The drinking doctors problem

Two thirds of cases referred to the General Medical Council are related to doctors' misuse of alcohol and other drugs, according to the British Medical Association's recent report on The Misuse of Alcohol and Other Drugs by Doctors. The fact that so many doctors' problems lead them into GMC disciplinary procedures seems to indicate that, more often than not, matters reach crisis point before action is taken. This is partly because doctors "are reluctant to seek help due to the stigma attached to psychological illness, in particular substance misuse, and the professional risks associated with acknowledgement of this."

The report's aims are:

• to support the paramount need to prevent any risk to the welfare of patients from impaired professional competence;

• to raise awareness of the nature, extent, complexity, and consequences of misuse of alcohol and other drugs occurring among doctors;

• to highlight the need for education on the manifestation and presentation of drug and alcohol misuse including the frequent occurrence of denial and avoidance of treatment;

• to ensure access to appropriate services for examination, diagnosis, and referral for treatment and to guide affected doctors towards treatment facilities;

• to highlight the need for long term rehabilitation, which may include retraining for reentry into the medical work force.

Another problem is that a large proportion of doctors is unaware of the range of services available. This is confirmed by those working in the field of rehabilitation, either in clinics or counselling practices. It is also the case that many doctors have observed "the lack of support provided for colleagues with similar problems." At the same time misplaced loyalty often prevents doctors intervening when they see others with a drug abuse problem.

As with the wider population, there is a perception that the problem largely affects males. In the medical world it is also seen as being more common amongst those past the mid-point of their careers and amongst general practitioners. On the other hand, those units which specialise in the treatment of doctors state that doctors of both sexes are affected, from those just out of medical school to those in retirement, and covering the whole range of the profession, GPs, those in hospital medicine, and those in the private sector.

The report makes the point that no strict division can be made between alcohol and other drugs where doctors are concerned. "Doctors who misuse alcohol are often at the same time involved in misuse of other drugs, most commonly benzodiapezines, and they may switch between one type of substance and another over time."

Among the main recommendations of the report are that the "recognition and management of drug and alcohol addiction must be highlighted in undergraduate, postgraduate, and continuing education programmes for doctors and all health care professionals"; active measures for the rehabilitation of addicted doctors and their retention in the profession once in recovery need to be taken; that there should be support available for those "who express concern about a colleague", especially those doctors who are still in training grades; that every medical school should have a drug and alcohol policy covering a wide range of issues, including permissible drinking times, services available to those with problems, and sensible drinking advice; and that doctors should avoid self-prescribing. The recommendations are directed, as appropriate, to the GMC, NHS Trusts and Health Authorities, the NHS Executive, the Department of Health, and the Association of Chief Police Officers.

In an editorial which discusses the report, the British Medical Journal says: "The phenomenon of the addicted doctor may shock and offend. Nevertheless, it must be addressed by both the profession and employers as an important cause of impaired performance through ill health. In America, state level 'impaired physician' schemes ensure that addicted doctors are confronted, receive adequate treatment, and return to work under supervision...The BMA report illustrates [that] greater professional awareness at all levels and visible dedicated services will enable many doctors to avoid the tragic consequences of drug and alcohol dependence that can so effect their patients, their family, and their careers. The current lack of a dedicated service leaves many addicted doctors unchallenged, untreated, and abandoned: the BMA report's failure to deal with comment on this point is an important shortcoming of an otherwise excellent document."

If the estimate of 9,000 doctors (one in fifteen) with an alcohol or other drug problem is correct, then the issues highlighted by the report need to be addressed as a matter of urgency. It is clear that too few doctors are aware of what is available, or indeed possible, in drug and alcohol treatment either for their patients or themselves.

The old joke that a problem is indicated when a patient drinks as much as his doctor is no longer funny, if it ever was.

The case of the well-oiled skipper...

A 57 year old man was referred to an outpatient department. He was late for his appointment because he had crashed his car in the hospital car park. He was anaemic and showed signs of chronic liver disease. The following morning he was admitted, smelling strongly of alcohol, for a blood transfusion. He expressed his desire for an early discharge so that he could return to his duties as captain of an oil tanker.

This case, and others like it, generated a lively debate as to what action doctors should take when faced with patients who are obviously abusing alcohol and prompted Dr Roger Barton, of the Academic Department, North Tyneside Hospital, to carry out a survey on the subject which is reported in the British Medical Journal of 15th November.

Dr Barton and his assistant, Ruth Dale, sent a questionnaire to 400 GPs and hospital physicians in the former Northern region. Out of 240 replies, 32 doctors (14 per cent) said they would not ask their patients to inform the Driver and Vehicle Licensing Agency (DVLA) and 33 (16 per cent) would not ask them to inform their employer. 68 (31 per cent) and 95 (46 per cent) would not check compliance. Dr Barton and Miss Dale point out that in up to 45 per cent and 62 per cent of cases the licensing agency and employer might remain ignorant of the potential danger.

The survey found that "general practitioners were more likely than hospital doctors to ask the patient to inform the licensing agency and employer, to check compliance, to ask a defence society's advice, and to discuss the problem with a colleague.

The actions taken by doctors would vary considerably, despite there being clear guidelines from the DVLC: "Medical practitioners may be failing in their duty of care if they do not alert their patients to the need to notify the Licensing Centre... Since many problem drinkers will not themselves notify the licensing agency, the doctor sometimes should do if he feels the public are at risk."

The code issued by the General Medical Council says doctors should "explain to patients that they have a legal duty to inform the DVLA. If the patient refuses to accept the diagnosis or the effect of the condition you can suggest that the patients seek a second opinion. You should advise the patients not to drive until the second opinion has been obtained. If patients continue to drive...you should make every reasonable effort to persuade them to stop. This may involve telling their next of kin. If you do not manage to persuade patients to stop driving, or you are given or find evidence that a patient is continuing to drive contrary to advice, you should disclose relevant medical information immediately, in confidence, to the medical advisor at the DVLA. Before giving information to the DVLA you should inform the patient of your decision to do so. Once the DVLA has been informed, you should also write to the patient, to confirm that a disclosure has been made."

As regards patients whose work is hazardous or could cause harm to others, such as the tanker skipper, the GMC guidelines state that "disclosures [of information about patients] may be necessary in the public interest where failure to disclose information may expose the patient, or others, to risk of death or serious harm. In such circumstances you should disclose information promptly to an appropriate authority."

Professor Jonathan Shepherd, of the University of Wales College of Medicine, in the same issue of the British Medical Journal, says, "The implications of the General Medical Council's guidance may not yet have been understood fully by many doctors. It emphasises doctors' wider responsibilities."

The legal situation is not straightforward. Doctors have a legal duty to maintain confidentiality but this duty is not absolute. Obviously, a doctor may disclose information to a third party if the patient consents. In addition, it is a defence in law that disclosure to a third party is in the public interest. What exactly this defence covers is at the moment decided in the courts case by case. There is no doubt, however, that the defence includes the disclosure to the DVLA or an employer of a patient's alcohol abuse in order to prevent injury to others. Public safety, in this case, outweighs the patient's right to confidentiality.

Another legal question is whether a doctor is susceptible to a charge of negligence if he fails to disclose information about a patient to the relevant authority and that patient subsequently injures someone. It is usual in English and American law to assume that there is no "duty of care" to take action to prevent someone injuring another. At present, this looks like remaining the case.

Deborah Brooke, a consultant in forensic psychiatry at Bexley Hospital, makes the point, when discussing the results of Dr Barton's survey, that "almost a third of medical and surgical admissions to hospital are for problems related to alcohol, and the profession has been poor at detecting and addressing these problems. A main cause is insufficient training and in recognising and treating substance misuse at undergraduate and postgraduate levels.

Dr Brooke says that the results of so many doctors being ill-equipped to deal with the problem - "uncertainty about management, accompanied by gloomy prognostications" - has led to the neglect of alcohol problems amongst colleagues in the medical profession. The GMC has made it clear that it is unethical for a doctor to fail to disclose information about a colleague whose abuse of alcohol is putting patients at risk.