CIVIL FORENSIC PSYCHIATRY-WHITHER OR WITHER?
Civil forensic psychiatry (CFP) is at a crossroads. Either we push for recognition of our work as a subspecialty within psychiatry or the status quo continues with covert and sometimes overt contempt for our choice of work and the further loss of any distinctive professional identity.
This talk is intended to give you my perspective of the current situation. I will highlight particular concerns and suggest some remedies.
In my experience all psychiatrists who do this work have learned by trial and error and have had no formal training. We have had to develop a specific skill set to work in multiple arenas..
OUR FIELDS OF OPERATION
MOTIVATION
Why do we do this work? I can only answer for myself. I like the lack of clinical responsibility. I like hearing stories. I like the detective work of teasing out what has happened. I like the process of compiling an opinion that is based on the data, that is defensible and that is fair. I am comfortable as a witness and this seems to suit my temperament.
The downsides are:
For example the requirement of WorkSafe that IMEs must perform 8 hours of clinical work a week in their field of specialty. This diktat ignores the fact that all colleges require compulsory CPD. This is a much greater indication of competence than eight hours of clinical work!
An enduring problem is the response of our peers to what we do.
PROFESSIONAL DISDAIN
We are the subject of negative views or comments from our peers, from benevolent schemes with regard to our motivation, our integrity and the perception that “you guys are just in it for the money!” as has been said to me. I have also been challenged in court by barristers asking questions like “you’re just a hired gun aren’t you doctor?”
In large part this disdain comes from the view that we have sold out for the dollar. We are perceived to have abandoned our clinical responsibilities.
In my view this is a reflection of the lack of understanding of the work we do and the specific skill set required to do the work. I am proud of the work I do and I believe it requires as much clinical knowledge, professionalism and integrity as any other subspecialty. Indeed, the problem is that others do not recognise or acknowledge that we are a subspecialty. We do not have a recognisable entity that speaks for us and advocates for us.
PROBLEMS GETTING STARTED
Many commence doing the work but find the lack of any training makes it too difficult. They find it too demanding of time and energy and the financial remuneration is vastly overstated considering the time involved. Some also find the possibility of being an expert witness very daunting and move to other areas of practice.
I have noticed a definite pattern over the years. WorkSafe and the TAC become frustrated with the relatively small number of psychiatrists who are IMEs and open up the system only to find that the new entrants are unskilled and cause more difficulty. They leave the system and WorkSafe and the TAC revert to using the small group who were there originally. This situation ebbs and flows as regularly as the moon.
A READY TARGET
Complaints against civil forensic psychiatrists are frequent and distressing to all those practitioners involved. We are ready targets when claimants disagree with our opinion. One has to only look at various websites to see the vitriol expressed about our colleagues and sometimes ourselves. The usual complaints are that we were late, rude, insensitive, we didn’t listen, we saw claimants for only 20 minutes or so, our reports were inaccurate, biased and our opinions were inconsistent with the body of the report.
We have seen that unfounded complaints to the Medical Board lead to so-called peer reviews that are time-consuming and a negative experience.
OUR OWN WORST ENEMIES
All too often I see reports that appear biased. I see reports that are predictable, one particular psychiatrist almost invariably writes “there is no diagnosable psychiatric disorder”.
Recently I came across a psychiatric supplementary report. The psychiatrist had diagnosed post traumatic stress disorder secondary to an industrial accident in which a truck had fallen on its side trapping the driver for some hours and he had sustained a right shoulder injury. Oddly, the psychiatrist considered that the right shoulder injury had partially contributed to the post-traumatic stress disorder!
The psychiatrist had been sent a report from an occupational physician whose opinion was that the right shoulder injury had resolved. The psychiatrist then wrote the following:
I conclude that the claimant’s psychiatric injury is now not materially contributed to by the accident because the psychiatric injury (the post-traumatic stress disorder) was always secondary to physical injury, and if the physical injury has resolved then the psychiatric injury cannot be related to work.
Ombudsman’s report Dec 2019 – WorkSafe management of complex claims
This is a recent report of the Victorian Ombudsman (December 2019). One section is entitled “Oversight of the IME System”. This section commented on:
The report focused on one IME, described as IME Y. This IME is not a psychiatrist, excerpts were provided from three of this IMEs reports to illustrate concerns.
The report then referred to complaints about IMEs and the lack of clarity of WorkSafe in dealing with these complaints. Excerpts were provided from eight reports of which seven were written by psychiatric IMEs. The concerns expressed included:
I have written a response to this report. In particular I considered that the matters referred to suggested a lack of appropriate training rather than deliberate bias and recommended a training program with a didactic component, mentorship and the ability to have supplementary retraining particularly if there have been any concerns expressed about the IME.
In short I noted the following:
THE COHORT OF CIVIL FORENSIC PSYCHIATRISTS
There are small groups of psychiatrists in Sydney, Melbourne, Brisbane, Adelaide, Hobart, Perth and Darwin who do the bulk of this work. Most of them do a good job, taking an adequate history, providing a defensible opinion that is consistent with the data and is written without prejudice or bias.
I think I do a good job, I believe I behave in an ethical manner and the reports I write are comprehensive and fair. However, I am now reaching the end of my professional life and I am concerned about those who come after me. How will they be trained? How will they be acknowledged? What support will they receive from the College?
DEVELOPMENTS
Because of my concerns about the lack of training and because of the inability to source appropriate material that we should be able to have ready access to I decided, in collaboration with Nigel Strauss to develop and implement a training program.
In preparation for the first weekend training session in 2013 I did a good deal of research including editing all the legislation in Australia with regard to workers compensation, motor accidents and personal liability claims together with fee schedules, judges comments about psychiatric evidence amongst other material.
We held the weekend workshop in 2013, despite almost no publicity we had a full house with people coming from as far away as Western Australia and Darwin.
I decided that the material I compiled should not be lost and this led me to establishing the website www.civilforensics.com.au.
I prepared a short book as a sort of primer and decided to charge a fee to join the website to exclude trolls. Since then I have been updating the website by adding resources, publications of interest and I have been writing a blog linked to other material.
Subsequently Nigel and I ran another training session with a similar result. Obviously people who had gone through the training session did not have any formal qualifications arising from it.
In 2018 I was asked to establish a civil forensic psychiatry component to the training course at Swinburne University and with the help of several colleagues, some around this table, we put together a comprehensive outline of such a course. However, nothing happened!
I became concerned that the book I had prepared was both too sketchy, too Victorian orientated and missed out on several important areas of practice. I totally rewrote the book for an Australian and New Zealand audience and the resulting book “The Guide to Civil Psychiatric Assessment” was published in October 2019, it is available from me and also on Amazon.
Dr Jonathan Phillips, a former president of the College and a very experienced forensic psychiatrist reviewed the book and wrote:
This book is a must for young psychiatrists with an interest in forensic matters, and also for mature practitioners of various backgrounds.
Michael Epstein is a vastly experienced psychiatrist, with a long interest in the civil aspects of forensic psychiatry.
He speaks in a simple and engaging way to you the reader, and covers all aspects of civil psychiatric assessment. The work is practical, to the point, up to the moment, and easy to follow.
Michael Epstein has high skills as an educator. He has a wealth of material for every reader.
I strongly recommend the text to you. It will enhance your library.
Dr Nathan Serry, a member of our group also reviewed the book and wrote:
An overdue and valuable resource for all psychiatrists
who undertake civil forensic assessments.
I mention this because although I have run courses and have written a book I have no standing other than being one of you. I believe more is required.
RESEARCH IN OUR FIELD
There is a good deal of research in the areas described above, particularly with regard to workers compensation and transport accident claims. However none of this work appears to have come from any department of psychiatry! The following paper was written by legal academics.
Understanding independent medical assessments – a multi-jurisdictional analysis Environmental Scan
This review examined how compensation bodies use medical assessments including their processes and policy, procurement models and quality assurance. The medical assessment process varies widely among jurisdictions and each approach has its merits and drawbacks. The review identified a number of practices that may improve aspects of the medical assessment process. The review recommended future research directions with the intention to improve medical assessments for compensation bodies, clients and healthcare professionals.
Authors: Kosny, A; Allen, A; Collie, A Date published: June 2013
One study: ‘The Cost of Comorbidity to the Transport Accident Commission Compensation Scheme’ noted that pre-injury mental health service use was associated with increased TAC cost. Other co-morbid factors that increased cost included diabetes, cardiovascular disease, previous surgery in the year before the accident and previous back pain.
Another paper on ‘The Health Effects of Compensation Systems (HECS) Study’ investigated the relationship between stressful claims experiences and long-term recovery after injury among transport accident and workers’ compensation claimants.
The most frequently-reported stressors were
Claimants who reported high levels of claim-related stress were at heightened risk of poor long-term recovery (with higher levels of anxiety, depression and disability).
This type of research is important but here are other areas about which we have particular concerns.
DO WE GROW OR WITHER?
I have a number of concerns about our future.
SEXUAL ABUSE CLAIMS
Sexual abuse claimants requiring assessment have become like a tsunami after the recent royal commission and other investigations.
Most of us find these claims difficult because:
As a result, most psychiatrists limit the number of assessment regarding sexual abuse claims to 2-3 per week and some to only two a month. There are only a small number of female psychiatrists who are prepared to do this work.
I have concerns that if psychiatrists do not meet the need for assessments of these claimants then psychologist may be enlisted with the possibility of a significant reduction in standards.
MEDICAL AGENCIES
There has been an increased tendency for IMEs to do work for medical agencies. There is a subtle pressure from these medical agencies to write reports that are most likely to please their major customers that are the benevolent schemes such as WorkSafe. I am not implying that psychiatrists who work for agencies are biased, I am stating that the key performance indicators of these agencies are not necessarily compatible with our independence.
Many IMEs like this work because they avoid all the pressures of providing supplementary services, office space, clinical responsibility and often have an opportunity to travel interstate.
The downside of that is that we have seen the encroachment of psychiatrists from interstate, often assessing claimants in jurisdictions about which they have little knowledge or expertise. In my view this diminishes the quality of their reports.
The agencies do very well but the IMEs receive a relatively small portion of the fee in return for regular appointments, transcription services and accounting. This tendency to become a contractor to an agency makes us functionaries in a larger system, akin to the role of many general practitioners in large medical clinics. I believe this will have a detrimental effect on our independence and credibility.
RANZCP ISSUES
THE FACULTY OF FORENSIC PSYCHIATRY
For some years some of us have advocated for a Faculty of Forensic Psychiatry. This has proven to be a mistake. The faculty has brought together psychiatrists who work in the criminal justice system with those of us who do civil forensic psychiatry. We have nothing in common. The psychiatrist who work in the criminal justice system are doing clinical work with a particular population group characterised by drug dependence, alcohol abuse, childhood abuse, personality disorders and violence. Civil forensic psychiatry deals with a quite different population. Psychiatrists who have been in normal clinical practice for some years are, in my view, much better equipped to do the work of a civil forensic psychiatrist than those who work in the criminal justice system.
The upshot is that the faculty has been dominated by psychiatrists working in the criminal justice system and civil forensic psychiatry is regarded as the poor cousin. We have no one to advocate for us in various fora.
My concerns about the Faculty were encompassed by a letter I wrote to the head of the Faculty and the President of the College in December 2018. I have received three or four emails from the head of the faculty but no response from the College President.
In that letter I referred to:
A questionnaire was distributed and the definition has been changed but nothing has happened apart from a change in the definition.. The definition of forensic psychiatry is now
Forensic psychiatry is the subspecialty of psychiatry which interfaces with the law.
I have attended the last three forensic faculty conferences and have been dismayed by the small number of presentations relevant to my area and, as a consequence, the small number of civil forensic psychiatrists to attend these conferences. Heaping insult on injury, the conference in Perth was only about criminal justice psychiatry.
CONTINUING PROFESSIONAL DEVELOPMENT¶
I have mixed views about the demand that we must all do CPD annually to retain our registration according to AHPRA but nevertheless this is a reality. My concern is that the CPD process for those of us who do this work is grossly inadequate. It does not seem to reflect the work that we do. It has been developed by the Faculty of Forensic Psychiatry with some limited input from civil forensic psychiatrists.
On 8 February, 2018 I received the following unsolicited email
I just wanted to pass on my thanks to Dr Epstein for his consistently thorough report histories and opinions. I am currently reviewing the matter of (yyyyyyyy) and once again Dr Epstein has provided a really comprehensive report of high quality. Every time I read one of his reports I know I am getting an informed decision regarding a client’s entitlements. If you could pass on my thanks for his consistent professionalism and high quality reports that would be appreciated.
Regards, xxxxxx
Senior Injury Coordinator
Senior Injury Team
Transport Accident Commission
I submitted this to the CPD program. It was rejected as it did not meet the criteria!
QUESTIONS
The lack of training and accreditation and the lack of recognition by the college of this subspecialty has led to problems with recruitment, especially recruitment of women.
When confronted with voluminous documentation, and unwilling interviewee, the demands to provide a timely report with an opinion that may be challenged in court and the prospect of being a witness in court, it is not surprising that a number of psychiatrists look for other areas of practice.
I believe we need a fully accredited training program for psychiatrists who do this work. There is a paucity of training provided by the College for midcareer psychiatrists who are looking to continue in their practice but would like to take on other areas of practice. This is particularly so for those who want to do civil forensic work.
The training program should include a didactic component, mentorship including an opportunity to have reports reviewed informally and the means by which concerns about performance can be addressed.
Those who already do this work should be grandfathered but new entrants should be required to complete a training program.
We also need to facilitate peer review groups to share concerns about issues and to provide support when problems arise such as complaints to AHPRA.
I believe organised training is unlikely to occur within the Faculty of Forensic Psychiatry for the reasons I mentioned above.
I believe that we need to establish a Special Interest Group including psychiatrists in a majority of the other states (a college requirement) and we should be provided with funding by the College to meet and plan a program. Furthermore money paid by us to the Faculty of Forensic Psychiatry should be directed to this Special Interest Group that could be part of the faculty but may have to stand alone.
The Special Interest Group should:
SUMMARY
ACTIONS
We need to acknowledge that we have a unique skill set, over and above what is required in clinical practice. We need to recognise that this unique skill set entitles us to be regarded as a sub-specialty.
As a sub-speciality we must:
How do we bring this about?
The Faculty of Forensic Psychiatry has been unresponsive to all of these concerns.
We need to develop a Special Interest Group that is either part of the faculty of forensic psychiatrists or separate from it (my preference).
The Civil Forensic Psychiatry Special Interest Group) would provide a formal structure to advocate and implement these ideas.
THE ALTERNATIVE
The status quo continues leading to:
I have prepared a comprehensive submission to the draft report of the Productivity Commission on mental health. My concerns were about 9 main issues. Primarily the loss of focus on those with severe mental illness by the discussion about mental health as if it is a single entity, the naive comments about workers compensation, the lack of any detail about recruiting, training and paying for the extra workforce required to implement their recommendations. You can see my response here. The Productivity Commission report overview is here and volume 1 and volume 2 can also be downloaded.
You may be interested to peruse the claims manual prepared by WorkSafe for use by claims agents. It provides comprehensive information about managing claims.
I don’t know about you but I find people with chronic pain, especially those who appear to have had little or no significant pathology very puzzling. As you would know a significant number seem to have experienced childhood sexual abuse or other forms of childhood abuse.
What is extraordinary is the depth of suffering that they experience.
I have been receiving 5 to 6 minute videos from medscape.com for some time. Most recently they have had a 4 part series on pain with titles including
My understanding of chronic pain has improved as a result. You may find them interesting.
Deteriorating performance of the NSW workers’ compensation scheme.
A review of the Nominal Insurer (NI) was commissioned in February 2019 to determine the reasons for deterioration in the NI performance. The final report was released in December 2019.
A report in the Australian Financial Review in September 2019 highlighted the problems.
The sustainability of the NSW workers compensation Nominal Insurer, which insures 3.6 million employees and collects over $2 billion in premiums a year, is in jeopardy according to Peter McCarthy the former workers compensation principal actuarial adviser to the State Insurance Regulatory Authority (SIRA).”I have been advising or working in personal injuries schemes like icare around Australia and overseas for nearly 35 years and I have never seen a scheme deteriorate as much in such a short time frame,” Mr McCarthy told The Australian Financial Review.
In Mr McCarthy’s view, if the scheme went into deficit, employer premiums would have to increase by between 45 and 60 per cent.
In addition to workers compensation, the $36 billion icare also insures builders and homeowners, provides treatment and care to those severely injured on NSW roads and protects over $193 billion of NSW Government assets. Workers compensation accounts for about 50 to 60 per cent of what icare does.
The company’s chief executive John Nagle rejected that the scheme was falling into disrepair.
However Mr McCarthy pointed to icare’s 2018 financial year results, which showed a blowout in the number of impaired premiums.
Impaired premiums increased by over $50 million from the 2017 to 2018 financial year, up from $35 million to $87 million. Further, as of the 2018 financial year there were $226 million in overdue premiums sitting on icare’s books, an increase from $39 million in 2015.
NSW Treasurer Dominic Perrottet said the Labor government had left the state’s workers compensation scheme facing a $4 billion deficit. “We have done the hard yards to repair their damage and provide financial stability, and icare’s board and management have been instrumental in this.”
Concerns over rising costs
Observers concerned with the health of the scheme also point to rising costs. According to a libaility valuation commissioned by icare in 2018 had a $1.3 billion surplus for the scheme. However, two years prior at June 30, 2016, a liability valuation by PwC estimated assets of $17.9 billion and liabilities of $14.6 billion, a surplus of $3.4 billion.
Medical costs for icare had risen by 40 per cent combined over the past four years. Mr Nagle said “we don’t control some medical costs as they are regulated.”
Data from the regulator showed that icare’s medical costs between the 2016 and 2018 financial years increased significantly more than those for specialised and self-insurers, and the Treasury Managed Fund.
icare’s return to work rate, which points to the speed at which injured workers get healthy and back to work, has fallen according to both SIRA data and icare data, although the degree varies. A major problem is that the definition of return to work differs between SIRA and icare.
SIRA has had concerns about whether injured workers were getting the right level of early support to assist in recovery, and whether premiums were being administered in a compliant, transparent and consistent way.
An overview of the executive summary
In 2015 NSW WorkCover was replaced by:
SIRA has had limited ability to enforce guidelines and standards or direct icare.
Icare implemented an ambitious model based on principles of triage, injured worker empowerment and straight through processing in January 2018. There is now one insurance agent for all new claims (EML).
The ambition of the model was matched by the ambition of the timeframe for implementation and the control by icare over EML. This has caused substantial confusion within the market and employers in particular, have complained about the lack of involvement in return to work (RTW) plans and claims verification. The new claims model has led to a significant deterioration in the performance of the NI, through poorer return to work rates, underwriting losses, no competition and therefore, concentration of risk.
The primary driver for the decline is the implementation and operation of the new claims model implemented by icare. icare has implemented a number of improvements to improve the performance of the NI. They have not reversed the decline.
The reviewer noted that an icare Board report shows that 46% of the NI’s claims are non-compliant with the legislation, and that icare considers this non-compliance as a lower order risk. This approach to compliance seems to indicate an absence of concern with regulatory matters.
Concerns were expressed in the submissions about lack of information about premiums, including reasons for marked increases, delayed or no response to queries and a call centre dealing with initial claims contributing to further delays, lack of proactive case management, inconsistent approach and errors, as well as lost paperwork. The outcome of this approach is seen as promoting reactive case management, poor communications and a lack of accountability.
Concerns were expressed about relevant case manager experience and skill levels,as well as a lack of understanding of workers compensation legislation/operations. Inappropriate hiring, inexperience and high staff turnover were all raised as issues. Positive comments were made about the motivations and attitudes of some individual staff
High caseload volume and inadequate resourcing were mentioned as adversely effecting the operation of the scheme. These issues were often connected with other issues of claims model design, communication, delays and RTW outcomes.
The single issue raised most commonly across claims submissions related to communication. The quality, frequency and clarity of communication from the NI and its agents was consistently seen by all stakeholders as an issue to be addressed. These communication issues were viewed as leading to delays, confusion, worse outcomes and increased frustration between participants.
Submissions specifically mentioned experiencing delays in obtaining approval and delaying required or agreed treatment.
The 2019 NI RTW rate has deteriorated to 84% from 93% in 2018 and 96% in 2016.This rate measures the percentage of injured workers who report having returned to work at any time.
The current NI RTW rate measured by a survey has reduced to 73% 83% in the 2018 NI RTWSurvey.
Many complained about the shift to the single scheme agent and the loss of choice and competition within the scheme. This had caused a deterioration in claims management as well as a depletion of the broader pool of experience of claims managers in the NSW workers compensation system.
The Medical Support Panel was thought to be completely unnecessary, creating more delays… The MSP process required multiple levels of internal review at EML, unacceptable MSP responses and further delays which effected the worker’s recovery and the employer’s premium.’
The review did not cover matters around medical treatment in any detail because the pre-eminent concerns raised were about delays to treatment caused by poor claims management. There were some concerns expressed about lack of choice and independent medical examiners, but this was regarded as a result of poor execution rather than an inherent problem with the new claims model.
i have been perusing the Annual Report of the Medical Board of Australia. The data in the report is worth mining. for comparison I have attached similar data regarding psychologists.
Notifications of medical practitioners to the Medical Board of Australia
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Specialty |
ACT |
NSW |
NT |
QLD |
SA |
TAS |
VIC |
WA |
AUST |
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Psychiatrists |
74 |
1174 |
27 |
803 |
310 |
76 |
1106 |
368 |
4027 |
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Population |
426,700 | 8,089.500 | 245,900 | 5,095,100 | 1,751,700 | 534,300 | 6,594,800 | 2,621,700 | 25,364,000 | ||
Ratio |
1:5766 |
1:6890 |
1:9107 |
1:6245 |
1:5650 |
1:7030 |
1:5962 |
1:7124 |
1:6298 |
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Most common type of complaint
| Clinical care | Medication | Communication | Behaviour | Documentation | Other |
| 56.2% | 10.2% | 6.1% | 5.2% | 4.8% | 17.6% |
Sources of Notifications
| Patient, relative or member of the public | Health complaints entity HCE(see below) | Other practitioner | Board’s initiative | Employer | Other |
| 60.5% | 20.7% | 7.7% | 2.0% | 1.8% | 7.3% |
From the AHPRA website
Under the National Law, AHPRA works with health complaints organisations in each state and territory, to decide which organisation should take responsibility for and manage the concern raised about a registered health practitioner. See: www.ahpra.gov.au/Notifications/Further-information/Health-complaints-organisations.aspx
What is a ‘Mandatory Notification’?
According to the Medical Board of Australia website
All registered health practitioners have a professional and ethical obligation to protect and promote public health and safe healthcare.
Health practitioners and their employers, as well as education providers, also have mandatory reporting responsibilities under the National Law.
Education providers, registered health practitioners and their employers must tell us if they have formed a reasonable belief that a registered health practitioner has behaved in a way that constitutes notifiable conduct.
Notifiable conduct by registered health practitioners is defined as:
The threshold for a person or organisation to make a mandatory notification is high. This means they need to have a reasonable belief that a practitioner has behaved in a way that constitutes notifiable conduct and that their belief is based on reasonable grounds.
There are specific exceptions to mandatory reporting for all practitioners in Australia that relate to the circumstances in which the ‘reasonable belief’ is formed, for example in the medico-legal context.
In Western Australia, there is no legal obligation for treating health practitioners to make mandatory notifications (raise concerns) about patients (or clients) who are also health practitioners in one of the regulated health professions.
Comparing this data with that for Psychologists
Psychology board 2018/2019
Most common types of complaints
| Clinical care | Documentation | Confidentiality | Communication | Behaviour | Other |
| 24.7% | 12.7% | 11.0% | 10.7% | 10.3% | 30.7% |
The Medical Board of Australia statistics for the last quarter of 2019 make for interesting reading. In particular workforce distribution, overall ratio psychiatrists vs general population is 1: 5635
The lowest ratio is the ACT with 1:5000, the highest ration is in the Northern Territory 1:8562. The other interesting data is about notifications. Out of a total medical workforce of 119,926 there were 5359 (4.5%) notifications in 2018/2019, of which 27% lead to
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| Speciality name | Field of specialty practice | ACT | NSW | NT | QLD | SA | TAS | VIC | WA | No PPP | Total | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Psychiatry | 74 | 1,174 | 27 | 803 | 310 | 76 | 1,106 | 368 | 89 | 4,027 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Population Ratio psychiatrists vs population |
366,900
1:5000 |
7,317,500
1:6,232 |
231,200
1:8562 |
4,599,400
1:5728 |
1.658.800
1:5,351 |
511,000
1:6724 |
5,640,900
1:5100 |
2.366.900
1:6431 |
22,692,600 1:5635
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Amongst the 5359 notifications
339 were mandatory notifications
234 were notifications re professional standards
169 were complaints against medical practitioners re criminal offences, almost 95% related to title and practice protection
What is a ‘Mandatory Notification’?
According to the Medical Board of Australia website
All registered health practitioners have a professional and ethical obligation to protect and promote public health and safe healthcare.
Health practitioners and their employers, as well as education providers, also have mandatory reporting responsibilities under the National Law.
Education providers, registered health practitioners and their employers must tell us if they have formed a reasonable belief that a registered health practitioner has behaved in a way that constitutes notifiable conduct.
Notifiable conduct by registered health practitioners is defined as:
The threshold for a person or organisation to make a mandatory notification is high. This means they need to have a reasonable belief that a practitioner has behaved in a way that constitutes notifiable conduct and that their belief is based on reasonable grounds.
There are specific exceptions to mandatory reporting for all practitioners in Australia that relate to the circumstances in which the ‘reasonable belief’ is formed, for example in the medico-legal context.
In Western Australia, there is no legal obligation for treating health practitioners to make mandatory notifications (raise concerns) about patients (or clients) who are also health practitioners in one of the regulated health professions.
On 170 occasions immediate action was taken by the Medical Board to restrict or suspend the registration of a medical practitioner as an interim measure.
Of the 1446, 5.8% conditions on registration = 84
3.6% caution or reprimand = 52
0.5% cancellation or suspension of registration = 7 (0.005% of all medical practitioners)
Comparing this data with that for Psychologists
| Speciality name | Field of specialty practice | ACT | NSW | NT | QLD | SA | TAS | VIC | WA | No PPP | Total |
| PSYCHIATRY | 74 | 1174 | 27 | 803 | 310 | 76 | 1106 | 368 | 89 | 4027 |
Psychology board 2018/2019 statistics
Most common types of complaints
| Clinical care | Documentation | Confidentiality | Communication | Behaviour | Other |
| 24.7% | 12.7% | 11.0% | 10.7% | 10.3% | 30.7% |
The draft report from the Productivity Commission is a comprehensive overview of mental health issues in Australia. I have selected some sections relevant to civil psychiatry. However first a few general comments.
• In any year, approximately one in five Australians experiences mental ill-health. While most people manage their health themselves, many who do seek treatment are not receiving the level of care necessary. As a result, too many people suffer additional preventable physical and mental distress, relationship breakdown, stigma, and loss of life satisfaction and opportunities.
• The treatment of mental illness has been tacked on to a health system that has been largely designed around the characteristics of physical illness. But in contrast to many physical health conditions mental illness tends to first emerge in younger people (75% of those who develop mental illness, first experience mental ill-health before the age of 25 years) raising the importance of identifying risk factors and treating illness early where possible.
In these 2 paragraphs it is unclear as to whether or not mental ill-health and mental illness are the same. Are the statistics in the second paragraph relevant to the first paragraph?
The result is equivalent to a report discussing prevention, treatment and social support options for all physical illness without clarifying what conditions are being discussed. In other words, by taking mental ill-health (their term) as an entity it misses out on the syndromal issues regarding different causation,symptoms, effects of symptoms and appropriate direct and other care.
2. The costing ranges from accurate (2018-2019 Commonwealth expenditure on mental health care – $3.6bn ) to a questimate (The annual cost of informal care provided by family and friends). The basis of this and other such estimates are discussed in an appendix but are impossible to obtain with any accuracy, nevertheless it and other estimates are placed side by side with much more accurate figures. In my view this is misleading. This figure is also said to be a conservative estimate!
3. The section on work and mental health is all encompassing. However it does not explore the complex psycho-socio-medical milieu of many mental health claims. Those of us who do the work of assessing claimants know of these issues and are aware that relationship issues are usually paramount, no matter the listed cause of the psychological injury.
I was pleased to see it picked up on the discrimination against claimants with work related psychological injuries in accessing benefits.
here are a few excerpts:
Table 1 Estimated cost of mental ill-health and suicide 2018-19
Cost category $ billion per year
Australian Government expenditure
healthcare (includes prevention) 3.6
other portfolios (eg. employment, psychosocial support) 1.3
State and Territory Government expenditure
healthcare (includes prevention) 6.9
other portfolios (eg. education, housing, justice) 4.4
Individual out-of-pocket expenses 0.7
Insurer payments for healthcare 1.0
Informal care provided by family and friends 15.0
Loss of productivity and reduced participation 9.9-18.1
Cost to economy (excluding the cost of diminished health and wellbeing) 43-51
Cost of diminished wellbeing (for those living with mental ill-health or self-inflicted injuries, and/or dying prematurely, including those who die by suicide) 130
Other costs that overlap with (and cannot be added to) the above
Costs to the economy of suicide and suicide attempts (excludes the costs of pain and suffering of the individual and their family and friends) 16-34
Income support payments for those with mental ill-health and carers 9.7
• Cost to the Australian economy of mental ill-health and suicide
– $43 to $51 billion per year
Including State and Commonwealth costs re healthcare, education, housing and justice-insurer payments healthcare-informal care family/friends/ loss of productivity
• Plus approximately $130bn per year associated with reduced health and life expectancy
TOTAL COST $173bn – $181bn
Productivity Commission modelled the cost of forgone output due to mental ill health $9.9 billion – $18.1 billion in 2018-19 (does not include absenteeism cost)
Workers Compensation
Provisional liability and interim payments
Some workers compensation schemes provide support for all workers compensation claims — not just mental health related claims — prior to liability being determined: the New South Wales scheme refers to these arrangements as provisional liability, South Australia as interim payments and the Tasmanian scheme as ‘without prejudice’ payments (table 19.2).
Under these arrangements, the injured worker is assumed to be entitled to benefits (including for the loss of income), and is supported on the basis of this assumption, unless and until a decision on liability is made to the contrary. These arrangements provide for the payment of benefits (for a specified period) and medical expenses (typically to a specified amount) before a decision is made on liability under the relevant legislation. For example, the Tasmanian scheme makes ‘without prejudice payments’ for limited medical expenses up to the value of $5000 and the New South Wales scheme meets medical expenses of up to $7500 under provisional liability. This can reduce delays for an injured worker in gaining access to the appropriate medical attention and income and reduce other potential stressors while the decision of liability is being determined. However, where a final determination is made to deny the claim any payments made are recoverable as a debt in South Australia whereas in New South Wales and Tasmania the insurer is not able to recoup these payments.
Productivity Commission Recommendations
These recommendations, especially 1 and 2 are already being done but the return to work rate for people with work related psychiatric injury has not changed for more than 10 years.
The 3rd recommendation is problematic, who will pay and why is this limited to people with mental health problems?
I commend the draft report to you for whiling away a pleasant Sunday afternoon.
I presented a paper on work trauma at a conference in August 2019. While writing the paper I was struck by the lack of any correlation between statistics compiled by SafeWork Australia and reports from the Australian Bureau of Statistics about the prevalence of mental health issues in Australia. The workers compensation statistics also do not ignore knowledge the issue of comorbidity. Of course it is a difficult task but nevertheless a significant number of workers develop mental health issues unrelated to their employment. It seems impossible to capture this overlap. You may be interested to read the paper. It can be found here
On 26 October 2018 I wrote “A Farce-The Faculty of Forensic Psychiatry” and sent a strongly worded document to the faculty criticising the lack of interest and resources given to those of us who did civil work. It is now a year later, what has been done? The definition on the College page has been changed, a questionnaire, most of which I wrote, was circulated and….that’s it!
I am presenting at the Faculty joint meeting in Singapore in early November. One of my complaints was the lack of space given to civil forensic work at conferences. So, out of the almost 60 papers how many are in this area? I counted 6.
Maybe, as some have urged me, it is time to move on, this Faculty is not making me feel welcome.
After two years of research and writing, editing, rewriting and more research I have at last completed my book The Guide to Civil Psychiatric Assessment. I wrote a much briefer version of this in 2013 called the DIY Guide to Civil Forensic Psychiatry. Some of the material from that has been included but much of it was outdated, a number of areas hadnot been covered and it was very Victorian focused.
The new book is intended to be a complete guide and is in two parts. The first part is “how to” with advice about establishing a practice, obtaining the work, interviewing, report writing and preparing an opinion. I have written extensively about complex claims, difficult claimants and court appearances. The second part refers to all the resources available including various websites. The book has links to legislation about workers compensation, motor accidents and civil liability claims in every state and territory and in New Zealand. I have also looked at all the impairment guides.There is an appendix that includes information about the impairment guides, various college statements plus other documentation.
The book is available through this website but also through Amazon and, if you have any problems you can contact me at michael@michaelepstein.com.au.
I came across this publication on the SafeWork Australia website. I am preparing 2 talks at the moment, one on Work trauma and Work ‘stress’ and the other on discrimination against injured workers and motor accident claimants with psychiatric injuries. I have been disappointed by the quality of some of the published material, this seems OK however.
I have complained to the Faculty of Forensic Psychiatry about the marginalization of civil forensic psychiatrists (see report). Justin Barry-Walsh, the chair has been very responsive. The definition on the College website has been changed. Forensic psychiatry is the subspecialty of psychiatry which interfaces with the law. ( It did read – Forensic psychiatry is a psychiatric subspecialty relating to the law and the assessment of mental health in the criminal justice system). A survey of all the members of the faculty will shortly take place to understand the numbers of people involved, the scope of the work and what will be required in the future regarding conferences,training etc.
Henry Chen has written an informative guide about concurrent evidence in New South Wales that has applicability to other jurisdictions. In Victoria concurrent evidence appears to have had a limited effect although of course it is permitted as a court procedure. Concurrent evidence also is a procedure in the Administrative Appeals Tribunal. It does appear however that Sydney Is the hot tubbing centre of Australia!
We were all surprised when worksafe produced a new fee schedule as of 1 April, 2019. We had complained for years about the poor remuneration compared with other jurisdictions and the failure to respond to our concerns. There were ridiculous fees like being paid little over $40 for reading documentation. Out of the blue a new fee schedule for psychiatrists was sent to IMEs in April 2019. I suspect this is because IMEs have been leaving in droves and worksafe have recognised that there is less and less incentive to be involved in the system, not only because of the poor fee structure but also because of the bureaucracy, the sudden cancellation of appointments, the inadequate time to review paperwork and the resultant strained relationship. It will be interesting to see what happens to the retention of IMEs.
A web-site called ExpertsDirect an agency for expert witnesses of all types has a good deal of information on its website relevant to expert witnesses. I have included in the Publications section 2 articles. One is on Expert Witness bias and the other on lawyers editing Expert Witness reports.
The website is https://www.expertsdirect.com.au/blog
The issue of the relationship between psychosis and injury has always been difficult for psychiatrists to resolve. In general, my own view is that if there is a very close temporal relationship between the injury and the psychosis there could well be a relationship. Complications include premorbid symptoms, cannabis use after the injury and a previous history of psychosis. The matter is a little clearer with regard to traumatic brain injury.
The research literature in relation to psychosis following traumatic brain injury reveals that there is a causal link between the two. Some of the significant findings are:
References
Batty, R., et al. (2013). Psychosis Following Traumatic Brain Injury. Brain Impairment. 14, 21-41
Fujii, D and Fujii, D. (2012). Psychotic Disorder due to Traumatic Brain Injury: Analysis of Case Studies in the Literature. The Journal of Neuropsychiatry and Clinical Neurosciences.24, 278-289.
Molloy, C, Conroy, R, Cotter, D, and Cannon, M
Is Traumatic Brain Injury A Risk Factor for Schizophrenia? A Meta-Analysis of Case-Controlled Population-Based Studies: Schizophr Bull. 2011 Nov; 37(6): 1104–1110.
The TAC has provided us with the results of a new study.
Before I tell you about the study I want you to guess the answer to this question.
Do a person’s previous health issues (especially involving mental illness or drug or alcohol use) reduce their chances of a good recovery from an accident? If you answered yes you are on the money. Here is another blinding glimpse of the obvious.
This new study has shown how pre-accident health can impact a person’s recovery from a transport accident. By linking pre- and post-accident data, researchers at the Monash University Accident Research Centre have revealed fascinating insights into the factors that contribute to a person’s recovery.
Led by Dr Janneke Berecki-Gisolf and Dr Trevor Allen, the project looked at TAC clients’ physical and mental health service use and health service needs before and after their transport accident.
“A better understanding of what’s going on with someone’s health before the crash [will] help to understand why some people recover more quickly than others,” said Dr Berecki-Gisolf. “So to find out about someone’s health before the crash, rather than ask them, we did a data linkage study which actually shows patterns of health before and how that relates to recovery.”
In one section of the project, the researchers looked at hospital admissions data to discover how someone’s pre-accident health might affect recovery outcomes. This showed that pre-existing chronic pain was common and associated with a range of adverse post-accident outcomes. Those TAC clients who then had a delayed recovery experienced a subsequent onset of chronic conditions such as hypertension and depression.
The researchers also analysed Victorian records of mental health service and alcohol and drug treatment. They looked at the overall use of these services before and after the transport injury, as well as associations between mental health and drug and alcohol related issues and claim outcomes. This showed that pre-accident use of these services was significantly associated with more complex claims and delayed return to work.
Sponsored by the TAC through the Institute for Safety, Compensation and Recovery Research, the project will help the TAC more effectively identify clients who may be at risk and provide additional services to achieve better outcomes.
The faculty of forensic psychiatry is both a misnomer and a marriage of convenience. It is time to call a spade a spade and for a divorce to take place (see my detailed comments)
The faculty of forensic psychiatry is an attempt to combine two quite disparate groups, psychiatrist who work with offenders in the criminal justice system and psychiatrist who do civil assessments. Their only point of contact if that they provide reports to courts and other Tribunals.
I have worked in both areas, in the criminal justice system and as a psychiatrist doing civil assessments. I was the only psychiatrist at the Fairlea women’s prison in Melbourne for five years and have been a member of the Victorian Forensic Leave Panel for 20 years. I have also assessed many prisoners.
I have also done more than 20,000 civil assessments and I have been a co-author of the psychiatric assessment guide used in Victoria and South Australia.
I believe that this gives me some experience and insight into the issues that have arisen with the development of the Faculty. There is now no doubt in my mind that this marriage of these unlikely partners has proven to be a failure. It is clear that the committee of the Faculty of Forensic Psychiatry has little interest in those who do civil assessment. This is manifested by the training programs, the content of conferences and by the College website description of the faculty highlighting its fundamental purpose.
Forensic psychiatry is a psychiatric subspecialty relating to the law and the assessment of mental health in the criminal justice system
My attempts to remedy these issues have proven to be a failure. Psychiatrist who do civil assessments have no opportunity for any systematic training. No academic department has focused on providing civil assessment training, the faculty has provided a grab bag of criteria that may lead to membership of the Faculty. It continues to be a struggle for civil assessment psychiatrist to gain a foothold in conferences. Despite this situation there are a significant number who do civil assessment and have a desperate need for some systematic training and an opportunity to meet in a collegiate fashion and write about and discuss issues relevant to this area.
I believe the time has come for the inevitable divorce to take place. let the Faculty of Forensic Psychiatry go it own way and fulfil its self defined core task, assessment of mental health in the criminal justice system
Let those of us who are involved in civil assessments establish ourselves as a legitimate subspecialty. We should form a special interest group, the college only recognises specialist interest groups that exist in each state.. We will need some publicity to gain members. Such a group should include those who do civil assessments together with those who work in the area of occupational psychiatry as these two significantly overlap. By freeing ourselves of the burden of the Faculty of Forensic Psychiatry we will have the opportunity to run our own conferences, to obtain college funding, to develop our own training programs and, it may be that some academic department become interested in providing appropriate training courses when they realise that these are likely to generate significant fees.
For many years I have been puzzled by the difficulty classified this group of people. With a co-author I wrote a book called “Falling Apart-living with stress breakdown” in 1989. I wrote this because of a sense of frustration. The term ‘breakdown’ did not appear in the professional literature however many people told me that they had had a breakdown and it seemed to have some general meaning. Since then I have continued to be frustrated by the failure of any about diagnostic systems to come up with a diagnosis that encompasses this group. The term ;breakdown’ continues to elude any academic discussion. At the recent Faculty of Forensic Psychiatry conference in Sydney in September 2018 I presented a paper about this called “What do we call people who have had breakdowns? The diagnostic dilemma of long-term psychiatric disability‘. Click on the link to read the paper.