Issue 22 / 29 November 2010

“FIRST do no harm” poignantly captures the raison d’être of our medical boards: to protect the public from the aberrant practices of the medical profession, due to a doctor’s professional or personal shortcomings.

Not so long ago, medical boards in each Australian State and Territory ensured that our citizens receive the highest possible standard of medical care through the fair and effective administration of relevant medical Acts.

The weighty power of medical boards resided in their capacity to deny or revoke registration critical to any doctor to enable him or her to practise medicine.

A committee of medical, legal and community representatives usually determined this process.

It is also important to note that their deliberations and appeals were made public. And many times, these proceedings were fraught, exploring the essential pathos of human frailty and fragility.

This is no more evident than in a recent judgment of the Supreme Court of South Australia in Taylor v The Medical Board of South Australia.

It concerned an appeal of the decision by the Medical Board of SA to not register a newly qualified doctor.

She had endured multiple attempts at suicide and self-harm, which had been attributed to an affective bipolar disorder, later relabelled as a borderline personality disorder.

Irrespective of the psychiatric diagnosis, this malady manifested itself in more than 30 attempts at suicide reaching back to her secondary school days.

Sadly and paradoxically, these days were also noteworthy for academic excellence and scholarship.

During her 6 years at medical school, the appellant presented to emergency services across the metropolitan area many times due to attempted suicide, mostly through drug overdose.

These episodes continued during internship at a major teaching hospital.

The report of the appeal proceedings is replete with legal manoeuvres, legal language and the opinions of leading psychiatrists.

But to an outside observer, such a process is problematic, driven and ultimately determined by an uneasy tension between facts and opinions.

Above all, as the players search for some grasp of truth, the process itself seemed to be insensitive, utterly oblivious to its human impact.

At the end of these deliberations, the presiding judge exhaustively outlined his black-and-white arguments and proceeded to dismiss the appeal.

And what do I make of all this?

Despite the recent moves by our medical schools to implement “fitness to practice” policies, the execution of these policies is a human process, subject to all the vagaries of human behaviour and inevitably the heat of an adversarial legal system.

But I also believe that the judgment, which underpins the judge’s reasons and details the background, should become part of the curriculum of our medical schools.

It reinforces two essential facts.

First, that students and doctors are but mere mortals; and second, that their shortcomings should not endanger medicine’s first principle:

“Primum non nocere”.

Dr Martin B Van Der Weyden is the Editor of the Medical Journal of Australia.


Posted 29 November 2010

11 thoughts on “Martin Van Der Weyden: The first principle of medicine

  1. Anonymous says:

    Sadly it reflects far more than those points
    1. What was the school that was educating here doing during this time?
    2.Why was this issue not followed up at this level with competent counselling, etc, if it was unlikey she would be allowed to practise?
    3. What were her colleagues, both students at university and within the hospitals, doing during this time?
    4. The very people that should be the most skilled at identifying and implementing a good outome, where are they?
    5. Frankly I don’t know enough about the case but it is a sad reflection on many things for the woman. But in my mind, certainly by the stage she got to in the course, she should have been well informed as to the likelihood of not being able to register.

  2. Skrik says:

    I got an MB BCh at a university with the motto of “Labore et Scientia” – that was fine and I worked at it. Then I got an MMed from another medical school, which made a great deal more sense: “Salus aegrotti suprema lex.”

  3. Richard Emmett says:

    Agreed. This is an apparent (I am also not familiar with the case) failing of the medical education system, not the registration system. It has been similarly difficult to redirect postgraduate trainees who are clearly unsuited for their chosen field, often leading to protracted legal proceedings and a very painful “due process” for all concerned. The later the issue arises, the harder it gets. Achieving the retrospectively obvious (career counselling and redirection) early on is the challenge.

  4. Sue Ieraci says:

    This example precisely illustrates the issues raised in my previous blog about the need for medical schools to take some responsibility for fitness to practise – not just for awarding academic degrees. Fitness to practise is not just about academic achievements – it includes all the professional abilities that allow a person to act as a capable and reliable patient advocate – including resilience. This is not a matter of blaming or punishing individuals for their illness or disability – just recognising the requirements for safe and effective clinical practice.

  5. Richard M says:

    But ‘fitness to practice’ is a very slippery slope, somewhat subjective and open to manipulation and one that could well be used by people (themselves flawed) with personal agendas.
    “First do no harm” should also be the motto of the boards, but it manifestly is not..
    Why was this left to turn into some terrible ‘legal tangle’ rather than be handled by a competent psychiatrist?

  6. Peter Arnold says:

    This sad incident occurred in SA.
    It was precisely to try to avoid this type of situation that we persuaded the NSW government to amend the Medical Practice Act in 1990 to include Medical Board jurisdiction – in matters of health – over medical students. We were one of the first medical boards in the world to do so.
    That amendment enabled the universities in NSW to notify the Board of students about whom they had serious health concerns. Until then, such notification was beyond their remit.
    It would not be proper for universities to refuse entry to their courses or the granting of degrees on anything other than entry exams or academic merit.
    The NSW approach – still in force despite the existence of AHPRA – is the best we could think of. An analysis of the Board’s experience since 1990 might reveal whether or not it has, indeed, reduced the number of ‘disabled’ interns.

  7. T. Craven says:

    There is a degree of judgementalism about mental illness in some of the above comments which I find very disturbing, particularly coming from such authoritative and senior members of the profession. From a fitness-to-work viewpoint she is clearly not currently fit to practise medicine, or indeed any other occupation. However, what about the (admittedly unlikely) scenario that her condition remits for a prolonged period of time? Is she still not a fit and proper person simply by virtue of her past history many years before? There is also no comment about her family background – surely it would be unusual to have such an extreme personality disorder without a history of family dysfunction or even early childhood abuse. This is a really tragic case concerning a severely disabled person and the response by the medical profession even more tragic.

  8. sue ieraci says:

    After T. Craven’s comment, I re-read the other posts, (including my own), and honestly couldn’t see the alleged judgementalism about mental illness that is being described.
    There are various factors that can influence fitness to practice. Not all relate to illness at all – some can be personality factors or attitudinal issues. A wide range of illnesses can be involved, both “physical” and psychiatric.
    While the people with the illness no doubt feel judged, I have witnessed an enormous amount of latitude given to people who have performed their duties very poorly – not necessarily because they didn’t have the intellect, but because they simply did not have the ability to reliably and competently carry out safe medical practice. The public hospital system can try to hold them safely (at a considerable cost to an over-stretched system) but at some stage they have to demonstrate the ability to practise safely and reliably.
    Not everyone can practise medicine – no matter how well they do academically. There is no “right” to be employed for a position that one cannot fulfill.
    I am not aware of anyone who has been “banned” for life from practising – if they show reliable recovery and appropriate skills, generally they can get back on track. However, people who have conditions that are likely to preclude them ever being able to practise safely and reliably are done a disservice if they are not counselled during (or before) medical school. How is it more humane to put them through hell and force them to fail?

  9. CJ says:

    It is also a shame that this intellect will be lost to the profession. Is there not a place for practice without patient contact, such as laboratory work or analytical research or epidemiology? I guess it would depend on the degree of disability – I know very little obout the effects of this syndrome.

  10. Anonymous says:

    I know doctors who were good pathologists although incompetent in general practice. Backroom practice could be specified by AHPRA; and allow her brain to contribute to the world; even if she does not love herself enough.

  11. David says:

    I agree with the other commentators that the case described represents a very bad outcome and is indeed a tragedy. Although the ultimate result may have been the same, it is unfortunate, but probably not surprising that the problem was not identified and managed earlier.
    There are a number of factors that are likely to be operating. My experience as a long time and recently retired clinical teacher is that clinical education is becoming increasingly dispersed and the resources devoted to medical education are diminishing, particularly in the University Medical schools. Dispersion means that students cycle through 6 or 8 week clinical rotations, often with different students in each group, and it may take almost all that time for clinical teachers to identify that poor performance has a serious underlying cause. When it is detected, the clinical teacher is unlikely to have the authority or resources to deal with the matter and experience suggests that medical schools are reluctant to do so. The problem is therefore passed on from one term to the next and comes to a head at registration, or some other crisis point. Very similar considerations apply to junior medical staff.
    Medicine has a very strong culture, which is simultaneously and paradoxically embracing and highly competitive. Medical students and doctors are intellectually very competitive and a high value is placed on success. Conversely there is a high price to pay for failure. There is therefore a reluctance to approach supervisors with problems. This combined with a risk management and/or disciplinary approach to mental illness and disability make students and doctors reluctant to seek help and to become experts at concealment. Conversely clinical supervisors tend to focus on performance and are not necessarily observant or even interested in the behaviour of their staff.
    My observation suggests that although some hospitals have developed excellent support systems, the problems are more severe in some of the larger teaching hospitals, where the environment is more competitive, there are higher expectations of performance, a greater availability of junior staff, consultants are more remote from their junior staff and the larger organisation is more likely to swamp the individual.
    There are no easy answers to this problem, but awareness of the problems, the development of support systems and awareness that poor performance may be a symptom that should be investigated, rather than a reason for “performance management” would be helpful.

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