Helping doctors to help themselves

WHEN applied to women, it’s called the madonna/whore syndrome. It’s an inability to see a group of people as they really are, with their mix of flaws and virtues; an over-idealisation whose flip side is an equally unrealistic denigration. And it underlies many people’s attitudes to doctors.

We all want them to be kind and clever, caring and capable. According to whether or not they live up to our expectations, we see them as saints or sinners. No wonder doctors feel so misunderstood.

But there is one consistent element of criticism of the profession: it is the perception that medicine is a club whose members sometimes have greater allegiance to each other than to the community they serve. Doctors are believed to close ranks to hide or minimise colleagues’ mistakes or misdeeds. It is a perception that the Medical Practitioners’ Board of Victoria must work harder to dispel, and the State Government’s review of the act that governs the board creates a chance to debate how best to do this.

The medical board stands between vulnerable patients and the doctor who is overservicing, unethical, misusing drugs or alcohol, incompetent, sexually abusive or impaired through mental or physical illness.

Nine of the 12 members of the board are doctors themselves. Their (admittedly narrow) brief is to set minimum standards and to protect the community, not to punish doctors for misdemeanors.

But sometimes the board seems to interpret even these basic notions of “minimum” and “protection” very narrowly. Take the case of a psychiatrist who developed a therapy that the board found to be unethical and destructive of some patients’ mental health. The board’s interpretation was that the community was safe if the doctor received a short suspension and promised to stop the therapy. Patients might wonder whether a therapist who could be so gravely misguided and oblivious of harm was equipped to influence the emotional lives of others for the better.

The board’s hearings are not always constituted in a way that preserves the perception of impartiality. Is it appropriate that a member of the board sit on a case involving a defendant with whom he has even a referring relationship? Is it appropriate that the board accept and rely on expert testimony (as opposed to character evidence) from doctors who have had close professional relationships with an accused doctor?

This kind of link between the parties would not be tolerated in most arenas in which allegations are adjudicated. It can only reinforce any suspicion that the rules of the “club” favor collegiality over impartiality, the doctor over the patient.

Cross-pollination by related professions would help. A psychiatrist sits on the psychologists’ registration board; a psychologist would bring to the medical board similar ethical concerns as doctors but a decreased likelihood of close links with defendants. The board also needs at least one member with a background in patient advocacy to ensure the consumer’s viewpoint is strongly represented.

The board has a problem with gender imbalance in some hearings. Women make up the majority of complainants overall and nearly all complainants in sexual misconduct cases. But one recent sexual misconduct case (in which the women’s complaints were dismissed) was heard by a panel of four male doctors and one woman.

The panel’s makeup was sharply criticised in private by mental health professionals not associated with the case, who believed it left the board open to charges of gender bias.

Other problems relate to the inadequacy of legislation governing both doctors and psychologists. Struck-off psychiatrists and psychologists have been able to set up shop again instantly by calling themselves “counsellors” or “therapists”.

Successive governments have been stymied because they didn’t want to accidentally ban others who use those descriptions, such as financial counsellors and beauty therapists. The New South Wales health complaints commissioner, Merrilyn Walton, has suggested that one possible solution would be to ban the use of those terms only by those who have been de-registered by a professional body.

There are also gaps in the protection the law offers doctors when they report colleagues. Doctors cannot be sued for defamation if they report another because he shows signs of having becoming mentally or physically ill. But if a doctor reports a colleague for sexual misconduct or potentially dangerous incompetence, the reporting doctor has no legal protection.

The law should be changed to cover all three categories. We can’t expect doctors to speak out to protect patients knowing that their own career, good name or financial wellbeing might then be sacrificed to the quirks of the legal system.

Most doctors are neither heroes nor villains. They’re like the rest of us, decent people who try to do the right thing in difficult situations, succeeding better some times than others. It’s their responsibility to struggle with implicit biases they might have in coming to ethical decisions about the public interest. It’s our responsibility to create a system that supports them in that task.

First published in The Age.