The elephant in the consulting room

The article by Forbes et al. (2018) is timely and cites a high prevalence of depression or depressive symptoms in doctors. Beyond Blue data indicates similar rates, with higher rates among females (Beyond Blue, 2013). The authors and Forbes et al. (2018) suggest that frequent exposure to traumatic events, lack of recognition of illness and the lack of consistently available services are factors. Medical practitioners worry about psychiatric diagnoses in themselves and colleagues with over 40% believing that mental health diagnoses imply less competence and are a sign of personal weakness (Beyond Blue, 2013). Suicidal ideation and the risk of suicide attempts are elevated in doctors; more so in female practitioners (Beyond Blue, 2013). Overcoming these barriers is important and the authors make some suggestions (Forbes et al., 2018).

The elephant in the room in the management of doctor’s mental health is mandatory reporting, and the administration of the Health Practitioner National Law (2009) by the Australian Health Practitioners Regulation Agency (AHPRA). The core role of the National Law is to protect the public.

Section 140 of the National Law requires that notification must occur if a practitioner:

1. practised the profession while intoxicated by alcohol or drugs, or

2. engaged in sexual misconduct in connection with their profession, or

3. places the public at risk of substantial harm in their practice because they have an impairment,

4. placed the public at risk of harm during their practice because of a significant departure from professional standards.

The responsibility to report falls on the treating practitioner. In Western Australia, practitioners are not required to make a mandatory notification when they are treating a health practitioner who may meet the criteria above, although there is a professional and ethical obligation to protect and promote public health and safety by voluntary reporting or self-reporting.

When annual registration is renewed, a health practitioner is obliged to report any physical or mental impairment (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect their capacity to practice their profession. These requirements create much anxiety, as usual it is best to make full disclosure on such documents, but there are risks.

Should a mandatory report be made it is important to consider what happens next. The notification will be to a State Medical Board and the investigation of this would initially be conducted by AHPRA (Senate Community Affairs References Committee, 2017). The breach of confidentiality is likely to be considerable as the National Law permits seizure of all documents including case notes. AHPRA may not be forthcoming about document seizure, duration of an investigation and what data is considered without a freedom of information request (Pike, Manager, AHPRA, SA, 2017, RE: Personal communication). The investigation may be devastating for the practitioner, and AHPRA’s performance and methods have been extensively criticised (Senate Community Affairs References Committee, 2017). The negative effects of the legal process of investigation are well described in workers compensation matters (Grant et al., 2014).

Psychiatrists are likely to be involved in treating doctors who could have a mental illness. The practitioner may not place the public at risk of harm, as they have presented for treatment and usually are or can be made aware of the risks of their condition to their practice. Such doctors are likely to be compliant with treatment, take time off, pace their return to work, be aware of early warning signs and have ongoing relationships with their GP and Psychiatrist. However, they may worry that mandatory reporting will occur if they present for treatment. They will also have to consider what to write for their next registration renewal. As the commentary notes, sometimes, doctors prefer to treat themselves for depression (Forbes et al., 2018), which may or may not be successful, and is unwise.

The intersection of public safety and practitioner health is awkward, and the National Law places practitioner health as secondary. This is reasonable, but what is not reasonable is that the methods employed can profoundly jeopardise practitioner health. It is difficult, to reassure the profession that presentation for treatment does not inevitably involve AHPRA. The subsequent processes may exacerbate a mental health problem.

In 2017, a Senate subcommittee considered this issue and concluded ‘This inquiry has revealed that practitioners and notifiers have lost confidence in the AHPRA administered process’. The committee concluded that AHPRA needed to reorient its administration to manage risk and engage and support notifiers and practitioners (Senate Community Affairs Reference Committee, 2017). When treating our colleagues, psychiatrists should be mindful of the above, be active in advocacy around the National Law and its implementation, and seek legal advice to clarify the necessity of reporting.