The past few years has seen article after article reporting doctors’ fears associated with the Mandatory Reporting system (administrated by AHPRA).  We’ve all read about the concerns registrants face when considering the impact of seeking health care for certain types of health issues, particularly mental health concerns.  

Advocates have been pushing for all States and Territories to adopt the Western Australian model; and with good reason.  There is no evidence that WA has a higher incidence of medical practitioners causing harm/risk to the public when practicing; but doctors in WA can access health care without the same concerns as their peers in the rest of Australia.

While taking a mental break from the intense task I face in preparing for my own appeal against conditions imposed on my medical registration (as the result of having a mental health history) I sat down last night to watch “The Castle”.  

“It’s the vibe of it.”  

At some stage, late in high school, I did read the Australian Constitution; that was a while ago.  I read it again.  We don’t have a Bill of Rights in Australia (which is quite unfortunate), but we do have two clauses in our Constitution that provide some degree of ‘protection’.

Section 117 is of particular interest to me, and perhaps to others interested in changing our Mandatory Reporting laws.  

Section 117:

A subject of the Queen, resident in any State, shall not be subject in any other State to any disability or discrimination which would not be equally applicable to him if he were a subject of the Queen resident in such other state.

It’s a little wordy, like so many things in law.  Let’s break it down:

Subject of the Queen = Australian citizen and/or resident

Resident in any State = Broad/Temporary

Disability or Discrimination = A less positive circumstance/situation

The essence of Street v Queensland Bar Association was that a State cannot impose limits on professional practice qualifications on the grounds that a person is not permanently residing in that State. While it can be said that this requirement impacts equally on residents of any particular State, it has a more significant impact on those not residing in a particular State.

All Australian States and territories have Mandatory Reporting laws; WA’s being the safest for doctors and the public.  The National Law, as worded in all other States and Territories does apply equally (within each State) to residents of all States:  A Western Australian doctor seeking certain types of ‘health care’ in NSW/VIC could well expect to be subjected to the Mandatory Reporting system of that State.  The issue here isn’t whether the Law applies equally to people from any particular State, it is that residents from any State/Territory other than WA are subjected to far more significant and serious consequences than a resident of WA would be subjected to under Western Australian Law.

Section 117 of our Constitution has been discussed amongst lawyers over the years without any finite conclusion about its ability, as a clause, to allow for equal treatment between residents of different States.  Perhaps it is time for a revival of those discussions.

#WAModelNow is a Constitutional proposal.  I’ll go further to say that any State/Territory applying Mandatory Reporting Laws that are more stringent and onerous to registrants are behaving in a manner that is unconstitutional!  

It isn’t just ‘the vibe of it’; it is a Constitutional right that health practitioners across Australia be afforded the same protections as their peers receiving health care in Western Australia.

April is now referred to by many as Autism Awareness Month. Many of us in the Autistic Community would prefer it was called Autism Acceptance Month; people seem adequately aware of autism these days, but acceptance is often lacking.  

I want to address something that is both an issue around awareness and acceptance.  Having recently been the subject of a number of media articles that highlighted the fact that I am a doctor and also autistic, I was faced with certain comments and assumptions.  The one below is worthy of discussion.

“Am I alone in thinking that autism is not compatible with seeing patients? Surely empathy is essential in a medical practitioner but this is by definition lacking in someone with autism?”

My immediate response to this comment was an internal monologue along the lines of “No, sadly, you are not alone in that thinking…  But, you are wrong.”

Let’s talk about empathy, and then let’s talk about that in someone who is autistic. 

Autistic people do not lack empathy:  This is an age-old myth that is harmful and quite lacking in insight! Empathy is the ability to understand and share the feelings of another; it relates to how good we are at sensing another person’s emotions and understanding what they are thinking or feeling.  Breaking it down, there are multiple parts to empathy:

• Sensing what someone else is feeling (distress, happiness, anger)
• Understanding what another person is thinking or feeling (being able to put yourself in their shoes, having theory of mind)
• How a person visibly responds to emotions expressed by those around them (perhaps you reach out and hug someone who looks sad).

Other forums might describe the two different types of empathy; Affective empathy and Cognitive empathy.  The first, affective empathy, refers to the sensations and feelings we get in response to others’ emotions.  The second, cognitive empathy, refers to that ability to identify and understand another person’s emotions by taking their perspective.

There is good evidence that autistic individuals do have a strong sense and awareness of the emotions expressed by others.  Often a heightened sensitivity to the emotions of others is something that overwhelms autistic individuals.  Now consider the role of affective empathy in medical practice; it is the feelings we get in response to others’ emotions:  We see someone sad, so we feel a bit sad.  We may see someone is fearful and become fearful too.  Often the role of affective empathy isn’t to ‘fix’ something driving another person’s negative emotion (if it is negative), but to ‘convey’ to that person a degree of understanding so that they feel heard and understood.  Consider that in the context of a doctor treating a patient.  If my patient is highly distressed about their illness, I would prefer that I not mirror that high level of distress, automatically. It is important that I understand they are distressed, and why that is likely (cognitive empathy, which we will come to), but there is little benefit in me mirroring their distress beyond communicating that I do have an appreciation of their predicament.  To be honest, the ability to not become enveloped by the emotions of those around, when faced with highly distressing scenarios can be an advantage; perhaps it allows you to step back and focus on finding a solution to the distressing situation, perhaps you can calmly handle a pressing medical emergency.  

Please don’t assume I’ve never cried with a patient or family member: I have.  When it has been appropriate, I have sat with patients or their loved ones and cried, laughed, and celebrated.  

Cognitive empathy is something we learn.  It is a developed social skill.  It is true that autism is a developmental disorder and that many individuals who are autistic need some extra assistance in developing certain skills, including theory of mind and cognitive empathy.  The point is, cognitive empathy is something you can be taught, and you can choose to develop in yourself.  Perhaps more than many of my neurotypical peers, I have specifically worked on my own skills in cognitive empathy (from quite a young age) after realising it didn’t come naturally.  

Here is an example of how age, and experience can impact on an autistic individual’s cognitive empathy.  

At the end of 5^thgrade, in primary school, I recognised that my teacher had clearly struggled having me in her class for an entire year.  I was pretty advanced in mathematics but struggled with the nuances of language. My teacher was amazing with language, but not quite so strong with basic maths.  I had affective empathy; I realised she felt stressed whenever she needed to teach what she considered ‘difficult mathematics’.  What was lacking was my cognitive empathy.  By nature, I am extremely caring, and I thought I should try and help my teacher so she wouldn’t feel so stressed the following year.  While we hadn’t managed to get along for most of the school year, I decided I would offer her a solution to her woes on the second last day of the year.  During recess I approached her and said the following:

“Ms Brown (name changed).  I’ve been thinking about how you could have a better year next year. I know you’ve found the maths quite hard while teaching grade 5.  Maybe next year you could teach Grade 2; then the maths and the English will be at your level and you won’t have to feel stressed.”

As an adult, with developed cognitive empathy, I both cringe and laugh at that statement.  It was said with the best of intentions and I was quite shocked at the absolutely volcanic response it received at the time.  Now, I understand how offended a grown adult would have been having an eleven-year-old suggest they were only capable of Grade 2 maths.  I only attended that school for one more day and then my parents moved me.  

Life experience, social stories and lots of practice mean that I have a reasonably strong cognitive empathy capacity now.  No, it isn’t always natural.  It doesn’t matter that it isn’t.  It is a bit like having to have learnt another language to communicate in.  I simply have to make the decision to think through a situation and actively consider what the other person’s perspective may be in any situation.  As with any other learnt, unnatural skill, it is more likely to ‘fail’ when tired or sick.  For many people with a second language, they prefer to use their native language when tired; that doesn’t mean they can’t be extremely proficient in the use of their non-native tongue. 

The development of cognitive empathy is foundational to responding in a socially acceptable manner.  A socially acceptable response can also differ depending on who you are responding to. Having invested into my own cognitive empathy abilities I am relatively confident that, in the majority of situations I can display an appropriately empathetic response to a patient or family member in a clinical setting.  After all, I never saw medicine as simply knowing a bunch of facts about physiology/pathology/anatomy; medicine is about helping people.  When I am with a patient, I see making an assessment of how they are feeling and responding as much a part of my job as interpreting their blood work or chest x-ray.  Because it is, to me, part of my role as a doctor, the cognitive empathy side of an interaction is something I actively consider and plan for.  

I have never had a patient complain about my level of empathy.  I have had a multitude of patients convey to me their gratitude to have been treated by someone that clearly stopped and considered their emotions and perspective; this is a far cry from the inference that an autistic doctor lacks empathy.

Being autistic, I often watch the same movies over and over again. In high school I watched the movie “Patch Adams” so many times that I can literally watch the movie in my own head with all the scenes and script lines perfectly recorded by my own memory. In my first year of medical school the walls of my college bedroom were plastered with quotes from the movie “Patch Adams”.

“If you treat a disease, you win, you lose.  You treat a person, I guarantee you, you’ll win every time; no matter what the outcome.”

“What’s the difference between a scientist and a doctor?… … People!”

“If you focus on the problem you can’t see the solution.”

Simply having that obsession with “Patch Adams” before I even commenced medical school was a strong foundation in ensuring I developed cognitive empathy alongside all the other requisite skills taught in medical school.  

Finally, we need to think about the response we exhibit once we’ve identified emotions in another person and considered their perspective. Every person is different (and that’s a good thing).  Some people will show they care by reaching out and hugging someone who is distressed. Another person may walk away to go hunting for a solution to whichever problem has caused that distress.  We need both of those kinds of people! There is nothing wrong with being the hugger.  There is nothing wrong than being the person who takes on board that someone is distressed and then walks away to try and find a solution.  Hopefully, the ‘hugger’ and the ‘solution hunter’ are paired together within a team, giving a distressed patient the best of both styles. They are also not mutually exclusive. With enough time available, a single individual can offer both responses.  

Personally, I am the ‘solution hunter’.  When I see a problem that is causing distress, I want to get to the root cause of that issue.  I’m that person that will be trawling through countless books and journal articles trying to come up with a creative and effective solution if there isn’t one that is immediately obvious.  I am the one whose mind won’t shut down while they’re eating dinner at home until I’ve solved that problem.  That’s my strength.  I can be the one to sit there, listen and be a shoulder to cry on; but I am much better at being the invisible solution finder.  Heading off to the library to try and find a solution to your patient’s problem is no less empathetic than sitting there and holding their hand while they process their own emotions. 

The ultimate positive of being an autistic doctor is that I have had to learn cognitive empathy and practice taking the perspective of a lot of people who think quite differently to me.  But there have been times when I have been the only doctor able to take the perspective of certain patients; my autistic patients.  

I have had autistic patients who have struggled with the same things I struggle with when I am in that patient role.  Sensory issues.  Food preferences.  Difficulties in a different environment.  All of these things impact on patients, and particularly autistic patients.  It amazed me while working on one unit that my entire team were quick to criticise how challenging one of our adult autistic patients was.  To me, it was completely logical.  The young man was in a 6-bed bay, in a state of sensory overload, and being denied access to his usual coping mechanisms.  The need for a ‘psychiatric consult’ vanished overnight when I implored the nursing team leader to implement some minor changes to his location and how nursing staff were approaching him.  With this patient, my own natural ability to understand what was causing him difficulty was superior to that of my neurotypical colleagues.  While they are more able to naturally relate to the perspectives of other patients, they struggled with their own cognitive empathy skills when faced with a neurodiverse patient.  

In concluding I’d ask the following.  If you are a doctor, or health professional, consider what I’ve written before you criticise yourself or a colleague on their ‘empathy’ skills. We are all different and we have patients who are all different.  Your way of expressing empathy may differ to the doctor sitting next to you; neither one of you is better.  You may be ‘better’ for Patient X in Bed 1 and your colleague may be ‘better’ for Patient Y in Bed 2.  Instead of criticising when someone responds differently to how you would, consider it a blessing that we have peers who are able to think differently to us and who have different strengths to our own; because when we team up, we are able to offer a broader level of support to the patients we come across.  

“I volunteer!  I volunteer…” 

If you can picture Katnis Everdeen saying that as she volunteers to participate in the Hunger Games then you will have some idea of the emotion(s) I felt on 9 March 2017:  But, that’s not where this story really begins.

Everyone has seen the articles about doctors ending their lives, the impact of mandatory reporting, and the desperate need for a complete overhaul of our regulatory system.  So, this is the point where I bring into the discussion a frank account of the lived experience of a doctor with a history of mental health issues, and what happens when AHPRA get involved.

I strongly contest the validity of the following statement made by Professor Anne Tonkin, current Chair of the Medical Board of Australia, in a recent interview. 

“I’m very concerned about people saying that they don’t think they can get help, because the Medical Board is not the slightest bit interested in hearing about anybody who has any kind of health issue that they are dealing with appropriately, and that doesn’t affect their practice. We don’t even want to know.” 

My own experience of AHPRA and the Board, including how my current appeal against imposed conditions that prevent me from practicing clinically is being handled, provides a wealth of evidence against there being any truth in what Prof. Tonkin has said.  It is my intention to progressively address why Prof. Tonkin’s words resonate so far from the truth in a series of posts.  

I surrendered my medical registration in 2015.  At that time, I was completely broken and continuing to fight would have, without doubt, cost me my life.  In the weeks leading up to my decision to surrender my registration one of my closest friends from high school told me that she was afraid that she would lose me in a battle against prejudice.  She told me “I would rather have you alive and working in some crappy, boring, desk job; than live having lost my friend to suicide because you kept fighting an in-just system.”  That message came with a link for a job advertisement in the Public Service. 

At that moment, I wanted nothing more than to be dead.  I didn’t want to wake up and face another day. I was, most certainly, clinical depressed; but, more importantly, I was traumatised.  Traumatised by the impact my mental health had on my career, traumatised by the actions of AHPRA and the Medical Board, and traumatised that I had found out over and over that as a doctor-patient I had no rights to privacy, no rights to treatment, no rights to have a health condition.  I couldn’t bear the idea of waking up one more morning to face the memories of those traumas.  

Less than a month earlier my family had ‘extracted’ me from a toxic situation in Tasmania and relocated me back to our family home, just outside Canberra.  I had just tried to end my life and gone to extensive length to ensure the attempt was successful.  I never expected to wake up and was disappointed, anguished and distraught when I did.  My final thoughts before at that time were not of loved ones and aspirations.  My final thoughts were focused on pure dread that if I woke up AHPRA, the Board and their lawyers would subject me to further torture; nobody should have to think that way.  When I returned to NSW, you could have described me as the walking dead: I was depressed to the point that I didn’t care about anything and, despite still breathing, was destroyed inside.

Like a robot, I applied for the job in the Public Service (APS) that my friend had sent me.  The chances of succeeding in your first application for a role in the APS are slim; particularly when you have a diverse work experience background.  I had no expectation that my application would be successful and applied to appease my friends and family.  What nobody knew was that I had also planned my disappearance and suicide, including a letter with final instructions, and that I was waiting for the confirmation that my application was rejected before I carried out my final plan.  In my mind, while depressed, I believed that if I could say I had at least tried that perhaps the impact of my death on loved ones would be less.  

The conditions imposed on my medical registration at that time were publicly viewable and I worried that if the people assessing my application for a role in the APS saw those conditions that it would jeopardise my prospects of success.  AHPRA had failed to process my registration renewal and my legal support advised me that it was unlikely they would allow me to remain registered; so, I signed a form surrendering my registration.

I will never forget the first appointment I had with my psychiatrist after surrendering my medical registration:  I had no intentions of even reapplying to be a registered health practitioner.  Choked up and struggling to breath, due to the flood of emotion associated with this particular realisation, I burst into tears and said.  

“I don’t know what to say to you:  This is the first time in my life where I’ve been able to attend a psychiatrist and ask for help knowing that I have privacy.  They (AHPRA) can’t go through my files anymore.  They can’t scrutinise everything that is private about my mental health conditions and treatment and throw it at me in my career. I have doctor-patient confidentiality… I don’t have to be scared when I see you now.”

My psychiatrist gave me the time I needed to digest that realisation and then prepared a plan to move forward and get me through the depression and trauma.

Each evening I dutifully took my antidepressant with no expectation of benefit or a positive outcome.  Friends and family continued to cheer me on from the sidelines totally unaware that I had already made my decision and was waiting for the right moment.  Then, I received an invitation to attend a job interview. My emotions were mixed; I was annoyed, but also saw the first glimmer of hope for any kind of future life/career in many, many months.  Consistent with my perfectionist personality style, I decided that it would be wrong for me to attend the interview and give it anything but my best effort.  

January 2016 was when I found out that I was successful in that application.  A number of weeks had passed where I was consistently able to take my antidepressant while also being safe from attacks, hostility and further trauma.  My depression had already begun to lift and suddenly there was a tangible piece of hope that I may have a ‘life’.  By the date I was due to commence my new career, I was safely out of the grips of depression.  Of course, I still had to face the memories and live with the trauma, but I was well and had a way forward.  

My first supervisor in the APS was supportive and a God-send; he made integrating into a new work environment easy and we remain friends even though we are no longer in the same team.  

That brings us to 2017.  By January of 2017 I had well and truly moved on from the traumas of the past. Living back in the region where I had grown up allowed me to rekindle old friendships.  Working in a job role that allowed for healthy working hours allowed me to manage my own health effectively.  I can honestly say that at some point between January 2016 and January 2017 I started to feel and experience genuine happiness again.  

Then it hit me.  The first article I read about the spate of doctor suicides in NSW and the impacts of mandatory reporting hit me like a freight train:  I actually threw up and sat curled up in a shaking, crying, mess on my bathroom floor for a number of hours.  There was a sudden realisation that the pain, trauma and fear that I had experienced at the hands of AHPRA and the Board wasn’t limited to my case.  Until that point, in an unintentionally self-absorbed way, I had assumed that the traumas I had experienced relating to my own medical registration were limited to me.  Certainly, in all my interactions with AHPRA I was left feeling like I was the ‘worst case’, ‘most terrible person’ etc and, that there could not possibly others they invested similar energies into.  

Suddenly my own resignation from medical practice became unacceptable.  I could live with feeling as though my own career was ‘stolen’ by those with prejudices. What I can’t live with is knowing that others are being subjected to the same processes, the same traumas, the same fears; and, that it is costing lives.  

“I volunteer.”  

On 9 March 2017 I mailed my application for (re)registration as a medical practitioner to AHPRA.  

I volunteer to stand up and fight against a serious flaw of our registration system and regulatory body.  I volunteer to stand up and speak out about how doctors (and other health practitioners) with mental health histories are treated and handled.  I volunteer to have my own history and story laid out publicly for the world to see in the interest of having a real discussion about what does and does not make a health practitioner a ‘risk’, or ‘impaired’.  

I am the perfect ‘test-case’ for a discussion about how we should assess if a practitioner poses a risk because of their mental health.  I have an extensive history of depressive episodes, suicide attempts and hospital admissions:  The details of how misdiagnosis, incorrect treatment, prejudice, and inability to access care without the focus being first on you as a doctor, and my own genetic susceptibility to certain medications played a role in this will most certainly come out in the near future.  Importantly, what I do not have, is any record of complaint by patient, family member, or colleague about my ability to perform well and behave appropriately in a clinical setting.  There are no complaints to AHPRA (or the previous state based Medical Boards) about my performance or conduct in practice.  I have taken time off from practice when unwell. Yet, despite a ‘clean record’ in my actual work as a practicing medical practitioner, I am blocked from working clinically.  

A De Novo hearing of my case goes before a tribunal panel of four members at the NSW Civil and Administrative Tribunal (Sydney) on 15-17 April 2019.  I am appealing the conditions on my registration.  If successful, there will be case law that other practitioners can rely on in their own struggles with AHPRA (that’s the goal, my own return to practice would be a bonus).  If unsuccessful, then we will be able to clearly state that how we assess whether or not a practitioner is a risk is not based on their performance or practice history, but merely on a presence of illness (past, or present); and we will have stayed in a place where stigma and prejudice prevail.  

I am all too aware that a statement like I have written here today opens the door for people to say all manner of things about me, my past, my future etc.  It opens the door for a discussion that may not always be pleasant.  Many people have their own views, and I accept that.  It may have taken me until age 35 to be able to say the following with any degree of integrity, but here it is:  

“I know who I am.  I know my past.  I know my history.  I am a doctor who has experienced mental health problems and made attempts on my own life.  I am autistic, and don’t quite ‘fit the mould’.  Many people think they know my story, or something about me; many people also don’t have the full story or context.  I will not be shamed, and I am not ashamed, for having experienced mental illness, nor for having been a less than perfect patient.  I am a good doctor and a safe doctor, regardless of what the Board’s imposed conditions may imply.  Most importantly, I will not be defined by the words of others, past, present or future.” 

With this in mind.  I start this series of posts about the lived experience(s) of a doctor with a mental health history faced with AHPRA and the Medical Board.