Inside the Medical Council: what every doctor needs to know (Part 2)

Hello and welcome to part two of our podcast series on the role the Medical Council of New South Wales plays in shaping the regulatory system through the perspective of doctors in training. Your host for this podcast is the Medical Director of the Medical Council of New South Wales, Dr Penelope Elix. Dr Elix is once again joined by Dr Saskia Fung, a basic physician trainee at the Royal Prince Alfred Hospital. And Dr Sajj Hedg, a senior radiology registrar based at NIP in hospital. Penelope, that's been great hearing about the complaint's process and how it works. It would be good from a doctor's training perspective to hear what's the way that you've seen it being handled poorly by a doctor and what's the way that's been handled well. And then also to hear a bit about what supports a doctor and trained should lean on during this time. Yeah, absolutely. And to me, it really comes down to your engagement with that complaint's process. So I can think of an example where a doctor in training had a complaint made and the response that came back from the practitioner was really defensive really quick. And you could tell that it was done without any sort of support or advice. So this practitioner wrote back an email response. It hadn't spoken to their indemnity insurer and really kind of deflected the issue that this was a difficult patient. I did everything by the book. There's nothing else that I needed to do here. And it's very hard for the council when you're looking at that or the commission where whatever stage of the assessment process it's up to. Keeping in mind that there are overarching mandate at the medical council is the protection of the public. That's what we're bound by in our legislation. We have to make sure that we ensure public health and safety. And what we're looking for in response is really sort of an idea that the behaviour of that practitioner is in line with practice that's going to make sure the public is safe. If we see a response that says, I didn't do anything wrong, leave me alone. That doesn't help us know that they're not going to be like that with another patient tomorrow or the next day or the next day. And so in that situation, that's a type of response that might encourage a referral of a complaint to council and further that process through the council's sort of performance arm because we just don't have that reassurance that the practice is safe. On the flip side, we'll have a complaint, say for example, like the one that I mentioned before around a practitioner who was a pediatric patient in an emergency department, thought they'd done the job right, but the parents had felt dismissed. The particular response on those on that sort of complaint where that practitioner had said, I was quite surprised by this complaint. I thought it had gone well, but I can see it didn't. I've actually had a chat with my insurer about this. They very commended a course in communication, which I've done. Here it is. And I'm really stopping and pausing now to consider how my communication is landing with a patient and their family. Great. That's a really reflective response and that's the idea is to the reflection. It's the inside and it's that change to practice that can assure us. Insights and changes to practice definitely is the way that we want people to engage with this process. I mean, Penelope, you mentioned that the indemnity insurance or your medical indemnity is a good person or place to reach out to for support in the process. And it sounds like they can give some advice on courses or things that you could do before your response about the complaint, but are there any other organizations or people that we can reach out to for support if we were to be in the situation because I can imagine that it would be incredibly stressful. And Sandra, I think you mentioned isolating. Yeah, I agree. And I think upper and the medical board have done a nice job on this and we maybe can link this to the notes for this episode around doctors sharing their complaint story because you're right. It's really isolating no one wants to talk about it. And for that reason, it's something that often people hold on their own. I'd sort of break down supports into kind of two parts. And one is the supports that you might look for personally and one is the supports that you might look for professionally because I think professionally, two things that I would really recommend. First is actually looking to whoever your management support is, right? So within your team, sharing that with your registrar or your JMO unit or something like that to kind of say, look, this is what's happened. And if you've got any support for me or any kind of ideas for me, it's probably a useful thing to do. But I think the best place for all practitioners is to lean on their medical indemnity insurer. And it's not a relationship that a lot of doctors in training have very firm in that early stage is that because often as an intern, you sort of joined up to a lot of the insurers because it's free and you don't have anything to do with them. But you're a member of their services and they know this system inside out. So the minute that a complaint gets made, I would encourage all doctors, even doctors in training to put that call into their insurer and say, this is what's happened. What do I do? They'll be able to help you with responses. They'll be able to talk about courses. They'll be able to sort of show this is the type of thing that the regulators are going to look favourably with and really sort of help you do that. And that shows that you've showed that level of insight to actually go and get some advice. As you get on in your training, there's always your first point of call. That's what you pay them for. So definitely, definitely lean on their support. They're very, very clever people. When it comes to those personal supports, though, like we said, that kind of isolating experience, we always encourage practitioners to seek some support for them. From people around them. And it's people that you trust, right? So for some people, that might be their family. It might be a close group of friends. It might be someone at work. It might be someone outside of work, but just sharing some of it with someone else is a helpful strategy. But if you haven't got that person or you need something stronger, there's a series of support services that are available to medical practitioners and to medical students, including the doctor's health, New South Wales and the medical benevolent association in New South Wales and ACT that can provide that kind of psychosocial support direction towards other services, financial services, things like that. If that's an issue that can really be very helpful. And again, they know this system inside out. They're going to know exactly where you're up to and know what sort of help might be needed. So now, if you have, I think we've talked a lot about complaints that can arise in the work environment. But are there situations outside of the work environment that can lead to complaints being pushing, for example, how we interact with social media or our behaviour outside of work? Yeah, absolutely. That's a really important point, Susky, because I think when people think about complaints, we often think about people complaining about how I do my job. And the regulators reach, expands beyond that and your behaviour outside of the practice might still come up in the form of a complaint or some sort of regulatory process. And social media is a good example of that at the moment, where we do get complaints. And this is probably a place where perhaps doctors in training might be a bit more overrepresented in terms of complaints that come out of post that were made on social media or comments or responses that were made to other things happening in social media that attract the regulators attention. I'm interested to hear what your initial thoughts are on the use of social media by doctors in training and what sort of concerns might be facing our doctors in training in this space. So I think two things that come to mind straight away is posting photos and comments about your work environment. I think these days social media is quite all encompassing and you feel like you need to sort of show your life and what your life is about. And a lot of our time is at work. And I think sometimes you can be influenced by, you've got access to people in other countries that are posting things and things like that and you know, get the idea that maybe it's okay to be posting things when clearly it's not because it can violate patient privacy. And the other thing is that I think we use social media a lot to help our cells and our colleagues. So a lot of us have got Facebook groups that we join that are communities of doctors that can help each other and provide comments. But I guess sometimes you can forget that these groups, people can take photos of comments that you post on here, things like that and that's nothing that you post is ever completely private in these groups. Hmm. I think, yeah, you've touched on a couple of really good points there and you're exactly right. First and foremost, you are always bound by your patient privacy and confidentiality rules. And I think we do get posts that do sort of, you know, have little screen grabs of a discharge summary of something that someone thought was funny, but there might have been something in the background of that shot or some way to identify a patient from the material that was posted and that's always going to come up against a bit of a hard line, you know, patient privacy and confidentiality is a legal obligation. There's no getting around that. So definitely encourage people to be really careful. And it goes into those kind of groups where we're seeking support from our kind of network there. And again, making just making being really mindful of what information you disclose and whether it is identifiable. You've also captured that idea of nothing is truly private and we get a lot of complaints that come through screenshots of something that's since been deleted. Some sort of comment that's been taken out of context because you don't have the thread that went above it to kind of explain what your comment meant and it's very easy and enticing for certain people to sort of raise complaints in that nature. So my advice would be understand your obligations. We've got a couple of bits of guidance that will come to you in terms of social media. The first is just knowing what your employer obligations are with social media. And as if you are an employee of a local health district, for example, there's probably a social media policy that you need to be adhering to. It's your job to know what that is. So understand what those obligations are. But more broadly, the Medical Board of Australia as the National Regulatory Body for Medical Practitioners sets out expectations in terms of professional standards. And the Medical Board of Australia via ARPA has a series of social media guidance documents that set out what is and is not likely to attract further regulatory attention. I really encourage people to have a read of that. And we can put a link in the show night for that resource. So that people just as I said, maintain awareness of what your obligations are in this space. So I suppose the other aspect of your life outside of your job, one we've sort of spoken about social media as a kind of conduct issue, where I'd really like to take this conversation to wrap up is around your health and the idea of health and impairment. Because I think Sunja, you touched on at that concern about mandatory notifications still is very present. I'm interested to hear from the two of you. What sort of things you hear from your colleagues in terms of worries about health and where the regulator may or may not need to be involved. I think there are a lot of myths and concerns about this space all the way from medical school through to training as a doctor. I can remember when I was a medical student being told, don't go to your GP, don't get a mental health care plan, because the diagnosis on that mental health care plan will follow you throughout the rest of your career in your ARPA registration. And so there was a discouragement to actually go and seek help if you needed it. And this myth that if you had anxiety or you had depression as a diagnosis on your record that that would follow you through the rest of your career. Yeah, definitely heard that. And I think even expanding that into physical elements, I think there's a real culture of downplaying physical elements as well, or trying to cover them up, because even though it might be seen as something that people would understand and you could get help with, I guess even in this day and age, seen as more of an issue than mental health, even though it's not, I think that you don't want to be the burden on your team and having to go to appointments during work, having to tell the team that you can't do certain things because of a physical element. You've really worried that's going to impact your job now and into the future. Hmm. Look, it's one of those messages that tries we might in terms of destigmatising this issue. It always breaks my heart to hear it, said the way that you just said at Saskia. I'm a GP, like I've said, and it's one of the best consultations you can ever have with a patient is an open conversation around their anxiety, their depression, and how you get people to engage with that care, and improve their wellbeing and their functioning in their workplace, be it a doctor or anything else, we really have to keep pushing hard with this message around the importance of seeking care and looking after yourself as doctors because what we do is difficult, it's stressful. We carry a lot of information about patients and their own stresses and difficult times that without seeking that support and without seeking that care, it definitely can have a long-term impact. Is it true that if we have a diagnosis of anxiety or depression that that would affect our registration or our practice in any way? No, is the short answer in terms of that idea of following, you know, a diagnosis or a label following you is not something that we would ever know about. The issue around health comes down to a term that we use in our legislation called impairment, and impairment is a specific term in the legislation that is defined to mean a health condition that is or is likely to detrimentally affect your ability to practice or engage in study for a medical student. So for the council to take any action regarding someone's health, it means that we need to sort of assure ourselves that the health issue that's been raised meets that definition. And so you can come up with a series of questions when we start thinking about health conditions then to figure out, look, is this something that would be an impairment? And most of the time the answer is no. So the way that we look at it is what is the health condition, right? Is this a condition that is likely to impact someone's insight or their judgment? And for those conditions, we're really looking at conditions that impact that space. So things like quite serious mental health conditions, you know, things where people's insight might be impaired, psychotic episodes, serious sort of manic episodes with a bipolar diagnosis, drug and alcohol, use disorders, obviously can impact that. But your run of the meal, depression or anxiety is very rarely going to impact your insight or your judgment. The next question we then usually ask is, well, what's the person doing about this health issue? And are they engaging with their treating team? And this is the crux of this issue. It's the very fact that you go to your GP to say, I'm having a bit of trouble with this, is the piece of information that assures us that we're not sort of talking about an impairment? Because a practitioner who's going to their GP, putting their hand up and saying, I'm having a hard time, I think I need to see a psychologist or I want to talk about antidepressants or whatever support they might need or I need some time off, can I have a medical certificate? That is a marker of good judgment, good insight and good engagement with the health system. And all of those things, if this came to us in a notification, the council would say, oh, well, that's all kind of ticked off. It would be very unlikely that that would ever meet, the threshold for that definition of impairment. And if it doesn't, the council can't take any further action on it. Now, you can appreciate there are obviously conditions where that's not going to be the case. And I've run through a couple of them there where if we've got a more serious condition that's really sort of impacting someone's ability to be safe at work, then we do need to look at that sort of a notification more closely. And the way we generally do that is to obtain some independent information about that person's health by requiring them to have a health assessment. And if there is a conclusion that that person might have an impairment, that then they undergo another process with us at the council called a hearing and impaired registrants panel, where they're given a chance to go through what's going on, what the health issues are, what the likely impact on their practice is going to be. And there's anything further that need to happen in terms of putting some safeguards in place for that practitioner. So, Penalpi, that's really reassuring, I think, for Dr. Zun Training. I guess the burning question that they have will be if I go with feelings of anxiety or depression to my GP, will their mandatory report me? Managing notifications are clearly an anxiety point for a lot of practitioners. The requirements for mandatory notifications are quite specific in terms of the component you're talking about is whether or not a person might have an impairment or are presenting to work intoxicated. If other those things are being met, there is a mandatory obligation from a treating practitioner to make a notification. But hopefully, rewinding back through that impairment definition, it's not very common that you're going to reach that threshold. Now, you occasionally get a treating practitioner who's unsure and doesn't know what they should do and might err on the side of caution and make a notification. If it's a mandatory notification or any other type of notification, the same process follows. We seek information, we can obtain one of those independent health assessments and we go through that same process. So, the mandatory notification in itself is not a magic tick. That's it. It's all over. We still go through that same assessment process to find out a little bit more about what's happening. So, I'd really encourage doctors in training to really think through the benefits of seeking care against a very small chance of a problem presenting that might reach a threshold for notification needing to be made. But to be assured by the fact that any notifications that are made are dealt with sensitively and information gathered before any decisions are made. Now, what we know, though, is prevention is always better than cure. So, I'm interested to hear from both of you. What you think might be good steps to take in terms of avoiding getting to the point where your health might become an issue for a notification. You mentioned it before, actually. I think the culture is shifting in terms of looking after ourselves from a mental health point of view. And the mere fact that we could go to a GP and ask for a mental health day off work, it's not something that you often validate yourself. That is a good enough excuse. You know, I got enough reason to take a day off work, is that you're struggling with your mental health as opposed to you've got the flu or you've got COVID or something where you might not hesitate to go get a medical certificate. So, I think that's a fencing. We can just remind ourselves that it's important to recognise if we need time off work and ask for it. Yeah, absolutely because this is that idea of self-care, right? And fitting your own oxygen mask first, you know, the same kind of rule applies. We have to look after ourselves. It's an absolute necessity and I'm not discharging. counting the stresses that are placed on doctors in training and that wanting to make sure you're not letting your team down. But we know that when you intervene early and take some time off and look after yourself, it's when you don't do that that things can compound, isn't it? Yeah, this has been asked me quite a few times now by junior colleagues and I think over the years from hearing about from other senior colleagues gone through but also just reflecting on what's happened to yourself and there are definitely times that I've had that anxiety at work and not wanting to come in and not knowing what to do about that right because you just feel like I can't handle another day in this workplace. And I think touching what Susuke said is about having a good GP. Now all GP's are good GPs. What I mean is having a GP you can relate to and feel comfortable confiding in. I think that's really important because they can just help you in so many ways that you haven't thought about. And I think we're so prone to wanting to treat ourselves and be like, well, I'm a doctor I should know what to do in the scenario, but having another doctor provide that objective advice to you and ways that you didn't even think about that could help is really important. The other things are so simple stuff that we give advice to our patients sleep. I think sleep is really important. And that's the one thing that goes, you're studying for exams, you're anxious about something, you're staying up two o'clock in the morning trying to distract yourself but just getting that good sleep is really important, eating well and finally having friends and that life outside medicine. And I'm glad we live in a day and age that that's encouraged, right? We're not beholden to just staying at the hospital the whole time, work like balance is important and we should encourage ourselves and our colleagues to really embrace that. Very well said. I think it's worth fostering a relationship with a GP and it's not always the first person that you see that you're going to be the one for you and actually shop around, find a GP that suits you. But also remember that if you're not sure, there are other services available. So AMA runs a list of doctors for doctors, people that are happy to see doctor patients. Don't forget about employee assistance programs. You've got access to a lot of these in hospital networks. And again, those two sort of health services was their sort of in place for more of a crisis service, doctors health news, health whales and medical benevolent association. It's often a good first call if someone's stuck and you're not sure. That's often a good call as confidential services that you can get a bit of idea of where to go next. So, in wrapping up, can I hear from you both, what are your key takeaways from today? Sanjay. I think one thing that really stuck with me is the points that you made, Penelope, about what you can do to engage in the complaint. The natural thing of being defensive and thinking that you've done perfect practice. It's probably not the way to go. Engaging with the process, reflecting on it, getting in contact with the MDO early, that really stuck with me. I think for me, it's that last point that we touched on the importance of looking after yourself. And actually, from today's conversation, I think we've realised that that can help you to prevent getting a complaint in the first place. So, yeah, exactly as we were talking about taking that time to put your own oxygen mask on before fitting others. Thank you so much, Saskia and Sanjay. This has been a really productive conversation and I think I've learnt a lot from the insights that you've raised in the issues regarding regulation that face doctors in training. I really hope that the comments that we've made and the conversation that we've had is helpful to you and your colleagues. So thank you for coming in today, Dr Saskia Fung. Thanks so much, Penelope. I've just finished Nightshift, so I think I might go home and have a nap and look after myself. And Dr Sanjay Hettich. Thanks very much for now, a big great to talk. I'm Penelope Elex, Medical Director of the Medical Council of New South Wales. Thanks for listening. You've been listening to our two-part podcast series on the role of the Medical Council of New South Wales plays in shaping the regulatory system through the perspective of doctors in training. For further information, you can access various resources in the description box located right here on your podcast player. Or you can contact the Medical Council of New South Wales via their website, mcnsw.org.au. [Music] This podcast was recorded on the land of the Gadigal people of the Aeorination. The Medical Council of New South Wales acknowledges the traditional custodians of the country throughout Australia and their continuing connection to lands, waters and communities. We pay our respects to Aboriginal and Torres Strait Islander cultures and elders past and present.