Physician heal thyself (Medice, cura te ipsum)

The doctor who called us was stunned. They had been reported to Ahpra and were being investigated for self-prescribing. “It’s my business if I prescribe to myself; and anyway, these were not Schedule 8 medicines!”

And so began a discussion of how the Medical Board views self-treatment by medical practitioners, and how this has changed over the years.

There is broad recognition that our health and wellbeing impacts on our practice, and we are extolled to accept self-care as a cornerstone of professional life.^1,2 However, there are distinct limits to the self-care we can and should provide to ourselves.

Stepping into providing ourselves care that only a registered health practitioner could deliver, likely means we are stepping outside the Medical Board’s Code of Conduct³ guidelines, with the risk of poor care outcomes or investigation. Every year, there are examples of practitioners who have registration-impacting outcomes at Tribunals resulting from inappropriate self-care and care boundaries.⁴

Section 11 of the Code, a relatively recent addition, talks about managing one’s own health. This section reflects similar constraints to the provision of care to close friends, family, and those you work with, discussed in section 4 (which was also updated).

• Medical practitioners should not be self-prescribing

  This isn’t just a reference to self-prescribing Schedule 8 drugs (which most jurisdictions restrict or prohibit) or select Schedule 4 drugs, including drugs of dependence. It refers to ALL prescriptions by a practitioner for themselves. In addition, practitioners risk breaching the specific, varying, and complex legislative restrictions on self-prescribing in each jurisdiction – ranging from full self-prescribing prohibition (Victoria) through restrictions on prescribing Schedule 8 drugs and some Schedule 4 medicines (Queensland, ACT, NSW, potentially WA/NT); or restrictions on self-prescribing Schedule 8 drugs. Such breaches may be a criminal offence.

• Health practitioners should have their own GP

  While I’m sure we all subconsciously self-diagnose at times, the value of independent objective workup, investigation and treatment cannot be overstated. This includes the importance of approaching your treating team for documents like medical certificates, and not issuing these yourself.

• Seek advice

  There is additional emphasis on the importance of seeking advice in relation to health issues that could impact your work, including stress, burnout and mental health.

• Contact the DHAS

  If you have troubles locating a GP, the Doctors Health Advisory Service (DHAS) in your jurisdiction may be able to assist in finding GPs who have identified themselves as having an interest in looking after the health of their colleagues. They can also provide confidential telephone call-back support in more acute circumstances, such as mental illness, stress, drug and alcohol dependence, and other personal issues.

• Mandatory reporting reassurance

  Where doctor-patients follow their treating team’s advice on whether their health issue impacts on work and how they should manage this (including modifying their practice), there should be no basis for a mandatory report. Complaints are generally straightforward to deal with if the doctor has sought and followed their treating practitioner’s advice. It is more common for doctors who don’t have a treating team to find themselves in difficulty if a concern about health impairment is made to a health complaints body. Tragically, we are also aware of terrible outcomes arising when doctors attempt to manage their own substance misuse or significant mental health conditions.

MDA National strongly supports all doctors having their own treating team. If you are concerned about the medico-legal implications of a health issue, our medicolegal advisers are happy to assist you and provide advice.

Extracts from the Medical Board’s Code of Conduct

11.2 Your health

Good medical practice involves:

• 11.2.1 Having a general practitioner.
• 11.2.2 Seeking independent, objective advice when you need medical care, and being aware of the risks of self-diagnosis and self-treatment.
• 11.2.3 Seeking help if you are suffering stress, burnout, anxiety or depression.
• 11.2.4 Making sure that you are immunised against relevant communicable diseases.
• 11.2.5 Not self-prescribing.
• 11.2.6 Recognising the impact of fatigue on your health and your ability to care for patients, and endeavouring to work safe hours wherever possible. 
• 11.2.7 Being aware of the doctors’ health program in your state or territory which provides confidential advice and support through the doctors’ health advisory and referral services.
• 11.2.8 If you know or suspect that you have a health condition or impairment that could adversely affect your judgement, performance or your patient’s health:
  • not relying on your own assessment of the risk you pose to patients
  • consulting your doctor about whether, and in what ways, you may need to modify your practice, and following the doctor’s advice.

4.15 Providing care to those close to you

Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship. In most cases, providing care to close friends, those you work with, and family members is inappropriate because of the lack of objectivity, possible discontinuity of care, and risks to the patient and doctor. In particular, medical practitioners must not prescribe Schedule 8, psychotropic medication and/or drugs of dependence or perform elective surgery (such as cosmetic surgery) to anyone with whom they have a close personal relationship.

In some cases, providing care to those close to you is unavoidable, for example in an emergency. Whenever this is the case, good medical practice requires recognition and careful management of these issues.

References

1. Black Dog Institute. Self-care planning for healthcare workers. blackdoginstitute.org.au/wp-content/uploads/2020/05/COVID-19_Self-care-plan-for-healthcare-workers.pdf

2. RACGP. Keeping the doctor alive: A self-care guidebook for medical practitioners. racgp.org.au/FSDEDEV/media/documents/Running%20a%20practice/Practice%20resources/Keeping-the-doctor-alive.pdf

3. Medical Board. Good medical practice: a code of conduct for doctors in Australia. medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx

4. Health Care Complaints Commission v BXD (No 1) [2015] NSWCATOD 134

Medical Board of Australia v GMZ [2017] VCAT 902

Health Care Complaints Commission v Geary [2018] NSWCATOD 15

Medical Board of Australia v Stephen Hadges [2018] SAHPT 6 (5 June 2018)

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