Dostoyevsky said: ‘Tyranny is a habit, it has its own organic life, it develops finally into a disease’.
It seems that in its latest examination of the medical profession by the Medical Board of Australia (MBA), yet another aspect of what we dreadful medical doctors are up to has been uncovered.
This time it is the turn of the worst of us, the over 70-year-olds to be dealt with, for according to the latest Medical Board of Australia’s MBA) musings contained within its 93-page Consultation Regulation Impact Statement (CRIS):
“…doctors have a reputation as reluctant patients, and the Board is concerned that doctors do not always seek the care they need. This is a particular issue for late career doctors (those aged 70 years and older), given that health challenges escalate with age. There is also strong evidence that there is a decline in performance and patient outcomes with increasing practitioner age, even when the practitioner is highly experienced.”
In my opinion that statement, at best misleading for want of the MBA’s claim of “strong” evidence for their allegations about our “reputation”, is a clear indication that it has already made up its mind action is necessary, and that any consultation with the medical profession is window dressing.
The justification relied on by the MBA is in large part drawn from a study conducted in 2018 by Thomas et al.
That study examined 12,878 notifications lodged with AHPRA between 1 January 2011 and 31 December 2014, including a cohort aged more than 65 years, the majority of whom are unlikely to still be in practice.
The results found older doctors had notification rates 1.4 times higher than for doctors aged 36 to 65 years (90.9 compared with 66.6 per 1000 practitioner years). Notifications resulting in regulatory action such as a reprimand, fine or imposition of conditions were 1.5 times higher among doctors aged 65 years and older.
It is on these figures the MBA justifies its proposal to subject all registered doctors 70 years and older to highly personal cognitive and physical examinations and, as if to rub salt in the wound, expect them to pay for it themselves. There are several reasons to doubt the veracity and applicability of the figures the MBA relies on.
The MBA/AHPRA CRIS indicates that of the 485 complaints received in 2022-3 regarding 6975 registered doctors over 70 years, nearly 80% led to no further action. The corresponding contemporaneous findings in the under 70s? Approximately 5130 complaints were received regarding the 125,391 doctors registered in that age group in the same period.
This gives a relative risk of 1.70 of a complaint (meritorious or otherwise) being lodged if a practitioner is over 70 years, a little higher than the RR reported by Thomas et al.
Out of the 5130 complaints made against registered practising doctors aged under 70 years in 2022-23, an estimated 708 doctors had adverse regulatory findings made against them. The penalties included fines, conditions on practice, suspensions and deregistration.
Out of the 485 complaints made against practicing doctors aged 70+ years in the same period, an estimated 90 doctors had adverse regulatory findings imposed on their practice. Of those 90 doctors that had conditions imposed on their practice, not one received fines, reprimands, or suspension of registration (the more stringent actions), unlike the under 70 years cohort.
Not one!
That, dear colleagues, is what the MBA considers sufficient reason to burden an entire cohort with the product of an ageist assumption, let alone the added burden to be visited on those doctors expected to conduct the examinations.
But that doesn’t tell the whole story.
Relying on relative risk alone to assess population risk (absolute risk), especially when based on small numbers relative to the populations being compared, is known to overstate population risk. Unfortunately, this basic epidemiological and statistical fact appears unknown to the MBA’s favoured researchers.
As the Australian Senior Active Doctors Association (ASADA) submission to the MBA CRIS puts it:
“Reporting relative rates of unsubstantiated complaints without reference to absolute numbers and outcomes serves to grossly overstate issues. For example, of what meaning is it to know that unsubstantiated complaints for one group are 1.7 times that of another group, if we know nothing of the veracity of the complaints, or the actual outcome of the complaints?”
What is the absolute risk difference of proven regulatory trespass as determined in a tribunal hearing, not simply an unsubstantiated complaint lodged with AHPRA, when patients are treated by over 70-year-olds are compared to the under 70-year-old doctors?
That calculation tells a very different story to the one being promoted by the MBA.
Ninety complaints against 6975 doctors older than 70 years resulted in regulatory penalty, none in the more serious categories. Seven hundred and eight complaints against 125,391 younger than 70 years resulted in regulatory penalty, including some in the more serious categories, including deregistration.
Applying these figures, the absolute risk difference is 0.726% and if the over 70s had the same risk as under 70s, then one would expect 39 adverse findings among the older cohort compared to the 90 experienced. This in turn yields an excess of 51 (but lesser) adverse findings in the older cohort of 6975 registered practicing older doctors, or 0.7% per 100 doctors.
So that’s what the MBA/AHPRA relies on to promote its ageist agenda. What does the MBA think it’s preventing with their CRIS proposals? How can the MBA be so unaware, if indeed it is?
Perhaps the answer can be found in the MBA’s favoured researchers’ statement:
“Our study adopted a regulator’s perspective.”
And in Thomas et al:
“Partnerships between researchers and regulators can enable new insights into patient safety risks and inform regulatory practices.”
The apprehension of bias must be obvious to all impartial observers.
The medical history that forms part of the triennial mandatory examination proposed as detailed in the MBA’s CRIS document is intrusive and extends into areas well beyond the purpose stated. Further, there appears no attempt by the MBA or by its “go-to” researchers to validate the cognitive tests they propose be used for their fishing purposes.
The feedback I receive from colleagues suggests some have brought forward retirement plans because of the MBA’s poorly justified recent changes to CPD requirements. I wonder how the politicians who direct AHPRA/MBA policies will react to the likely loss of doctors from the medical workforce resulting from the regulators’ poorly researched imposts?
To assess the true effect of what the MBA proposes, one would need to conduct a prospective study that shows clinical and statistically significant adverse differences in patient outcomes for practitioners with, versus without any measured impairment especially if, as they propose, the MBA uses assessment tools not validated for that purpose. That prospective study has not been done.
None of the cognitive screening tests the MBA proposes using have been evaluated to discover what scores would determine the doctor’s capacity to practice, and the Board has shown no evidence of interest in validating the tests for that purpose.
The American Medical Association in 2015 noted: “the effect of age on any individual physician’s competence can be highly variable”.
In 2018 it withdrew its support for testing physicians cognitively at 70 years of age. None of this is mentioned in the MBA’s CRIS document.
The detailed submission made by ASADA addresses many more shortcomings including in data gathering and presentation, miscalculation of numbers, and biases in the MBA’s CRIS document. They are too numerous to detail here so I encourage you to read the CRIS document and ASADA’s submission in response, to obtain a more complete picture on what rotted foundations the MBA/AHPRA’s latest regulatory edifice is built.
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As a result of these considerations, I do not believe AHPRA or the MBA possesses the competence, impartiality, or the ethical capacity to use such highly personal information only for its stated purpose.
I would not consent to being subject to such an examination without robust, independent validation of their predictive ability and with iron-clad guarantees as to its privacy and its non-use for other purposes. If the MBA’s proposal remains unchanged, I suggest my over 70-year-old medical colleagues should do likewise.
Taking the time necessary to conduct such a study, presuming the MBA and its preferred researchers possess the willingness and ability to do so competently and impartially, lies well beyond the three-year attention span of the state and federal health ministers who direct the policy behaviour of AHPRA and therefore the MBA, but all is not lost. Their proposal can only work if we doctors agree to perform the examinations.
The Australian Constitution prohibits the use of the medical services power to authorise any form of civil conscription (subsection 51 [xxiiiA], and thus it would be difficult if not impossible for the MBA to lawfully compel doctors to conduct assessments of questionable validity in this setting.
As a fully registered (for now) non-GP specialist, I will not be doing so without such evidence.
It is also clear that the MBA has not conducted (or if it has it has chosen not to reveal the results) a cost-benefit analysis on their latest proposal, just as they did not when changing CPD requirements without good evidence as to benefit. How many competent, highly experienced doctors will bring forward their retirement because of these changes? Where will the impact fall more heavily, in metropolitan or in rural/remote areas?
Will the MBA’s decision to bypass the medical colleges and speed through the registration of overseas trained doctors from certain countries be enough to counter any further Board-aggravated shortage?
Does the MBA believe leaving large tracts of the country without relatively easy access to medical coverage is in the interest of patient safety? If so, why not simply deregister us all. There is a ready supply of pharmacists, naturopaths, chiropractors and herbalists keen to replace us.
Regular health check-ups for all doctors and targeting assessments based on specific performance issues would provide a more equitable and effective strategy for safeguarding patient care. This would be consistent with the Medical Board of Australia’s Code of Conduct that requires “all doctors to have their own general practitioner (GP) to help them take care of their health and wellbeing throughout their working lives”.
The Medical Board of Australia should reconsider its approach and adopt practices that uphold principles of fairness and evidence-based regulation, rather than implementing poorly researched mandates that may lead to discrimination, unnecessary damage to or destruction of medical careers, and the loss of valuable experience in the medical field.
Dr Michael Gliksman is a physician in private practice in Sydney and a past vice-president and chair of Council of the AMA (NSW), and a past federal AMA councillor. He has never been the subject of a patient complaint to any regulatory body.
