The Legal Underpinnings of Medical Discipline in Common Law Jurisdictions.

Medical regulators have a responsibility to protect, promote, and maintain the health and safety of patients. Here, we compare and contrast the processes for addressing concerns about doctors in four countries with legal systems based on English common law: the UK, Australia, the United States, and Canada. The legal provisions underpinning each jurisdiction's disciplinary processes depict distinctive outlooks from the different authorities as each works toward the same goal. The initial stages of the investigation process are broadly similar in all of the jurisdictions examined. Each process, however, has subtle differences with regard to its comparators. Factors include how matters of discipline are framed, the constitution of disciplinary panels, and how the perceived independence of these panels all philosophically affect the public safety remit of each regulator. This work constitutes the first comparison of international regulatory frameworks for the profession of medicine.

Medical Licensure Questions About Mental Illness and Compliance with the Americans With Disabilities Act.

Substantial numbers of medical students and physicians live with some form of mental illness. Over the years, many medical licensure boards have asked physician medical licensure applicants with Doctor of Medicine (MD) degrees intrusive questions about whether they have any psychiatric history. This has discouraged many who need psychiatric treatment from seeking it because of fear of the questions. Gradually, court decisions and the United States Department of Justice have established that such questions violate the Americans with Disabilities Act (ADA). The 2014 Louisiana Supreme Court Settlement Agreement set definite limits on law licensure mental health questions, followed by a least one licensing body revising its physician licensure questions to be consistent with ADA standards. In this article we examine the current medical licensure questions from each state and the District of Columbia about the mental health of applicants and discuss their validity under ADA standards. Our original investigation of these questions found that the majority still ask questions that are unlikely to meet ADA standards. The judicial and Department of Justice developments, however, may compel them to abandon these questions. If not, legal action will enforce ADA compliance. This change will significantly benefit applicants who need psychiatric treatment.

Alcohol Consumption and Impairment of Surgeons: A Case for Total Abstinence?

In the 2016 appeal Health Care Complaints Commission v Schmidt [2016] NSWCATOD 145, the New South Wales Civil and Administrative Tribunal heard evidence to the effect that the influence of alcohol (alertness, judgment and co-ordination) could occur at blood alcohol concentrations as low as 0.01% and that on-call health professionals should not consume any alcohol. The NSW Health Code of Conduct requires all staff, including contractors, "not to be under the influence of alcohol or drugs when commencing work and while at work", and the Public Health Regulation 2012 (NSW) similarly requires that "health practitioners must not practise while suffering from a physical or mental impairment … that detrimentally affects, or is likely to detrimentally affect, his or her ability to practise or that places clients at risk of harm". If this were to be accepted as a professional standard for on-call medical practitioners, then it would have major implications for much of the medical profession, particularly those on continuous call in private practice whose hours are not delimited. The evidence for alcohol-induced impairment of clinical performance is assessed here through the prism of the cognitive and psychomotor skills requirements for surgeons.

Monitoring a "Menace": Peer Review and the Regulation of Substance-Addicted Doctors, 1933-1948.

This article examines the first power that Victorian parliamentarians granted to the Medical Board of Victoria (Board) to regulate impaired doctors. Convinced that substance-addicted doctors were a "menace", in 1933 the legislature gave the Board discretion to remove their names from its register of "legally qualified medical practitioners". In the next 15 years, however, the Board chose not to cancel the registration of several doctors who came to its attention for their addiction to alcohol or drugs and instead the Board monitored those doctors; it mostly sought assurances from the practitioners that they were obtaining treatment for their addiction, abstaining from consuming alcohol and drugs, and refraining from practising medicine, usually until their treating practitioners considered that they were fit to resume medical practice. This article evaluates the benefits and pitfalls of the Board's regulation of these doctors, including in light of Anglo-American legal scholars' discussion at that time about the merits of the growth of administrative agencies and their work. The article then considers the lessons that can be learnt from this history about how substance-dependent doctors should be regulated and who should be involved in decision-making regarding their regulation.

The impaired and/or disabled anesthesiologist.

PURPOSE OF REVIEW: Impairment and/or disability resulting from any of a number of etiologies will afflict a significant number of anesthesiologists at some point during their career. The impaired anesthesiologist can be difficult to identify and challenging to manage. Questions will arise as to if, how, and when colleagues, family members, or friends should intercede if significant impairment is suspected.This review will examine the common sources of impairment among anesthesiologists and the professional implications of these conditions. We will discuss the obligations of an anesthesiologist and his/her colleagues when there is sufficient suspicion that he/she might be impaired. RECENT FINDINGS: Substance use disorder remains one of the commonest sources of impairment among both resident and attending anesthesiologists. Other common etiologies of impairment include various physical ailments, major psychiatric disorders, especially depression and burnout, and age related dementia. Many regulatory organizations, healthcare systems, and state licensing agencies have developed programmes and protocols with which to identify and direct into treatment those suspected of significant impairment. SUMMARY: Some degree of impairment will occur to one-third of anesthesiologists during the course of their career. It is important to understand how such impairments might impact the safe practice of anesthesiology.

Views on mandatory reporting of impaired health practitioners by their treating practitioners: a qualitative study from Australia.

OBJECTIVE: To explore the views and experiences of health sector professionals in Australia regarding a new national law requiring treating practitioners to report impaired health practitioners whose impairments came to their attention in the course of providing treatment. METHOD: We conducted a thematic analysis of in-depth, semistructured interviews with 18 health practitioners and 4 medicolegal advisors from Australia's 6 states, each of whom had experience with applying the new mandatory reporting law in practice. RESULTS: Interviewees perceived the introduction of a mandatory reporting law as a response to failures of the profession to adequately protect the public from impaired practitioners. Mandatory reporting of impaired practitioners was reported to have several benefits: it provides treating practitioners with a 'lever' to influence behaviour, offers protections to those who make reports and underscores the duty to protect the public from harm. However, many viewed it as a blunt instrument that did not sufficiently take account of the realities of clinical practice. In deciding whether or not to make a report, interviewees reported exercising clinical discretion, and being influenced by three competing considerations: protection of the public, confidentiality of patient information and loyalty to their profession. CONCLUSIONS: Competing ethical considerations limit the willingness of Australian health practitioners to report impaired practitioner-patients under a mandatory reporting law. Improved understanding and implementation of the law may bolster the public protection offered by mandatory reports, reduce the need to breach practitioner-patient confidentiality and help align the law with the loyalty that practitioners feel to support, rather than punish, their impaired colleagues.

DISCIPLINARY PROCEEDINGS AGAINST DOCTORS WHO ABUSE CONTROLLED SUBSTANCES.

This study examined 27 reports from disciplinary tribunals throughout Australia (save Tasmania where reports were not accessible) against medical practitioners who abused narcotic analgesics (often combined with other drugs of addiction) between 2010 and 2015. The reports revealed that 12 medical practitioners were in their 40s; five in their 30s; and one person still in their 20s. Although the majority were general practitioners (15 out of 27), other medical specialties were also represented. Self-administered pethidine was the most prevalent opioid (11 out of 27) and was the only drug used alone. Morphine was self-administered by six doctors; the same number used high doses of Panadeine Forte, codeine and codeine phosphate. Fentanyl was abused by five doctors. Surprisingly, fewer medical practitioners appear to use propofol, and similar opiates such as tramadol (Tramol) and/or oxycodone (Endone). The examination of cases suggests lack of consistency in the imposition of professional sanctions and penalties by the relevant tribunals. To remedy this problem, it is suggested that disciplinary tribunals should apply the test of proportionality in the form of "reasonable necessity" when deciding whether to remove or suspend the addicted medical practitioner from the Register.

Refusal to grant provisional General Medical Council registration to U.K. medical graduates.

In the last five years, 2010-2014, there have been 17 instances when an application for provisional registration by a U.K. medical graduate was refused by the General Medical Council because the Registrar considered that the applicant's fitness to practise was impaired. While this number is small, the fact that this can happen is largely unappreciated by medical students and their teachers, the prevailing false assumption being that passing finals and graduation is the final hurdle before taking up a Foundation Programme post. It is a poorly recognised fact that just because a university fitness to practise committee has concluded that a student is fit to practise there is no guarantee that the General Medical Council will come to the same decision. This paper explains the reasons for these refusals and makes suggestions for students and medical schools.