Your Health
Since its implementation, mandatory reporting of impaired colleagues has proven problematic.
Smart Practice
DOCTORS ARE HUMAN TOO
Your Health
Professor Leanne Rowe
Why you should have your own GP
Help or hindrance?
YOU are a GP and your next patient, a doctor, has a history of mental health issues. She is currently on sick leave following a near miss involving patient care two weeks ago. This exacerbated her anxiety, but she is being pressured to return to work. She is not sure whether she is ready to return to work and is concerned she will be putting patients at risk. She attends seeking your help and is keen to follow your advice.
Along with all the challenges of assisting a patient in distress, because your patient is also a health practitioner you need also to consider whether their conduct is notifiable and whether you are obliged to report them to AHPRA. Although mandatory reporting has been in the National Law since it was enacted seven years ago, the legislative requirements still cause confusion.
What do you have to report? As a health practitioner, you must notify AHPRA when you have a reasonable belief that another health practitioner has:
• practised while intoxicated by alcohol or drugs; or
• engaged in sexual misconduct in connection with their practice; or
• placed the public at risk of substantial harm in their practice because the practitioner has an impairment; or
• placed the public at risk of harm because they have practised in a way that constitutes a significant departure from accepted professional standards. These constitute“ notifiable conduct” under the legislation. There are some exemptions discussed below. The obligation to report includes students who are impaired and engaged in clinical training as part of their course. However, a“ reasonable belief” should not be based on speculation, gossip, rumour or innuendo.
There is no simple solution to this scenario.
MEDICOLEGAL
Since its implementation, mandatory reporting of impaired colleagues has proven problematic.
GEORGIE HAYSOM
If you don’ t believe your doctor-patient posed a public safety risk, you do not need to notify AHPRA. If you believe your patient’ s conduct has raised a public safety concern, the jurisdiction in which you practise determines your obligation to notify.
In WA, you are not obliged to notify AHPRA if you form your belief about the notifiable conduct in the course of providing health services to the practitioner( the‘ WA treating practitioner exemption’).
In Queensland, since 2013, there has been an exemption for treating practitioners who reasonably believe the otherwise notifiable conduct“ relates to an impairment which will not place the public at substantial risk of harm and is not professional misconduct”. The effect of this is that you only have to report it if you have a reasonable belief that there is a future risk to the public and the practitioner has engaged in professional misconduct.
Why are these provisions problematic? Confusion remains about mandatory reporting obligations. Because the section defines notifiable conduct in the past tense(“ placed the public at risk” and“ practised while intoxicated”), conduct that occurred in the past is notifiable, even if there is no future risk. This seems inconsistent with statements from the Medical Board of Australia that“[ a ] n unwell practitioner whose health is being well managed does not need to be reported to the board”.
Problems also arise because the legislative requirements are complex. What is“ a risk of substantial harm”( as it relates to impairment) vs“ risk of harm”( as it relates to departure from accepted standards”)? What is a significant departure from accepted standards?
Practitioners are often unsure about whether they have formed a“ reasonable” belief, as distinct from a mere suspicion or concern.
As well as this, the legislative requirements
Online resources Avant guide to mandatory reporting bit. ly / 2rfiYoY
AHPRA Guidelines for Mandatory Notifications
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Avant position paper on mandatory reporting
bit. ly / 2sZMmAN
may be inconsistent with practitioners’ ethical obligations, which would be to report based on present or future risk of harm.
Importantly, the legislative requirements may have the effect of deterring unwell practitioners from seeking treatment. The evidence suggests that fear of being reported is a barrier to practitioners asking for the help they need.
Since these provisions were first proposed, there have been calls for governments to amend the legislation to clarify the reporting obligations and to adopt the WA exemption.
What happens in practice? The legislation is at odds with current practice. Research into mandatory notification data indicates that treating practitioners report their doctor-patients relatively infrequently, and generally where the relationship was compromised because of dishonesty, lack of insight, a disregard for patient safety or an intention to self-harm.
Other exemptions Medical practitioners do not need to notify if they know or reasonably believe that the conduct has already been reported. There are a number of other circumstances where you won’ t be required to notify AHPRA, including where you are providing legal advice. Check with your medical defence organisation if you are unsure.
Ms Haysom is head of advocacy at Avant.
“ I CALLED in sick because I had been vomiting and I was told:‘ You don’ t sound that bad— you need to toughen up’. After I gave myself an anti-emetic injection, I went to work, and it was implied that I wasn’ t pulling my weight. I’ m a doctor and I don’ t have the right to take sick leave when I need it.”
This reflection from a doctor-patient illustrates the overt pressure on doctors to keep working through illness. Being a doctor can be a health risk. Doctors carry an enormous sense of obligation and commitment to patients. They have a long and admirable— but often unhealthy— tradition of selflessness at work. They’ re reluctant to take sick leave as it places burdens on colleagues and is particularly difficult to do in a small business such as a GP clinic.
The culture of the medical profession is such that the signs of burnout are often worn as badges of honour. However, it’ s time to change the mindset that being stressed and miserable is the sign of a dedicated doctor.
How many of us are surviving or enduring our careers, rather than thriving?
In corporate life, many professionals in senior positions routinely seek coaching, mentoring, leadership training and comprehensive preventive health assessments to maintain optimal performance. Many healthcare professionals, particularly psychologists, regularly debrief with a trusted mentor to ensure they maintain their wellbeing, particularly if exposed to trauma and grief.
Unfortunately, doctors do not usually avail themselves of this level of support.
Many doctors do not have their own GP because of fears about breaches of confidentiality, a dislike of waiting in a GP’ s waiting rooms, embarrassment at being in the patient role, difficulty relinquishing control, and fear of being judged as weak and not coping by colleagues. Doctors may be particularly concerned about presenting to a colleague for a mental health problem, and many accept low levels of wellbeing as a normal state.
On top of this, doctors, like many other patients, often underestimate the impact their mental health problems have on themselves and their families. They continue to work and function adequately while depressed, and many don’ t seek help until a crisis forces them to do so. Unfortunately, for all these reasons, doctors tend to self-medicate and seek adhoc treatment from medical friends, rather than accessing the support and management they would recommend for a patient.
Our profession should be encouraging prevention and early intervention for physical and mental illness. An easy way to do this is via an annual comprehensive health assessment, including mental health screening, for all doctors. A regular GP appointment when you’ re healthy helps build trust with your GP, which is particularly important if you hit a rough patch in the future. Having your own GP, also means you have an effective advocate if you need time off work. Professor Rowe AM is a GP in Melbourne. Her blog on doctors’ health and self care can be found at: www. medicineisbeautiful. com
This column is part of our coverage to raise awareness of doctors’ mental health.
DOCTORS ARE HUMAN TOO For support on suicide prevention call: Lifeline 13 11 14.
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