Mandatory reporting is a hot topic of the moment. The increased awareness on mental health for doctors, twitter campaigns #MH4Docs and #Socks4Docs, the loss of great doctors due to mental health issues – have all contributed to raising the debate again on mandatory reporting . At the recent Business for doctors conference, this was one of the main concerns for doctors attending the workshops on Burnout and the one on Wellness for Doctors . So before we go further what are the regulations on mandatory reporting?
Regulations
“All registered health practitioners have a professional and ethical obligation to protect and promote public health and safe healthcare. Health practitioners and their employers, as well as education providers, also have mandatory reporting responsibilities under the National Law.”
The AHPRA guidelines go on to state:
“Education providers, registered health practitioners and their employers must tell us if they have formed a reasonable belief that a registered health practitioner has behaved in a way that constitutes notifiable conduct.”
What are notifiable conducts?:
- Practising while intoxicated by alcohol or drugs
- Sexual misconduct in the practice of the profession
- Placing the public at risk of substantial harm because of an impairment (health issue), or
- Placing the public at risk because of a significant departure from accepted professional standards.
What does this mean?
On the face of it these regulations and points are reasonable. In general most people would accept those points of notifiable conducts are acceptable standards of behaviour we would expect from doctors and colleagues.
The point of “reasonable belief” also seems … well …. reasonable – though maybe difficult to define. The guidelines suggest, this should be based on direct knowledge and not gossip or innuendo. That the person making the notification has to have direct knowledge or observation of the impairment.
Also very very importantly :
“if the only risk is to the practitioner alone, and there is no risk to the public, the threshold for making a mandatory notification would not be reached. For example, in a case where the risk is clearly addressed by being appropriately managed through treatment and the practitioner is known to be fully compliant with that, mandatory notification would not be required.”
Perceptions and fears
The main problem with all this is the perception of mandatory notification, I’m sure we can all agree that there should be some form of safety net to protect the public and even the actual doctor who may be impaired. However the fear of mandatory reporting is something that will actually prevent doctors from seeking help. Why ?
This is probably tied into the identity of being a doctor that we talked about in a previous post. Our identity and our public persona/mask of a doctor is so infused with who we are that any threat to that part of our identity is an existential threat. When you add in uncertainty about the process, the public and exposed nature of this (with a public register showing conditions, tribunal decisions etc) and threat to livelihood and by association threat to home and family, you can start to see why there is the fear of mandatory reporting.
Language and Focus
Part of the problem is the actual language and focus of mandatory reporting. AHPRA and other medical boards across the globe (GMC in the UK is another good example) have repeatedly stated – they are there not to support or advocate for doctors but to serve and protect the public – we won’t go into how this plays with doctors, especially as doctors pay (more than any other health profession) to allow the board to exist. This along with the whole process being setup with, a focus to remove the problem from circulation, and isolate the “pathogen”. The whole tone then changes into a vilification and accusatory exercise – or so it may be perceived. This is important as again this puts a barrier to those who may actual seek help. If the language and focus is changed to one of treatment rather than stigmatisation there could be improved engagement with doctors who may be going through some form of mental health or substance abuse problems. Please note for the most part in this post, I’m talking about doctors who may be going through mental health, or substance abuse issues (usually linked), and seeking or receiving treatment. Rather than doctors who may be acting inappropriately professionally and dangerously, without regard for others (admittedly this can be a fine line with the previous cohort).
Ways forward
As you can imagine any stigma or threat to career and livelihood will lead to those doctors who need help the most not seeking it. This can lead a doctor into territory where, he or she may indeed become more of a danger to themselves or patients. Instead of protecting the public, it has been suggested mandatory reporting is doing the opposite.
So how can we change things? One way may be to remove mandatory reporting as in Western Australia (WA) and this is now being considered in New South Wales (NSW). Does this mean we excuse and allow impaired doctors to work as they see fit and put patients at risk? Obviously not.
We need to find more effective measures. This can begin by changing the language to focus on treatment and support for impaired doctors rather than stigmatisation. Addressing the issues of financial and professional security, protect privacy and avoid ‘public shaming” of impaired doctors. There seems to be a belief by AHPRA and regulatory bodies, that by publically, and loudly being seen to do something about impaired doctors, shows strength and increases confidence in the health system. However all it seems to do is to show failings in the system and erodes confidence in the governing bodies and the medical profession as a whole.
We need to address the underlying issues that lead to doctors being burntout and
Message to Doctors
You may be in a position where you are concerned about mandatory reporting of yourself, or indeed be in a position where you may need to report someone else that you have concerns about.
Firstly for those who may need to report someone: If you have a reasonable belief that there is a threat to patient safety or to the doctor themselves then you should make steps to confirm the situation, and should see if the person in question is getting treatment or are there any other safeguards. If there is any uncertainty, then you do have a duty to make sure that the safety of patients or the doctor is secure. The AHPRA website has guidelines on how to proceed.
If you are worried about being reported : You need to seek help first if you have not already done so. Beyond the regulation and registration concerns, your health comes first. You need to make that decision and choice to put your health and by association your family’s well being ahead of other factors. You need to look for help. Importantly Medical Defence Organisations (MDOs) are exempt from mandatory reporting (legal representative), so that’s a good place to start. Call your MDO – talk to them, and they can often guide you on your first steps. Next if you haven’t already got one, get a good GP. I’ve mentioned a few times previously about the Australian Doctors Health Network (ADHN) which has a number for each state that you can contact. They will find a GP near your location who takes on other doctors as patients. There are further contacts through Lifeline and BeyondBlue – I’ll put the links and some numbers below in the Useful Links and resources section.
Whatever your fears about being reported to AHPRA you need to look after your own health and also have a duty of care to your patients. If you are impaired in any way you should not try and push through it and see patients. I’d like you to remember that paragraph from the guidelines:
“if the only risk is to the practitioner alone, and there is no risk to the public, the threshold for making a mandatory notification would not be reached. For example, in a case where the risk is clearly addressed by being appropriately managed through treatment and the practitioner is known to be fully compliant with that, mandatory notification would not be required.”
Hopefully the current open discussions and push leads to some change if not in regulation at least in language and focus.
Useful links and resources:
AHPRA information on mandatory reporting – http://www.ahpra.gov.au/Notifications/Make-a-complaint/Mandatory-notifications.aspx
Lifeline -Anyone across Australia experiencing a personal crisis or thinking about suicide can contact (confidentially), on 13 11 14
If you are in an emergency, or at immediate risk of harm to yourself or others, please contact emergency services on 000.
BeyondBlue call 1300 659 467
ADHN contact numbers by state:
- Australian Capital Territory
02 9437 6552 - New South Wales
02 9437 6552 - Northern Territory
08 8366 0250 - Queensland
07 3833 4352 - South Australia
08 8366 0250 - Tasmania
03 9495 6011 - Victoria
03 9495 6011 - Western Australia
08 9321 3098 - New Zealand
0800 471 2654
Some of the main MDOs in Australia –
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Categories: Burnout
Tags: adhn, AHPRA, doctors, GP, help, impaired, mandatory, MDOs, mental health, Regulation, reporting, serenity