CONTENTS:

ABSTRACT

Background:

Doctors are at risk of developing distinct patterns of mental health problems and they have a reduced likelihood of obtaining early and optimal treatment for them. These problems stem from vulnerability factors within doctors, unique stressors of medicine causing occupational stress, and factors that relate to the culture of the medical community, impinging upon the therapeutic relationship between the doctor and treating psychiatrist. Addressing the mental health problems of doctors thus needs to be considered separately from that of the general population. An Internet Web site resource on doctor's mental health has been developed as part of a prevention, early intervention and education program launched by the NSW Doctors' Mental Health Implementation Committee.

Aim:

This paper discusses the conceptualisation, planning and development of an Internet Web site as a mental health resource for doctors. As such, it explores the ethical, cultural, economic, practical and political issues that shaped the resource. The author's role, the role of psychiatrists and future directions are also considered.

Method:

The Web site resource was designed to meet the objectives of the implementation program. The benefits and limitations of the Internet as a medium to disseminate this information is examined, as are its uses in medicine, psychiatry and as a tool for distributing best practice protocols. The local and international contexts are described as the resource was developed to compliment and augment existent organisational structures. A qualitative Web review of doctors' mental health resources currently on the Internet was undertaken. The author's roles within the NSW Doctors' Mental Health Implementation Committee and the Medical Benevolent Association of NSW are examined. Also discussed are the ethical issues of developing an Internet Web site about the sensitive topic of doctors' mental health problems, and the compromise solutions advanced to resolve them. Questions for the psychiatric profession to consider, regarding its role in optimising prevention and service delivery for the medical community, are raised. The technical details and practical process of constructing the Web site are outlined in the Appendix, which may be useful to those embarking on developing a medical Web site.

Results:

The Web site was developed by the author. Certain design and content decisions were made in response to concerns that were raised about the use of the Internet as a new technology in the implementation program. The issues of concern related to stigma, ethical dilemmas, and general misconceptions about using a Web site as part of a campaign to reduce the morbidity and mortality of mental disorder in doctors. The future methodology for undertaking outcome evaluation of the strategies and resource are explored.

Conclusion:

The Internet is a form of telemedicine that should be utilised and trialed to assist the medical community to implement the doctors’ mental health program developed by the Implementation Committee. This will launch the next stage of self-regulatory reform of doctors' mental health problems, focusing on education, prevention and early intervention. The resource should be monitored and evaluated to ensure it is being used discerningly.

INTRODUCTION

The NSW Doctors' Mental Health Implementation Committee was established in December 1997 as part of a campaign to reduce the morbidity and mortality of stress and mental disorder within the medical profession, which had been recommended by a precursor Working Group. To accomplish this, the committee recruited a wide range of medical representatives from the medical community in New South Wales. These members collaborated on the development of a policy statement that detailed prevention and early intervention strategies for doctors' mental health problems. Separate strategies were also developed, which targeted major medical groups in NSW. The objective of the campaign was to implement these strategies by encouraging groups of doctors to tailor them into individualised programs across the state. In June 1998, the author joined the NSW Doctors' Mental Health Implementation Committee as the representative of an industrial organisation of doctors. In July 1998 the author was also invited to join the Medical Benevolent Association of NSW (MBA), a charitable organisation that assists doctors in need of practical and financial support.

1. To launch a program of self-regulatory reform addressing doctors' mental health.
2. To refine the recommendations into a program of policies and strategic guidelines, through collaboration and consultation.
3. To find a balanced position with regard to focusing on mental disorders, occupational stress, prevention and early-intervention strategies.
4. To assist in the development of state-wide doctors' mental health programs by consulting with key groups within the medical community. This may develop into a nation-wide program in the future.
5. To encourage the medical community to accept ownership of the campaign.
6. To promote ongoing cooperation and integration amongst the network of regulatory organisations.

The author offered to develop a Web site resource to help achieve the Implementation Committee's aims, because it was an information system that had features permitting access to an evolving information base. The author established the project as a joint venture between the NSW Doctors' Mental Health Implementation Committee and the MBA. As a result of this project, my roles within the two committees expanded.

1. To publish the strategic guidelines so that they would be accessible to a wider audience. Policy makers will have access to readily available online sources of information, which they may incorporate and implement into local programs. The process may promote cooperation, familiarity and bonding between the network of regulatory organisations.
2. To disseminate educational, research and organisational information, including treatment referral sources. This may promote further data collection and research into prevention and response measures.
3. To promote referral of impaired doctors and medical students so they may gain access to treatment at early stages.
4. To establish a platform which could be used to house accessory educational resources in the future.

The dissertation discusses why the Web site resource was conceptualised and how it was considered to be of potential benefit to the medical community. Ethical issues arose in the course of the project regarding the desirability of merging sensitive information with a new information/communications technology. This discussion was part of the larger issue of how the medical community can deal with the increasing symbiosis between medicine and information/communications technologies, which is expected to grow even stronger. The future implications, options and opportunities for the resource are likely to be shaped by technological and ethical factors. The dissertation qualitatively reviews the process of applying the Internet, as an information system, to assist in implementing strategic policies, guidelines and resource materials developed by the Implementation Committee.

1. To describe the fundamental issues related to doctors’ mental health, which generated the need for the campaign and resource.
2. To discuss how the goals of the campaign, information developed for the Web site resource, and the Web site itself (listed above), were addressed. This includes demonstrating how the information system was conceived, planned and developed, with the view to structure the process of implementation, improving the reliability, efficiency and consistency of the process.
3. To discuss how ethical, cultural, economic, practical and political issues shaped the resource. To identify the limitations and predict potential problems of the resource related to these issues.
4. To discuss how the resource ‘fits’ into the existing organisational structures within the local and international contexts.
5. To consider the future of the resource—how it should be monitored and evaluated.
6. To consider the role of psychiatrists with regard to the issue of doctors’ mental health. This involves considering my role in the development of this resource, the current role of psychiatrists, and questions regarding possible future directions.

The aims of this qualitative review is limited to the rationale for establishing the resource, choosing the information system, reviewing both organisational and Internet based resources, and the methodology of developing the resource through the committee work. In regard to the content of the policy and strategies, it is beyond the scope of this dissertation to discuss how they were developed.

The actual Web site is located at the uniform resource locator (URL): <URL:http://www.mbansw.org> or <URL:http://www.dmh.org.au> (being acquired).

International & local contexts

International context

The local environment would be expected to be more influential than the global one on the development of the resource. But reciprocity would be expected due to its widespread accessibility in the broader context of the international medical community. The resource would be accessible worldwide and a design assumption was that the strategic guidelines were templates that should evolve into local programs following their access by medical organisations situated anywhere, although NSW, of course, was the focus. The ‘impaired physician movement’ has been a global Western phenomenon and much of the literature on the subject was non-Australian. Thus the overseas response to the issue of doctors’ mental health problems sets the resource in a broader context.  

North America

The ‘impaired physician movement’ began in the United States (US) following a conference on the topic by the American Medical  Association. The US Disabled Doctors Act 1974 instituted mandatory reporting, evaluation and treatment of impaired practitioners¹. Since the 1970s, the American focus has been on substance abuse and to a lesser extent depression². State physician heath programs were developed in every American state³. The essential components of these programs include comprehensive medical and psychiatric assessment and treatment, and active long-term follow-up. The approach was coercive, with practitioners usually removed from practice and required to undergo periods of inpatient treatment. Treatment outcomes have been shown to be superior to those for the general population, with rates of reinstatement usually quoted above 90%⁴. The focus has shifted to rehabilitation in the last decade. The Federation of State Physician Health Programs was established in 1990, which provided a national forum for education, information exchange and the development of common objectives. A unified intake data collection system is being devised⁵.

Preventative programs have been introduced at an undergraduate level in some US universities that focus on the dangers of drug abuse, the recognition of early warning signs of impairment, stress management, developing better coping skills and problem solving. There have been reports of confidential peer assistance programs run by medical students, support services established by psychiatrists, and informal seminars on mental health and substance use⁴.

Physicians with an interest in the management of impaired doctors have assembled on 14 occasions at the International Conference on Physician Health between 1975-98. These meetings provided opportunities for discourse, collaboration and research. The most recent conference took place in Canada in 1998. There were 300 delegates, mainly from Canada and the United States. Five doctors from Australia attended, including the Chair of the NSW Doctors' Mental Health Implementation Committee, Dr Anthony Williams, to obtain an overseas perspective. Traditional topics addressed in these conferences include substance abuse, depression and impairment in trainees. Recent trends involve deliberating on the health of female doctors, boundary issues, doctors’ quality of life and well being, the effects of healthcare system changes (such as ‘managed care’) and behavioural problems. There has been recent interest in so-called "disruptive behaviour", referring to unprofessional conduct not directly related to medical treatment. This may include sexual harassment of employees or patients, abusive language, threats and intimidation².

The Canadian Medical Association's Policy Summary on Physician Health and Well-being was launched at the 1998 International Conference⁶. Many of the issues in the document were similar to those of the subsequently developed NSW Doctors’ Mental Health Policy, reflecting a similar health system in both countries. Both adopted a broad definition of mental health. The consultation process used was also similar, being conducted with medical schools, Colleges, Area Health Services and other professional associations. Groups of doctors with special needs were identified as female doctors, minority groups, and those practising in rural, remote and under-serviced areas.

In contrast to the American method, treatment programs arising in Britain, Canada and Australia over the past twenty years have attempted to adopt a less coercive approach. The aim has been to retain impaired practitioners in practice wherever possible, within a framework of treatment, support, monitoring and follow-up. A recent development has been the establishment of confidential referral services for impaired practitioners that operate independently of the registration bodies.

United Kingdom (UK)

A recent development in the United Kingdom is the concerted effort by the medical profession and the National Health Service to concentrate efforts on ensuring local arrangements are instituted to contain and manage doctors’ problems where they arise. The term ‘local self regulation’ has been used to embrace the policies and arrangements used by doctors at their place of work, in their locality, and within their specialties to maintain standards of practice and address dysfunctional practice. The goal is to create a mutually supportive environment that helps to maintain the clinical effectiveness and integrity of the team. If team-based attempts at remediation fail to resolve the problem, colleagues of the impaired doctor may be less hesitant about obtaining external assistance. The Medical (Professional Performance) Act 1995 gave the General Medical Council the powers to investigate a doctor’s performance and, where it finds the standard of performance to be seriously deficient, to impose conditions on or suspend the doctor’s registration⁷.  

Review of local resources

Investigating the available organisational resources guided the development of the Web site resource so that it might promote the continued collaboration that was occurring between the local organisations. During the evolution of the Web site, it became clear that it might maintain the binding together of the key players in the network of organisations. Thus, obtaining an understanding of the history, politics, legalities, recipient profiles, organisational philosophy and methodology of each of the organisations dealing with impaired doctors appeared pertinent to the resource’s development.  

Network of local self-regulatory organisations

‘Local self regulation’ was a phrase used by the General Medical Council (UK) to espouse the approach of maintaining standards of practice by creating mutually supportive environments by doctors at their workplaces, locality and within their craft groups⁷.  

The Medical Benevolent Association of NSW (MBA)

The MBA, founded in 1896, assists medical practitioners and their families with financial and social work assistance. It is financed by donations from the medical community. The social worker is the first point of contact and reports to council members at monthly council meetings, where a plan of assistance is formulated. The members have access to personalised folders that contain historical summaries about the recipients and are not permitted to leave the premises.

The Doctors’ Health Advisory Service (NSW) (DHAS)

The DHAS is an independent, collegiate service that offers professional medical assistance to doctors, dentists, veterinary surgeons and students. It may be approached directly by medical practitioners and students, or by their colleagues, family members, and members of the public. The Service began operating in 1981 following a conjoint meeting between the Australian Medical Association (AMA) and the MBA. It offers a 24-hour telephone service providing advice and referrals. Incoming calls are referred to a member of a panel of experienced general practitioners who either manage the caller themselves or refer on to a member of the specialist panel. If a call is received from a person other than the doctor, the referral is discussed by two or more members of the Management Committee and checked for validity. There are often associated financial difficulties and referrals may be made to the MBA social worker.

United Medical Protection

This medical defence union is an indemnity provider that defends doctors in civil complaints and incidents referred to the Medical Board or Health Care Complaints Commission. It is a mutual, non-profit organisation providing occurrence-based discretionary cover. The organisation resulted from a merger of four defence unions in 1998. The membership totalled 33,000 Australian doctors at the beginning of 1999 and there is a medical council whose role is to facilitate communication with the members.

Three goals have been recently developed as part of a program of preventative strategies, by the organisation’s Risk Management Department. This refers to "the identification, investigation, analysis and evaluation of risks and the selection of…methods of…reducing identifiable risks"⁸. Firstly, profiling high-risk practitioners may allow specific strategies to be developed to reduce the risks. To do this, a database was developed to monitor and analyse claims and incidents, such as disciplinary and legal proceedings. The second goal was the development of strategic alliances with the Colleges and professional associations for information and resource exchange. Thirdly, for the development of a peer review process and best practice standards, the instigation of seminars, workshops, publications and a Web site was planned. The Web site’s objective was to update members regarding medicolegal issues and to disseminate an up-to-date calender of presentations and workshops⁹.

For members distressed by potential litigation or a disciplinary hearing, the Risk Management Department coordinates referral to one or a number of services^8,10. Selected members of the organisation’s medical board have agreed to act as informal supports. A "buddy" system was developed so that peers from a similar area of medicine who had faced similar circumstances in the past could provide support. A direct referral to the DHAS and/or MBA is available. An educative information booklet was developed titled ‘Coping with the Stress of Litigation or Disciplinary Hearings’¹¹. It describes common reactions to a complaint and provides sensible advice on how to cope, presented in a goal-oriented manner. It gives permission to feel grieved, angry and temporarily disconcerted. It advises doctors to obtain support from family, colleagues and professionals. The doctor is advised to maintain regular contact with a general practitioner to monitor their health and obtain support. 

The Australian Salaried Medical Officers’ Federation (ASMOF)

ASMOF is a registered industrial organisation representing senior medical practitioners employed in public hospitals in NSW. The Federation’s membership was in excess of 1,500 in NSW and 5,500 nationally. In 1998, it covered psychiatry registrars, career medical officers and staff specialists. Under the guidance of the medical council, industrial officers provide industrial and legal advice, represent members in the Industrial Relations Court and on committees related to the Industrial Award, occupational health and safety issues and health policy issues. The organisation addresses the occupational stress factors purported to play a role in adversely affecting doctors’ mental health and well being.

In cases of impaired doctors, industrial officers have served in advocacy roles, mediating with employers to ensure the doctor is not discriminated against. Industrial officers may accompany members to Impaired Registrant Panel hearings. This has permitted a formal framework to be put into place to enable the doctor to continue working in approved duties whilst being monitored¹². Doctors may be more open to the advice of their own advocates, which is why these organisations may play a key role in impaired doctors’ triage to routes of assistance, whilst providing support and sentry for their occupational and financial interests.  

The Australian Medical Association, NSW Branch (AMA)

The AMA, NSW Branch, provides ongoing financial assistance to the DHAS and administrative resources to the MBA. It has a nominee on the Medical Board’s committee. There are many senior members who occupy roles in other medical organisations, which enables a free exchange of information and awareness about relevant issues affecting the medical communities. Issues regarding doctors’ mental health, such as the progress of the Implementation Committee have been reported in AMA publications. The AMA Safe Hours Project involved the development of a National Code of Practice for Hours of Work, Shiftwork and Rostering for Hospital Doctors, implemented as a voluntary code¹³. The project began at the same time the Doctors’ Mental Health Working Group report was commissioned, having also been precipitated by the deaths of a number of young doctors. The comprehensive literature review did not determine conclusive evidence of any direct relationship between extended hours of work and mental health problems. There was a finding of disruption to quality of sleep, task performance due to fatigue, and dislocation of family and social life that may cause pressure on relationships and stress. There were also findings of adverse effects on gastrointestinal, cardiovascular and endocrine systems¹³.  

Official local regulatory organisations

The NSW Medical Board

The NSW Medical Board is an independent regulatory body that oversees the registration of medical practitioners and medical students in NSW. It may receive complaints about medical practitioners from members of the public, the medical profession or the Health Care Complaints Commission. The Board’s primary responsibility is to protect the community from below standard levels of medical practice.

 The Impaired Doctors’ Program

A process was developed to separate matters of impairment from those of professional misconduct. Prior to 1992, the Board operated under the Medical Practitioners’ Act 1938, which only provided for disciplining doctors. During the late 1980s, an informal program was developed where impaired doctors undertook voluntary monitoring. This program evolved into the Impaired Doctors’ Program, embodied in the Medical Practice Act 1992¹⁴. The new Act introduced student registration, enabling the Board to disseminate information about the Program and to provide early intervention for impaired students.

Doctors referred to the Impaired Registrants Panel have the opportunity to address their problem in a cooperative fashion. The doctor may be required to undergo a medical examination by a Board-nominated psychiatrist and/or physician. The usual outcome is that the doctor agrees to enter a rehabilitation program, during which the Panel places conditions on their registration. Structured management plans are devised with clear guidelines, end-points, feedback and review, in a treatment-oriented context. Where the problem has involved the abuse of drugs, routine urine drug screening will be required. The doctor continues to be reviewed by a Board-nominated specialist. The roles of the psychiatrist are to assess new referrals to help separate health from disciplinary matters, recommend further action, monitor progress, approve changes to the treatment plan and perform periodic reports.

The program was a revolutionary approach. It was rapid, non-punitive and relatively non-coercive. It usually resulted in the doctor remaining in practice and undergoing treatment. The overseeing role of the Board psychiatrist and use of an independent assessor and treater permitted transparency and minimised conflict-of-interest or bias. The program resulted in fewer cases being managed by disciplinary means (the Professional Standards Committee) and led to increased self-notifications and reports from colleagues.

The Panel receives 100-110 referrals per year (0.25% of the total number of doctors registered to practice in NSW). In 1994, 54% of referrals were for self-administration of drugs, 35% for mental disorders, usually depression, 10% had alcohol problems and 1% physical impairments. In 1996, the numbers referred for drug abuse had decreased to 41%, alcohol increased to 17%, mental disorders remained stable and physical impairments increased to 5%, being mainly HIV, dementia and Parkinson’s disease^4,15. In 1997, of those identified as impaired, 13% were in their twenties, 63% in their thirties and forties, and 24% over fifty years old. Psychiatric disorders were the major cause of impairment amongst doctors in their twenties. Those between thirty and fifty years old displayed a high prevalence of mental illness and drug self-administration. The over fifty years old were more likely to suffer from alcohol abuse. There was a significant input by psychiatrists in the development and implementation of this program, which has been successful with doctors suffering from mood disorders, substance abuse and those with anxious and dependent personalities. It has been less successful in those with borderline, antisocial and paranoid personality disorders, especially if there is comorbid substance abuse¹⁶.

Proposed Performance Review Program

The Board submitted a proposal¹⁷ to introduce a third tier in the system — a Performance Review Program, to respond to under-performing doctors with a deficient standard of practice, but who are not suffering from a mental disorder or misconduct. The model is an educational and remediation based one, developed in liaison with medical organisations in the local self-regulatory network, including the Colleges. The proposal appears to resemble the United Kingdom’s Medical (Professional Performance) Act 1995, which gave the General Medical Council the powers to investigate a doctor for deficient standards of practice.  

The Health Care Complaints Commission (HCCC)

This independent statutory body, dealing with complaints from consumers against health practitioners, was established in 1994 under the Health Care Complaints Act 1993. The Complaints Unit of the NSW Health Department previously performed its function. The main purpose of its establishment was to provide a clear and easily accessible route for the resolution of complaints to facilitate the maintenance of high standards of health services in NSW. There have been a number of criticisms of the HCCC by the medical community. A common complaint is that there are frequently delays in the Commission’s investigation of complaints. There appears to be minimal consideration given to the doctor. Many believe that the Commission pursues investigations with an unjustifiable zeal. Finally, there is concern because the HCCC has attempted to expand its powers, to take a more proactive role in the prosecution of doctors. The organisation plays an indirect role in the triage of doctors with mental health problems as it determines whether consumers appear to have a case against a doctor. It investigates consumers’ complaints and may present cases to the Medical Board. However, the HCCC did not have a representative on the Implementation Committee.^10,12,18

The Pharmaceutical Services Branch, NSW Health Department

The Pharmaceutical Services Branch of the NSW Health Department is responsible for administering the Poisons Act 1966, which has a Regulation stating that a practitioner may lose their authority to prescribe, administer and dispense opioids if they are discovered self-administrating for non-medical purposes. The approach tends to be non-punitive when the doctor agrees to relinquish authority and seek treatment. Withdrawal of drug authority does not automatically effect registration status, thereby allowing an individual to continue in practice whilst undergoing voluntary treatment⁴.

Web review of existent doctors’ mental health Internet resources

Rationale for Web review

A Web review of existing Internet resources relating to doctors’ mental health was conducted as part of the literature search, to determine the nature and content of such resources, and to assist in determining the effective structural features for the proposed Web site. The work of the Implementation Committee and envisaged features of its proposed resource could complement or augment existing Internet resources.

Method of conducting Web review

‘Search engines’ were used to hunt for relevant Web sites already in existence on the Internet. These online software programs searched for key words on Web pages. When a search engine finds pages that match a search request, it presents brief descriptions and hyperlinks to the sites¹⁹, ranked in order of relevancy according to how closely the matches resemble the search criteria²⁰. Key words used to conduct the search were doctors’ mental health; impaired, stressed and addicted doctors, practitioners and physicians, in various combinations. The alternative method was ‘surfing’ or ‘casual browsing’²⁰. Local search engines were available on some Web sites specialising in indexing medical information. These were directories of medical sites, focusing on providing links to other resources, rather than providing clinical information themselves²¹. An advantage of manually created directories is the ability to include an annotation describing the resource—a rudimentary form of peer review²⁰. ‘Links’ pages—indexed lists of hyperlinks—were smaller directories found within the Web sites of principal medical organisations.

Results of Web review

Only three sites were found specifically dealing with doctors’ mental health. Three sites were identified that contained archives of organisational activities that related to doctors’ mental health. There were also relevant journal articles that had been reproduced or listed online. There was a low success rate using search engines, which produced high numbers of sites discussing mental disorders.

Physicians Guide to the Internet

Located within this site was Physician Lifestyle, an informative site containing three doctors’ mental health resources. Physician Health and Well Being contained advice about coping with stress. It contained articles from two conferences in 1993 and 1994, the latter being the third International Conference on Physician Health, ‘Stress: The Profession, the Family and You’, held in Canada. The other conference was held by the Society for Professional Well Being, a local support group. Stress and Burnout Hotline was a resource that contained an e-mail posting ‘advice column’. A psychologist responds with counsel to e-mails sent to him from medical practitioners regarding overwork, anxiety and role conflict. Brief e-mail questions and responses were displayed publicly on the Web page. Peer Support.doc was an experimental site established in June 1999. It provides an opportunity for online peer support using anonymous e-mail correspondence. The coordinator was a pioneer of online discussion groups pertinent to psychology. Reasons provided for why physicians might take up the option was anonymity, time constraints and brevity.

Physician Support Program

This Web site matched the anticipated structure that a Web site relating to a local doctors’ mental health program might be expected to use. This was clearly a resource site with the aim of disseminating essential information about its parent organisation to doctors and their families throughout the state of British Columbia in Canada. The model appeared to be a hybrid of the Doctors’ Health Advisory Service (NSW) and the MBA. Its primary purpose appeared to be to distribute its contact help line telephone number, e-mail address, mission and referral details of individuals and groups servicing specific mental health problems, presumably with an interest and experience in treating doctors. It also made available dates of relevant venues and articles of interest. It was oriented towards early intervention and referral. It contained articles with themes such as breaking through denial and ensuring a support structure exists within the local medical communities. There were no prevention or intervention strategies, nor a research component. The site appeared likely to be useful to the local medical community.

The PhysicanWellness Foundation

This Web site was established by a Californian based charitable corporation helping physicians cope with major changes occurring in the American health system. It aimed to promote doctors’ well being through conferences, retreats, support groups and educational self-help materials. The organisation’s Board of Directors (12 members), International Advisory Committee (30 members — predominantly American) and Executive Team (6 members), with biographical sketches, was available online. These contained photographs, academic histories and achievements. Upcoming conferences were listed with access to their programs, times, titles, presenters, abstracts and objectives.

Physician health and well being [Policy Summary]

This Web page was accessible from the Canadian Medical Association Web site, CMA Online. It was an example of a landmark article being published online prior to being published in a peer-review journal. The policy is similar to that of the Implementation Committee’s. It had a preventative emphasis, although with greater leaning towards the role of stress rather than mental disorder. It, too, produced lists of separate recommendations for different subgroups within the local medical community. A full text version of the policy, which contained early intervention strategies, was accessible on the Web site.

Stress and general practice, Royal College of General Practitioners (United Kingdom)

This document was an electronic version of an information sheet titled ‘Stress and General Practice’, produced by the Royal College of General Practitioners (UK). It reported on local British doctors’ mental health program, the Fellowship in Stress and General Practice, which operated between 1995-97. The program appears to have focused entirely on stress, disregarding depression, substance abuse and relationship problems.

Impaired professionals, Isaac Ray Center, Chicago, Illinois

This was a Web page listing publications that had originated from within the parent organisation, regarding the topic of impaired professionals. The Isaac Ray Center is a corporation providing consultation on forensic psychiatric matters, affiliated with the Cook County Jail. The Web page listed the authors, titles and publications containing the 10 articles. No full text online versions, abstracts or descriptions of the articles were available.

Online articles and editorials

Most of the major medical and psychiatric journals are available online in full text for a subscription fee. Most of these have contents pages, abstracts and selected articles archived on Web pages permitting free public access and complex search capabilities. Articles regarding impaired doctors were found in the Medical Journal of Australia, Australian Family Physician, American Journal of Psychiatry and the British Medical Journal sites. Selected articles that were accessed are listed in the references. 

Conclusions drawn from Web review

It was laborious to sift through the vast amounts of information, especially because of the low specificity of the key words, which stifled the ability of most search engines to refine their searches. This experience was concordant with that of others looking for substantiative information on the Net²². The Web sites appeared to be targeting local doctors who were aware of the URL addresses and did not need to conduct a search.

Most of the sites identified in the Web review were a storehouse of static information. Their value lay in their information’s widespread, easy and immediate accessibility (assuming a Web search did not need to be conducted to find the URL). For example, the Physician Health and Well being Policy Summary developed by the Canadian Medical Association and the Fellowship in Stress and General Practice on the Royal College of General Practitioners (UK) Web sites, would not have been available had it not been for their online publication.

Two sites provided contact details for local referral agencies and helpful information about stress management. They were rudimentary, with minimal educational information regarding doctors’ mental health. However, they were easily available to anyone wishing to refer a doctor, gaining access to the information in an anonymous manner. The possible referral sources were indexed alphabetically to assist the user to conduct a triage process if they chose not to use the programs, preferring to reduce the number of colleagues involved. One of the sites provided detailed information on an organisation’s motivational, self-help conferences encouraging peer support activities.

One site attempted to utilise the interactive benefits of the Internet, enabling doctors to anonymously communicate with other clinicians for support and advice, possibly like a telephone help line. However, the quality of the support was uncertain. Obtaining medical advice or therapy over the Internet is controversial because of legal, privacy, security and efficacy concerns.

In contrast to the plethora of information regarding medicine, surgery and mental health, there was a paucity of activity on the Internet pertaining to the mental health of doctors. The meagre quality and quantity of the existent doctors’ mental health Internet resources left open a gap that the Implementation Committee could fill by developing a comprehensive resource reflecting its leading role.

Role of psychiatry

There are questions that have only barely been touched upon in the literature, with regard to how to address the third tier of factors creating a special need for consideration of doctors’ mental health—treatment factors. A number of factors have been identified which inhibit doctors receiving optimal management of their mental disorders. This tier involves doctors’ difficulty in reversing roles to that of patient and factors in psychiatrists. The former requires a paradigm shift by the medical community. The role of psychiatrists could be considered with regard to the resource, the local network of organisations and the medical community.

To encourage incorporation of the strategies and educational messages into existing structures, the entire medical community needed to accept ownership of the campaign and resource. It was important, therefore, that not even psychiatrists claim a special role in its development. There were, however, a number of psychiatrists participating, representing various medical organisations, bringing psychiatric knowledge and skills to the campaign.

Neither the psychiatrist nor the doctor patient is accustomed to the minefield of role complexities. With regard to the medical community, the question was raised whether a selected group of psychiatrists should develop expertise in managing doctors with mental disorders. The growth of subspecialty faculties, sections and special interest groups within psychiatry reflects the usefulness of selecting sub-populations that have special needs for the optimal management of their mental health problems. There needs to be advantages in examining the needs and problems of such sub-populations that are being considered separately²³.

If psychiatrists should subspecialise in treating doctors, this raises the question of what qualifications should they have to treat this group. Forensic expertise would be beneficial because of the familiarity with ethical dilemmas. Drug and alcohol experience would be helpful because substance abuse is the main reason doctors are referred to a regulatory body. Psychiatrists with seniority and past experience treating doctors would have familiarity with the transference and countertransference issues arising in the therapeutic relationship. Affiliation with the Medical Board, Doctors’ Health Advisory Service (DHAS), Medical Benevolent Association (MBA) or medical defence union, may all provide advantages for different reasons, such as having the support of a regulatory organisation’s experience and resources. The access to professionals with knowledge of legislation, for example, may also be of benefit if the doctor will require legal representation. The benefit of collaborative decisions and supervision are also noteworthy.

An issue for consideration is whether there would be benefits from establishing a formal training process, peer review system or special interest group. Confidentiality, relationship with official regulatory organisations, and public versus private sector contexts for management, are related issues. The stress experienced by the treater needs to be heeded. Special-interest peer groups and guidelines regarding quantity of workload and duration of exposure to such work might need consideration. The source of funding of any special training program or support group would need to be established.

With regard to the local network of organisations, it could be considered whether it would be beneficial for psychiatrists to be strategically positioned in medical committees and organisations, where policymakers reside and many doctors from the medical community have contact. Associations of doctors may be ideal opportunities for education regarding optimal responses to impaired colleagues, to improve early identification, triage and intervention of doctors thus encountered. The model is not unlike that of the consultation-liaison model utilised in general hospitals to reduce the morbidity and mortality of high-risk patients.

My experience of the network of organisations indicated that psychiatrists do tend to acquire strategic positions. For example, at the time of writing, there were three psychiatrists and one trainee in the MBA’s council. There were three psychiatrists in the DHAS’s management committee. There was the Board nominated psychiatrist on the Impaired Registrants’ Panel of the NSW Medical Board and a number who provide periodic reports for registrants. There was a position for psychiatric hospital representative on ASMOF’s council. There was a psychiatrist employed as consultant for the medical defence union. The AMA had a number of psychiatrists in leadership roles. Psychiatrists chaired both the Working Group and the Implementation Committee.

The procurement of strategic positions by psychiatrists may have effects on community perceptions. For example, the sizable role of the Board nominated psychiatrist in the state’s official regulatory body may influence the disposition of doctors to refer versus self treat. For example, the swing away from disciplinary models, to medical and educative models, may have cast psychiatrists in a more favourable light and made them appear more approachable by doctors. Alternatively, the effect may have been more negative, casting the psychiatrist as an authoritative figure to be feared.

Fellows and trainees of the Royal Australian and New Zealand College of Psychiatrists should not be exempt from developing their own mental health programs, being a Medical College targeted by specific Strategies. Psychiatrists and trainees, especially females, have been found to have high rates of mental disorder and suicide even within medical populations^24,25,26,27. The inherent conflict-of-interest that arises because a psychiatrist with a mental disorder belongs to the same College to that of his/her likely treater (when required in addition to the doctor’s general practitioner) may provide psychiatrists with an even greater motivation to self treat rather than help seek. Perhaps the special situation of psychiatrists and trainees with mental health problems requires further research and discussion to consider ways of most effectively addressing the problem.

CONCLUSION

Until the last two decades, there had been an inattention to ensuring that members of the medical community obtained the services that they themselves have provided for others. The international literature accentuates a negative profile of doctors’ mental health and a career in medicine. There appear to be three tiers of factors influencing development of mental disorder and the delivery of psychiatric care to impaired doctors.

Firstly, there are factors within doctors. There have been consistent findings of increased stress, marital discord, alcoholism, opiate abuse, depression and death by suicide, accident and cirrhosis in the medical community. There has been a pattern of increased numbers of junior doctors being referred and more substance abuse occurring with opiates rather than solely alcohol. Future research should consider morbidity from mental disorders in doctors that have not been examined in the literature to date. Subgroups of doctors relevant to the Australian context, such as rural doctors, should also be examined. This dissertation, in line with the campaign and resource, focused on addressing the first tier.

There also appear to be unique factors to the practice of medicine that influences the development of stress-related health problems. In Australia, workplace reform may have assisted to reduce depression in the early clinical years, whereas high rates have been a consistent finding in overseas studies. The role of psychiatrists is the third tier because there are complexities and obstacles for both the impaired doctor and the treating doctor regarding the formation of the therapeutic relationship. However, this is an area that clearly requires more attention by the specialty. Appropriate goals and strategies need to be developed.

Official regulatory bodies were established by governments as a means of protecting the public from impaired practitioners. Self-regulatory organisations have been established by the profession, more recently, to encourage early intervention and avoid the trauma involved with disciplinary procedures. The trend has been for the official regulatory bodies to recruit rehabilitative medical models rather than punitive approaches to deal with doctor impairment, in recent years. Associations of doctors in Australia and overseas, especially general practitioners, have begun to take an interest in considering the effects of occupational stress on its members and encourage doctors to take more interest in their own and their colleagues’ health. Coping strategies, peer support and educative approaches have been employed. However, there appears to have remained an evasion to addressing the more serious mental health problems such as depression, substance abuse and suicide.

The self-regulatory organisations have an opportunity to pave the way for a next stage in the evolution of addressing the mental health needs of doctors—that of prevention. The first step in this process is accepting some responsibility for educating the medical community. This requires de-stigmatising and educating the medical community that mental disorder in doctors is a fact.

The Canadian Medical Association developed a policy on physician health and well being in 1998. It was groundbreaking in that no other organisation had developed an organised list of recommendations advising structural and attitudinal changes, whilst leaning towards prevention and early-intervention. It was published online. The NSW Doctors’ Mental Health Implementation Committee has taken a leading role in developing an ambitious, far-reaching program of strategic guidelines, aimed at preventing the development of mental disorder and improving early identification and intervention when they arise in doctors. To implement the guidelines, medical groups targeted by the strategies need to be assisted to incorporate them into their organisational policies and structures. The aim is to enable the development of local self-regulatory doctors’ mental health programs. The Implementation Committee needs to make widely available the evolving information base to assist this process to occur. If successful, the next stage would be the encouragement of a state-wide implementation.

It is becoming increasingly recognised that "the need for ongoing dissemination of information on physician health is essential". In the past, psychoeducation of the medical community was conducted individually by psychiatrists through "workshops and seminars, and modelling by key faculty members"²⁸. Psychiatrists and others have also published increasing numbers of studies on the topic, began teaching undergraduates about doctors’ mental health, and informally ‘migrated’ into strategic positions within medical organisations, where they may be in a position to educate colleagues in administrative roles. The non-clinical vignettes and scenarios that have become part of the Royal Australian and New Zealand College of Psychiatrists’ final examinations perhaps need to be adopted by other Colleges and the undergraduate curriculum. It is ironic that the Internet was not included in the list of dissemination methods, considering it was quoted from a paper presented at the International Conference on Physician Health, where the theme was ‘Managing Our Own Care: Surviving the Health Care Revolution’.

Utilising the Internet for the Doctors’ Mental Health Web site resource was seen as a problem-oriented solution to the challenge of how to promote access to the evolving base of information that was designed to be ongoingly refined and adapted. The online publication model suited this design. However, controversial aspects of the resource were the issues of community privacy and protecting the public from unnecessary anxiety, in view of the Internet developing into a mass medium permitting the public unfettered access to the information. Issues for further consideration are the monitoring, evaluation and future of the resource.

The Internet should be included in the list of methods for the medical community to use in its struggle to redress the imbalance due to the ingrained neglect of its own its mental health problems. The representatives of the medical community considered the resource practicable, possible and desirable. Perhaps utilising the Internet will provide the medical profession with an easily accessible method of adapting to the healthcare revolution, and using the technology for the benefit of the medical community and the population at large.

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This information has been excerpted from my Dissertation: Developing a Doctors’ Mental Health Web Site Resource. NSW, 1999, Royal Australian and New Zealand College of Psychiatrists.

Citation suggestion: Dr Gary Galambos, Doctors Mental Health, RANZCP Dissertation 1999 (http://www.ep.org.au/gg/int/diss.htm) [date accessed]

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