Health and Wellbeing for Rural Doctors and The Risks and Impacts of Medicolegal Claims (Part 2)
Dimitri
Welcome to our latest instalment of the Rural Health Webinar series. My name is Dimitri and I will be hosting tonight's webinar. Tonight's webinar is part two of the Medical Insurance Protection Society's three-part series on Medicolegal Issues and Risk Management in Rural Practice. This webinar will explore common health problems experienced by doctors and discuss ways to implement strategies to minimise your medicolegal risk. It follows on from part one - Common Medicolegal Risks in Rural Practice. Our presenter this evening is Dr Owen Bradfield. Dr Bradfield is the Chief Medical Officer at the Medical Insurance Protection Society or MIPS, and is a GP, Health Lawyer and Health Law Researcher. Owen has 15 years of experience in the medical indemnity industry, having advised and represented health practitioners in a range of medicolegal disputes. Dr Bradfield is a fellow of the RACGP and combines his role at MIPS with academic research at the University of Melbourne.
Before we jump into it, just as you can see from this slide, if you have not started your PDP with regarding your CPD, please feel free to look into that. The RACGP has wonderful resources which could all be found when you log in. We would like to begin tonight's webinar by acknowledging the traditional owners of the lands on which we are coming together from and the land on which this event is being broadcast. I would like to pay our respects to the elders, past and present, and would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening. RACGP would also like to thank our sponsor MIPS. MIPS membership includes comprehensive indemnity cover for the provision of healthcare to individuals. MIPS exists to promote honourable practice and protect the interests of its members. MIPS provides a range of benefits in addition to insurance covers such as a 24-hour medicolegal support and accredited risk education workshops. We greatly appreciate the support of this webinar series. Before we start, just a few housekeeping things to cover. You have probably all noticed that you are set on mute, and this is just to ensure that the webinar is not disrupted by any background noise, but of course we do encourage you to use the chat function or the Q&A box to ask questions. When using the chat function, we do ask that you address your questions and comments to all panellists and attendees rather than just the panellists, so that everyone can see your questions and comments, and finally, the webinar has been accredited for one hour of educational activities CPD. To be eligible, you must be present for the duration of the webinar. We also kindly ask that you complete the short evaluation at the end of the webinar. This should only take a few minutes to complete and will help us to improve the format and content of future webinars. We have got the learning outcomes. At the end of this webinar, you will be able to discuss or understand mandatory reporting obligations as they apply to practitioners with the health impairment, identify resources and supports available for treating practitioners to assist in decision making, understand the impact that rural practice and claims can have on the health and wellbeing of doctors, and discuss ways to minimise medicolegal risk by implementing strategies in daily practice, but for now, I am going to hand over to our presenter for this evening, Dr Owen Bradfield. Thank you.
Dr Owen Bradfield
Thanks very much, Dimitri, and thanks for the warm introduction and the kind invitation to present. I would also like to begin by acknowledging the traditional custodians of the various lands upon which we are all gathered this evening, and pay my respects to their elders, past and present, and I would like to extend that respect to any First Nations people who are joining online. Just a bit of a recap. A couple of months ago, I presented part one of this three-part series relating to medicolegal issues in rural practice. Here is a QR code for anyone that missed part one. It will take you to the recording so you can view it on demand, and essentially what I talked about in session one was some of the common medicolegal issues that we often deal with here at MIPS when our rural members have particular questions about medicolegal issues that arise in the context of their practice. We talked a little bit about managing patient relationships, terminating therapeutic relationships, dealing with confidentiality in small rural communities. We talked a little bit about telehealth and some of the new guidelines around telehealth, death certification and also prescribing, particularly in a rural context where they may also be the need to consider interstate prescribing. And so tonight's webinar moves on to the sometimes vexed issue of doctor's health. We know that doctors are not great at managing their own health and wellbeing. We know from the literature that whilst doctors overall have better physical health than the general population, we know that they have higher rates of mental health and substance use challenges compared to other professional groups and to the general population, and so I guess tonight's webinar is an opportunity to have an important conversation about doctors health, not only from the perspective of us all as doctors who experience the challenges of daily work life that can sometimes predispose to burnout and mental health challenges, but also as doctors who may be treating other doctors in a therapeutic context. The last major survey that was conducted into Doctors Health now is some ten years old, and it was a Beyond Blue Survey into the mental health of the medical profession. Many of you may be familiar with the report and its findings, but the findings were quite sobering and have been the topic of research since then. The survey was conducted, 40,000 doctors were invited to participate. I think there was about a 27% response rate, so overall, I think 12,000 doctors responded, and it was quite an extensive survey that touched on lots of different facets of doctors professional and personal lives, and so what the results showed was that medical practitioners experienced higher rates of psychological distress compared to the general population or to other professional groups such as lawyers. For those doctors under 30, they also experienced higher rates of psychological distress compared to other professional groups and to the general population. 21% of respondents said they had a past history of a diagnosed mental illness, while 6% said that they had a current diagnosis, and there were also higher rates of depression, anxiety, substance abuse and suicidal ideation in the preceding 12 months, again when compared to other professional groups and to the general population. The report also focused on particular subgroups within the medical profession and found that younger doctors and female doctors reported higher levels of psychological and work stress, suicidal ideation, and burnout. It also found that female students and indigenous students were more likely to experience mental health challenges, and that international medical graduates and rural doctors were also more vulnerable to psychological distress due to the stressful nature of their work experiences and environments. The report also looked at other reasons why these findings might be the case in relation to the medical profession, and talked about long working hours and poor work life balance, but also importantly talked about the persisting, stigmatising attitudes that still exist within the medical profession when it comes to doctors who might be experiencing mental health challenges, and these persist today, so this idea that and it is often quoted in the medical literature particularly in relation to qualitative research involving doctors who have lived experiences of mental health challenges that they often themselves and their colleagues feel that mental illness should be for patients but not for doctors, and so there is this idea that the profession still expects resilience and stoicism in the face of adversity. The report also came up with some recommendations for improvement, and I will be looking at some of my own research just briefly later on that that supports some of these recommendations as well.
I guess the reason I am going to be focusing on doctor's health and leading into a discussion on mandatory reporting is that when we think about often when we think about doctor's health and when we talk to doctors who have medical conditions or who are unwell themselves, many talk about the fear of talking to another doctor, another health practitioner about their symptoms and about how they are they are feeling, and much of that fear relates to concerns around mandatory reporting and the impact that mandatory reporting might have on their career. One of the things that I think is really important and why a big focus of tonight's presentation is on mandatory reporting is, as I will outline shortly, it is not only a legal requirement to make a mandatory notification in certain circumstances, but it is also important to ensure that you understand what those mandatory reporting obligations mean, and in examples of when you probably should make a mandatory notification, and circumstances where you probably do not need to make a mandatory notification because making a mandatory notification about another doctor is a big step and a step that can have huge ramifications for the doctor who is being reported, and in our experience here at MIPS, we often take calls on our Medicolegal advisory service from doctors who are the subject of a mandatory notification. We see firsthand just the devastating impact that that any notification can sometimes have on a medical practitioner. One of the principal purposes of tonight's presentation is not just to talk about and reflect upon doctors health, but to also talk about mandatory reporting to ensure that that we all have a better understanding of what those requirements are and what they mean and how we can apply those to different sets of circumstances. In Australia, doctors are regulated by the national law. It is called the Health Practitioner Regulation National Law Act, and it is an Australia wide. It is a legislation that has been enacted in each state and territory that mirrors legislation that was initially passed in Queensland, and its purpose is to regulate practitioners and set standards for the registration of practitioners across the country. There are specific provisions within the national law sections 140 and 141 that set out these requirements for mandatory notification, and so essentially what it requires is that any registered health practitioner and that obviously includes medical practitioners, must notify the board in the course of practising their profession if they form a reasonable belief, and we will get to what reasonable belief means, that another registered health practitioner, including a medical practitioner, has behaved in a way that constitutes notifiable conduct. It creates this definition of notifiable conduct, and there are four types of notifiable conduct in the law. The first is where the practitioner is practising the profession while intoxicated by alcohol or drugs. The second is where they are engaging in sexual misconduct in connection with their profession, and although sexual misconduct is not defined, it is widely understood to mean professional misconduct of a sexual nature. The third is where a practitioner is placing the public at risk of substantial harm in their practice because they have an impairment, and the fourth is where they are placing the public at risk of harm by practising in a way that represents a significant departure from accepted standards.
Now, what we will be focusing on today is the third and we may touch a little bit on the first, but primarily what we are focusing on today is health impairment. You can imagine that there may be circumstances where particular facts or particular allegations could give arise to the possibility of possible notifiable conduct under those four criteria for notifiable conduct. I can imagine a set of circumstances where an inappropriate intimate examination could give rise to an allegation of both sexual misconduct or practising in a way that substantially below accepted professional standards. Let us look at this in a little bit more detail because there are also some additional requirements for treating practitioners, and these were inserted into the national law more recently to I guess respond to some of the concerns that that many doctors had about the impact that reporting their unwell patients might have for their patients and for the therapeutic relationship and whilst not significantly different in terms of the standard expected, they do clarify somewhat when a mandatory notification in relation to a health impairment might be required by a treating practitioner and things to consider by a treating practitioner according to the law is the nature, extent and severity of the impairment, but also really importantly, the extent to which the health practitioner who may have the impairment is willing to take steps to manage that impairment, and that is really important, and although that is not a specific requirement for other practitioners, I think it is still a relevant consideration when you are faced with a dilemma in front of you about whether or not to make a mandatory notification, and again, some of the cases that I will get to a little later will touch on that, so hopefully that becomes clearer. The other thing to think about is whether or not or the extent to which the impairment can be managed with appropriate treatment. For example, a patient of yours who is a medical practitioner has for example schizophrenia, they have had schizophrenia for some time and they are having signs and symptoms of a relapse, and you are concerned about those that relapse potentially impairing their ability to safely practice and potentially putting the public at risk of harm. If they have previously responded to medication and medication exists to treat that relapse and they are willing to take that treatment or undertake other steps or follow other advice that you might have in order to protect the public, such as stepping away from work for a while, or maybe if they have early signs of a relapse, maybe limiting their hours or working under direct supervision. There may be other things that you might suggest. If they are willing to follow that advice, if they are engaging in treatment and treatment exists that can treat the condition, then they are all things to consider whether or not there is, in fact, an obligation to make a mandatory notification.
Importantly, there are some exceptions. In Western Australia, treating practitioners are exempted from making mandatory notifications about their patients who might have an impairment, and that has been the case since the inception of the National Law in 2010. Also importantly, registered health practitioners who are employed by Medical Defence Organisations such as MIPS are also exempted from making mandatory notifications, and that is really important as well because of the nature of what we as insurers do. We receive calls from doctors who are concerned about other doctors who might be impaired, or we might receive calls from doctors themselves who are perhaps unwell and unsure about whether or not they need to report themselves to the regulator or what their obligations are in particular circumstances, and in order to ensure that they get the advice that they need fulsomely and fearlessly, it is really important that they have our trust and that we are not under an obligation to notify.
Here is another QR code. So the Ahpra and the medical board have published some guidelines around making mandatory notifications. They are not too long, but they are really clear guidelines that do step through what the obligations are not just in relation to health impairment, but also in relation to the other three examples of notifiable conduct, and they are really clear and do give some worked examples as well, and in my view make it clear that there are many circumstances in which despite a practitioner perhaps being unwell, they may not necessarily be impaired or as I previously mentioned, if they are accepting of treatment, then a notification is not required. If you have the time, I know we are all time poor, but I would urge anyone who is interested to have a have a quick look at these guidelines. In terms of what an impairment is. I have sort of touched on this before. The National Law does define an impairment as a physical or mental impairment disability condition or disorder, including substance abuse or dependence that detrimentally affects the practitioner's capacity to practice. It is really important. That is an important definition because it is not the same as having a medical condition. Sometimes we get calls from doctors who perhaps, I am just thinking of an example, pulling an example that comes to mind, perhaps a doctor working in an emergency department who has just treated a doctor who had who is intoxicated, for example, they are not at work. It is on the weekend. They are on annual leave, perhaps and they are intoxicated or a GP who sees a patient for the first time who happens to be a physiotherapist who has depression, and although they have a diagnosable medical condition, it does not mean that they have an impairment. To have an impairment, it has to detrimentally or potentially detrimentally affect their capacity to practice, and in the case of mandatory reporting, there must be a substantial risk of harm to the public as well. It is not just having an impairment, but it is also having there must also be this substantial risk of harm to the public when we are talking about mandatory reporting. Then there are various court decisions that talk about what are some examples of medical conditions that are impairments, and you can imagine often things like bipolar disorder, schizophrenia, dementia, but also there are some cases where a doctor or a health practitioner does not have to have a diagnosable medical condition in order for there to be an impairment. It could be a severe personality disorder, or perhaps a personality trait. They are unusual in extreme circumstances, but by and large, the issue is whether or not there is an impairment rather than whether or not, there is a just a diagnosable medical condition. As I talked about before that you have to form a reasonable belief, and as I have said, mandatory reporting is a serious step, and there must be some foundation for the belief and there must be some serious concern about a substantial risk of harm to the public and importantly as well, and this will come up in some of the cases, it is really important that mandatory reporting is when there is a current or future risk to the public, not just based on something that has happened in the past. Even though past behaviour can often be an indicator of future risk, the requirement is for there to be a current or future risk of harm, and again, I will get to this in some of the examples. In terms of reasonable belief what does it mean, well there must be more than a mere suspicion. It must be based on direct knowledge or observation of the behaviour. This is more in relation to other types of notifiable conduct, and mere speculation, rumours, gossip or innuendo are not enough to form a reasonable belief. In the case of an impairment, if you hear that somebody else is unwell, but you cannot see any sign of that, then as a colleague, you would not be under an obligation to report. It must be something that you are aware of, so maybe the person themselves has told you something or you have observed something that that gives rise to a concern, and again, this will become clearer hopefully in the cases that are to follow.
What I want to do really briefly next is just touch on some of my PhD research. I do not want to take up your valuable time by talking all about what I have done in my research, but I did just want to touch on it because I think it is really important. We have talked about what the obligations are, what the legal obligations are to make a mandatory notification, but the idea of mandatory notification is controversial. I think whilst the medical board and Ahpra and the regulators would say that mandatory reporting is really important to make sure that we protect the public, others, particularly in the case of treating doctors who are treating a health practitioner who has an impairment, many would say that it actually interferes with the therapeutic relationship and can create fear on the part of the unwell doctor, and that that fear might prevent them from coming forward and getting the help that they need. This is really what I looked at as part of my PhD. One of the things that I observed having worked in medical defence insurance now for nearly 15 years is there really is a connection between doctor's health and the risk of medicolegal claims arising, and it is bidirectional. I have seen doctors who have had long illustrious careers where they have really never had any major complaints or claims against them. They are highly regarded, highly respected in their field. They might have been leaders in their field, and then all of a sudden, they seem to get a cluster of claims and complaints against them and not just relating to one incident, but like a series of incidents and a series of patient interactions, and then when you get to know the doctor through helping them with their claims and complaints, you come to understand that often something is not going right for them in their personal lives, and that may be a factor that is contributing to these claims. It might be perhaps a relationship breakdown or perhaps they have suffered a recent family bereavement, or perhaps they are suffering or demonstrating early signs of a cognitive decline, and the poor health is often an underlying factor when it comes to medicolegal claims and complaints, but then also thinking about it the other way around. It is incredibly stressful to be the subject of a medicolegal claim. There is a lot of research out there that shows just the impact that having a claim can have on doctors. There was a large UK study that was a questionnaire that was sent to 7000 doctors as was about ten years ago now this study. It went to 7000 doctors in the UK and they essentially asked a whole series of questions about how the doctor was feeling before and after they had a claim and it showed that having a medicolegal claim doubled a doctor's risk of depression, anxiety and suicidal ideation and that lasted for up to two years after the claim finalised. There are a few really important things to think about with all of this. It is not a positive finding, but I guess it is really important, not only for any of you, if you do have a claim or a complaint against you, just to make sure that you are surrounded by supports. There are supports available, not just medical defence organisations, but also other support services as well. There is doctor's health programs, there is medical benevolent societies, all sorts of other services that can support doctors who are going through the stress of a medicolegal claim, but also if you know of somebody else who is going through that process, you as a colleague can reach out to them and help as well, and I think in particular for GPs. GPs are ideally placed to help their colleagues and to understand the pressures of medical practice, particularly rural practice, and we know from the Beyond Blue Survey that I presented before that rural practitioners are at a higher risk of some of the health challenges that I have outlined before from the complexity of the work, the long working hours perhaps less supports available than in other parts of the country. Some interesting things to think about, but the whole idea of mandatory reporting does raise this kind of balancing act. On the one hand, there is this idea that it is important to protect the public. On the other hand, if regulation is too draconian and causes so much distress to doctors that doctors leave the profession, then how is that good for the public? How is that protecting the public when there are workforce shortages? My research was looking at how do regulators get this balance right. One of the things that I did was that I interviewed some doctors who had gone through a regulatory process relating to their health. Some of the questions that I was interested in asking is "What impact does that have on these doctors that are going through these processes? Does it help them get access to healthcare? Do they experience delays in accessing healthcare? Are they more likely to relapse following a stressful regulatory process? Does their illness last longer? What impact does it have on on their ultimate health outcomes being going through these processes?" I interviewed 25 doctors in all, six GPs who were experiencing health issues and two GPs who treated other doctors who were experiencing health challenges. I will not go through all of what I found and what I did and everything that participants told me. What I found really interesting was, one of the things I explored with these doctors who were going through these regulatory processes was "Why do you think you became so unwell? In many cases, these doctors had perhaps chronic health challenges where perhaps they had had symptoms in the past, and they knew for some time that things were not right and that they were getting more and more unwell. Despite that, they kept working and thought that things might pass, but then unfortunately, things got worse for them and they eventually either were the subject of a mandatory notification or ended up coming to the attention of a regulator anyway. What they told me primarily was that there was this fear of being reported. Many denied that they that they had a problem at first. Many talked about the stigma of being a doctor who was unwell and just not feeling safe being able to speak up either to their colleagues or to another doctor or to their employer, which really fits in with what the Beyond Blue survey said in terms of these ongoing stigmatising attitudes within the profession. Many had financial concerns as well. They were concerned that if they took time off from work in order to get well, then how would they pay the mortgage? How would they pay the school fees? Others talked about perhaps a commitment to their patients, and if they had to take time off work, even if they were not functioning 100% themselves anyway, who would care for their patients, if they had to take time off. Some really real and personal challenges here were raised. What I found was that for many doctors, they said that they delayed or avoided accessing healthcare. Primarily this was related to fear of some of the financial implications or regulatory implications. As a result, their health deteriorated. Looking back on their experience, many said that "well, then when I did go through the process, it meant that I finally got access to the treatment that I really needed, and I really wish that I had been able to get that help and support sooner. Given that the process was lengthy or stressful, many said that if they had to do it again, they would try and do it anonymously if they could or that they would go overseas and try and seek help overseas, which bespoke a fear of and lack of trust in the process. I know what I am talking about sounds very negative, but what I am really keen to try and focus on tonight is to talk about the important role that GPs can play in making a difference. One of the most important ways that GPs can make a difference for their patients who might be doctors or for their colleagues who might be unwell is to really understand that mandatory reporting is a serious step. Most of the time it is not necessary. Most of the time there are other ways to intervene that mean that you can be assured that the public is not at risk and therefore that there is no need to make a mandatory notification because as my research demonstrated, making a notification can have a significant impact on the doctor concerned. Let us finally get on to some cases because this is really where some of these ideas and concepts really start to come together. Before I do that though, I am just wondering, Dimitri, do we have any questions in the chat so far?
Dimitri
We actually do not, Owen.
Dr Owen Bradfield
Great. All right. Well, I will keep going then. Please, if anyone does have any questions about anything, do not hesitate to just pop those in the chat and we have got 25 minutes left. Hopefully, it will not take that long to get through all of these cases, and we will give us a couple of moments at the end just to go through any questions that anyone has. These cases are all made up. They are all bits and pieces of different scenarios that I have come across over the years. Apologies in advance. Some of them do perhaps come across as a little bit overly simplistic and intentionally I have left out details for a couple of reasons, but one is to try and indicate that very often when we receive a call from a doctor about "what do I do now?" Often there is more information that that you can gather or steps that you can take to intervene before a decision needs to be made about mandatory reporting. This is the first case that I wanted to talk about. Again, it is a little bit extreme and made up, but if you are a rural GP and you notice that one of the other doctors at the clinic at which you work, they have started coming to work smelling of alcohol and you have noticed it, perhaps reception staff or other staff have noticed that over the last couple of weeks. Then one morning you notice that they are arriving in the morning for work. They are parking the car. They seem to be having difficulty parking the car, and when they get out of the car, maybe they are a bit unsteady on their feet. They take a gulp of liquid from a bottle, put the bottle in the bin. You then go over and inspect and see that it is an empty vodka bottle. You are wondering we have got a problem here. We have got a doctor that is coming to work, possibly been coming to work intoxicated. We do not know. They have just arrived and it is maybe 8.45 and they are about to see their first patient at 9 o'clock. What do you do in this situation? Do you have to make a mandatory notification? The reason I have raised this here is because there are lots of what ifs and this is only the beginning of the story. What you do next might determine whether or not there is an obligation to make a notification. In the first instance, as a colleague and perhaps as a doctor, you may share patients with this other doctor. You have a perhaps a professional obligation, certainly not a legal obligation, but as a professional courtesy, you should confront the doctor to find out what is happening and maybe explain what you have observed because there is an opportunity for them to go home. If you tell them what you have observed, tell them that you are very concerned that you have noticed that they have not been seeming quite right the last few weeks, that they have been smelling of alcohol. You were not sure if it was alcohol or not, but this morning you have seen them coming to work, you have seen the bottle. You are putting all these pieces of evidence together that points to perhaps they have a drinking problem. That is a very, very difficult conversation to have with a colleague. It might not be a conversation that you have with that colleague on your own. If you have that conversation with the doctor and they might then say, "look, things have been really tough recently. I did not know it was that obvious, but look, I am going to go home". You might have a conversation with them about the need for them to see a GP. You might say "look, I am going to cancel your patients for today. I will get the receptionist to cancel all your patients and we will get you to go home". Hopefully not driving home. Maybe call a taxi for them or maybe somebody else can drive them home if they feel safe to do so. There are many ways. That is a very challenging situation for any GP to have to manage when it comes to a colleague and possibly a colleague that you have had a close working relationship with over a long, long period of time. That is probably a better approach than allowing them to start seeing patients, for something bad to happen to a patient, for you to then have to ask yourself why you did not intervene or to have to make a mandatory notification against a colleague with whom you have had that long working relationship. The reason I have raised this this case is to draw out the fact that if you did not intervene and they then proceeded to see patients and you were concerned, okay they are now seeing patients. They are putting the public at risk. This is notifiable conduct. That would not be incorrect. That would be a correct interpretation of the law. The point I am trying to make is that as a GP, as a colleague, you do have an opportunity to intervene. Depending on how that intervention goes, whether you are assured that the doctor is going to go home, that they are going to get help and support from their GP, then there may not be a need to make a mandatory notification. Then the really common question that arises in this circumstance is okay, they go home, somebody drives them home, maybe they go home in a taxi and they tell me they are going to go and see their GP. What if they do not? How do I how do I know that they are not going to work somewhere else without me knowing or do something else that might put the public at risk. There are a lot of what ifs in those situations. What I come back to is what the legal requirement is. The legal requirement is you have to have a reasonable belief that they are placing the public at substantial risk of harm because they practiced whilst impaired. It does not mean that you have to be able to exclude any risk. What it means is you only notify if you have a reasonable belief that they are placing the public at risk of substantial harm. If they return to work the next day, they might be sober the next day, but they might be withdrawing. Depending on how it goes, each situation must be judged on its merits. These are really tricky situations. Often the sorts of situations that we never like to think about that we would ever have to face this situation in relation to a colleague. Again, I come back to ensuring that you also have supports available. In this situation, contact your medical defence organisation for advice. We have probably given advice to other doctors in similar situations in the past, and we can help to talk through what the issues are. What the relevant considerations might be when deciding whether or not there is an obligation to notify because it is very difficult to be objective in these situations and to do it alone. That is the first case.
This is a similar case. Perhaps a little bit easier. It is probably a little bit easier, but again attempts to highlight the same advice as before that often there are ways that you can intervene in these circumstances. A rural GP has recently developed a small tremor in their hand which they attribute to increased stress. They consult their own GP that might be you about the tremor and tell them that they are very anxious of it impacting on their work, and so they have decided to stop performing procedures for a while. In this situation, it seems as though they have got insight into the problem. They recognise that there is an issue. They recognise that something is going on and it needs further investigating. They recognise that it is impacting on their ability to safely perform procedures. On the face of it, they are doing the right things. Although they might have a diagnosis and although the tremor might be impairing their ability to safely practice, there is no requirement there to make a mandatory notification because they may have operated in the past with the tremor and that may have put the public at some risk. As I have said before, it is about whether or not there is a current or future risk. They have identified the problem and they voluntarily stepped back from performing procedures. Now, of course, like any situation and as GPs, you would be well aware of this that there can be nuances, there may be other diagnoses. Although they think it might be due to stress, there might be something else going on. It might be a neurological condition, for example, but the tremor could be due to substance withdrawals, for example. This is unlikely, but again, just things to think about. In that situation, is it enough that they step back from just performing procedures or could they also be putting the public at risk even if they consult with patients, even when they do not perform procedures because they might be withdrawing. There are always nuances, but I think in a case like this, primarily this case is here to demonstrate that even if a doctor has a medical condition or a symptom and even if that condition or symptom impairs their ability to safely practice, if it seems as though they have demonstrated insight and they have taken steps or you have recommended steps that they can take to protect the public, then there is no need for a mandatory notification in those circumstances.
Moving on to case 3. Again, as a rural GP, you have started to consult with the medical students and the medical students on a long-term placement in the rural clinical school. The first time you see them, you get a history from them and they tell you that they have a history of ADHD and borderline personality disorder. Perhaps they come back some weeks or months later and tell you that they are enjoying the work. They are very excited to be doing their clinical rotations, but they are facing some difficulties with the work. We have had calls in this situation to our medicolegal advisory service where doctors are unsure because the medical student has got diagnosed medical conditions and then say they are having challenges and then perhaps the GP becomes very worried about mandatory reporting and what the obligations are and is not sure whether they have to make a notification. Again, this case is designed to demonstrate that really you need more information in order to be anywhere close to saying that you have to make a mandatory notification in this situation. If for example, they had schizophrenia, and if they were saying that they were hearing voices or they were experiencing other psychotic symptoms, then that is kind of slightly different because in that situation, those symptoms may have the effect of impairing their memory or their judgement or their insight or sometimes their ability to make reasoned or reasonable decisions which can put the public at risk even at an early stage. It is important to really try and get a good thorough history and the decision about whether or not the requirements for mandatory reporting are met, whether there is a reasonable belief, whether there is substantial risk of harm. All of those factors require a good thorough history and to figure out what do they mean when they say that they are having some difficulties? It might be that they are having difficulties with a particular consultant in the hospital that they are finding it really difficult to work with or maybe there is a personality clash or something like that. Again, just to highlight the point that it is really important to a) understand what the obligations are, but b) to make sure that you have enough information to be able to figure out whether those criteria apply in given circumstances.
This is a much longer case. Again it is a variation on a similar theme. This is the last case. I will just read it out, so we can all be clear. Trevor is a 54-year-old GP in a rural community. He has got a past history of alcohol and substance abuse and major depression following the death of his wife. He has previously misused prescription opioids for over three years. Back then he had obtained opioids by either self-prescribing or prescribing for family members, and then taking their scripts to different pharmacies and using the medication for himself. This was eventually reported to APRA by one of the pharmacists. This all occurred about 10 years ago. He was put on conditions. APRA imposed conditions on his registration. He had to have regular urine drug screening and was not allowed to prescribe certain medications, including opioids. He complied with all of those conditions, got himself well again, was in sustained remission and cut his hours back at work. He identified that he was struggling. Poor work-life balance, recent bereavement, a whole host of factors had contributed to all of this. He stepped back from work and managed to sort things out and was back practising without any restrictions on his registration. This is all in the past. He then comes into the emergency department one evening. It is a small rural hospital. You know him. He might work at your clinic or maybe there are only two clinics in town, so you know him. There is only a handful of GPs. Maybe he has seen you in the past once or twice. You are familiar with all of this that has happened in the distant past. He comes in tonight because he has been to a wedding, so say his daughter has recently got married, for example. He has had a few drinks and he has fallen over and cut himself. He has got a laceration. He has come into the emergency department. Somebody else at the wedding has brought him in, and you are there to assess that and to suture him. You want to know more about what is happening. Was it just tonight that he was drinking or has this been a regular thing? He is too intoxicated and sleeps through most of the suture repair. From what you can gather, he was not at work. It was a wedding and he is not due at work until later the following week. This is a really complex situation. Again, there would be situations where some doctors would and have made a mandatory notification in this setting where a doctor presents to the emergency department, perhaps with a diagnosis. I have certainly known of doctors who have been admitted to a psychiatric unit, for example. Upon discharge from the psychiatric unit, they have been reported to the medical board, and it is not apparent why because the doctor who was being discharged had no intention of returning to work until they were better. In this situation, again, I raise it as more perhaps a vignette to consider because it raises a number of questions. Obviously, if what happened on the Saturday night at the wedding is part of a pattern and the doctor concerned is relapsing. They have got an alcohol use disorder that is relapsing. If they do go to work on Tuesday that might be a situation in which they might put the public at risk of harm, but that is not an assessment that you can make on Saturday and certainly not when they are intoxicated and cannot give you a history. In a situation like that, it comes back to the question, "is there a reasonable belief today, tonight, Saturday night that the doctor has an impairment that puts the public at substantial risk of harm?" and in a situation where they are intoxicated but they are not due to return to work for another three or four days, it is hard to see at that point in time with the information we have available right now that there is a substantial risk of harm to the public. Now, of course, when the doctor sobers up the following day, if they are still in the department and if we have information to the contrary then you would need to reassess that at that time. If they were due back at work on Sunday and they had been drinking other than just on the Saturday, and it was an ongoing problem, they turn up at work either intoxicated or withdrawing or impaired and putting the public at risk. Then yes, if you have a reasonable belief and there is substantial harm, then a notification would need to be made. It is always dependent on the circumstances in front of you. As I have said a couple of times, it is about there being a current or future risk of substantial harm. Not based only on a past risk or a past situation where the public may have been put at risk in the past. I might stop talking now. I have been talking for about 58 minutes. Thank you, everyone, for your attention. I might see if there are any questions.
Dimitri
No questions or comments have come through, Owen.
Dr Owen Bradfield
Well, in that case, I will just use the last couple of minutes just to summarise my main points. I have touched on these throughout, but I think I would just like to draw everything together in the last couple of minutes. We always hear, I heard at medical school, we hear where we GP registrars and it is often said, but it is so important and so true that every doctor should have their own GP. Help is available and there are many support services out there. Part 3 of this three-part series will talk in more detail about some of the supports that are available and the other important points as well. If you are a doctor who treats other doctors or you have doctors as patients in your patient list, then I think as GPs, we are ideally placed to understand the challenges that our doctor patients experience. We have first-hand experience of what they are going through, so we can contextualise many of those stresses that are the reality for many doctors. What is most important is to understand and to put in context the mandatory reporting obligations and nine times out of ten, it does not happen, but occasionally I do see situations where doctors do become unsure or anxious about their mandatory reporting obligations and sometimes make notifications in circumstances where it was not required. Although there is nothing unlawful about that and although on one level, I can understand why the doctor would want to do that because there is this obligation and where they are not sure, they think perhaps the safest thing to do is to make a notification and to let a regulator investigate that. That is entirely understandable as well. It is also important to understand that it does have an impact on the doctor concerned. Hopefully, tonight's webinar has helped to put into context what some of those mandatory reporting obligations are and what they mean and importantly, what those thresholds are. Even if you are not treating other doctors who might be unwell, even if you are a colleague, I think it is really important if you come across a doctor who is struggling or you are aware perhaps of a registrar who is struggling, if you are in doubt, reach out. That is a really important motto because many doctors who are going through these experiences themselves of being unwell often feel isolated and professionally stigmatised. Reaching out can certainly help to break down some of those barriers and remember that there is help available. If you are not sure about your mandatory reporting obligations, then you can contact your MDO or you can contact one of the doctors' health advisory services.
Just the very last slide, just another QR code. This link will take you to a website that does set out some of the services that are available to support unwell doctors and also provide other resources in relation to mandatory reporting obligations. Thanks very much, everyone and thanks, Dimitri. Thanks. Happy to hang around if there are any questions. Thanks very much.
Dimitri
Thank you so much. That was great. RACGP Rural would just like to thank our sponsor again, MIPS and also thank everyone for joining us this evening. A reminder to please complete the evaluation that will pop up in a moment when the webinar session closes. It will only take a couple of minutes to complete. Certificates of attendance will become available on your CPD statements within the next few days. If we have any non-RACGP members who have joined us this evening, if you would like a certificate, please email rural@racgp.org.edu. Lastly, part 3 of this series which is Achieving Work-Life Balance, Diversifying a Career in Medicine is scheduled for Thursday, 6 June at 7.30 pm Australian Eastern Standard Time. To register for this free webinar, please click on the link, which I will put in the webinar chat box just now. We do have a whole range of other webinars for the rest of the year, so do not forget to tune in, held on the first Thursday of every month. On that note, I will end the webinar for everyone, so you can all have a wonderful evening. Thank you and good night. Before we do that, we do have a question. There was something that popped up, maybe not. If you could just put it in the chat box or in the Q&A box. The question there "is there a link for those seeking medical help for blood cancers?"
Dr Owen Bradfield
That is a very specific question. The QR code that I provided has a link to General Health Services. There is doctors' health services available in each state and territory. There is also Doctors for Doctors. There is the Rural Health Foundation and peer support services such as Hand in Hand. They offer general advice to doctors. They do not specialise in any particular medical conditions. I am not aware of any services specifically for doctors with haematological malignancies.
Dimitri
Fantastic. If anyone else has got any questions or comments, just feel free to include those in the Q&A or chat box. You can also email any questions or comments that you have and I can forward those over to Owen as well. We have run a little over time this evening. For the second time, around have a great evening and thank you for joining us.