Practice dilemma - A GP with an alcohol problem

The dilemma - A patient you know well comes to see you with symptoms of lethargy and fatigue. He works nearby as a salaried GP and his wife has recently divorced him. You know he likes more than the occasional alcoholic drink and he has admitted several times in the past that he probably drinks too much. You are concerned he has a drinking problem, which may be affecting his judgment as a doctor. You know that if you disclose details about this to his employer or the GMC he will probably deny everything and find another doctor. What should you do?

A GP's view - Dr Alison Glenesk is a GP trainer in Aberdeen
Caring for our colleagues can be a big challenge. It is important we treat them as patients, not as doctors, while recognising they share our knowledge and skills.

This case has the added jeopardy of potential social, psychological and addiction problems. Nevertheless, it is important not to jump to conclusions.

The normal consultation course of history-taking and examination must be followed. Look for any possible physical cause for his fatigue and ask for his views of the problem.

Taking a psychiatric history is important to identify past mental health problems and evidence of depression. Don't worry about asking about self harm - he will understand that you have to do this. If the consultation is going well, you may want to ask about the divorce.

You must ask about alcohol and drug use. It may be, as you suspect, that he is drinking too much. On the positive side, he has come for help, knowing that you have discussed his alcohol use in the past.

It is probable he has a hidden agenda of seeking help for his drinking and will be happy for you to arrange this.

Reporting him to the GMC at this stage would be a breach of trust unless he refuses to take action on his problem.

A practice manager's opinion - Daniel Brookbank is a practice manager in East Sussex
The biggest issue here is that the GP in question is salaried and thus subject to all the protection of an employee.

If he were a partner, then the rights of an employee would not come into play and discussing the situation with colleagues would be based on a clinical need. As an employee, it is far more complex.

If you disclosed anything about him to his employers, not only are you breaching his confidential rights but if his employers used the information against him, he could sue for constructive dismissal and would probably involve you.

To disclose information of this nature to his employers, even if you have known them for years, you would need his written consent.

As his GP, tell him that you feel his problem is going to affect his clinical judgment and that he needs to do something about it.

If you fail to get through to him then the only course of action would be to report the matter to the GMC - but check your indemnity provider will cover any fallout.

A medico-legal view - Dr Jonathan Bernstein is a medico-legal adviser for the Medical Protection Society
This man's relationship to you is that of a patient who happens to be a doctor. Thus, your primary obligations to him are the same as those you have to any patient.

You should explore the current state of his alcohol problem and what help, if any, he has obtained. Discuss the stresses of his private and working lives, how these affect his drinking and whether the drinking impacts on his practice.

Does he have insight into how his problems affect his work and his interactions with colleagues and patients?

If you feel his drinking affects his ability to work, consider whether he should be certified as unfit for work. Advise him to discuss his difficulties with his employers.

You could seek his consent to contact them, enabling you to reassure yourself that he was not putting his patients at risk.

If your patient shows a lack of acceptance or insight into his problems, and you believe there is a risk of serious harm to patients, you may be justified in breaching his confidentiality. It may be appropriate to inform his employer or even the GMC of your concerns even without consent, but it may be prudent to take advice beforehand.

A sympathetic and supportive approach would hopefully enable you to retain his trust sufficiently to persuade him to follow your advice and remain your patient.

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