Pride and prejudice: the mentally ill GP
Should doctors with mental health issues continue to practise? Pamela Wilson investigates.
Sydney magistrate Brian Vincent Maloney has fought a very public battle with bipolar II disorder – and because of it he very nearly lost his job.
Earlier this month he survived a motion in the NSW Legislative Council to remove him following a string of complaints about inappropriate behaviour in the years before his illness was diagnosed, including that he repeatedly asked a pregnant woman to stand up to show how pregnant she was and showing a screensaver of half-naked women to a female colleague.
In May, a NSW Judicial Commission had deemed him incapable of performing his role as a magistrate, despite his condition now being treated and well controlled. MPs’ debate centred on whether Mr Maloney remained incapacitated for the job – though for him their decision had more important implications.
“Upon your decision, in this case, depends whether a person suffering from a mental illness will dare to seek medical assistance,” Mr Maloney said in an address to the Upper House in June.
He could have been speaking for the one in five GPs with mental illness, many of whom are continuing in their professional role: should a well controlled mental illness be a barrier to employment for those in positions of responsibilty?
“We know that even with severe mental illness, doctors can practise safely once it is controlled,” says Brisbane GP Dr Margaret Kay, who works with the Doctors’ Health Advisory Service Queensland.
The only time a doctor’s health status should be called into question – legally and ethically − is when it severely impacts on their ability to perform their job within the accepted standards and puts the public at risk, she says.
“We are not allowed to have untreated depression that is affecting our practice because we can hurt people. But we also know that it’s very rare for that to happen,” Dr Kay says.
The law governing medical practice states that anyone who places the public at risk should not be working, but as Medical Board of Australia (MBA) chair Dr Joanna Flynn points out, conversely this means that anyone not placing the public at risk is well within their rights to practise medicine.
If a doctor’s behaviour is brought to the attention of the board, the conditions or penalties they face are not draconian.
“It’s an extremely rare thing for someone to have their registration taken away because of a health problem. It’s only in circumstances where someone is severely ill and not taking the medical advice they are given that their registration would be taken away,” Dr Flynn says.
“There is a process of assessment and negotiation with the practitioner about the conditions under which they can work safely and what monitoring needs to be put in place.”
Despite the laws mirroring the medical profession’s long-standing philosophy of what constitutes best practice in these situations, national mandatory reporting legislation introduced last year seems to have blurred the lines of perception and reality for many in the medical fraternity.
Because doctors are now bound by law to report ‘notifiable’ behaviour of their colleagues, many doctors with mental illness are not seeking help for fear of putting their livelihoods at risk.
Legal sanctions can be imposed on doctors who fail to report colleagues who place the public at risk of substantial harm because they have an impairment or severely breach professional standards. Practising while intoxicated and sexual misconduct in connection with work are also considered notifiable conduct.
Western Australia is the only state in which treating doctors are exempt from mandatory reporting laws.
Since the introduction of mandatory reporting, there has been a drop in the number of doctors seeking help. While hard data is not available, anecdotal evidence suggests a direct correlation between the two.
Dr Kay says the advisory service reported a marked drop in doctors calling for advice at the same time that mandatory reporting was introduced in Queensland.
“It was very hard for us to not think this sudden precipitous drop in calls was related in some way, and then we started getting a number of calls from people asking about mandatory reporting,” she says.
“It’s not that much different to what we have always been professionally and ethically required to do... It’s the perception that is different.”
Dr Kay says the service’s consultants also report that callers are now admitting they delayed seeking treatment because of mandatory reporting, and that they are seeing an increase in doctors reporting to be suicidal.
AMA president Dr Steve Hambleton says it’s regrettable that doctors don’t feel they can seek the advice of a treating doctor without fear of being reported.
“As it stands, doctors are actually not self-reporting, not going to see their doctor as much as they were because they are concerned their livelihood is going to be put at risk,” he says.
Dr Flynn concedes this perception now exists, but stresses it is an unjustified fear.
“The biggest concern we have is that people misunderstand the situation and don’t seek care when they need it because they’re afraid of being reported,” she says.
Melbourne GP Dr Caroline Johnson, a spokesperson on mental health for the RACGP, believes the issue is a complex one that needs more debate to get it right.
“The goal is that health professionals can seek treatment, advice [and] support without fear of being reported. By the same token, we obviously need to make sure there are standards in place and there are safety measures, and I think the legislation hasn’t really addressed that balance.”
The first annual report into mandatory reporting will be released in coming weeks, but Dr Flynn says there has been no major increase in mandatory reports since the change in legislation.
All doctors who come before the medical board are treated individually and sensitively.
“The people who do that role understand they need to look at their public protection role but also need to weigh against that the legitimate interests of the doctor in continuing to work… and their health needs,” she says.
Starting the conversation
TWO years ago federal politician Andrew Robb announced he was stepping down from his duties for three months to seek treatment for a depressive illness.
Openly admitting to having a mental disorder took some strength. Mr Robb says in his memoir, Black Dog Daze, that he knew it could be seen as a weakness and could count against him politically, but he “couldn’t be cowered by that”.
However speaking up and seeking support for a mental illness can actually preserve professional integrity, explains Dr Caroline Johnson.
“If you put your head in the sand... [it could] increase your risk of being unable to work,” she says.
Usually when it comes to mental illness, most doctors who come before the MBA achieve a good outcome, says Dr Kay.
“Even with severe mental health problems, when people are involved with the medical board most of them get back to work very safely,” she says.
Speaking up also helps reduce the stigma of mental illness in the community, says SANE Australia executive director Barbara Hocking.
“[Doctors] have an important role to demonstrate to the community that in fact there is no shame in having mental health problems, and the earlier you get the support and treatment you need, the better it’s going to be for everyone.”
Under the Australian Medical Council’s code of conduct, any doctor concerned that their health status may adversely affect their judgement, performance or their patient’s health must seek medical advice and not rely on their own assessment of the risk posed to patients.
In its document, Guidelines for Mandatory Notification, the MBA offers advice and questions to help reporting doctors choose the best course of action.
It stresses that the threshold that must be met to trigger a mandatory notification is high.
“The notifiable conduct of the practitioner must have placed the public at risk of harm as well as being a significant departure from accepted professional standards before a notification is required,” it says.
AVANT’s special counsel in professional conduct, Helen Turnbull, says the first step for reporting doctors is to approach their colleague with their concerns and encourage them to seek advice.
It is also vital they take time to consider the facts and seek advice from colleagues, medical defence organisations and/or support services so the burden of reporting is a shared decision.
“As they talk through it, they realise in many cases that it’s more an element of a colleague simply being unwell, i.e. suffering from depression, but there is no actual impact on patient safety,” Ms Turnbull says of many of the doctors who call them for advice.
Dr Johnson says all doctors should try to become involved with a GP support network so they have a forum where they can seek advice in these situations.
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