All medical boards have as their primary objectives
protection of the public; and
maintenance of the highest possible standards of medical care.
The Boards are state-based and constituted under Acts of Parliament. However, they are independent, operating at arm's length from government, and are self-funded through medical registration fees. While it is often stated that the medical profession is self-regulated, the reality is that the profession, community groups, politicians and departments of health all have input into the Acts which the medical boards administer. Therefore, it is probably more accurate to say that the medical profession is self-administered rather than self-regulated.
There is a widespread misconception about medical boards — that they are populated by grey-haired, eminent, elderly men, long retired from their field of medicine. This is most certainly not true of the New South Wales Medical Board, which also recognises the vital importance of community representation: five of the 22 members of the current NSW Board are from non-medical backgrounds.
Registration of medical practitioners (and, in NSW, medical students): The core activity of all boards is the registration of medical practitioners, ensuring that their qualifications meet a required minimum standard. In NSW, medical students are also registered. This came about when the Board recognised that, each year, a number of young doctors coming to the Board's attention because of illness had problems dating back to their student years. The Board recognised that if it could have been involved earlier the transition of these students to the workforce may have been much smoother. Student registration has been in place in NSW since 1992. The only provisions of the NSW Medical Practice Act 1992 that apply to students are those relating to impairment.
Managing poorly performing practitioners: The second domain in which medical boards are active is in managing poorly performing practitioners though a variety of disciplinary and non-disciplinary processes. It is in this area that there is the most variation in the approach of the various medical boards. In NSW, there are 25 000 registered doctors. Every year about 1200 complaints are made against them. Only 20% of these are formally investigated, and less that half of the investigations proceed to a disciplinary hearing. Each year, the NSW Medical Board holds 25–30 Medical Tribunals, with about half these doctors being deregistered. Contrary to popular belief, deregistration is the outcome for only about 1% of doctors about whom complaints are made.
Management of "impaired" practitioners: The third domain, and the most important in the context of this Conference, is the management of "impaired" practitioners. While the definition varies from State to State, a practitioner is generally considered to be impaired if he or she suffers from any physical or mental condition which detrimentally affects, or is likely to detrimentally affect, his or her capacity to practise medicine.
It is important to recognise that doctors and students may be unwell or disabled without being "impaired", according to its statutory definition. Impairment is very specifically related to risk to the public. For example, if a surgeon develops Parkinson's disease and gives up procedural practice, then he or she is clearly unwell, but not impaired. The single most important factor in determining impairment is the practitioner's insight into his or her illness and its effect on practising medicine.
The objective of impairment programs is, like all Board activities, to protect the public. However, a strong secondary objective is to maintain the doctor in safe practice whenever possible.
Doctors: Of the 25 000 registered doctors in NSW, about 130 are currently involved with the Health Program. Half have problems with drugs or alcohol, 40% have a mental illness, and the remaining 10% have other medical problems.
In the drug-dependent group, pethidine is very much the drug of choice because of its ease of access for medical practitioners. Medical students are more likely to use illicit drugs. In NSW, these registrants would be required to undergo an extended period of urine drug screening, along with other Board monitoring and treatment requirements. Other States have different approaches, and it seems that NSW and Queensland require a much longer period of monitoring than other jurisdictions.
Medical students: Of the 25 medical students involved with the NSW health program, 20% have drug or alcohol problems, 70% have a mental illness, and 10% have other conditions, such as motor disability.
There is still uncertainty in the three medical schools in NSW about which students should be referred to the NSW Board, and when. There are two important criteria:
Public protection — is there a risk or a potential risk to the public? An individual with bipolar disorder may pose no risk if the condition is stable, but there is significant potential risk if the individual becomes floridly manic.
The needs of the student — if the student is likely to require support or special consideration in their transition into the medical workforce, then early notification is essential.
The Board does not want to know about every distressed, unwell or disabled student. Clearly, most of these students are not impaired within the Board's definition. However, if the individual has special needs, there is great value in early notification, as the Board needs time to ensure that a suitable internship can be devised.
The NSW Medical Board's approach to impaired students is illustrated by the case study given in the Box.
Notification of both students and doctors requires a shift in culture. The profession is historically reluctant to "dob in a mate", and problems are frequently "swept under the carpet" or poorly managed in "corridor consultations". Some States and Territories have legislated a statutory obligation to notify impaired practitioners to the Board. There are pros and cons to this approach. Of greatest concern is the potential for mandatory notification preventing unwell doctors from seeking treatment.
Internships used to be extremely regimented and prescriptive. In NSW, and I believe in most other jurisdictions, there is now a much more flexible approach. Internships can be individualised in terms of hours, terms, location and duration, provided that the core competencies of internship are achieved. However, flexibility does raise important employment issues. Unimpaired interns have expressed concerns about favouritism and reverse discrimination. In addition, hospitals do not have a limitless capacity to accommodate interns with special needs. In NSW, some hospitals are very good at looking after impaired interns, but it is unfair to overload them.
Medical boards discharge their responsibility for public protection in a variety of ways. The structured, compassionate and fair management of impaired practitioners is an important component of a board's work. The NSW Medical Board has 10 years' experience with student registration, and commends it to other jurisdictions, and to students themselves, as a valuable and mutually beneficial approach.
Case study — a medical student referred to the NSW Medical Board
Dr A was a final-year student when first referred to the Medical Board. He was a mature-age student in an undergraduate program who had been displaying inappropriate behaviour in his clinical terms, and had refused all offers of help by the Faculty. When he was notified by the Faculty, he was in a manic episode of bipolar disorder.
The student was independently assessed by a psychiatrist nominated by the Board and placed in a monitoring program. He had a further manic episode, but it was detected early because of the support structure around him. We were able to intervene rapidly and his condition stabilised quite quickly with treatment. We required him to have a treating psychiatrist, and we had his authorisation for the psychiatrist to let us know if he did not comply with treatment or if his health deteriorated.
He attended for regular review by the Board-nominated psychiatrist and for Board review interviews on a six-monthly basis. On graduation, we notified his employer of his conditions of registration, as it was important that his internship was conducted in an informed and supportive environment. He did very well, and is now in specialist training. (All colleges have stopped denying specialist training to doctors with conditional registration.)
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.