MBE FRCGP MRCPsych
General practitioner with special clinical interest in substance misuse
In addition to her work as a GP, Clare is also currently Chair of Ethics for the Royal College of General Practitioners (RCGP). Her special interests are mental health, women's health and substance misuse
James is 31 years old. He has been an assistant GP at the practice for 18 months, working fulltime. Of recent months, reception staff have been concerned that he is "not himself" on Monday mornings. His eyes are red; he seems to be very agitated and restless. Staff have also noticed that James is arriving later and later on Mondays, jokingly saying he has a terrible hangover from partying at the weekend. There are murmurs around the practice that James is spending all his weekends in nightclubs, taking some sort of stimulant to stay awake, and not finishing until just before surgery on Monday mornings. You are concerned.
Harry is 48 years old. He has been a GP partner at the practice for the last 15 years. He has always been an "odd" partner, never really engaging with other staff, and is very much an outsider in the practice. The other four partners have concerns about Harry's clinical work – he seems to take on more and more work with drug users, and has been known to give them his home phone number and to meet some of them for "counselling" after work in the local pub. The last partners' meeting was rather heated, as words were exchanged between the doctors. You realise "something has to be done", but what?
Dealing with GPs you suspect of abusing drugs or alcohol is a tricky issue. Doctors are not immune to substance misuse and, for many reasons, compared with peers in other professional groups, such as the law, they may be at increased risk.
The Shipman case highlighted the ease with which doctors, and especially GPs, could access controlled drugs. Although new regulations following the Shipman Inquiry have made it harder to obtain drugs, it is still relatively easy for a doctor to write a prescription for themselves or others, and obtain large supplies of opiates, tranquilisers and even stimulants.(1) Who, after all, would suspect a doctor presenting a prescription to a pharmacist for 100 dihydrocodeine tablets or 56 diazepam tablets, saying he was on his way to a home visit and was taking the medication to the patient?
All professional groups work long and stressful hours, and doctors cannot claim the moral high ground by having a "stressful job". However, listening and responding all day to patients' needs can leave some doctors exhausted and wanting to drown out the day with alcohol – and perhaps for some, with opiates or tranquilisers.
Doctors are at increased risk of mental health problems.(2) The misuse of drugs by healthcare professionals may begin with a "legitimate" reason, such as insomnia, depression or back pain, particularly when these professionals choose to diagnose and treat themselves, usually inappropriately.(3) The most frequent pathways into substance use are personality difficulties and anxiety or depression.(4) It is estimated that as many as one doctor in 15 may be affected by drug or alcohol dependence problems at some point during their professional lives.(1,5)
It is common for doctors to drink heavily at an early stage of their careers. Doctors who misuse alcohol are often also taking other drugs, most commonly benzodiazepines, and may switch from one substance to another over time.
Frequently, the primary problem of the doctor in this category appears to be alcohol, but on closer scrutiny it is often found that they are dabbling in other substances, such as opioids, amphetamines and other controlled drugs. Junior doctors and nurses may be among the first to recognise such problems in senior colleagues, but may be reluctant to take action for fear of damaging their career or because of the sense of loyalty owed to a mentor or senior colleague. After all, it is difficult to "shop" a senior.
Extent of the problem
It is a sad fact that drugs and/or alcohol are often implicated when doctors appear in front of the General Medical Council (GMC). In such cases, either the doctor's own addiction has caused him/her to run into problems, or their management (or strictly speaking mismanagement) of drug users has been deemed as seriously irresponsible or inappropriate.
More than two-thirds of the cases considered by the GMC's Health Committee in 2002 involved the misuse of drugs or alcohol.(6) Most of these appearances should never have seen the light of day at a GMC hearing. Often, telltale signs that a doctor was having problems were ignored, and the doctor concerned was forced to continue digging themselves into deeper and deeper holes, sometimes with tragic consequences.
With respect to drug misuse, lack of training plays a part – often, a doctor has a blind spot in his/her training and is unaware of this, so the idea of engaging in training in this area never crosses his/her mind.
Once the seed of doubt has been raised and concern has been voiced, doing nothing is not an option. The problems posed by both of the above scenarios may be, and most likely are, affecting the GPs' performances when seeing patients, and therefore must be acted upon.
The act of disclosure is often given the unfortunate term of "whistleblowing". The GMC states that if concerns are felt about a doctor's performance they should be raised, and that doctors "must protect patients from risks of harm posed by another doctor, or other healthcare professional's, conduct, performance or health, including problems arising from alcohol or other substance abuse. The safety of patients must come first at all times. Where there are serious concerns about a colleague's performance, health or conduct, it is essential that steps are taken without delay to investigate the concerns, to establish whether they are well founded, and to protect patients."(7)
So, what should you do? In the first scenario, clearly you cannot sanction a doctor for having red eyes. Red eyes on a Monday morning might be due to a number of factors – including allergy.
However, there are enough concerns being raised, and enough signs that this doctor may not just be burning the candle at both ends, but also enhancing the process through the use of psychoactive drugs. It is not your responsibility to determine whether this doctor is using drugs and what they are, just whether he is safe to work in your practice.
However, it is useful to have some idea of the drugs or substances that have the potential to enhance an individual's capacity to "party through the night" (and beyond). A new drug on the scene is "crystal meth", which is one of the street names for methamphetamine. It is also know as "speed", "meth", "chalk", "ice", "crystal", "crank" and "glass". Methamphetamine belongs to a family of drugs called amphetamines – powerful stimulants that speed up the central nervous system. When methamphetamine is injected or taken by mouth, the effects may last 6–8 hours. When it is smoked, the effects can last 10–12 hours.
As with other amphetamines, users experience increased wakefulness, a sense of wellbeing and decreased appetite when they take the drug. Often, people who use methamphetamines do so in a "binge and crash pattern", which can have harmful effects on the person's health, and can lead to dependence on the drug. As well as methamphetamine, this young doctor may also be using a host of other substances at the weekend, including ecstasy, alcohol, amphetamines and opiates. In this scenario, it would be important to discuss the concerns raised by the staff with the partners or senior doctors, and to begin to ascertain the facts:
Once you have an idea of the extent of the staff's concerns, it is important to have a discussion with the GP concerned. How this is carried out depends on local systems.
A practice may, for example, have a designated clinical governance lead, with the manager taking the responsibility to meet the GP and relay the concerns. Alternatively, this role may fall on the senior partner or other nominated person within the practice. An informal discussion may be all that is needed, but if the concerns are serious – or if, having carried out your investigation, you find there is a pattern of poor practice that could put patients at risk – then immediate and more formal steps must be taken.
I am not an expert in employment law and would urge you, as the manager, to consider the precautions you need to take before calling the GP in for an interview. If you are unsure what to do, discuss your concerns with an impartial colleague or contact a defence body, a professional organisation, the local medical committee (LMC) or the GMC for advice.
This situation is altogether more difficult to deal with. It appears that this GP is sailing too close to the wind with respect to breaching the doctor-patient relationship. Whatever his reasoning for socialising with patients, it must stop immediately.
Unfortunately, a small number of doctors do become embroiled in the lives of their patients, and naively assume they can solve all their problems. Often, the more vulnerable the patient, the more enmeshed the doctor becomes. Where managing drug users are concerned, such doctors often feel it is their "mission" to treat these patients, believing that if they don't, no-one else will.
These doctors tend to work in an isolated manner, sometimes in singlehanded practices. If part of a group practice, they might be the only doctor caring for drug users. Unsupported, and often not working with other professionals, these doctors take more and more patients. Unless assisted, such doctors are likely to become either "burnt out" or to end up crossing a professional line – either in prescribing or behaviour – and being reported to the GMC.
This case sounds like it has gone too far for simple internal solutions and it would be important to call in outside help. If the concerns about this GP lead you and the partners to believe that he may have serious performance issues, the process should follow that described in the previous scenario. Again it would be important to interview staff, identify whether there have been complaints from patients, and consider involving the local deanery to examine random surgeries.
A search of the computer will indicate how many drug users this doctor is seeing; for a single full-time doctor, more than 20 patients would be excessive. It might be useful to approach the drug dependency service to offer help with these patients and to review prescribing alongside.
However, if it appears to be a problem of isolation, scapegoating, unfair distribution of workload and other partnership issues, then it may be that you need to allow time for a root and branch review of the partnership and the practice. The LMC or the primary care trust may be able to offer advice on where to get independent and confidential advice.
Identifying and addressing poor performance in colleagues is a complex issue, and poor performance can be multifactorial. Clarifying the facts may involve discussion with the GP concerned and with colleagues. Wherever possible, local procedures would be the first avenue to be tried. A formal investigation or audit may be required if problems cannot be resolved informally. The British Medical Association (BMA), the GMC and other medical protection organisations can all offer advice.
In the next issue of Management in Practice, healthcare training consultant Glenys Bridges will look at how best to confront a senior GP or partner over such issues, in order to avoid undue conflict and ensure that potentially divisive matters are dealt with in a harmonious manner.
Gerada C. RCGP guide to the management of substance misuse in primary care. London: RCGP; 2005.