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1 Prelude

Doctors are human and as such are subjected to same vagaries of ill health both physical and mental as any other member of the community.There are however some differences.Doctors are in a privileged position and position of power when it comes to professional practice exercising care for their patients,many of whom are vulnerable.Doctors also are exposed to risks associated with self diagnosis and self management.A common hallmark of doctors′ behavior in the face of personal physical and mental illness is"denial".This may be particularly problematic when the doctor is afflicted with a serious mental illness in which,one of the symptoms is loss of insight (e.g.severe depression,psychosis).In both cases not only may the doctor at grave risk personally but also importantly if the doctor is impaired the community is placed at increased risk.It is this risk to the community that necessitates protective and legislative measures to be put in place to protect the community from doctors who may be psychologically or physically impaired or indeed co-morbidly impaired.These legislative measures will vary from country to country and indeed may vary from one State/Province in any given country to another.

Doctors have a higher risk of depression than other professionals and almost twice the suicide risk compared to professionals in a similar social class.Access to drugs and the tendency to self medicate for pain and sleep disorders raises the risk.In addition,unfortunately a small percentage of doctors have been found guilty of sexual abuse of vulnerable patients,prescribing prohibited substances to known addicts for profit and various forms of malpractice due to poor judgment (sometimes related to physical or mental illhealth) or incompetence inflicting suffering on scores of patients.In Australia recently a surgeon was found guilty of manslaughter due to alleged incompetence.This is now before the court of appeal.In another heartbreaking case,an anaesthetist who had a long history of drug addiction has recently pleaded guilty to infecting 55 women attending an abortion clinic,with Hepatitis C.

Legislation in Australia requires all doctors (and in some States medical students) to be registered with the AustralianHealth Practitioners Registration Agency (AHPRA).If a doctor is found to be impaired due to ill health be it physical or mental the Board is able to restrict or suspend the practitioner from practice.The Board can also insist on supervised medical treatment.In the State of Victoria,where we work,the Board has established the Victorian Doctors Health Program (VDHP)which oversees the medical management of impaired doctors ushering many of them back to good health and to professional practice.Over 100 doctors per year are referred to the VDHP.Doctors may be reported to the Board by colleagues or members of the public,usually patients.Doctors reporting colleagues have statuary immunity which means the doctor making the report cannot be sued in court.

2 Case study

Dr.Ben is a 45 year old GP who has worked for the past 15 years in a group general practice with 4 other GPs,including yourself,2 nurses and 3 allied health practitioners.

Up till 12 months ago when he was involved in a car accident he seemed to be functioning normally.He was injured in the car accident,albeit not seriously but has had neck pain ever since.The police attended the scene of the accident and found him to have a blood alcohol reading of 0.14,almost 3 times the legal limit.His license was suspended for 6 months forcing him to use taxis to travel to work and do home or hospital visits.

Since the accident he has been arriving late at work,seemed short tempered with staff and patients,some of whom have complained about his behavior.He also has been noted to be drowsy at times during meetings and consultations.

Dr.Ben is married with 3 teenage children.You are aged 55 and the senior partner in the practice.As far as you have been aware Dr.Ben has enjoyed good family relationships.However,you receive a phone call from his wife who is very worried about him.He often comes home late smelling of alcohol and at times has not been home at all saying he attended a conference interstate.She suspects he is having an affair with one of the office staff in the practice who has also been noted to be performing erratically.She asks you not to divulge this telephone conversation.

3 Questions

3.1 What may be contributing to Dr.Ben′s changed behavior?

3.2 What are your responsibilities in these circumstances?

3.3 How will you manage the immediate situation?

3.4 What if he refuses treatment?

4 Answers

4.1 There are a number of possible causes for Dr.Ben′s behavior:(1)His episode of drink driving suggests that there have been problems prior to the accident.He may have had a drinking problem or even alcoholism,which was concealed in the clinic environment.His current behavior in the clinic as well as the information provided by his wife,is suggestive of alcoholism.(2)Alcohol abuse is often associated with or secondary to another problem/disorder.Common examples,anxiety and depression,relationship difficulties,financial problems and chronic stress or ′burnout′.He may have had long standing mild or moderate depression,which he has not acknowledged and which others have not noticed,or stresses associated with professional " burn out".Failure to recognise depression or deal with it precipitants commonly has deleterious consequences.(3)Having a painful neck injury may lead to depression and to self-medication to deal with both the pain and mood problems.This may involve oral opiates which are themselves highly addictive or in some cases doctors are known to self medicate with pethidine or morphine injections usually prescribed for unsuspecting patients but used by the doctor himself.So opiate addiction or addiction to other drugs such as benzodiazepines needs to be considered.

4.2 Responsibilities (1)You have a responsibility to your colleague Dr.Ben,to the practice staff and in particular to the patients of the practice.You also have a responsibility toDr Ben′s wife to maintain confidentiality.(2)You may need to seek advice from a trusted colleague,from your medical defense /insurance organization and from the Health Practitioners Board to ensure that you handle the situation sensitively and without prejudice to DrBen,his personal or professional wellbeing.

4.3 Immediate management Having sought and obtained advice you should meet with Dr.Ben,preferably with another colleague present,and outline your concerns about his wellbeing.You indicate that at all times you are concerned for him and wonder whether he feels he needs help and is prepared to seek it immediately.You should also point out that there have been complaints from patients at the practice and that you have a responsibility to protect their interests.He may need to take paid leave from the practice on the basis of ill health whilst these matters are being managed.If he has his own GP he should be encouraged to seek assistance from him,you may suggest voluntary attendance at the local Doctor′s Health Program[1].You should point out that like every other person in the community each doctor should have their own GP[2],someone they can confide in and who can be trusted to manage their medical problems with integrity and confidentially.

4.4 Refusal to accept advice If Dr Ben refuses to accept advice and offers of help then you may have little choice but to report the matter to the Health Practitioners Board.Whilst this may be difficult and painful it is in the best long-term interests of Dr Ben and your practice.

5 Further developments

The staff approach you as the senior partner saying that they are no longer willing to work with the receptionist Helen,who is alleged to be having an affair with your troubled colleague who is 20 years older than Helen.They claim that she is constantly late for work,refuses to take instructions from the practice manager,and is rude to patients.They have noted these changes in her behavior over the past 3 months.They are aware of the relationship she is having with Dr Ben,having seen them embracing in treatment room,and believe that her behavior is related to that.They would like her dismissed.

6 Question

As the senior partner what is your course of action?

7 Answer

The work performance of the receptionist Helen,needs to be treated on its own merits,as an industrial or human resources issue.The allegations made by your other staff need to be investigated,and even if verified,in Australiashe cannot be dismissed without due process.

This involves meeting with her and the practice manager examining the reasons for the change in her work performance and giving her a warning that if her performance does not improve in a given time period and a further warning is ignored she will be dismissed.This needs to be documented and agreed to.The staff who have complained need to be aware of this.

8 Ongoing Developments

Dr Ben promises to find a local GP who can look after his medical needs.He expresses anger at the shabby way he and Helen have been treated by the staff at the clinic.He claims that they are being victimized and that the staff are jealous of Helen because of the relationship she is having with him.He threatens to leave the practice if Helen′s employment is terminated.

9 Questions

9.1 What are your concerns should Dr Ben leave the practice?

9.2 How will you address these concerns?

10 Answers

10.1 There is ongoing concern for Ben′s health and well being and the impact that the relationship with Helen may be having on his family.Suicide rates amongst doctors are twice as high as those in other professionals[3],and the combination of stress,alcohol abuse and possibly depression place Dr Ben at high risk.

There is also concern for Ben′s patients and the quality of care they may be receiving whilst he is under stress.Whilst leaving the practice(along with Helen) may alleviate some of the damage which is occurring in an organizational sense there is no doubt that many of the patients who have had a long relationship with Dr Ben as their GP will be upset and also inquisitive.

10.2 The practice will need to implement a contingency plan and hope that if Dr Ben leaves he does so gracefully,at least as far as the patients are concerned.This entails informing the patients that Dr Ben,for personal reasons,has decided to leave the practice to work elsewhere.There may be a clause in the partnership agreement which prevents Dr Ben from setting up practice within a 5 km radius of the existing practice.This may be hard to enforce.Ben′s patients will need to be cared for by the GPs in the practice and new doctor may be employed.Again the patients should be made aware of this.So communication via a newsletter mailed to all patients may be appropriate.

Should you have serious concerns about Dr Ben′s mental state adversely affecting his ability to practice you may still decide to report this to the Health Practitioner′s Board.

11 Final developments

Helen′s performance continues to deteriorate and her services are terminated.Dr Ben is outraged and gives 4 weeks notice to quit the practice.A legal and financial settlement are agreed to.He leaves his wife and family and moves interstate with Helen.News filters back to the practice that the relationship with Helen broke down after 3 months and that Dr Ben is now traveling around the country doing rural locum work and remains estranged from his wife and family.

12 Concluding Remarks

Depression and stress associated with "professional burnout"[4]is common in doctors all over the world including China[5-6]and may manifest in many ways including,alcohol and drug dependency as well as family and marital breakdown.Lack of insight into the real causes of problems may result in attributing blame on others including colleagues,one′s partner or even patients or clients.Searching for a new relationship may appear to provide a solution but this is often temporary and may even lead to greater complications.This appeared to be the case with Dr Ben.

1 Warhaft N.The Victorian doctors′ health program:The first 3 years[J].Medical Journal of Australia,2004,181(7):376-379.

2 Rogers T.Barriers to the doctor as patient role.A critical construct[J].Aust Fam Physician,1998,27(11):1009-1113.

3 Carpenter L,Swerdlow A,Fear N.Mortality of doctors in different specialties:Findings from a cohort of 20 000 NHS consultants[J].Jnl of Occup and Environ Med,1997,54(6):388-395.

4 Kirwan M,Armstrong D.Investigation of burnout in a sample of British General Practitioners[J].BJGP,1995,45(394):259-260.

5 Zhou Hongwei.Mental health status of Chinese hospital doctors:A prevalence study using SCL-90 in three tertiary hospitals[J].Contemporary Medicine,2010,10(1):7-8.

6 Zhang Wenshun,Qiu Yousheng,Duan Weidong,et al.A study of mental health of community physicians in Shenzhen[J].Med Jnl of Chinese People′s Health,2010,22(13):1718-1719.