AHPRA has made changes to how it administers mandatory notifications, and the Medical Board say it is educating doctors about the threshold for reporting; but the scheme remains a barrier to doctors seeking mental health help.
The threshold for a mandatory notification to AHPRA is set at a “very high” level, the regulator says, to make prevent healthcare practitioners avoiding care out of fear.
According to the guidelines, a treating practitioner – say, a psychologist – needs to have a reasonable belief that their doctor patient is placing the public at substantial risk of harm by practising with an impairment or intoxication, or that they are significantly departing from professional standards, before they are obliged to make a notification to AHPRA.
Suspicion, speculation, rumours, gossip and innuendo are not grounds to form a reasonable belief; you need direct knowledge.
The only exception is for sexual misconduct related to practice, which has a slightly lower threshold.
But in practice, these standards can be somewhat misunderstood.
Recent research commissioned by AHPRA found 16 health practitioners who were the subject of an investigation or regulatory action had died by suicide over the last four years.
It has since made various changes to the way it handles investigations.
Here’s the story of rural generalist in training Dr Sarah Saunders, who went through two AHPRA investigations in the space of four years as the result of mandatory notifications, as told at the Rural Medicine Australia conference in Tasmania last week.
Notification 1, 2018
Dr Saunders trained in the UK and moved to Australia in early 2018.
Towards the middle of that year she felt herself slipping back into depression, a condition she was first diagnosed as a teen and had been successfully managing for some time.
It was bad enough for her to take a week off work and see a local psychologist, where Dr Saunders discussed fleeting thoughts of self-harm alongside other aspects of her life, like drinking socially during her downtime.
Two days later, her psychologist wrote a mandatory notification to AHPRA with concerns that she was practising with an impairment, due to her depression, and could potentially pose a risk to patients in the emergency department she worked in.
“I remember feeling like it was a big breach of my trust,” Dr Saunders told delegates.
“I felt very sick, very confused.
“I had lots of questions that I didn’t feel I could ask … and I felt very ashamed, for the first time.”
Still being new to the country, Dr Saunders was not aware of all the options open to her, like contacting her medical indemnifier for advice.
The next steps were not clear.
“I have to say that I was incredibly lucky to be working in a really supportive emergency department with really fantastic colleagues,” she said.
“They called AHPRA on my behalf and asked what this meant for me and what I need to do next.
“They were then told at this stage that I was still allowed to work if I wanted to and I felt well enough, but I needed to prepare what they called a submission to the board as my response.”
Less than two weeks after receiving the initial email notification that she was being investigated by AHPRA, Dr Saunders fronted up to a board of five peers and one layperson to deliver her submission in person.
The layperson panel member was not physically present; they phoned in from a neighbouring town.
“I have to say it was very much like an exam in the sense that I didn’t have any reactions from anyone in the room,” Dr Saunders said.
“I didn’t have any direct feedback, but I was told to expect a call within a week … to let me know whether immediate action will be taken.”
The board decided against immediate action, but Dr Saunders would be subject to a continued investigation.
It became invasive.
“When I had started seeing my therapist, I had spoken about drinking socially and a connection had been made [by the psychologist] between having a low mood and then somewhere along the line that I could have been intoxicated at work,” Dr Saunders said.
“I attended a pathology laboratory, where I had a piece of my hair cut out and I was asked to produce a urine sample with the practitioner in the room.
“It’s not something I have experienced before. It [was] humiliating, degrading and I felt like a criminal.”
At that time, AHPRA also required a health assessment from an independent practitioner.
The psychiatrist that Dr Saunders went to see was one member of a panel of available practitioners kept by each state and jurisdiction for this purpose.
Dr Saunders described the setup as “bizarre” – the psychiatrist ran her clinic from her house, with her husband as the receptionist. He used a yellow legal pad to sign Dr Saunders in and out.
“[The psychiatrist] wanted to go right back to my birth – was I preterm? Have I had time in NICU? When did I walk? When did I talk? Did I have friends in primary school? Did I make friends at secondary school? What were my grades like?”
In February 2019, around six months after the initial notification was made, Dr Saunders got a phone call from AHPRA to thank her for her time and let her know that her notification had been closed, no further action taken.
Notification 2, 2021
Dr Saunders joined ACRRM training, moved house, moved job and found a private psychiatrist whom she saw every six months.
In late 2021 she had another, more severe episode of depression.
Even though she took precautions like time off work and multiple medication changes, Dr Saunders was eventually admitted to hospital.
This time, the inpatient psychologist told her he was obliged to make a mandatory notification, but also encouraged her to contact her indemnity provider.
Dr Saunders’ indemnity provider connected her with a lawyer who worked in her state who then dealt with AHPRA on her behalf.
A psychiatric report was required again, but rules had changed, and Dr Saunders was able to elect her own treating practitioner to complete the report.
“That was someone that knew me, they had known me over [a few] years, they could vouch for me,” she said.
“They knew what I was like when I was well, they knew what I was like when I was unwell and they were able to provide a summary without me having to go through an independent health assessment.”
Six months on, in May 2022, Dr Saunders was cleared by AHPRA for a second time, with no further action taken.
This time, she was also asked to give feedback on the process, something she had not been offered in 2019.
Her lawyer had also handled most of the communications the second time around.
“Preparing for this talk, I looked through some of the emails that happened in 2018, and they really were just a string of emails back and forth from me and AHPRA, most of which were me asking them to clarify terms, clarify jargon and asking things that I didn’t understand,” Dr Saunders said.
“In 2021, there were only three emails between me and my lawyer.
“One was at the beginning to tell me about the notification and one was at the end to say that it was finished.”
Life after AHPRA
Now, Dr Saunders tries to make sure that she has at least one colleague in her circle with whom she feels she can be open about her mental health and what she is going through.
“In 2018 I had no idea what I was facing,” she said.
“And I really did feel like the only doctor that was practising with a mental health condition and the only doctor that was going to have a mandatory notification, but it’s simply not the case.
“We are here, we’re working and we do exist. It is my hope that by hearing each other’s stories, by sharing our experiences and by being vulnerable at times, we can arm ourselves with the tools that we need to help our colleagues face AHPRA together.”
Anecdotally speaking, the fear of being subject to a mandatory notification is enough to put a sizeable portion of doctors, medical students and other healthcare practitioners off seeking mental health treatment.
One junior doctor spoke up after Dr Saunders’ talk at RMA23 to say she would like to see it more widely known that up to 85% of all notifications result in no further action. For mandatory notifications the proportion is 65%.
“There are some very strongly held views among the junior doctor cohort about mandatory reporting and the implications of help seeking that result in deaths before help seeking and then during the process itself, so it is quite grave,” she said.
It’s a fear that even prominent clinicians like AMA president Professor Steve Robson, who survived a suicide attempt during his intern year in 1988, have spoken to in the recent past.
“To this day, I can remember the GP’s advice [after I disclosed my suicide attempt],” Professor Robson wrote in 2018: “Under no circumstances tell anybody or see a psychiatrist … if I had a record of suicidality or mental illness, I would never be able to buy income protection or life insurance, and I would probably never get a good job.”
He was also advised not to disclose his prescription for antidepressants, lest he be struck off by the medical board.
Dr Andrew Mulcahy, a Tasmanian anaesthetist and longstanding Medical Board of Australia member, told RMA23 delegates that the board had worked to insert the various guidelines on mandatory reporting into the medical education curriculum.
The idea is that knowing more about the high threshold for a mandatory notification and the low rate of adverse findings would encourage younger doctors to get help when they need it.
OR asked AHPRA for further detail on whether it provides additional education to practitioners who make a mandatory notification without meeting its threshold of evidence, but did not receive a response before deadline.
If this article caused distress or if you are prompted to reach out for support, these services are available:
Doctors4doctors crisis support hotline: 1300 374 377
Lifeline: 13 11 14
Beyond Blue: 1300 22 46 36