A reasonable number of trainees can become ill during training: of these, most have a psychiatric or stress-related problem. Many can be ill for some time, & either not recognised that they were ill or decided against reporting this. A small number use drugs or alcohol.
There are several things to consider. Immediate patient safety must come first; a person currently under the influence of drugs or alcohol must be removed from the clinical situation.
Once this is done, & assuming the person is sober enough to talk, it’s important to find somewhere appropriate to hold a confidential conversation. As I’m doing this, I run through a mental check-list: what would it be like to be this doctor, who is the best person to have this conversation, what skills must I demonstrate, & what practicalities need sorting out?
What it would be like to be the doctor in difficulty?:
In most circumstances, doctors who abuse drugs or alcohol have begun the habit as a coping strategy because of stress or illness. Doctors who are ill, particularly those with psychological or stress-related illness are concerned about being stigmatised. They describe a feeling of shame, of letting themselves down by not meeting their own high personal standards, worries about confidentiality & loss of control & fears about damage to their livelihood because of disciplinary action or referral to the General Medical Council (GMC). Particular concerns for those in training grades are that they may lose the respect of others, & that disclosing a mental illness, especially alcohol or drug use, may threaten their career & job prospects. So the person is being very brave in talking at all. He or she will have mentally rehearsed this situation many times & reached the conclusion that it’s safer to say nothing about his or her problem. Even if the person wanted to talk, deciding who to tell is difficult.
Who is best to have this conversation?:
It is important that the doctor speaks to someone he or she respects & trusts to keep the matter as confidential as possible. So I ask “You need to talk to someone about this. Should this be me or is there someone else you would prefer to talk to?” I offer the trainee the option of bringing someone with them. Sometimes, but in my experience rarely, they will want to.
What skills must I demonstrate?:
The conversation will only be useful if the trainee feels that the conversation is confidential & he or she is being treated with respect, empathy & genuineness. I need to make sure I demonstrate these qualities, not just feel them. I start with a comment such as “We need to talk about what’s happened, & how you are. The most important thing we need to do is explore & understand what’s going on from your perspective.” The first thing I do is to listen. It might seem a rather weak response when you have a hundred questions going round in your head. But just listening actively to everything the person says, summarising & being sure to notice the trainee’s feelings & reflect them back accurately, is likely to achieve most. You’re not the person’s doctor – you don’t need to know what substances, how often, where or when.
Caught in the act, most people acknowledge events. Those who refute what is described or deny their involvement are almost always using a coping strategy of putting blame on others or on circumstances; they know they’ve got a problem but don’t feel safe to talk about it. If this happens, I start by explaining what I saw or has been reported to me as having occurred, outline what happens to doctors with drug & alcohol problems & what we are required to do to meet governance & GMC requirements. I also make clear that they are not alone, & that many colleagues who have found themselves in this sort of difficulty return to work &/or to training. There are a number of services for doctors with health difficulties & for doctors with drug & alcohol problems* & I make sure the trainee is made aware of these.
What practicalities need sorting?
Three aspects need to be managed; the doctor’s health & treatment, governance, & informing those who need to know that a trainee has a drug or alcohol problem.
Health & treatment:
The outcome I aim for is that the trainee gets to the right services to treat & support them, but in a way that preserves his or her dignity & keeps the details of his or her situation as confidential as possible. Treatment of their underlying problem might be achieved through their GP, via the consultant occupational physician or through direct contact with the local drug & alcohol service. As many such people have an underlying illness which also needs treatment, a consultation with the GP can be helpful. However there are a group of doctors for whom the GP is a family friend, or part of a social, ethnic or religious community, when the problem of disclosure & potential stigma can be a significant barrier.
If there is a good Occupational Physician in the Trust or available via the Deanery, it is very useful for the trainee to see this person. It is the responsibility of the Occupational Physician to advise the trainee, Trust & Deanery as to whether the doctor is well enough to continue working & if so, what adjustments are needed to their duties or working pattern. In practical terms this usually means the doctor is “given permission to be ill”, & to take time away from work to address the underlying causes of their problem as well as their drug or alcohol usage. If the doctor is well enough to remain at work in some capacity, the Occupational Physician acts as the doctor’s advocate in making sure the duties &/or training requirements expected of a trainee are realistic in the context of their health difficulties. The Occupational Physician may also refer them on to the appropriate clinician (often a psychiatrist) & to the drug & alcohol service, as they will know which doctors are used to treating fellow professionals.
Governance:
The GMC requires every doctor to:
- Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.
- Consult a suitably qualified colleague if your judgement or performance could be affected by a condition or its treatment & ask for & follow their advice about investigations, treatment & changes to your practice that they consider necessary.
In practice, this means that every doctor has a responsibility to remove a colleague from the immediate clinical situation if the doctor is under the influence of drugs or alcohol. The doctor him or herself must not put patients at risk, & must consult & follow the advice of the Occupational Physician, their GP & the consultant who treats them as a patient.
When identified, matters relating to ill-health or to substance misuse should be dealt with through employers’ occupational health processes & outside disciplinary procedures where possible. Thus, the Trust in which a trainee works & the Deanery in whose programme he or she is training both have a responsibility to provide the trainee with the means to get treated & to address their tendency to use drugs or alcohol as a coping strategy.
In the medium term, the Trust & Deanery should support the trainee in returning to work, & returning to training, once they are well enough. Many such situations fall under the disability discrimination act, which places a duty on employers to make ‘adjustments’, such as to working hours, place of work or by modifying procedures for assessment. Again this is something for which the advice of a consultant Occupational Physician is important.
Who else will need to know?
The Postgraduate Dean, Trust Medical Director & Clinical Director will need to know of the trainee’s drug or alcohol problem because of their accountability for patient safety, & the GMC must be informed because of its fitness to practice responsibilities. I find this part of the discussion quite tricky to phrase well & introduce at the right time. If the earlier conversation has gone well, & I have managed to demonstrate respect, concern & empathy with the trainee, trust should be starting to develop between us. But this is often tenuous & can be easily broken. By introducing the need to inform those responsible for patient safety & fitness to practice too early in the conversation, I might add to their feelings of embarrassment & disgrace.
Sometimes this is too much of a challenge & the trainee resists. The worry for me is that, quite often, the underlying reason for the drug or alcohol use is depression, & further disempowerment could have dire consequences. Doctors with psychiatric conditions & particularly those who use drugs or alcohol describe feelings of shame at not meeting their own high standards & humiliation at being found out, & unfortunately, faced with discovery, there is the possibility of self-harm or suicide.
On the other hand, if the trainee can be brave enough to seek the help they need & to inform someone senior in the Trust & the Deanery, then this is likely to set them on a better footing. They can then be seen as someone who has taken ownership of their problem, & is doing something about it. If the trainee is known to be seeking & complying with treatment, & using appropriate support, this will also stand them in better stead with the GMC.
When discussing the trainee’s health with third parties, I myself, the Clinical Director, Medical Director, Postgraduate Dean & GMC must each provide the same standard of confidentiality as is afforded to patients. The trainee must not become the subject of corridor gossip or the matter discussed where you can be overheard.
The GMC guidance on confidentiality makes clear that expressed consent must be sought if details about the trainee’s health are disclosed to third parties, unless the disclosure is required by law or can be justified in the public interest. Such disclosures should be kept to a minimum. The trainee must have access to or copies of information exchanged about them & be informed about how information will be used. In practical terms this means that informing the Clinical Director & Medical Director that the trainee has a health issue, is possibly not well enough to work & has told you that he or she has been using drugs or alcohol, is in the public interest, but saying that the doctor is depressed & binge drinking is not, unless the trainee has consented to revealing this information.
The situation is slightly different if the trainee has been arrested for drunk driving or has been obtaining drugs fraudulently by self-prescribing. Both of these are illegal activities which should be disclosed to those in authority.
The GMC will need to be informed at an appropriate point if the doctor has a drug or alcohol problem. The psychiatrist from the drug & alcohol service is often best placed to do this, as they have a better understanding of the clinical picture.
Information about health can be disclosed to the GMC without the trainee’s consent, but the trainee must be informed as to what the GMC is told, even though their consent is not required. When a doctor is arrested or cautioned on a drink driving charge, or has been caught self-prescribing opiates or benzodiazepines by a pharmacist, the Police automatically inform the GMC.
So how do I pick my way through this minefield? I explain that the Medical Director, Clinical Director & GMC will need to know that the trainee has a health problem. Sometimes I find it useful to look together at the GMCs “Good Medical Practice” guidance. If the trainee is feeling brave enough, we draw up an e-mail or letter together, so that the trainee has control over what is said about his or her own health, or we ask the Clinical Director if we can meet urgently in private. When the trainee is too uncertain to inform the Clinical & Medical Director straight away, I ensure that they do not go back to clinical work & they “go off sick”. I arrange to meet them again in the next few days, to agree how we ensure those in authority are informed, & gently point out that, if they don’t turn up, I would still have to tell the Clinical & Medical Director, & Postgraduate Dean & would send them a copy of what I had said. I am lucky in that I can offer the opportunity of talking to someone else who has been in similar circumstances, as some of the many trainees whom I have managed & supported with psychological or stress-related illness, & some with drug or alcohol problems, are willing to share their own experiences.
Many doctors who abuse drugs or alcohol have started the habit as a coping strategy because of other difficulties. If treated fairly & with respect & empathy, many will address their difficulties & get back to safe, effective practice. So first impressions count; a thoughtfully conducted initial discussion can be the gateway the doctor needs to taking ownership of the problem & addressing their difficulties. Any lastly, these are difficult conversations, so do get support for yourself from someone with the skills to help you reflect confidentially about your performance.
Photo courtesy [http://www.generationnext.com.au/]
Doctors in Difficulty - Drugs and Alcohol
