Doctor. Lawyer. Academic. Author. Researcher. Dr. Marie Bismark is many things, but across it all, she is a passionate, articulate, and driven advocate of patient safety, mental health among health care workers, and complaints resolution. And as such an advocate, much of Dr. Bismark’s career has been in and around health care regulation. In addition to completing advanced training in psychiatry as an active clinician, Dr. Bismark currently leads the Law and Public Health unit at the Centre for Health Policy at Melbourne’s School of Population and Global Health.

Dr. Bismark joined Ascend Radio podcast host Paul Leavoy on a recent episode to talk about her research, which examines the intersection between clinician well-being, medical regulation, and patient safety. They began their conversation by discussing the mental well-being of health practitioners, the common features of sexual misconduct complaints in health care, and the effectiveness of regulatory interventions in cases of sexual misconduct. This interview has been lightly edited for length and clarity.

Is the well-being of health practitioners something that hasn’t been looked after in a holistic way? 

We know that health practitioners have higher rates of depression than many other health professions. We did a large national study of suicide across all different occupations in Australia, and we found that female health practitioners were twice as likely to die by suicide as women working in other occupations. Increased suicide risk among doctors in particular has been identified in other national studies as well. I think part of it is the stresses of the job, and I think part of it is the personality types of doctors and other health practitioners. We tend to be people who are very driven to provide great care and when things go wrong, they can have devastating consequences.  

Also, when a health practitioner does develop suicidal thoughts, they have access to very lethal means. What we saw in our study was that many of the deaths by suicide among health practitioners used prescription medicines as the means of death. If you’re a doctor and have both the access to and the know-how to use those medicines, it can be a very lethal form of suicide. 

For health care practitioners who are experiencing suicidal ideation, are there resources available for them? Is there a standard path to get help? 

Unfortunately, we still see a lot of stigma around accessing mental health care among the health professions. I think it’s slowly starting to change. Some of our recent research suggests that younger health practitioners are more willing to seek help for mental health issues than older health practitioners. But I think there is still some internalized and institutional stigma around health practitioners seeking help for mental health issues. There’s some amazing work being done to overcome that. We know for many health practitioners, they feel more comfortable speaking to a trusted peer or a trusted colleague than an independent third party. There’s a wonderful new peer networking service called Hand-n-Hand that’s been established in Australia by a young psychiatry trainee. So that’s one avenue for health practitioners to gain support. And then there are also networks of doctors’ health services which are run by general practitioners and psychiatrists who have a really good understanding of practitioner health. 

But unfortunately, there are a lot of misconceptions around [this issue]. In Australia there’s a legal requirement of mandatory reporting if you’re aware of a doctor with a health impairment that is causing serious risk to patients. The threshold for reporting is very high but unfortunately there are a lot of misunderstandings about that law, so some doctors are fearful to seek help for their mental health issues in case they are reported to the regulatory authority. Even though in most cases if you are seeking help and taking leave appropriately and engaging in treatment, that’s not something that needs to be notified to the regulator. 

What are the common stressors that lead to these sorts of situations? 

We’re really interested in exploring that further because I think it does vary by different life stages. For the younger trainees, there are still very long working hours for a lot of junior doctors in Australia. There’s the stress of having to fulfill the responsibilities of a full-time clinical job plus study for exams on top of that – I’m currently studying for my final psychiatry specialist exam, so I appreciate how stressful it can be to be working full-time as a doctor and also studying for exams on top of that. And then for many of those young doctors it’s a time of life when they’re forming relationships or thinking about starting a family, so they’re really being pulled in many different directions.  

And then right at the other end of the life course, we see a lot of stressors around older doctors. I think the medical profession hasn’t done a great job of thinking about those transitions to retirement. Some of our research in Australia has shown that there are increased rates of complaints to regulators about older doctors over the age of 65. There are some doctors who are working well into those traditional retirement years, so doctors are working at the age of 70 or 75 who may have some cognitive impairments. It’s just very recent in Australia that there are now requirements for doctors over the age of 65 to have regular health assessments as part of their registration process.  

Have any recommendations come out of the work you’ve done in this area? 

The requirement for older practitioners over the age of 65 to have regular health assessments was a policy change that was partly in response to our research findings about the increased rate of complaints to regulators within that age group. Some of our other research [that spurred change] has focused on patterns of concern. For a long time, medical regulators operated on a legal model where they would look at each complaint on a case-by-case basis, and what our research has shown is that it’s really important to look at a pattern of behavior across a number of years or across the course of someone’s career. We did also see some legal changes in Australia which gave regulators greater powers to look at patterns of concern rather than just individual complaints.  

I want to chat about the prevalence and patterns of sexual misconduct complaints. In an earlier conversation you pointed to the fact that fewer than 5% of practitioners account for about 50% of the complaints to regulators. Is that correct? 

Yeah, that’s absolutely right. Our research has shown that complaints to regulators cluster among a relatively small group of practitioners, so fewer than 5% of health practitioners account for about 50% of all complaints to regulators. I think that’s such an important finding in terms of how regulators focus their limited time and resources. It’s telling us that most health practitioners are doing a very good job and will very rarely come to the attention of health regulators. But there is a small group who receive these recurring complaints and it is important to identify them early, both to protect patients, but also to try and support those practitioners back into safe practice if you can.  

I always find it heartbreaking when I see a practitioner who’s received eight or nine or 10 complaints to a regulator and ends up in front of a disciplinary board where they may risk losing their license, when you think perhaps if something had been done after the second or third complaint, it might have been possible for them to be rehabilitated back into safe practice.  

What are some of the most common features that you’ve seen regarding sexual misconduct complaints? 

We did a large study where we analyzed all of the complaints to the national regulator in Australia. We looked at over 700,000 health practitioners from 15 different health professions, so everyone from nurses to midwives to psychologists, to doctors – it was probably the world’s largest study of sexual misconduct notifications.  

What we found was that among those 700,000 health practitioners, about 1,000 were the subject of a sexual misconduct notification. So the absolute numbers are relatively low, but every single one of those complaints reflects a really serious concern. It’s not easy for patients to bring concerns to the attention of a health regulator. Particularly when it comes to complaints about sexual misconduct, I think many patients are fearful that they may not be believed; that there’s a significant power imbalance between themselves and the health practitioner. What we saw was that many of the complaints about sexual misconduct were not made by the patients themselves. It was actually a fellow health practitioner who became aware of the sexual misconduct who notified the regulator.  

Overwhelmingly, the health practitioners who were subject to sexual misconduct reports were male. In fact, almost all the practitioners who incurred these reports were male. There were a very small group of females who received sexual misconduct reports. On the whole, these related to sexual relationships with patients rather than sexual assaults.  

We also saw that certain health professions were more likely to be the subject of sexual misconduct reports. We saw that most of the sexual misconduct reports related to psychiatrists, psychologists, and general practitioners. And it was interesting for me to think, “what do these three groups have in common? Why are we not seeing more sexual misconduct reports about surgeons, or about physiotherapists, or about midwives?” I think that the factor that these three professions have in common is that psychologists, psychiatrists, and general practitioners all have ongoing, longitudinal relationships with patients, one to one, behind closed doors. So that seems to be a real risk factor for these sexual misconduct reports. For example, if you’re a surgeon or an anesthesiologist working in a team environment, you’re least likely to be subject to a sexual misconduct report. But it seems to be these professions where you have a one-to-one relationship with patients over a period of time, behind closed doors, where those concerns are more likely to arise. 

What about repeat complaints? Is it fair to say that an individual who has had a complaint against them is likely to have more complaints against them as well?  

We did see quite high rates of recidivism among the sexual misconduct reports. One in five health practitioners who had a sexual misconduct report to the regulator had a further sexual misconduct allegation made within the next few years. So about a 20% rate of recidivism in terms of the reports being made to the regulatory boards.  

What about regulatory interventions? What efforts are taken to resolve these issues? 

There are a couple of interesting legal and regulatory questions that arise in response to these sexual misconduct reports. One question is what regulators should do after an allegation has been made but before a final investigation has been concluded. One of my students, Owen Bradfield, is doing his PhD on this question of immediate actions and how regulators should balance that tension between wanting to afford health practitioners procedural fairness – so giving them an opportunity to be heard and not jumping to conclusions – but at the same time protecting the public where a very serious allegation has been made.  

The other question is what regulatory interventions actually work? And unfortunately, there’s very little evidence around the world about the effectiveness of different regulatory interventions. One option that has been tried in the past with sexual misconduct reports is having a requirement to have a chaperone present, so a doctor who has been found guilty of sexual misconduct can only see patients if they have a chaperone in the room. There was a recent report by Professor Ron Patterson which suggested that this may not actually be very effective as a regulatory condition. There were some really devastating cases where even with those chaperone requirements there was ongoing offending. So, Ron’s recommendation was that if the allegations are serious enough, then you should probably be preventing that practitioner from seeing patients rather than thinking that a chaperone will solve the problem.  

One of the difficulties was that often the chaperones were placed in a very difficult position. It would often be the practice nurse or the receptionist working for that doctor who was asked to be the chaperone, so it was a very difficult position that they were placed in, being asked to be the eyes and ears of the regulator in a situation where they’re actually the employee of the doctor who’s the subject of these allegations. 

What about mandatory courses or ethical training? 

Some of my friends are lecturers in professional ethics and health law, and every now and then they’ll have a health practitioner in their class who has been mandated to undertake training in professional ethics in response to a serious breach of conduct. And what these lecturers say is that they really wonder how much it changes a practitioner’s behaviors to be required to sit through a course on professional ethics. Sometimes these practitioners will sit in the back row with their arms folded – they’re clearly there under duress because it’s been required by a regulator as a condition on their practice that they undertake further practice in professional ethics. But we really haven’t evaluated whether it makes a difference or not; whether being mandated to do further training in professional ethics does change people’s values and attitudes and behaviors, or whether perhaps it just makes it easier for them to conceal their future offending. I think there’s a real need for us to evaluate the effectiveness of those regulatory interventions.  

Do we have any sense of the prevalence of sexual misconduct complaints over the years? Do we know if this is something that is becoming more prevalent or more tracked? 

It would be great to know how the prevalence of sexual misconduct complaints is changing. Overall, the number of patient complaints to regulators has gradually been increasing over the years, I think as people become more aware of their rights as patients and as regulators do a better job of helping patients to know about the complaints processes that they can access. So that’s a general trend that there has been an increase in the number of patient complaints. 

When it comes to the sexual misconduct complaints specifically, we did see that after the #MeToo campaign there was an increase in sexual misconduct complaints. Regulators have indicated to me that whenever there is high-profile media publicity about sexual misconduct, either in the health professions or more generally, they will sometimes see an increase in sexual misconduct reports.  

The other thing is that once a practitioner has been publicly named, you’ll often see more patients coming forward with very similar stories. As I mentioned earlier, patients are often very reluctant to complain about health practitioners. They may feel a sense of shame about what has occurred; they may be concerned that they won’t be believed because of the power imbalance. But once a practitioner has been named in public, they may feel less alone with those feelings, and they may feel a greater degree of confidence that their story will be believed because this practitioner already has a known track record for this kind of behavior. So, we do see that once a practitioner has been named, further complaints will sometimes come forward.  

When you look to the future of this after all the work and study you’ve done, do you see any critical moves that need to be taken to address this issue? 

One of my longstanding concerns is that so many different agencies and individuals have small pieces of information about the conduct of different health practitioners. Their employer may have some information, the health complaints commissioner may have some information, the medical board may have received some complaints, perhaps a funding body or an insurance agency or one of the agencies that monitors the prescribing of prescription medicines may also have some information – but it’s very siloed. I think that for identifying high-risk practitioners, there’s so much more that could be done if we were better able to share information between those different agencies and organizations. 

We had a tragic case in Australia where there were dozens of deaths of babies – still births of babies or babies dying soon after they were born – and what was very apparent in that inquiry was that over the years many people had tried to raise concerns, but those concerns had gone to multiple different agencies. So, the College of Midwives had some information, the Department of Health had some information, the Perinatal Mortality and Morbidity Review Committee had some information, but it took a very long time for the pieces of the puzzle to be put together. I think that improved information sharing will really help with identifying these concerns earlier. 

What do you think is key to that improved information sharing? Is it process, technology, policy – all of the above?  

One of my favorite concepts in all of this regulatory work is that patients who have been injured and doctors shouldn’t be seen as adversaries. The common enemy is the patient harm, and I think that if we’re able to achieve this cultural shift where we recognize that patient complaints and regulatory processes are actually serving the interests of both patients and health practitioners, that’s where we’ll start to see real change. Because at the moment, there’s still quite a lot of resistance from the medical profession towards increased information sharing between these regulatory bodies. I think many doctors still feel quite defensive and afraid of regulatory processes. So, for me, one of the crucial changes is helping doctors to understand that improved patient safety is in everybody’s interests and that the sooner poorly performing practitioners can be identified, the better it is for the practitioners themselves and also for the patients they serve.  

Read Part 2 of the conversation, where Dr. Bismark discusses her research on the impacts of the COVID-19 pandemic on health practitioners, her own experience of living and working through the pandemic, and her recent book, “Experiences of Health Workers in the COVID-19 Pandemic: In Their Own Words.”