We operate in a vacuum regarding the impact of our decisions financially. Some recent data from Victorian WorkSafe gives us some idea of the cost in Victoria.
GEPIC psychiatry examinations…………………1310
Cost GEPIC exams…………………………………..$1 325 000
Average cost per examination………………….$1 011.45
Psychiatric claims with entitlement paid…. 33
The total paid for the 33 claims………………$2 502 441.40.
Total cost……………………………………………….$3 827 441.40
Today I received by email the AMA Psychiatrist Newsletter, 15th Edition. I must say that i was not aware of the other 14. Nevertheless I thought it might be useful and I might learn something. Such was not the case. The topics covered included the following:
Mental Health Reform
Medicare Benefits Schedule Review
Activity Based Funding on Mental Health
Private Mental Health Alliance
Operation Life Mobile Application
RANZCP-Message from the President
AMA branch roundup (with no content but with a sidebar referring to interviews with Dr Kerryn Phelps from 2003 when she was then president of the AMA!)
I am sure this is a worthy endeavour but I found it almost incomprehensible. For example the section on Activity Based Funding on Mental Health included the following acronyms:IHPA, AMHCC, ABF MHC DSS, MHCS, MHWG and MNCERG.
This gives you of flavour of this article here are the 1st two paragraphs:
The Independent Hospitals Pricing Authority (IHPA) is developing the Australian Mental Health Care Classification (AMHCC) including a supporting Activity Based Funding Mental Health Care Data Set Specification (ABF MHC DSS). The development of the AMHCC is intended to significantly improve the clinical meaningfulness of mental health classification, leading to an improvement in the cost predictiveness and will support the new models of care being implemented in all states and territories.
To date, the classification development work has been informed by the findings of the University of Queensland Definition and Cost Drivers for Mental Health Services project, qualitative feedback from participants of the Mental Health Costing Study (MHCS) and analysis of the MHCS dataset.
Since our last edition, IHPA has been working through its MHWG and its Mental Health Classification Expert Reference Group (MHCERG) to develop and refine the AMHCC. MHCERG comprises mental health subject matter experts, classification system development experts and data analysis expert.
And on it remorselessly goes for another 8 paragraphs with equal incomprehensibility. Can you read it?
The Faculty of Forensic Psychiatry on the face of it, formally acknowledges that the work done by psychiatrists treating mentally ill offenders and those doing civil assessments constitutes a subspecialty. It is an odd subspecialty because court appearances are the only thing these two groups have in common. Furthermore there are state funded training programs in criminal forensic psychiatry with due recognition but there are no formalised training programs for psychiatrist doing civil assessments. We now have the odd situation where all those who are members of the former section have been grandfathered in as Fellows of the Faculty of Forensic Psychiatry but the only pathway to Fellowship now is through a training program and hence any newcomers involved in civil assessment can no longer become full members of the Faculty.
This was highlighted for me by the recent joint meeting with ANZAPPL that I did not attend because there were no sessions of any relevance to the work that I do. I wrote a letter of complaint to Ness McVie, the chair of the Faculty who provided a belated response, amongst other things she wrote “I have forwarded it to Sophie Davison, convenor of the 2016 FFP conference for consideration. From the conference perspective, it would be best if a suitable keynote could be suggested. I suspect this may be too late for 2016 though nothing formal planned for 2017 yet”.
I found this astonishing, an annual meeting of my faculty does not include any sessions relevant to the work that I do and will not have one in 2016 but may have one for 2017.
I was beginning to get heated about it until I began ruminating about whether or not it actually mattered. In one sense it is useful to have an opportunity to discuss the issues we face in common, to share ideas and to look at interaction with the court system and the legal profession. On the other hand, on a day-to-day basis it doesn’t matter a scrap. I have never been asked in court as to whether or not I am a Fellow of the Faculty of Forensic Psychiatry and I doubt whether anybody in the court room would know that it exists.
Increasingly I feel that the Faculty of Forensic Psychiatry has been hijacked to the exclusion of those of us who do civil assessments and I see no change occurring in the foreseeable future. Maybe it is time we start looking at setting up a Section of Civil Forensic Psychiatry and go our own way?
This is the executive summary from this, the first document of its type I have seen (click here to see the complete document). You can see why all governments put obstacles in the way of claimants, with specific wording eg the specific injury rather than a specific injury (Queensland and South Australia), different thresholds for psychiatric as opposed to physical injury (all states) and exclusions, in South Australia no compensation for non economic loss. Note that general clerks, police officers and school teachers accounted for the majority of ‘work pressure’ claims. i have also included sub-categories of ‘work stress’ for your information.
The mechanism of Mental stress is assigned to claims where an employee has experienced an injury or disease because of mental stress in the course of their employment. Mental stress includes sub-categories distinguished by the nature of the actions, exposures and events that might lead to disorders as specified. The sub categories are:
As we use the median method to find the class that most reflects a centralising tendency, similarly we can use the Severity rating in the same way. This method has no official recognition. If you use it don’t record it on any template. Rather than just using the severity rating for the median class, use it for each class.
For example
Intelligence 1 L
Thinking 2 M
Perception 2 L
Judgment 2 M
Mood 3 L
Behaviour 2 H
Determine the median class, here Class 2 (the middle number).
Then determine the median severity of all the classes in the median class. .For severity ranges in classes outside the Median Class, the rule is to adjust ratings in any class below the Median Class to the Low range in the Median Class and for any ratings in classes higher than the Median Class to the High range in the Median Class.
! L 2 M 2 L 2 M 3 L 2 H becomes L M L M H H
In order = L L M M H H, the median severity in Class 2 is M
Percentages for Range of Severity
| Classes | 1 | 2 | 3 | 4 | 5 |
| Low | 0-1% | 10-12% | 25-30% | 55-60% | 75-80% |
| Medium | 2-3% | 14-16% | 35-40% | 65-70% | 85-90% |
| High | 4-5% | 18-20% | 45-50% | 70-75% | 95-100% |
The WPI impairment is then between 14-16%.
If there is no clear median eg L L L M M H where the 2 middle letters are L and M, then the WPI is a percentage between these 2 ranges, in the example above if the severity ratings in order were L L M H H H, the final WPI is between the range for medium and the range for high, I,e, 16-18%. The final figure is for you to decide.
The South Australian government has chosen to use the GEPIC both for motor accident claims and for workers compensation claims. This should make life simple however legislation is not that easy. The changes to the Civil Liability Act have incorporated the system called Injury Scale Values from Queensland (apparently originally from the UK) that is a means of converting impairment into what I would regard as disability. See the Regulations. It is up to the medicos to determine impairment and then on the basis of their assessment together with a variety of other factors a person is given an ISV number that determines whether or not they gain access to a variety of other benefits including economic loss, noneconomic loss, so-called loss of consortium and access to other services. This has meant that the use of the GEPIC changes if one is assessing a South Australian ReturntoWork claim as opposed to a South Australian MAC claim.
What does this mean in practice?
For a South Australian ReturntoWork claim the usual procedure, as with any method of psychiatric impairment is followed. That is, one determines the whole person psychiatric impairment and then eliminates impairment unrelated to the work injury that is either pre-existing or has occurred since the work injury and also eliminate impairment caused by “Consequential Mental Harm” that means impairment secondary or consequential to physical injury, one is left with a percentage figure due to Pure Mental Harm, in other words impairment that is not secondary or consequential to physical injury. This is all fairly straightforward.
Because of the nature of the legislation with the Motor Accident Corporation those apportionments have to be done before you actually get to work out the level of impairment. In other words you must strip out impairment unrelated to the accident, impairment due to “Consequential Mental Harm leaving you with symptoms as a result of “Pure Mental Harm” such as from post traumatic stress disorder. You then determine the class of impairment for each of the six mental functions, only taking into account those symptoms arising from Pure Mental Harm. The median class is then regarded as the GEPIC rating. The GEPIC rating is then used to determine the ISV Item number ranging from, at the lowest 13 to, at the highest, 10. Each item number has a range of numbers within it but it is not for the psychiatrist to determine that.
I have now run two training sessions with regard to the South Australian ReturntoWork method and one with regard to the Motor Accident Impairment Assessment Scheme. It is interesting that in all three sessions using cases in groups there has been considerable consensus. Impairments assessments will commence on 1 July 2015 so it will be interesting to see what transpires.
When I started my psychiatric training it was a time of great ferment. Psychiatry seemed to be at the cutting edge of new discoveries. It was a time of psychedelic drugs, anti-psychiatry, RD Laing, community mental health centres and a cornucopia of new drugs for treating anxiety, depression and psychosis. Psychoanalysis was on its last legs, the biological substrates of psychiatry were becoming predominant, psychosurgery was out, ECT was on the nose, particularly after “One Flew over the Cuckoo’s Nest” (who could forget nurse Ratched).
Since then, sadly, psychiatry has become about as exciting as rehabilitation medicine. It is disheartening to think that psychiatrists are now just part of a team whose only responsibility seems to be medication. All the promise of neurotransmitters has come to nought. We still test new antidepressants for efficacy against nortriptyline, it is like comparing a new Ford against an FX Holden. More and more the focus in psychiatry has become early diagnosis of psychosis but this has also proved to be a chimera. The mental health industry badgers government irresponsibly talking about one in four people having mental illness when the true figure for severe mental illnesses is a prevalence of 3% that has remained unchanged. The one in four referred to people who have troubles, so-called mental health problems leading to a plethora of “helpers”, lifestyle coaches, counsellors, grief counsellors, relationship counsellors, psychologists who do CBT, EMDR and various other acronyms.
I have been dismayed by the role psychologists have played in advising general practitioners about what medication to use. In particular quetiapine 25 mg now routinely prescribed for anxiety.
A recent article in the New Yorker http://www.newyorker.com/magazine/2015/05/18/lighting-the-brain ( I can’t make a direct link, you will need to cut and paste this) has started turning all that pessimism around. The article focuses on the work of Professor Karl Deisseroth, a neuroscientist with a large lab at Stanford who is still a practising psychiatrist. Karl Deisseroth, now 43 has made two amazing discoveries that have the promise to transform psychiatry and allow treatment to become very specific. These two changes include Optogenetics, a technique developed by others that he has refined. “This is a technology that render individual, highly specific brain cells photosensitive and then activates those cells using flashes of light delivered through a fibre optic wire. It gives researchers unprecedented access to the workings of the brain, allowing them not only to observe precise neural circuitry in lab animals but to control behaviour through the direct manipulation of specific cells. The technique allows researchers to trigger activity of cells at the speed that the brain actually works but also to target cells and regions, like the amygdala, where there are mixed populations of hundreds of kinds of cells allowing a previously unthinkable level of experimental precision.”
This has not yet been used on humans but he is already using a variety of other techniques on his patients including vagus nerve stimulation for the treatment of treatment resistant depression with benefit. He only takes on patients who have received no benefit from other treatments. He adapts knowledge gained from his optogenetic experiments to use on patients in his clinical practice. He is currently treating an elderly man with severe depression associated with Parkinson’s disease. He had worked on mice who showed a correlation between depression like states and a dearth of dopamine producing neurones. He had prescribed his patient pills that acts on the dopamine system and it had proven to be very effective.
He has also been instrumental in developing another technology which also has amazing possibilities. He has developed a technique for displacing the fats and water in the brain with hydrogel that allows the brain to become transparent. The director of the NIMH has written a blog about this, go to http://www.nimh.nih.gov/about/director/2013/new-views-into-the-brain.shtml to see a video of this in action.
The New Yorker article goes on to say “increasingly, neuroscientist believe that the key to understanding how the brain works lies in its overall neural circuitry, and the way that widely separated brain regions communicate through the long-range prediction of nerve fibres. In this view, mental disorders resulting from the shorting out or disruption of the largest circuit wiring of the brain-and it is in defining and describing me circuit connections that Karl Deisseroth’s innovations promise to be especially helpful.
I urge you to read this article and like me, it may lift your spirits with regard to our demoralised profession. It does seem that we have a future!
What do you think of my claim Doctor?
So do you think I’m mad or not?
Do you believe me?
Do you think I should go ahead with my claim?
So, do I reach the threshold?
Ever been asked these questions or similar. I know I have.
I saw a young woman for a solicitor, she had no money and the solicitor had asked me to see her briefly to decide whether or not to proceed to a full interview. Alison was a thin anxious woman with 2 children who she brought to the interview, fortunately they were quiet and not disruptive. Alison had a subdued, meek, almost child-like manner and seemed younger than her years.
Her story was unusual. She was suing a local hospital for having done a ‘therapeutic abortion’ that had been successful and for which she had given full consent.. The unusual part was that she had a bicornuate uterus and had a foetus in each component. The abortion had killed the foetus in one horn but not the other! This emerged as it became clear she was still pregnant. She proceeded to give birth full term to a healthy boy who was at the interview.
I was confused, was her claim that the hospital staff had not terminated both pregnancies? That seemed a reasonable claim. No, it was that the termination had been done at all,as her son did not have a twin.
I felt sorry for her, her situation, having to cart 2 kids around on a hot day etc.
She asked me ‘ What do you think of my claim Doctor?
Silly me, I had decided that there could be no claim on the basis of what she said, recognising I’m not a lawyer.
“ I am not a lawyer but it seems to me that if you signed a consent form, you can’t complain that they did an abortion”
Well, she swelled in size with outrage, her voice rose and she screamed at me, “ I was told I’d get hundreds of thousands of dollars, you’re a bloody idiot, I’m not going to say here and listen to this crap” . With which she got up and swept out of the office with her 2 kids. I was a little shell shocked. I told the solicitor what happened, she seemed un-fussed.
That was the last time I have ever given an opinion.
Now what I say is something like, ‘ I am not sure, you have given me a lot of information, I need to sit down and think it through.’
There are rare occasions when I strongly urge people to seek treatment and offer to speak to their GP. I negotiate with claimants about irrelevant history that I may exclude or make anodyne, eg ‘ my mother died of AIDS.’ Please don’t mention it, no-one in the family knows. It was not relevant to the work related back injury so it became ‘ his mother died of a chronic disease.’
I never comment on whether or not the claimant should or should not make a claim. A colleague told me of her distress when seeing a patient making a claim against a close friend of hers, a surgeon. I asked her what she did, she told me she had tried to persuade the claimant to abandon the claim!d ‘ I told him how much good my friend did and how upset he would be if he was sued.’
I told her that she had put herself in jeopardy, her opinion was now useless and she had behaved unprofessionally.
I think that you say as little as possible but in a pleasant way
I had an interesting discussion with a member of the Medical Board expressing my concern about board procedures, in particular review visits. He mentioned that this was a real dilemma and there was some uncertainty amongst members of the Medical Board about how best to proceed with what is clearly a very important issue. The issue is highlighted by a paper on the website entitled:
Prevalence and characteristics of complaint-prone doctors in private practice in Victoria: Marie M Bismark, Matthew J Spittal and David M Studdert MJA 2011; 195: 25–2
Among doctors in private practice in Victoria, 20.5% had at least one complaint over the decade (to the Victorian Health Services Commissioner). Among doctors who were the subject of a complaint, 4.5 had four or more complaints, and this group accounted for 17.6% of all complaints. Surgeons and psychiatrists had higher odds of being in the complaint-prone group than general practitioners. Doctors trained overseas had lower odds of being complaint-prone than those trained in Australia.
The Medical Board has extensive data about a small group of doctors, possibly less than 5% who are subject to multiple notifications. The problem with many of these notifications is that they are difficult to establish. The concern of the Medical Board is the frequency of similar complaints regarding the same doctor. The question is what can be done in the interests of the public and to some extent the interests of the profession. Recently developed has been here review visits these are clearly problematical, the question is what else can be done? I began to see APHRA in a more positive light.
These emails speak for themselves
On 30/03/2015, at 12:02 PM, J G wrote:
Good Morning
Please note the attached invoice cannot be paid by the Agent of the Victorian WorkCover Authority as the report requested was a Clarification report and no additional information was requested
Kind regards
J G | Senior Case Manager – Authorised Agent of the Victorian WorkCover Authority
Date: 30 March 2015 9:08:57 PM AEDT
Dear Ms G
There is no such thing as a clarification report. A report was requested and issued and at no time was it stated in the request that no fee would be paid. The report, if unpaid, was obtained by fraudulent means and I reserve my rights to report this matter to WorkCover and seek a legal remedy if it remains unpaid by close of business tomorrow.
Yours sincerely
Dr A
Sent 2/04/2015 1:08 PM
Dear Ms G
Please note that I have not received payment and as advised I am referring this matter to the VWA, the Medicolegal Group and to the AMA. I am seeking advice regarding debt recovery. Costs of debt recovery will be borne by your company. No further supplementary reports will be undertaken for your company until this invoice has been paid.
Regards
Dr A
Sent 02/04/2015 03:02:58 PM
Good Afternoon Dr A
This account has been paid however will take a few days to arrive in your account given the Easter period
Regards
J G | Senior Case Manager – Authorised Agent of the Victorian WorkCover Authority
I have quoted extensively from a judgment in the NSW Supreme Court (Zahr v TAL Life Limited) where the judge has written extensively about the issue of malingering. This raises important questions about our role. Do we need to learn to administer psychometric testing to be regarded as credible? Certainly the psychiatrist in this case did not come out well.
The real point of difference between Dr Smith and Mr Haralambous is that Dr Smith accepted at face value the plaintiff’s account of his history and symptoms, while Mr Haralambous, fortified by the results of the extensive neuropsychological testing that he administered, was not prepared to do so. Underlying the issue exposed by this difference is a social and economic problem that has become endemic in contemporary western society. It frequently arises in claims for compensation or other financial benefits by persons who allege that they have suffered psychological illness or injury.
26 That problem is malingering. It is not itself a mental illness. Its essential feature is the intentional production of false or exaggerated physical or psychological symptoms, motivated by external incentives such as the obtaining of financial compensation. The problem is said to be prevalent among combat veterans who seek compensation and benefits for disorders such as Post Traumatic Stress Disorder, but it exists in all areas where compensation is sought. One study apparently reported that 53% of treatment-seeking (especially compensation-seeking) veterans, ‘exaggerated symptoms or malingered on psychological tests’: T Freeman, ‘Measuring Symptom Exaggeration in Veterans with Chronic Post Traumatic Stress Disorder’, (2008) 158(3) Psychiatry Research 374.
27 For some time, there has existed a substantial body of literature relating to the issue of symptom validity and mechanisms for testing claims, especially by those seeking compensation. Some of the literature includes G Young, ‘Malingering, Feigning and Responsive Bias in Psychiatric/Psychological Inquiry’, (2014) 56 International Library of Ethics, Law and the New Medicine 401. K Brauer Boone, Assessment of Feigned Cognitive Impairment: A Neurological Perspective, (2007 Guilford Press). L Binder, 1992, ‘Deception and Malingering’, in A E Puente & R J McCaffrey (eds), Handbook of Neuropsychological Assessment, a Biopsychosocial Perspective, (1992 Plenum Press, New York, pp. 353-374). E Eggleston, ‘Consideration of Symptom Validity as a Routine Component and Forensic Assessment’, (2011) The New Zealand Psychological Society. H Hall, Detecting Malingering and Deception: Forensic Distortion Analysis, (2nd ed 2000, CRC Press). T Merten, ‘Symptom Validity Testing in Claimants with Alleged Post Traumatic Stress Disorder: Comparing the Moral Emotional Numbing Test, the Structured Inventory of Malingered Symptomatology, and the Word Memory Test’, (2009) 2 Psychological Injury and Law 284.
28 Much more of the literature was referred to by Mr Haralambous. He stated, and I accept, that it is now widely recognised that, where a claimant seeks a financial reward on the basis of the diagnosis that his or her account is designed to elicit, the opinion formed by a medical practitioner, even by a highly trained psychiatrist, on the basis of the claimant’s self-serving account given in a clinical interview, may be problematic.
29 It is a fact of life that, unlike judges operating in a courtroom, who are assisted by an adversarial process and time-honoured techniques for testing the truth of a witness, (or interrogators in other contexts who use more brutal methods), medical practitioners are not as well suited, by nature, training or circumstance, to detect lies, dishonesty, exaggeration or embellishment. The usual, and entirely understandable, starting premise of a medical practitioner is to accept and believe a patient’s account. Medical practitioners are not prosecutors and most are probably uncomfortable adopting an inquisitorial role. They are not trained in the art of cross-examination. And they are not exposed on a daily basis to persons who lie and cheat for financial reward.
One of the things that makes medicolegal work so interesting and so challenging is appearing in court. Everyone, especially those who have just started working in the area worry about making a mess of it.
I estimate I have been a witness in court more than 2000 times. Well, on Tuesday it was a stuff up. I am getting pretty good at avoiding the usual hurdles, saying too much, getting argumentative, lack of preparation and I dress conservatively and appear on time.
Let me digress a little and talk about preparation. Preparation obviously involves reading my report, seeing any potential problems and correcting them where possible, checking on words that I may have put in the report that I do not really understand, and sometimes being a little creative. There was one case that turned on the issue of when pethidine was known to cause malignant hypertension when used with MAOIs. Instead of chucking out MIMS annuals, I keep every fifth one. In this case I could demonstrate that this interaction was well-known at the time the victim, a psychiatric patient, well known to be addicted to pethidine, had been prescribed an MAO inhibitor. I made photocopies of the relevant pages both for when the event occurred and from the MIMs annual five years before that. I made copies for the judge and for both sides.
When I asserted that this interaction was well-known at the time the event occurred, the judge in a kindly patronising way told me, “that’s all very well Dr Epstein but we have had expert evidence to the contrary so it really is a case of your word against the other expert witness isn’t it?” It was with some pleasure that I produced the photocopies. The case settled that afternoon.
I realise I am avoiding talking about my stuff up so let me tell you about another stuff up while I’m still on a roll. I appeared in a “hot tub” in Sydney in 2013 with two other psychiatrists about a man claiming income protection insurance payments due to a mental illness preventing him working. His illness had commenced in 2000. The highly regarded psychiatrist from Sydney was an impressive witness-until he was told “there is nothing in your report doctor about what happened to this man from 2000 onwards? Why is that?” This was an astonishing lapse. To his credit the expert said “I have no explanation, it’s clear I made a mistake.”
Let’s get back to my stuff up. This was a man who had worked in his father’s construction business from school and had married and had two children. He had become a project manager but was still “on the tools” and expected to take over when his dad retired. In the same year his marriage broke down, his father borrowed a large sum of money from him because of a “temporary financial situation” and a week or two later his sister told him that the business was bankrupt. His father promptly had a breakdown and was hospitalised and he was left to deal with the train wreck. An administrator was called in, he had to assist the administrator, try and complete the jobs they were already doing and deal with subcontractors.
About three or four months later, when the dust had settled he finally had an inguinal hernia repair that he had been delaying because of the pressure of work. There were a host of other pressures on him over the next 10 years or so including a drug dependent son who assaulted him and his new partner, alcoholism and various physical health issues.
I saw this fellow four times from 2007 onwards. Each time I wrote a comprehensive report but I failed to pick up that the critical issue was whether or not his mental state was contributed to by his employment. I had detailed information about a host of other things that happened to him but what I wrote above was pretty much all I had gathered about the critical three or four month period when the business failed.
In cross examination I was asked such questions as “how many projects had to be completed?” and “how many subcontractors were involved?” and “what other pressures were on him at the time coming from the business?” and “what is your understanding of the role of the administrator?” and “when did he and his wife separate and what was their relationship like after the separation?”. I hesitate to go on with the other questions because it is too embarrassing. The fact is I did not have any answers to these questions because I had not asked them.
My report contained only one paragraph to do with the collapse of the business and this paragraph included a quote “he was left to pick up the pieces” that I had lifted from a psychologist’s report but that I had never explored.
What I found particularly annoying was that I had seen this man four times and I had never picked up how inadequate was my history.
When I stuff up in court I go through about 24-48 hours of distress until my ego gets over it and I can then work out what I did wrong and how to make sure I don’t put myself in that position again.
The lesson I learned here was to focus on the main game, the history of the accident or injury that led to the claim. The rest is important but unless I have that information, it is irrelevant. It’s like doing all the preparation for a lecture and not turning up.
I walked out of the courtroom feeling like an idiot and for a short moment was tempted to waive my witness fee but fortunately sanity and greed prevailed.
I am sure that APHRA would regard itself as neither. APHRA regards its role as protecting consumers. No one would argue that there is a legitimate concern about the practices of a small number of health-care providers. My experience and that of others is that APHRA does acknowledge that performance assessment can be a stressful experience for practitioners however our concern is that a significant number of complaints about independent medical examinations are from disgruntled people who want to lash out at the IME if the opinion provided is not acceptable.
Doctors are frustrated by the trivial nature of many of the complaints, they are frustrated by the time and emotional energy expended in responding to these and by the economic cost.
The recent issue of Australian Medicine of 16 February 2015 on page 8 has an article about “Flawed Complaints Process Undermines Health and Care”. Their article makes the point that research published in BMJ Open Has Found Significant Levels of Depression and Anxiety amongst Medical Practitioners Who Have Had a Complaint Made about Them. The Study Involved 7926 doctors and found that 70% of those who are currently or as recently the subject of a complaint or moderately or severely depressed and 15% reported moderate or severe anxiety.
Alarmingly, doctors who currently or recently had complaints against them were twice as likely to consider hurting themselves or contemplate suicide.
This study found that not only did being the subject of a complaint affect a doctor’s health, but it could also have a significant impact on how they practised. the vast majority of doctors involved reported adopting a defensive approach to how they practised, 20% felt victimised, almost 40% felt bullied and 27% took more than a month off work.
Dr Browne, the senior medical officer with Avant said the results were “virtually identical” to a similar study co-conducted in Australia in 2006. She said the way patient complaints were handled in Australia risked making doctors “a second victim” causing them an enormous amount of stress and undermining their health.
The AMA has called for an overhaul of the system. The complaints system is being examined as part of a review of the National Registration and Accreditation Scheme for Health Professionals in both the AMA and Avant have made submissions urging major changes in the way complaints against doctors are handled.
The AMA has called for improved triaging of complaints and notifications, greater transparency and fairness, and changes to make the scheme more responsive to medical practitioners and accountable to the medical profession. The notification process was noted to be arduous and lengthy with more than 30% of investigations to open after nine months.
The AMA noted that it was disappointing that the findings of the review had been pre-empted by the Australian Health Practitioner Regulation Agency, which last year released an action plan of changes.
APHRA wanted more information to be provided to complainants, and a greater focus on improving the experience for consumers, when “in fact, efforts need to be directed to improving the investigation process-that is, the practitioner experience. Medical practitioners and consumers, equally, want a regulatory system that is is timely, fair, transparent and effective.”
I have provided a summary of this report. The recommendations are focussed on ‘the consumer’ although Recommendation 7 mentions health practitioners, burrowing down we find a sub-set of recommendations including in the short term:
In relation to NFA (jargon for cases where there is to be no further action). Particularly where there are issues but they do not reach the AHPRA threshold, create an opportunity for notifiers to contribute to the collective patient voice and lead to improvements down the track, translating cumulative issues into recommendations for improvement. So while an individual complaint may not have a result for the particular consumer, it contributes along with other complaints to improving the system.
The assumption is that although there is to be no further action, the complaint has some legitimacy but did not reach the threshold.
In the long term:
Provide more publicly available and easily accessible information about individual health practitioners.
There is no mention of whether or not this would include health practitioners about him complaints have been made as opposed to health practitioners who have had adverse findings.
You will also note that recommendation 8 talks about measures to increase APHRA’s engagement with consumers and the community but no mention about better engagement with health practitioners.
Recommendation 1: Provide better information on the website, using professionals with skills in health communication with consumers working with a consumer panel
Recommendation 2: Develop more meaningful communication with consumers throughout the notification process
Recommendation 3: Improve the initial contact and invest in skills and expertise at this first point of contact.
Recommendation 4: Build on current collaboration between AHPRA and the OHSC ( Office of the Health Service Comissioners) to develop seamless complaint management and resolution across the two organisations. This should be based on the ‘consumer
journey’ and seeking to address the full range of issues in the consumer’s complaint in the most timely and complete manner.
Recommendation 5: Use process redesign and lean principle to explore options for swifter resolution and more timely management of notifications.
Recommendation 6: Reconsider the role of the consumer as a notifier in the ‘model of practice’.
Recommendation 7: Ensure that complaints and notification contribute to systems change and that is demonstrated to the community and to health practitioners.
Recommendations 8: Consider measures to increase AHPRA’s engagement with consumer and the community
The IME complaint I have mentioned previously is a good example of this process. The IME has written to APHRA requesting information about the assessors, issues regarding confidentiality and the provision of a support person.
The response from the Manager Notifications with APHRA stated that on 5 February 2015 the Medical Board of Australia formed the relief that the way the IME practices may be unsatisfactory and decided to require the IME to undergo a performance assessment. The Board noted that the issues raised by two complainants were similar (see below). The IME was informed that both assessors are psychiatrists one of whom is an IME, the date of the assessment was provided and indicated that a schedule would be forwarded. In response to a request to have a support person the IME was told that the support person can remain present:
Surprisingly the writer goes on to show say “however, to ensure the independence and objectivity of the assessment, the support person is not present during the interview sessions of the practitioner and his/her patients.”
The letter goes on to say “The Board will decide what, if any, action is to be based on the assessment and the outcome of the discussions with the IME about the assessors report. The Board’s actions are not intended to be punitive, but aimed to enable the IME to practice safely” (my emphasis, note that the IME here had been notified on 14 January 2013, 17 March 2014 and 6 October 2014 that the replication lacked in substance, no further action was to be taken and “this matter has now been closed”. The last letter noted that the complaint it alleged “that your manner and communication with X during an IME was unprofessional in that you were angry, board and abrupt.”)
These complaints mirror similar vague complaints made about other IMEs.
APHRA has to recognise it must not be seen as the enemy if it has to have more than grudging co-operation from us.
I have already written a post about problems experienced by psychiatrists dealing with APHRA ( see 5 September 2013). More recently, a colleague in Melbourne, an independent medical examiner contacted the forensic section because of concerns over actions taken by APHRA via the Medical Practitioners Board of Victoria. There had been three complaints from workers to APHRA with regard to the IME’s matter and demeanour. Each had been found to be “lacking and substance”. Following a fourth complaint in late 2014, that has not yet been resolved, the IME was told ‘AHPRA have requested that I undergo a Performance Assessment, which involves 2 peer colleagues sitting in with me during a medicolegal assessment.’
Understandably the IME was concerned that despite three previous complaints having been thrown out, the fourth complaint, that had not been resolved, lead to this action. The IME contacted the forensic section of the College.
The Victorian forensic committee, including myself, did some research including looking at the legislation.
This legislation is interesting because it is not within the powers of the Commonwealth to regulate health care providers so all the states have enacted legislation initiated by Queensland that establishes the structure and function of APHRA and the various regulatory boards including overarching boards for Australia and boards for each state and territory.
In Victoria we have adopted the HEALTH PRACTITIONER REGULATION NATIONAL LAW
4 Application of Health Practitioner Regulation National Law
The Health Practitioner Regulation National Law, as in force from time to time, set out in the
Schedule to the Health Practitioner Regulation National Law Act 2009 of Queensland—
(a) applies as a law of Victoria; and
(b) as so applying may be referred to as the Health Practitioner Regulation National Law
(Victoria); and
(c) so applies as if it were part of this Act.
The most interesting sections are the following:
Part two Section 7
Exclusion of legislation of this jurisdiction
The following Acts of this jurisdiction do not apply to the Health Practitioner Regulation
National Law (Victoria) or to the instruments made under that Law—
(a) the Audit Act 1994;
(b) the Financial Management Act 1994;
(c) the Freedom of Information Act 1982;
(d) the Health Records Act 2001;
(e) the Information Privacy Act 2000;
(f) the Interpretation of Legislation Act 1984;
(g) the Ombudsman Act 1973;
(h) the Public Administration Act 2004;
(i) the Public Records Act 1973;
(j) the Subordinate Legislation Act 1994.
One cannot use these Acts to obtain any information about the activities of APHRA and nor does there appear to be any avenue of appeal!
Section 151 (2) was the section that was used with regard to the Victorian IME. In other words if they find, as they did, that three complaints lacked in substance nevertheless they can use those dismissed complaints as a reason to take further action!
151 When National Board may decide to take no further
action
(1) A National Board may decide to take no further action in relation to a notification if—
(a) the Board reasonably believes the notification is frivolous, vexatious, misconceived or lacking in substance; or
(b) given the amount of time that has elapsed since the matter the subject of the notification occurred, it is not practicable for the Board to investigate or otherwise deal with the notification; or
(c) the person to whom the notification relates has not been, or is no longer, registered by the Board and it is not in the public interest for the Board to investigate or otherwise deal with the notification; or
(d) the subject matter of the notification has already been dealt with adequately by the Board; or
(e) the subject matter of the notification is being dealt with, or has already been dealt with, adequately by another entity.
(2) A decision by a National Board to decide to take no further action in relation to a notification does not prevent a National Board or adjudication body taking the notification into consideration at a
later time as part of a pattern of conduct or practice by the health practitioner.
(3) If a National Board decides to take no further action in relation to a notification it must give written notice of the decision to the notifier.
(4) A notice under subsection (3) must state—
(a) that the National Board has decided to take no further action in relation to the notification; and
(b) the reason the Board has decided to take no further action.
Sections 170 and 171 give APHRA the power to require a performance assessment. You will notice that there are two types of assessment, and health assessment and a performance assessment.
170 Requirement for performance assessment
A National Board may require a registered health practitioner to undergo a performance assessment if the Board reasonably believes, because of a notification or for any other reason, that the way the practitioner practises the profession is or may be unsatisfactory.
171 Appointment of assessor to carry out assessment
(1) If the National Board requires a registered health practitioner or student to undergo an assessment, the National Agency must appoint an assessor chosen by the Board to carry out the assessment.
(2) The assessor must be—
(a) for a health assessment, a medical practitioner or psychologist who is not a member of the National Board; or
(b) for a performance assessment, a registered health practitioner who is a member of the health profession for which the National Board is established but is not a member of the Board.
(3) The assessor may ask another health practitioner to assist the assessor in carrying out the assessment of the registered health practitioner or student.
(4) The assessor’s fee for carrying out the assessment is to be paid out of the National Board’s budget.
You will notice that the person or persons doing a performance assessment must be, in this situation, a medical practitioner, not a psychiatrist and certainly not the person experienced in doing independent medical examinations when we know that the very process of doing an IME leads to complaints especially when claimants are unhappy with the opinion..
So we have a situation where complaints have been made about an IME that have been dismissed. Following a further complaint of a similar type the IME has been required to have a performance assessment with no requirement that this be done by a peer.
You will notice that the quote in the letter from the IME refers to “two peer colleagues” doing the assessment, I assumed that a ‘peer colleague’ would be, at the least, a psychiatrist and ideally another IME. This is not going to happen.
The IME has received legal advice and has been told to proceed with the assessment! A further question is whether the assessment will only be with WorkCover claimants or with other clinical patients, inasmuch as the complaints were only to do with IME work I would expect that the assessment would be with this group, but who knows?
Information received from the College has been that APHRA has the power to order a performance assessment. The College has also raised concerns about the difficulties of the notification system, specifically around medico legal reporting, and the implications and stress this causes practitioners, especially in civil and family court matters. This continues to remain on the agenda for the College when it meets with AHPRA and Medical Board representatives.
The College has also informed us that: AHPRA has a pool or predetermined assessors which they generally contact directly except for when there is a direct need.
What has been our advice?
We have told the IME to have a colleague sitting in on the assessment. We have also recommended that the IME have that colleague present at an earlier session to pick up any possible problems.
We have been astounded by the powers of APHRA especially in view of the level of morbidity in medical practitioners about whom complaints have been made. I have included two relevant articles,
I have a certain sympathy for APHRA, it is a difficult task but those of us who do independent medical examinations are very much in the firing line. Especially because complainants have ready access to a number of blogs ,for example ‘aworkcovervictimsdiary‘ and the injured workers support network that feed that feed into workers’ hostility towards the WorkCover system and those who work in it. Ironically, in Victoria, I am not aware of any complaints about IMEs with regard to transport accidents. I can find only one site complaining about the Victorian Transport Accident Commission.
Doing medicolegal assessments gives you a snapshot of the prescribing practices of GPs. Over the last year or two I have been astonished by the number of people being treated for anxiety by their GP with atypical antipsychotic medication, mainly quetiapine (Seroquel) and to a lesser extent olanzapine (Zyprexa).
I am an unashamed advocate of the use of benzodiazepines in anxiety. I have followed the professional literature for years and in the midst of the raging against their use there are a number of papers that continue to advocate for them on the basis of their safety and lack of serious side-effects.
Treatment recommendations for anxiety disparage benzodiazepine use.
For example :
The most commonly prescribed anti-anxiety agent for this disorder has historically been benzodiazepines, despite a dearth of clinical research that shows this particular class of drugs is any more effective than others. Diazepam (Valium) and lorazepam (Ativan) are the two most prescribed benzodiazepines. Lorazepam will produce a more lengthy sedating effect than diazepam, although it will take longer to appear. Individuals on these medications should always be advised about the medications’ side effects, especially their sedative properties and impairment on performance.
Tricyclic antidepressants often are an effective treatment alternative to benzodiazepines and may be a better choice over a longer treatment period. (on PsychCentral.com 15 December 2014, quoting a 2004 paper)
The most recent edition of Therapeutic Guidelines 2013 states:
Anxiety and associated disorders
Psychological interventions should be used first-line for most anxiety disorders. However, sometimes adjunctive pharmacotherapy may be needed, usually with antidepressants rather than benzodiazepines. If short-term prescribing of benzodiazepines is necessary, consider the precautions given.
The BeyondBlue website states:
Benzodiazepines (sometimes called sedatives) are a class of drug commonly prescribed in the short term to help people cope with anxiety and panic attacks. Benzodiazepines reduce tension without making people drowsy but they are not recommended for long-term use as they can be addictive.
It appears to be a given that benzodiazepines are “bad”. Many papers attest to this and there are many papers about strategies that have been used to reduce the prescribing of benzodiazepines.
Benzodiazepine use by elderly patients is associated with adverse outcomes including increased risk of falls and fractures, motor vehicle accidents and cognitive impairment (CMAJ. Apr 1, 2003; 168(7): 835–839).
According to a paper in BMC Health Services Research 2010;10:321. doi:10.1186/1472-6963-10-321.
“Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide”
and
Benzodiazepines are used to treat various psychological disorders including sleep disorders, some neurological disorders and aspects of addiction and anxiety [1]. Utilization patterns show variation in the use of benzodiazepines over the last 2 decades. During the 1990’s there was much publicity around the harmful effects of long-term use of benzodiazepines in Australia, including new guidelines and efforts to increase community awareness. This resulted in a decrease in prescribing of benzodiazepines, however since the end of these campaigns, use has been continually rising, with a 21% increase in utilisation by concession beneficiaries in Australia (elderly, over 65 years of age, and those with a low income or receiving benefits) from 2000 to 2006.
There has been recent publicity about a number of deaths associated with combined use of opiates and benzodiazepines, there is no doubt that benzodiazepines can effect respiratory centres and may potentiate the respiratory depressant effects of opiates. In particular there is concern about recreational use of alprazolam. All that is understandable but most people with anxiety do not fit into this category.
In my clinical practice I have found benzodiazepines, used appropriately, sometimes long term, have proven to be far more useful in treatment of anxiety with far fewer side effects than antidepressants that often cause obesity and sexual dysfunction.
Here are two anecdotes about my involvement with benzodiazepines.
Some years ago I was involved with a GP training program in which I was a tutor doing telephone tutoring to a group of GPs interested in obtaining a diploma of mental health. The tutorials is proceeded well until we came to the topic of anxiety. I made some comments about use of benzodiazepines. I could not believe the hostile response. It was like I was prescribing poison. Their view was that all benzodiazepines are bad, if used they should never be used for more than a few weeks and that anything was preferable to their use. They confused dependence with addiction and did not acknowledge the relatively minimal side-effects of benzodiazepines compared with antidepressant medication. Within a short time I was asked to cease my involvement in that training program, possibly because of this unpleasant tutorial.
About 10 years ago a friend of mine developed breast cancer, I had never treated her. She had been using clonazepam for 20 years for treatment of panic disorder. Her panic disorder had been crippling to the extent that she had been housebound for three or four years. After using clonazepam her panic disorder became well controlled and she was able to go back to work as a teacher and became involved in a long-term relationship. She was using anywhere between 0.25 mg-2 mg of clonazepam a day.
Whilst in hospital after breast cancer surgery she developed an acute severe panic attack. She had mentioned that she had been using clonazepam but was not allowed to bring that to the hospital. After she was discharged I suggested that she be reviewed by a psychiatrist experienced in treating women with breast cancer. She saw the psychiatrist who was horrified that she had been using clonazepam and told her to stop using it and prescribed Aropax instead. She began using Aropax but developed weight gain, insomnia, sexual dysfunction and her panic attacks did not improve. She mentioned this to the psychiatrist who increased the dose of Aropax with a significant increase in side-effects but no improvement in her panic disorder.
She came to me in some distress “what can I do? I like my psychiatrist and it has been useful to talk about my cancer but my panic attacks are making it impossible for me to work and putting a lot of strain on my relationship.”
I suggested an option. She had two prescriptions for clonazepam at home and I suggested that she stop using the Aropax slowly and immediately start using clonazepam but not tell her psychiatrist what she was doing. She did so and her panic attacks settled. Her psychiatrist, rather smugly, said “I told you so, all you needed to do was to increase the dose!” Was I unethical? Possibly but any concern about that was outweighed by the improvement in my friend’s health.
So where are we with regard to anxiety disorder and medication. There have been many public health efforts and a great deal of money expended in trying to reduce benzodiazepine use. In Australia quetiapine is listed for treatment of Generalised Anxiety Disorder and most therapeutic guidelines recommend use of antidepressant medication as first-line treatment for anxiety.
There appear to be few people who have any neutral view about benzodiazepines. The accepted wisdom is that the BDZs are bad and that anybody who prescribes them is either incompetent or wicked and, their use must be reduced. It is noteworthy that education programs to reduce prescribing benzodiazepines by GPs have been totally ineffective. Nobody seems to have questioned whether or not the alternatives may be worse.
There is major concern about use of benzodiazepines long term but there appears to be little commensurate concern about long-term use of atypical antipsychotic drugs despite the strong possibility of long-term adverse side-effects. There appears to be little concern about giving antidepressant medication long-term for treatment of anxiety although we are all familiar with all the side-effects of that group of medications, including withdrawal symptoms.
At times I have wondered if the pharmaceutical companies have conspired to demonise benzodiazepines as they are no longer in patent and this allows them to profit greatly from use of newer antidepressant medications and atypical antipsychotics in treatment of anxiety.
The 2011 statistics from the Pharmaceutical Benefits Scheme give the following information.
Total cost of quetiapine $130 million, total number of prescriptions 820,620.
25 mg tablets (the usual dose used to treat anxiety by GPs) 294,062 prescriptions at a cost of $16,819,606. Each prescription cost $57.
Total number of prescriptions for diazepam; 2,258,000 237 prescriptions at a cost of $17,769,988. Prescriptions for 5 mg tablets totalled 1,977,635 at a cost of $15,533,180 giving a cost per prescription of $7.85.
Amitriptyline, total number of prescriptions 1,627,201 at a cost of $14,251,045. There were 555,169 scripts written for 10 mg tablets at a cost of $4,692,995 at a cost of $8.45 per prescription.
Paroxetine, commonly used for treatment of anxiety, total number of prescriptions 969,084 at a cost of $30,553,212 at a cost of $31.52 per prescription.
Sertraline, also used for treatment of anxiety in addition to treatment of depression, total number of prescriptions 2,774,837 at a cost of $74,698,325, cost per prescription $26.
My sanity was briefly restored when I read the following article. It was like hearing the first sounds of rain on a tin roof after a long drought.
The reappraisal of benzodiazepines in the treatment of anxiety and related disorders Expert Rev. Neurother. Early online, 1–12 (2014).
I urge you to read it. I will leave you with its introduction:
Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.
Some have requested information about the The American Board of Independent Medical Examiners. I see that a number of medicos in Western Australia and other states have this qualification. Some of the training appears to be quite generic and might be useful as a basis for commencing in medicolegal practice but there seems to be little to offer for psychiatrists. I was especially concerned by one module: “How to write winning reports”.
This group have provided some training in Adelaide and I would be interested in feedback from anybody who has gone through their training in October last year. For the moment I would be very cautious.
I have written in other posts about changes to the Victorian TAC including the introduction of Joint Medical Examiners. Joint Medical Examiners are Independent Medical Examiners who see claimants and prepare reports for both the TAC and plaintiff’s solicitors. Since the JME process has been implemented there have been a number of disputes including the fee schedule, the lack of coordination between the two parties leading to excessive documentation and questions and the distaste many IMEs have for the requirement that they must complete TAC documentation and receive TAC accreditation before they can participate in the process. The other issue, of course, is the potential for the TAC to veto some examiners.
There have been a number of changes in position by the TAC; the initial fee schedule was $1368.79 (including GST) with an extra payment of $150 including GST in the transition period that was to expire on 1 January 2015. Subsequently since the legislation refers only to paying “a reasonable fee” the TAC agreed that JMEs could charge their usual fee until the end of the transition period. There was then consultation with a number of JMEs where complaints were made about several issues. This led to the establishment of the TAC/JME Reference Group, the transition period was extended to 1 April 2015 and rather than a single fee, a fee range was to be implemented. ($1231 -$1800 + GST).
The TAC/JME Reference Group has now met three times, it includes JMEs and representatives of the TAC and the Australian Lawyers Alliance. it has been agreed that the fee within the range above will be determined by the JME and will be paid automatically subject to the usual periodic reviews. There will be some leeway at the upper end of that range so that a fee that may be $300 or thereabouts above the top fee in the scheduled range will usually be paid automatically. JMEs will be provided with information about issues that are regarded as leading to complexity and the need for additional payments. This information will vary according to the different craft groups involved . There will be further meetings to explore cutting back on documentation, reducing document duplication and similarly cutting back on the number of questions asked.
Most of us have been surprised by the conciliatory stance taken by the TAC and are still crossing our fingers.
culminating in
This post has little to do with forensic psychiatry but is fascinating. Apart from “eat shit” being a term of abuse it has become a reality in the world of medicine, the latest New Yorker magazine has an article about faecal transplants.
This apparently simple procedure has been life-saving, in particular for people with Clostridium difficile infections due to use of prophylactic roared spectrum antibiotics, the article states that this afflicts more than 500,000 people each year, killing 15,000, almost all hospital patients who received antibiotics. A cottage industry has grown up with friends and neighbours providing the raw material. I was astonished to read that in our digestive tracts there are about as many as 100 trillion bacteria, fungi, viruses, and other tiny creatures and that 40% of faeces is composed of microbes. The first known account of faecal transplantation dates to a fourth century Chinese handbook but for years the only proponent has been Thomas Borody, a gastroenterologist in Sydney who has performed more than 5000 faecal transplants for a variety of conditions including people with autoimmune disorders including Crohn’s disease and multiple sclerosis. It is known that patients with Crohn’s disease have a gut microbiome that is less diverse than average and is lacking in key species of bacteria. A nonprofit organisation has set up an anonymous faecal transplant business with donors such as Vlaidimir Pootin and Dumpledore. The FDA has decided that faeces are a drug! This has the potential to shit on the whole process (excuse me, I couldn’t help it). The implication is that only major pharmaceutical companies with massive amounts of money will be able to fund the FDA requirements. One company is trying to produce an enema derived from faeces and has spent millions of dollars and is very opposed to the work of the nonprofit organisation.
Whatever you may think of DSM 5 the question remains when and if should we use it. DSM 5, in particular, disparages the axial diagnosis scheme used in DSM IV and the GAF. The DSM 5 is poor with regard to persistent pain. However, de facto it clearly replaces DSM IV. I work in the medico-legal area where such a change has significant implications. The new South Australia impairment guidelines will specify use of DSM 5. There appears to be no direction from the College and, one may ask, is that the role of the College? So I have been using both in my reports, eg when dealing with claimants with persistent pain, but I prefer persistent depressive disorder DSM 5) to dysthymia (DSM IV). I believe that shortly I will have to make the transition complete. but it does seem a messy process. What are your thoughts.
As I have already written, the fee schedule as from 1 July 2014 is increasingly irrelevent as JMEs have continued to charge their usual fee. We were told, in no uncertain manner that as from 1 January 2015 the fee schedule would definitely apply. Now the TAC has extended the transition period to 31 March 2015! The fee schedule will ( some scepticism here) be from $1231 – $1800 + GST), with complexity criteria to guide examiners billing within this range. There will be exceptions, examiners can contact the TAC to discuss circumstances where the reasonable cost for the service may be above the fee range when the transition period ends.