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A POLL run by InSight+ recently showed that 67% of doctors still believe that seeking help for their mental health problems will endanger their career. This is not new information, and yet doctors’ mental health continues to be an ongoing concern.
Beyond Blue’s now famous 2013 National Mental Health Survey of Doctors and Medical Students found that “approximately 40% of doctors felt that medical professionals with a history of mental health disorders were perceived as less competent than their peers, and 48% felt that these doctors were less likely to be appointed compared to doctors without a history of mental health problems”.
“Approximately 59% of doctors felt that being a patient causes embarrassment for a doctor. The prevalence of stigmatising attitudes differed by gender. For example, female doctors were more likely than male doctors to view doctors with a mental health history to be as reliable as the average doctor (69% and 55% respectively).”
Doctors take their own lives significantly more often than the general population – female doctors 2.2 times more, and male doctors 1.4 times more. This too is not new information.
But following what has been, anecdotally and off-the-record at least, an horrific couple of months of doctor and medical student suicide, on the back of 2.5 years of overstrained hospitals, underappreciated workforce stresses, and chronic underfunding, it begs the question:
Why are doctors not seeking help?
The regulations
Mandatory reporting legislation is perceived as hanging over doctors’ heads and as a threat regardless of the actual wording of the regulations.
In an interview with InSight+ in 2019, the late Dr Harry Nespolon, then President of the Royal Australian College of General Practitioners said:
“Mandatory reporting as it is currently atrocious and I would actually call it something like regulatory bullying. It stops doctors from visiting their GP. GPs don’t need to be put in the invidious situation in which they might need to report one of their colleagues. We don’t want doctor patients, whatever their specialties, be they GPs or other specialists, not coming to see their GPs because they’re afraid they’ll lose their job.
“GPs do this every single day of the week. We deal with patients who are seriously mentally unwell, and some of them shouldn’t be working, and if that’s the case, then it’s highly likely that the GP will say to that doctor, “perhaps you should think about not working”. That is more likely to make people seek help.
“Mandatory reporting laws work very much against that.”
The AHPRA regulations about mandatory reporting state that there are four reportable conditions: impairment, intoxication, departure from standards, and sexual misconduct. Mental health concerns come under the impairment category.
In Section 1.3:
“Treating practitioners [and non-treating practitioners and employers of practitioners] MUST report practitioners who are practising with an impairment, AND place the public at SUBSTANTIAL risk of harm (our emphases).”
In Section 1.6:
“Treating practitioners in Western Australia providing a health service to a practitioner-patient or student are exempt from the requirement to make a mandatory notification. However, these practitioners still have a professional and ethical obligation to protect and promote public health and safety, so they may consider whether to make a voluntary notification.”
In Section 3.2, AHPRA supply three case examples as a guide for when a treating practitioner does or does not need to report their doctor-patient. Example 2 relates directly to mental health:
“A practitioner-patient has a mental health condition, which is stable. Because the practitioner-patient is engaged in and complying with treatment, there is no substantial risk of harm to the public. This would not trigger a mandatory notification.”
That all seems clear, but to a doctor who is depressed, anxious, fearful and perhaps ashamed, the regulations loom.
Dr Margaret Kay, GP and doctors’ health advocate, told InSight+ that “unpicking” the details of legislation and regulations was not something that doctors with a mental health concern were going to do.
“The 90% of practitioners who don’t need to seek treatment don’t worry about mandatory reporting,” Dr Kay said.
“But when a doctor becomes mentally unwell, suddenly they get frightened. Their fears and anxieties are heightened and it’s harder to get [the regulations] straight in their mind. They remember the bad things they’ve heard from colleagues or friends, and that’s what sticks.”
Dr Helen Wilcox, Medical Director of the Doctors’ Health Advisory Service WA, agreed.
“Once a doctor has burnout symptoms, once they have that reduction in their sense of personal agency, and there’s no reduction in cognitive load, it’s difficult to reason your way out of some of those fears,” she told InSight+.
“There needs to be a lot of very strong evidence to counteract those themes, especially if the doctor is suffering a significant component of anxiety as well.”
Currently, legislation is before the Queensland Parliament which, if passed, will mean the Office of the Health Ombudsman can make public statements about a reported doctor, before the results of their investigation has been finalised.
“The Bill inserts new division 7B into part 8 of the National Law and new part 8AA into the Health Ombudsman Act to empower the National Agency, National Boards and Health Ombudsman to issue public statements about persons, including registered practitioners, who are the subject of investigations or disciplinary proceedings, and whose conduct poses a serious risk to public health and safety. This will allow regulators to warn the public about the risks posed by the person … the regulator would be able to notify the community of their potential health risk WHILE ALSO undertaking disciplinary proceedings against the person (our emphasis).”
“Their names can be circulated before a final ruling has been made,” said Dr Kay.
“If they are cleared their names can be removed, but by then the damage has been done. If a doctor has been on the brink of deciding to step away from the profession, that’s going to be the push that makes them do it.”
Dr Louise Stone, a GP and Associate Professor at the Australian National University, told InSight+ that there was no doubt that mandatory reporting was a big factor in stopping doctors from seeking help.
“There is no question that fear of mandatory reporting stops help-seeking behaviours,” she said.
Are the regulations the only barrier to help-seeking? In WA, where mandatory reporting is not legislated, have doctors sought help more often?
“I would expect that proportions in WA may not be much less,” said Dr Wilcox.
“It’s not just fear of the regulator that deters doctors from help-seeking, it’s concern about the response of the hospital administrators, or the training program, and the impact on their reputation if their mental health concerns were to become known, as well, of course, as the guilt and shame that comes from the self-stigma.”
“The fear of the regulator is an added burden, no question.”
Resilience
Speaking at the Thrive Symposium in November 2021, Dr Stone said doctors need to rethink the concept of resilience.
“Resilience is often described as the ability to bounce back from adversity,” she said. “The problem is, it’s not just a function of us. You can take the most super ball in the world and try and bounce it in a swamp and it’s not going to bounce anywhere.
“We know that the swampier the ground, the worse it’s going to get. Every layer of disprivilege that we work with, increases the sogginess of that swamp.
“The whole ‘problem’ is seen as doctors are not resilient enough,” said Dr Stone. “If people have got through medicine they’re pretty resilient. If they’ve got through their internship, they’re extremely resilient.
“It’s not a question of resilience. To blame a doctor for a lack of resilience, is cruel, heartless, unnecessary, and wrong.”
Dr Geoffrey Toogood, founder of the crazysocks4docs day, and a doctors’ health advocate, wrote in InSight+:
“Medicine takes a bright group of people who are caring, self-reflective and sensitive – is this not what one requires in a doctor? – and places them in a hostile and increasingly unforgiving environment. The result is an increase in mental health issues, especially in that first year of residency. It’s hardly the place to thrive rather survive, and where does that leave the very people we wish to look after?
“In all my years in medicine, I have learned very little from the very people that demand resilience of me.”
Other barriers
Dr Stone explained what she sees as the barriers stopping doctors from seeking help when they need it.
- Bullying and harassment.
“This is a layer of ‘sogginess’ that is very, very common,” she said.
A 2014 systematic review and meta-analysis found that “59.4% of medical trainees had experienced at least one form of harassment or discrimination during their training”. Also, 33% of trainees experienced sexual harassment.
- Cumulative microaggressions.
“We work in a community, and communities are not always pleasant,” said Dr Stone. “Once or twice it’s a small thing, but cumulatively it becomes something that changes the way you are in the world and creates all sorts of ‘sogginess’.
“It’s a lot more difficult to survive as a doctor who is not in the dominant group.”
- Beneficial mistreatment.
The theory that cumulative exposure to trauma means protection in the future. According to a 2015 study published in the MJA, 74% of medical students either experienced or witnessed “teaching by humiliation” during adult clinical rotations.
“The humiliating and intimidating behaviours students experienced were mostly more subtle than overt and included aggressive and abusive questioning techniques,” wrote Scott and colleagues.
“The students’ responses to these practices ranged from disgust and regret about entering the medical profession to endorsement of teachers’ public exposure of a student’s poor knowledge.”
Dr Stone said beneficial mistreatment was seen as “necessary and effective” and “professional warm-up”, and involved war vocabulary and “cruel rites of passage”.
- Hidden curriculum, hidden policy and importance of professional leadership.
“We know that institutions have ‘fairy dust policies’ sprinkled over the policies, and yet underneath there is toxicity and a lot of harm that is occurring,” said Dr Stone.
“It’s the undercurrent that you learn. It can be quite tricky for those doctor-patients to trust you, because they’ve heard it all before, and it wasn’t true, and it wasn’t consistent.”
- Emotional contagion.
“There is a lot of anger, and sadness in the community. It is very easy to find yourselves absorbing that through the pores,” said Dr Stone.
- Moral distress.
“Moral distress is when we know what we want to do with a patient but we are unable to because of the unhelpful structures around us, that we have no control over,” said Dr Stone.
Loss of trust
Dr Stone told InSight+ that “a number of institutions have lost the trust of doctors over the past few years”.
“The days of doctors feeling supported are gone. Nudge letters, fear of mandatory reporting, and the feeling of being under fire from the public.
“Doctors are feeling besieged.”
Hope for the best, plan for the worst
Dr Wilcox told InSight+ that changes to the internal culture of medicine around help-seeking, mental health and supportive workplaces “may take decades”.
“That’s a big cultural change, a generational change,” she said.
“Within most, if not every hospital system, there are small islands where the culture is good, where there is good collegiate support between doctors, and modelling of imperfection and vulnerability, and anticipation of some of the difficult times that might come along, and early intervention with informal supports.
“I hope that over time this environment becomes the norm.
“Much of the organizational aspects rest with the employer, but we have a shared responsibility to contribute to such an environment. After all, doctors are best at supporting other doctors.”
Connecting early with medical students was a vital part of preparing them for what might be ahead, said Dr Wilcox.
“Advertising avenues of help when things are going well, or at the start of the term is all well and good,” she said.
“But it’s really important to build a support network, to build an action plan when you’re feeling well, in anticipation of the times when you are in distress.
“We would encourage all early career doctors and medical students to do that forecasting – what will I do when I get into difficulty?”
If this article has raised issues for you please reach out to any of the following resources:
DRS4DRS: 1300 374 377
- NSW and ACT … 02 9437 6552
- Victoria … 03 9280 8712
- Tasmania … 1800 991 997
- Queensland … 07 3833 4352
- WA … 08 9321 3098
- SA and NT … 08 8366 0250
Medical benevolence funds
AMA Peer Support Line … 1300 853 338 or 1800 991 997
Hand-n-Hand Peer Support … www.handnhand.org.au
If you or someone you know is having suicidal thoughts, there are people here to help. Please seek out help from one of the below contacts:
- Lifeline| 13 11 14 | 24-hour Australian crisis counselling service
- Suicide Call Back Service| 1300 659 467 | 24-hour Australian counselling service
- beyondblue| 1300 22 4636 | 24-hour phone support and online chat service and links to resources and apps
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67% of doctors?? Do you really mean 67% of responders to your poll? Can you please discuss the selection bias involved in this type of data gathering and the potential sensationalising of results when extrapolated to a population which was never included in the study? Alternately explain how your statement is justified by the survey method employed.
Mandatory reporting provisions are bad law. Once reported a doctor is very likely to be suspended from their workplace until investigations are performed, because employers are not willing to take the risk of the performance of an impaired doctor’s performance. Thus the effects of the law is punitive. I suspect that doctors are one of the few groups in society for whom the management of mental impairment is punitive. Generally speaking psychiatrists can detect those doctors who are a risk to patients and medical boards can act accordingly.
Secondly, the law imposes a vicarious responsibility on doctors for the actions of others as a failure to report may lead to the doctor being notified and sanctioned by the medical board, if a doctor they are treating acts in an unsafe fashion or commits suicide.
Just because the clause states that there must be a substantial risk of harm, AHPRA will not cease persecuting the doctor for the ensuing years, until the matter finally gets a fair trial in the Supreme Court. During that time, the doctor will have to defend himself from unsubstantiated attacks by AHPRA every day and will have his or her identity made known to the public.
He or she will never recover.