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Harms of self-prescribing

In the GMC’s latest State of medical education and practice in the UK report (SOMEP), prescribing has been identified as one of the top three areas where doctors seek further information or advice. Whilst this report focusses on the many and varied questions related to prescribing in general, there is also a clear message about the risks of abusing a prescribing system.

Reference is made to a particular case study involving a hospital doctor fraudulently obtaining prescription-only medicines. He was referred to the GMC after a conviction for stealing prescriptions over eight months, some of which were forged under the names of non-existent doctors and using the names of non-existent patients.

The doctor explained that this was to treat his own medical condition and acknowledged that his actions were a "stupid mistake" and a "one-off". A fitness to practise panel concluded that, despite some evidence of insight, his actions were premeditated and prolonged, which indicated an underlying attitude problem fundamentally incompatible with being a doctor. He was subsequently erased from the medical register.

Abuse of prescribing is taken very seriously by the GMC because of the adverse consequences for both the doctor and patients involved. For patients this may include falsified notes and the effects this can have on their future healthcare and medical records.

Doctors and dentists are in a position of great trust and have easy access to both prescriptions and medicinal products. It is easy to abuse the system by issuing prescriptions, e.g. as described above or by taking drugs directly if available in a hospital setting or if handed in by patients.

A common feature of many such cases dealt with at MDDUS is an underlying health problem. The SOMEP report confirms that “doctors may be more vulnerable to mental health problems than the general population….A higher proportion of doctors experience social dysfunction, fatigue, depression and substance abuse than the general population.” Although the case summarised above lead to the doctor being erased this is not typical of health cases. Indeed a doctor cannot be erased for ill health.

At MDDUS we assist many doctors and dentists with health issues who are either reported or self-report to the GMC/GDC. Often they have significant underlying health issues which they have not adequately acknowledged or sought assistance for. Sadly, many speak of early embarrassment and a consequent reluctance to seek help. An initial lapse and self-medication can then lead to an escalating picture where ultimately the health issue comes to light – but possibly only after very significant abuse of prescriptions and medication. We always advise that members seek appropriate healthcare and if in difficulty they should discuss their professional concerns in confidence with one of our advisers.

In our experience the complexity of prescribing systems allows many routes for abuse. These include:

  • staff adding medication to records/computer scripts and overriding the system to print off a new script
  • doctors changing medication recommended on hospital letters to access medication themselves
  • ad hoc prescriptions generated by any member of staff where there is no system regarding such scripts and no system to identify those requesting or picking up a prescription/medication
  • doctors using medication they issue in patients’ names.

In order to try to minimise the risks it is essential to have in place robust systems which are clearly understood by all staff involved. In addition, regular audit of prescribing patterns can help to identify anomalies – and perhaps deter staff from trying to misuse the system. This is particularly so where controlled drugs are involved. Careful checks should be in place to ensure that those patients receiving repeat or continuing prescriptions for controlled drugs have an ongoing need.

When abuse of prescribing systems comes to light this is invariably very distressing for all concerned. Please seek advice from the advisory staff at MDDUS as we have a breadth of experience which we can employ to assist our members. With appropriate guidance both the practice and the doctor concerned can be helped through the processes that follow.

ACTION: Ensure that robust systems are in place for the issuing and review of prescriptions, particularly for controlled drugs. These should cover all prescriptions, no matter the format or how generated, and should include regular tailored audits. Doctors are encouraged to seek prompt advice from MDDUS if they have concerns about health issues or professional issues related to mis-prescribing, be it on their own behalf or relating to a colleague.

Suicide of doctors while under fitness to practise investigation

GMC review contains wide ranging proposals

Keith Hawton professor and director, Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK keith.hawton@psych.ox.ac.uk

In several countries doctors’ rates of suicide are higher than those for certain other professions and the general population.1‐3 Some studies have found the main risk to be among female doctors.4 5 Several factors contribute to this problem, including mental disorder, substance misuse, work problems,6 and awareness of and easy access to methods of suicide.3 7 Doctors have higher rates of mental health disorders, including depression, anxiety, substance misuse, and “burn out,” than other occupational groups yet getting help may be undermined by lack of willingness to access services.8 9 Some 10‐20% of doctors are thought to become depressed at some point in their careers.10

Doctors facing fitness to practise and other investigations understandably find them particu‐ larly stressful.11 They may experience challenges to both their professional and personal identities and may feel isolated, stigmatised, and angry. For many doctors their work is their main source of self esteem, making investigation threatening, especially when the process is prolonged. When these circumstances are compounded by lack of support (perceived or otherwise), depression, and possibly alcohol or drug misuse, it is easy to see how feelings of hopelessness and thoughts of suicide might develop. A recent survey of a large sample of UK doctors subject to complaints pro‐ cedures indicated that depression, anxiety, and suicidal ideas, together with adverse changes in their clinical practice, were increased compared with doctors not subject to complaints.12

The General Medical Council (GMC) has just published a wide ranging report into suicide among doctors under fitness to practise review and made extensive recommendations.13 Between 2005 and 2013, 28 doctors died by suicide or suspected suicide; nine during 2013 alone. The GMC investigation relied on GMC and medical examiner records, together with a review of GMC fitness to practise policy and procedures. In addition, it conducted interviews with GMC staff, doctors who had been subject to GMC inves‐ tigation, and external stakeholders.

Of the 28 doctors dying by suicide, 20 were men, two thirds were younger than 50, and two

Justice deferred

were trainees. The most common reasons for investigation were health and conduct concerns. In nearly half, the investigation procedures had lasted more than a year at the time of the deaths. Although suicide risk had been highlighted in some cases, in most there was a specific record that there was no known risk.

The GMC investigation identifies a wide range of concerns. These include the style and nature of GMC fitness to practise procedure and processes; the nature and effects of GMC com‐ munications to doctors under investigation; the length of time involved; and the

ticipation of the doctor concerned). Non‐medical GMC staff are to receive training to improve their awareness of issues facing doctors in clinical practice, and staff involved in investigations will be given more support. Importantly, the report also highlights the potential benefits of working with medical schools to ensure resilience train‐ ing for medical students.

The most radical recommendation in the GMC report is for developing a national support service for doctors, along the lines of the practi‐ tioner health programme for London based med‐ ical practitioners.14 This service might provide early prevention through encouraging health professionals with mental health problems to disclose them in a timely and confidential man‐ ner, an alternative to GMC investigation for some doctors whose practice could be affected by ill‐ ness, together with assessment, treatment, and case management of doctors with mental health disorders. Where necessary the service might provide the GMC with reports that could be used to determine a doctor’s fitness to practise, per‐ haps through a memorandum of intent between

The investigation also noted that doctors under review felt “guilty until found innocent”

the national support service and the GMC’s registrar.

Clearly such a national ser‐ vice would be costly; the report, however, suggests that it would provide value for money by

tackling the health problems of doctors more efficiently. Based on current annual funding of London’s practitioner heath programme the report estimates that a UK service would cost about £16m (€22m; $25m) for three years.

The report suggests that an initial two year pilot be funded by the GMC, NHS England, the Department of Health, and the health authorities of the devolved administrations. It proposes that subsequent funding could be provided by adding £22.61 to the average annual GMC retention licence to practise fee (a 5.8% increase). If the pilot is successful in encouraging troubled doctors to seek help (including those subject to review) this would surely be a small extra financial burden for doctors to bear so that they can receive support when they most need it. It might also reduce the level of suicide in the profession.

requirements (“undertakings”)

of doctors under review. Other
problems highlighted were the
need for greater recognition
of factors that may contrib‐
ute to complaints or referrals (such as marital breakdown, mental health, legal issues, and workload); local review procedures not having been pursued before referral to the GMC; and inadequate support available while doctors are under investigation. The investigation also noted that doctors under review felt “guilty until found innocent.” The report highlights the need for better provision of support and care for all doctors who experience mental health disorders.

Can do better

As a result of the findings the GMC has proposed extensive changes to its fitness to practise proce‐ dures. These include modifying the review pro‐ cess, with more emphasis on aspects relevant to wellbeing; a simplified medical reporting mechanism; employing a senior medical officer to oversee the fitness to practise procedures; and a case conference approach (including par‐

icipation of the doctor concerned). Non‐medical GMC staff are to receive training to improve their awareness of issues facing doctors in clinical practice, and staff involved in investigations will be given more support. Importantly, the report also highlights the potential benefits of working with medical schools to ensure resilience train‐ ing for medical students.

The most radical recommendation in the GMC report is for developing a national support service for doctors, along the lines of the practi‐ tioner health programme for London based med‐ ical practitioners.14 This service might provide early prevention through encouraging health professionals with mental health problems to disclose them in a timely and confidential man‐ ner, an alternative to GMC investigation for some doctors whose practice could be affected by ill‐ ness, together with assessment, treatment, and case management of doctors with mental health disorders. Where necessary the service might provide the GMC with reports that could be used to determine a doctor’s fitness to practise, per‐ haps through a memorandum of intent between

 

the national support service and the GMC’s registrar.

Clearly such a national ser‐ vice would be costly; the report, however, suggests that it would provide value for money by

tackling the health problems of doctors more efficiently. Based on current annual funding of London’s practitioner heath programme the report estimates that a UK service would cost about £16m (€22m; $25m) for three years.

The report suggests that an initial two year pilot be funded by the GMC, NHS England, the Department of Health, and the health authorities of the devolved administrations. It proposes that subsequent funding could be provided by adding £22.61 to the average annual GMC retention licence to practise fee (a 5.8% increase). If the pilot is successful in encouraging troubled doctors to seek help (including those subject to review) this would surely be a small extra financial burden for doctors to bear so that they can receive support when they most need it. It might also reduce the level of suicide in the profession. 

the bmj | 28 February 2015 

The Max Glatt Lecture from the MCA Conference 2014

Every year the MCA holds a memorial lecture in Max Glatt's name.  The MCA board selects someone who has been working tirelessly in the field of addiction to present a memorial lecture and be awarded the Max Glatt medal. In 2014 the lecture was delivered by Dr Allan Thomson

Doctors' well-being: back from the brink BMA Oct 2014

For doctors facing addiction and mental health issues, a GMC investigation can exacerbate stress to dangerous levels. Fortunately, there is a plethora of help available, if only doctors can overcome the stigma of seeking it

When a GP found himself fantasising about driving into a wall on the way to work, he knew something was seriously wrong. 

After a stressful time at his practice when a senior partner left, he turned to alcohol in an attempt to relieve his anxiety.

The London GP, who we will call Dr Jones, says: ‘It took me to extremely dark places. I couldn’t sleep and was drinking into the early hours of the morning. At 3am I’d still be awake, looking at the ceiling having panic attacks.’

His situation deteriorated over two years, until he was reported to his medical director for smelling of alcohol and was advised to self-refer to the confidential London-based mental health and addictions service for doctors, the NHS PHP (Practitioner Health Programme).

He says: ‘Until then I didn’t know there was help out there. With a lot of doctors there’s a feeling of shame and embarrassment. It was a sense of complete and utter failure. I thought I could try and handle it and get better by myself.’

 

Suffering in silence

This is a common experience, according to PHP medical director Clare Gerada (pictured below). She says: ‘Doctors suffer in silence. They may be registered with their friends or so shamed by their illness they don’t seek help.’ 

gerada

It is this stigma that makes the existence of confidential services such as the PHP and the BMA’s Doctors for Doctors, which offers counselling and peer support, so important. 

Doctors for Doctors service coordinator Tom Rapanakis says: ‘In the face of rapidly changing work environments and ever-increasing pressures on doctors, their health and well-being is a priority. 

‘Support services are required that take into account the stigma that can prevent doctors from accessing help.’

Being investigated by the GMC can exacerbate stress for doctors facing addiction and mental health issues. 

 

Character destroyed

Dr Jones was referred to the GMC for an interim orders panel, which looks at whether a doctor’s registration should be restricted while allegations about conduct are resolved. 

As a result, he was allowed to return to work for four sessions a week, subject to conditions such as being treated by a psychiatrist, having a GMC medical supervisor and showing evidence of attending the British Doctors and Dentists Group, a confidential peer support group for practitioners. 

He says: ‘It’s quite a daunting process. Your character is basically destroyed. 

‘My whole career prior to that was of no relevance at all. It didn’t take into consideration my 20-plus years as a professional. It’s very black and white.’

Doctors who have been away from work with a health problem find the GMC’s processes ‘anxiety-provoking’ and ‘distressing’, according to research from King's College London published in BMJ Open. 

 

Appropriate measures

Dr Gerada agrees: ‘We think that doctors who are mentally ill should be dealt with in a different pathway. 

depressed woman‘Clearly if a sick doctor does something despicable they really have to be dealt with appropriately, but for most, being dealt with in a sickness service rather than an adversarial service is much better.’

The PHP, which has seen nearly 1,500 patients since it opened in 2008, offers a wide range of care services including a group specifically for doctors who are suspended by the GMC.

Dr Gerada says: ‘For many suspended doctors their whole social and professional network is gone in one instant. They usually feel ostracised and shamed. It’s a very hard time for suicide risk.’ 

 

Procedure review

The GMC is due to publish a report into the deaths of 96 doctors who were under investigation in the past 10 years. 

Chief executive Niall Dickson says the GMC is reviewing the way it communicates with doctors in procedures and tries to avoid hearings in cases relating to a doctor’s health when possible. 

‘We must always act first to protect the public and that can involve taking immediate action when we believe patients may be at risk. But at the same time, we have a duty of care to the doctors who are referred to us,’ he says. 

The good news is that there is a high level of recovery in doctors who follow an evidence-based programme. 

 

Return to work

BMA forensic medicine committee co-chair Michael Wilks (pictured below) is a trustee of the Sick Doctors Trust, which offers an anonymous helpline for addicted doctors. 

Michael WilksHe says: ‘If the GMC encourages doctors who are reported on health grounds to follow these programmes, their chance of a prompt return to work and the removal of restrictions is high.’

Other services specifically for doctors include MedNet in London, which offers sessions with a psychiatrist and confidential helpline Health for Health Professionals in Wales.

Dr Jones has abstained from alcohol for two years and has now returned to full-time work.

He says: ‘Without [the] PHP I don’t think I’d be here today. My perspective on life has completely changed. Although I take my work as a GP and partner seriously, it isn’t what defines me anymore. 

‘We’re not trained to reflect on our own well-being, but it’s the most important thing and without it everything else falls apart.’

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