Identifying the characteristics of doctors with health problems that disrupt their ability to practise medicine may help to identify young doctors and students at risk. I describe here the experience of the Health Committee of the South Australian Medical Board, which has been active for 18 years, in the hope that this might assist in formulating a prevention and early intervention program.
Four main types of health problems are encountered in doctors.
drug misuse, particularly narcotic drugs such as pethidine;
mental health problems;
general health problems that threaten vocational status; and
infection with blood-borne viruses, such as hepatitis B and C and HIV.
Here, I will concentrate mainly on drug misuse and mental health problems.
The Board hears of doctors with potential problems in several ways. The most common is notification by the doctor's practice partners. In addition, members of the doctor's family may seek advice or a doctor's patients may contact the Board, usually saying that their doctor seems "to be behaving strangely" or "to have changed". The Pharmacy section of the South Australian Department of Human Services often detects abnormal prescribing practices, especially in relation to pethidine, and routinely notifies the Board. Finally, about 20% of health-impaired doctors self-notify.
It is perhaps reassuring that it is very unusual for a health-impaired doctor to come to the attention of the Board because of a medical misadventure or an adverse event.
When the Health Committee is notified about a doctor with a potential health problem, it writes to the doctor (and quite often also contacts the doctor by phone) and invites him or her to meet with the Health Committee. The letter stresses that the doctor may bring his or her spouse or a friend, and informs the doctor that the Medical Defence Association lawyers are very used to working with these types of problems with the Health Committee. The aim of this initial communication is to emphasise that the interview will have the qualities of intervention, treatment and rehabilitation rather than being a disciplinary activity. Confidentiality is given very high priority and the doctor's identity is only divulged to the members of the Board's Health Committee.
There are a lot of subtle issues involved in contacting doctors. It is unwise, for example, to contact on a Thursday or Friday, because this leaves them the whole weekend to worry. Indeed, there have been instances of suicide as a result of this period of isolation and concern.
About half the doctors who come to the Committee meeting are accompanied by their spouse, about half by a lawyer, and about 40% come on their own. When these doctors are interviewed, it is relatively rare for them to deny that they have a problem, for example with drugs or with depression.
The Health Committee is responsible for coordinating a response to the problem. This usually involves
arranging for advice from specialists, such as psychiatrists;
arranging for a general practitioner for the doctor; and, in the case of drug misuse,
arranging for urine tests three times a week.
A health-impaired doctor usually takes at least three months' leave from work.
Voluntary undertakings are signed at the initial meeting and include permission from the health-impaired doctor for the specialists to send their assessments to the Health Committee. The voluntary undertakings are gradually changed over time. When doctors return to work, the undertakings often include that the doctor will not prescribe S8 drugs; will not work in a solo practice; and will not prescribe for themselves or their families.
As it has developed and matured, this program has had increasingly good outcomes — and this particularly relates to earlier detection. Relapse rates have fallen considerably and suicide has been reduced.
Pethidine misuse: About half the doctors have a relapse in the course of their "first round" of treatment. In the second round, again about half relapse, and this relapse rate also applies to the very small number who go on to a third treatment program.
Mental health problems: The vast majority of these involve depression or post-traumatic stress disorder, and this group of doctors generally does well in treatment and complies very well with the management program set out by their treating specialist. The program is particularly useful in the case of hypomania. The backing of the Board for the specialist's management program goes a long way towards ensuring compliance with medication in doctors with this condition (which is characterised by poor medication compliance).
Some of the characteristics of health-impaired doctors that may assist in early intervention and education programs are given in the Box.
It is not unusual for a doctor to be introduced to the effects of pethidine during the course of a medical procedure, commonly orthopaedic procedures. The doctor comes to see that pethidine (which is by far the most abused drug) gives the patient a profound sense of relief and a false sense of objectivity.
Many of the doctors misusing drugs obtain wider benefits from the Health Committee program than merely achieving abstinence. In the context of psychotherapy, it is common for them to rethink their approach to medicine and to their families. They may achieve a more mature relationship with their wife or husband, although, equally, it is not uncommon for relationships to break up at this point.
I have emphasised findings which might be called demographic or sociological in nature because they are easy to recognise. It is not hard to see that some special support might be provided to doctors who come from a different culture, or who have found themselves in solo practices, or whose families are struggling in the context of setting up life in a new culture.
I would like to especially note here that, at least in South Australia, doctors in the community and in hospitals and other institutions are generous in providing support and help for impaired doctors, and later when they are trying to return to work. The role of the Board in this context is to facilitate the doctor's return to work; to help often new medical partners to understand the problems commonly faced; and to support the doctor concerned.
It is essential for the doctor's new colleagues to feel that the Board remains interested in the long-term future of a previously health-impaired doctor. Thus, long-term follow-up is the rule. The Board's Health Committee has noted that, with long-term follow-up, the number of doctors who bring their spouse or partner with them increases as time goes on. This appears to be a good prognostic sign.
We have found that it is possible
to set up a system which has the powerful backing of the Medical Board, but which is, at least in the first instance, non-punitive;
to identify risk factors for drug misuse and mental health problems; and
to detect these problems early if the system, especially the medical system, is made well aware of possible avenues of help.
A result of the Health Committee activity, as described here, is that there is less stigma associated with the notion of impairment and therefore the opening up of more opportunities for helping impaired doctors. Assisting doctors who are isolated or not part of the culture to integrate in an atmosphere of collegiality seems to be an important part of achieving long-term favourable outcomes.
Some characteristics of health-impaired doctors
Working style: When these doctors describe their working style (and this is often supported by information from colleagues and their family), they appear as very conscientious people who work very long hours. They often have few friends within the medical profession and do not attend continuing medical education sessions. Sometimes an impression is gained that they have reached a point where "their only friends are their patients".
Family relationships: At the time of presentation, it is common to find that the doctor's family relationships have become disturbed and dysfunctional.
Isolation and alienation: A common finding is that more than half the doctors presenting with drug misuse did not train in Australia. In addition, there are a number who are sons or daughters of first-generation Australians, who are often by far the most highly educated of the extended family, and a great deal of faith has been put in their futures. In addition, solo practice is often over-represented, as is rural practice. As these doctors tell their stories, it becomes clear that they feel isolated, and perhaps even alienated, from Australian-trained doctors, and Australian customs and cultures. Their main solace as a doctor is in the actual practise of one-to-one medicine, and they do not share their experiences with their partners or in the wider setting of medical societies. They are often depressed or at least dysthymic.
In the wrong career: Some doctors feel isolated and estranged because they have come to recognise that they have made a mistake in going into medicine and do not know what else to do. Some of these doctors come from families with a strong medical tradition.
- Ross S Kalucy
- Department of Psychiatry, Flinders Medical Centre, Bedford Park, SA.