HPCSA Guidelines: Booklet 5, paragraphs 9.3.1 and 9.3.1.1 

Introduction

Stretched resources and unspoken pressure for practitioners to work long hours lead practitioners to be unwilling to disclose any illness or health-related issues, or take time off from work to properly recover.

It is important to emphasise that practitioners with health problems must be able to access confidential and non-judgmental sources of assistance. Of particular importance are conditions relating to stress and mental health problems. These conditions pose particular challenges to healthcare practitioners, as they are prone to discrimination and stigma. Specific examples of such disorders are depression, anxiety and abuse of drugs and alcohol. Allied to this is a sense of isolation which healthcare practitioners may feel, coupled with uncertainty as to where to obtain assistance in a secure environment.

The effect of litigation on practitioners’ health

Of particular relevance is the impact which disciplinary or litigation procedures can have on the mental health of practitioners. These processes are lengthy, often taking a number of years to resolve. Even relatively minor incidents can have a disproportionately adverse effect on the mental health of practitioners. When one bears in mind that, in certain cases, the stakes are very high for the practitioner in such proceedings (such as where a patient has died in the care of the practitioner, or where an adverse finding could have a serious effect on the reputation or finances of a practitioner), then the potential impact on the physical and mental-health of the practitioner could be particularly serious.

When practitioners suspect they have an infectious condition

When doctors suspect that they may have infectious conditions such as hepatitis B or HIV, they should take advice from a practitioner who is suitably qualified and experienced as to whether they can continue their professional practice. Should the advice be that the practitioner should not practice, this advice should be followed, or they should limit their practice in a way in which they do not pose a risk to patients. Practitioners should not continue in clinical practice merely because they assess that they do not pose a sufficient risk to patients.

Where a practitioner treats a colleague with a serious communicable disease who refuses to modify his or her professional practice in order to safeguard patients, then the HPCSA Guidelines permit the disclosure of personal information without consent where failure to do so may expose a patient or others to risk of death or serious harm.  Where third parties are exposed to a risk so serious that it outweighs the patient’s right to confidentiality, healthcare practitioners should seek consent to disclosure where practicable. If it is not practicable to seek such disclosure, then healthcare practitioners should disclose information promptly to an appropriate person or authority. The disclosing practitioner should generally inform the patient before disclosing the information. If practitioners are in doubt about whether such a disclosure is justified, they should consult an experienced colleague, or seek assistance from a professional organisation. The principle which applies, however, is that the safety of patients must come first at all times. (Booklet 5, paragraphs 9.3.1 and 9.3.1.1).

Exposure to health risks

Doctors are routinely exposed to health risks in the course of their work, including exposure to infection, needle-stick injuries and possible attacks by violent or mentally ill patients. Practitioners can also experience health problems as the result of challenging working patterns. Factors which may negatively influence practitioners’ health include long working hours, workload pressures, and dealing with patients’ anxieties and emotions. Besides directly affecting their professional abilities, these factors can have a negative effect on practitioners’ personal and family life. Being overworked, stressed and fatigued can have a serious impact on practitioners’ ability to perform at an acceptable level and are a factor which contributes to clinical mistakes.

Self-treatment and treatment of friends and family

It is not advisable that practitioners treat themselves, their friends or family members. In an emergency situation, there may be no alternative, but self-treatment should be avoided, as well as the informal treatment of colleagues, friends or family. Wherever possible, practitioners should avoid providing medical care to anyone with whom they have a close personal relationship. Practitioners are advised to register with a GP who is not a family member or close personal friend in order to ensure access to independent and objective medical care. There are many dangers to self-diagnosis, with particular concerns including the temptation to extend oneself beyond one’s competence, and the ever-present possibility of denial about the true nature or extent of the condition.

The HPCSA Guidelines require practitioners to refrain from engaging in activities that may affect their health and leads to impairment. Practitioners should therefore protect their patients, their colleagues and themselves by being immunised against common serious communicable diseases where vaccines are available.

Where practitioners know that they have, or suspect that they might have, a serious condition that could be transmitted to patients, colleagues or others, they should consult a suitably qualified colleague. Similar considerations apply where practitioners suspect or know that their judgement or performance could be affected by a condition or its treatment. In these circumstances, they should seek and follow advice about any investigations, treatment and/or changes to their practice that they are advised to make.

The British Medical Association provides the following advice regarding practitioners’ health, which can be accepted in the South African context:[1]

 All doctors should be registered with a GP and act promptly on any early warning signs, especially where they have a suspicion that their health is affecting their performance.

Informal or ‘corridor’ consultations with colleagues should be avoided.

Doctors need to monitor their own health and also take action if colleagues’ health gives cause for concern.

Doctors are entitled to the same strict rules of confidentiality as other patients.

Doctors should seek and follow advice from a suitably qualified practitioner if they may have been exposed to a serious communicable disease.

Practitioners’ trauma as the result of an adverse event

For advice on how to handle the aftermath of a work colleague’s suicide, as well as general advice on how to handle the multitude of demands encountered during an unexpected or traumatic clinical event, see:  Clare Gerada: The aftermath of a colleague’s suicideBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2290 (Published 28 May 2019).

Gerada states that most health care providers adjust well to the multitude of demands encountered during an unexpected or traumatic clinical event. Providers often have strong emotional defenses that carry them through and let them “get the job done.” Yet sometimes the emotional aftershock (or stress reaction) can be difficult. Signs and symptoms of this emotional aftershock may last a few days, a few weeks, a few months, or longer.

Frequently, practitioners:

Feel personally responsible for the unexpected patient outcomes.

Feel as though they have failed the patient.

Second-guess their clinical skills.

Second-guess their knowledge base.

High-risk Scenarios and Recovery Stages.

There are several types of clinical events that can evoke a second victim response. Examples of high-risk situations that may induce a stress response include:

Patient who “connects” to a health care professional’s own family;

Unanticipated clinical event involving a pediatric patient;

Unexpected patient death;

Preventable harm to patient;

Multiple patients with bad outcomes within a short period of time within one clinical area;

Long-term care relationship with patient death;

Clinician experiencing his or her first patient death;

Failure to detect patient deterioration in timely manner;

Death in a young adult patient; 

Notification of pending litigation plans; 

Community high-profile patient or event;

Health care professional who experienced needle stick exposure with high-risk patient; 

Death of a staff member or spouse of a staff member. 

For more information see University of Missouri Health Care’s forYOU team: “Caring for caregivers.” Available at https://www.muhealth.org/about-us/quality-care-patient-safety/office-of-clinical-effectiveness/foryou.

Footnotes

[1] British Medical Association. Medical Ethics Today (Kindle Locations 31053-31061). Wiley. Kindle Edition.