essential for treating doctors to seek guidance from their medical indemnity organisations when considering whether or not to make a mandatory report to ensure there is comprehensive documentation supporting the decision, or lack thereof.
Our medical membership organisations can lead change
Most doctors do not have a legal degree and cannot be expected to understand the interpretation and clinical application of the new Law, without ongoing quality evidence-based education and consistent support from medical organisations, particularly from our Colleges and the Australian Medical Association.
In its recent report, the Parliamentary Committee also recommended an education program on the new mandatory reporting requirements. In view of the serious challenges, education will fail unless the appropriate scope, timing and ongoing support is determined by our medical leaders, not by a Parliamentary Committee or the Minister.
Our medical leaders must also continue to call out the stigma and discrimination of doctors with mental health problems, particularly as the challenges of the medical workplace are often the root cause of chronic stress.
For example, patient complaints about doctors are a common cause of doctor distress. There were 6348 voluntary notifications of medical practitioners to the regulators in 2017–18, up from 5913 the year before. Although about 80% of voluntary complaints resulted in no action in 2017–18, each lengthy investigation predisposes doctors to mental health problems, whatever the outcome.
The negative stigma associated with mental illness in the medical profession was identified as a major issue in the 2013 beyondblue national mental health survey of about 14 000 doctors and medical students, with about 40% of doctors believing that colleagues with mental illness were less competent than their peers, which is clearly untrue. Five years on, doctors who disclose mental illness continue to be discriminated against in their workplaces, ignoring protections under the Fair Work Act.
Despite a recent Senate inquiry, unlawful bullying and harassment persist in medicine, which creates a negative medical culture and predisposes doctors to mental health problems and their fears about disclosure. This travesty requires greater leadership from us all.
United we can implement large-scale solutions based on evidence not emotion
Many doctors have advocated strongly, but unsuccessfully, for the abolition of mandatory reporting, in line with Western Australian law, due to valid concerns about high levels of suicide in the medical profession. In the 2013 beyondblue study, over 10% doctors admitted to having suicidal thoughts, and 5–6% admitted to self-medicating with antidepressants in the previous year.
By applying these percentages to the current numbers of registered medical practitioners, over 11 000 Australian doctors experienced suicidal thoughts in 2018, and about 6600 doctors self-medicated with antidepressants, breaching the Medical Code of Conduct. Of course, the validity of these extrapolated 2013 figures can be easily questioned, but the numbers illustrate the scale of our problem and the gaps in our knowledge. The fact is that no-one knows if the mental health of doctors has changed as nobody has followed up the disturbing trends since the 2013 study, which reflects a complacency.
For many decades, a growing group of dedicated doctors representing the Australian Medical Association, the Colleges, the Australasian Doctors Health Network, the Doctors Health Advisory Service, hospitals, other medical services and beyondblue have implemented a myriad of initiatives to improve the health of doctors, including clinical services in each state, policies, resilience training, workshops, forums, websites, apps, peer support programs and mentoring programs. However, resources have not been allocated to fully evaluate and roll out evidence-based initiatives nationally to meet the enormous and diverse needs of doctors at risk – that is, young, female, overseas-trained, Indigenous or rural doctors.
Medical organisations that claim “we are doing/have done” doctors’ health may be undertaking some activities, but many are not doing enough to achieve significant outcomes. While there are many competing priorities in medicine, the poor mental health of doctors, which reflects global trends, deserves ongoing urgent action, constructive consistent messages and resources from a united medical profession. Unfortunately, recent media headlines of doctors blaming governments for “regulatory bullying”, “putting doctors lives at risk” or encouraging doctors “to go to Western Australia for help” are inflaming crippling, unjustified fears in our profession.
Conclusion
We cannot solve high levels of mental health problems in the medical profession with the same thinking as before. Doctors should be confident that they can disclose their mental illness to their treating doctor without fear for their career. Only we can create this change by uniting to eliminate the myths, misinformation, stigma and discrimination associated with mental illness in doctors.
Collectively, we must take responsibility and leadership for this if we are to help our colleagues, particularly the many thousands of doctors who are quietly suffering.
Clinical Professor Leanne Rowe is a GP, past Chairman of the Royal Australian College of General Practitioners, and co-author of Every Doctor: healthier doctors = healthier patients. She is a non-Executive Director of the Medical Indemnity Protection Society (a membership organisation), but all her views in this article are her own. She is not employed by AHPRA or the government.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.
If this article has raised issues for you, help is available at:
Your own treating doctor, or
Doctors’ Health Advisory Service (http://dhas.org.au):
NSW and ACT … 02 9437 6552
NT and SA … 08 8366 0250
Queensland … 07 3833 4352
Tasmania and Victoria … 03 9280 8712 http://www.vdhp.org.au
WA … 08 9321 3098
New Zealand … 0800 471 2654
Medical Benevolent Society (https://www.mbansw.org.au/)
AMA lists of GPs willing to see junior doctors (https://www.doctorportal.com.au/doctorshealth/)
Lifeline on 13 11 14
beyondblue on 1300 224 636
beyondblue Doctors’ health website: https://www.beyondblue.org.au/about-us/our-work-in-improving-workplace-mental-health/health-services-program
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I have suffered mental illness since childhood and am happy to see the stigma that’s been attached with it is fading I myself believe that not being affected by certain life experiences is of far greater concern and GPs especially the ones that are committed to there patients are more likely to suffer from a mental illness that’s without everything that came before being a GP and what happens at home.
A GP with mental illness doing everything to be treated is a GP I could feel comfortable with as they know the struggles of getting med correct and the rest. I have moved around and had my share of great GPs also GPs with no empathy I would say a couple of narcissistic doctors that have caused health problems with there ignorance and made my mental health escalate.
GPs being treated with mental health issues should be rewarded ,the public seeing professionals whose ability is enhanced being more empathetic would go a long way for both mentally ill people being more trusting of the medical community and family friends and workmates seeing that mental health is not a buffed up word for psycho.
Someone has to assume responsibility for this issue, and publish data. For example, there is an unacceptably loose use of the words “ mental illness” when I assume anxiety/depression is meant; and there is a shying away from declaring gender specific contributions to illness. My personal experience, which covers decades, suggests the following: women RMOs soften feel uncomfortable when tersely spoken to – and over all this as bullying or teaching by humiliation, when it was nothing of the sort. Women and men RMOs feel stressed. and in some cases call this an illness, when it’s really a normal psychological state under the circumstances. Women have more trouble speaking up when they need time off, but should be prepared for compromise(e.g. I’ve been up all night, have rooms fully booked, and if the RMO needs a break, I might be inclined to say: “Give me a few hours to rearrange my rooms, wait till I get through the 32 week Caesar at the Private Hospital, and ring me tonight at 7 to discuss – I could probably take calls tonight”). I’ve had to deal with RMOs who demand time off without notice, and make no reckoning of the consultant’s workload! Then ignorantly call this bullying!
Is it possible that there is a larger percentage of recently graduated women RMOs which is pushing up these figures?
A theme about discrimination against doctors with mental illness by other doctors is emerging in these comments and on social media in response to my article. It appears it is safe to disclose mental illness to a treating doctor, but not in a medical workplace, despite protections under the Fair Work Act.
In reality, doctors take very little sick leave, and medical workplaces should support doctors when they request a lower patient load or time off work for any physical or psychological condition. Doctors who seek help and comply with treatment for any physical or psychological condition, continue to provide a high standard of patient care, but sometimes at great expense to themselves unless they allow themselves to take time off work for a while.
In this scenario, the necessary medical certificate may be supplied directly to a workplace by a treating doctor, without divulging the medical reasons for the temporary absence, particularly if there are fears about discrimination. A doctor with a gynaecological/urological or gastrointestinal problem is not required to divulge their personal symptoms to their employer, although these symptoms may prevent them from working from time to time. Similarly, no employer has the right to ask about a doctor patient’s mental health symptoms if they require time off work to get better. Work performance issues are another matter.
Unfortunately, discrimination, bullying, harassment and other dysfunctional behaviours persist in medical workplaces, which predispose doctors to mental health problems. A number of dedicated doctors have recently undertaken a lot of activity to try to change this, but we require a more concerted united effort by our many medical organisations to roll out evidence-based solutions at a local and national level. I will be writing more on this topic in March.
I have experienced significant discrimination over simple depression over the years. I hate to think how a doctor would fare after letting slip bipolar, schizoaffective disorder or substance abuse.
In the last 24 hours, the response by thousands of people to my article on twitter #caring4everydoctor and the 3 valid comments/questions above indicate the need for support and better education on the new Law on mandatory reporting by our medical organisations, rather than scaremongering. Only the Royal Australasian College of Surgeons has responded positively so far. What are our other Colleges planning to do on this important topic?
The sentence from the article stating “There are no penalties prescribed under the National Law for failing to make a mandatory report; however, the treating doctor may have their clinical assessment reviewed if the doctor patient later causes harm to patients.” is the most salient to this discussion. Until the consequences of “have their clinical assessment reviewed” if the review is negative is spelled out clearly, then the profession will justifiably demand that mandatory reporting be dropped in favour of the Western Australian model of dealing with this problem. Who reviews the treating doctor’s assessment? Can the author please describe what happens to a doctor who’s clinical assessment is deemed inadequate? I look forward to an informative reply.
The experience of colleagues who have been unjustifiably hounded by APRHA with decision delays even over simple issues of vexatious patients leads me to keep any serious medical or psychiatric issues to myself until we can freely seek medical help without mandatory reporting. No other people in our society are open to such bureaucratic control over our lives. I don’t have a problem with compulsory medical examinations for doctors separately from their own doctor.
The changes to the National Law are welcome, and the evidence about the relatively small numbers of mandatory notifications is revealing, but it is interesting that many do not reach the threshold.
The fact remains that mandatory reporting is not penalty free and the Law makes doctors vicariously responsible for the conduct of others, as identified in the paragraph below.
“There are no penalties prescribed under the National Law for failing to make a mandatory report; however, the treating doctor may have their clinical assessment reviewed if the doctor patient later causes harm to patients.”
Doctors will need to be made aware of the changes to the Law as will officers in AHPRA and other regulatory bodies. In one instance before a State board, officers of the complaints body wished to pursue a General Practitioner of a patient who committed suicide within a few days of seeing the GP, on the basis that he should have detected the risk of suicide. The patient had been discharged from a mental health hospital the day before he saw the GP, when it was considered that he was not at risk.
In terms of relative risk, the chance of a doctor, who has been assessed by a competent doctor as fit to practice, despite mental health issues causing harm may be less than the risk to patients of doctors who do not seek treatment when suffering from mental health problems.