“I don’t know how to begin….”
Members often use this phrase to introduce a difficult subject and one of the most difficult to broach is that of concerns about a colleague. The GMC has made it clear that doctors have a duty to take steps when they have concerns about a colleague’s fitness to practise. In Good Medical Practice the regulator states at paragraph 25c:
“If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, you must ask for advice from a colleague, your defence body or us. If you are still concerned you must report this, in line with our guidance and your workplace policy, and make a record of the steps you have taken.”
Most members are aware of this and do not wish to risk criticism by the GMC for failure to comply. However, they are often concerned about the conflict this can cause, whether their concerns are merited and if they need to take any action. One particular source of concern is in relation to colleagues’ health.
What are the signs to look out for?
General changes in demeanour and behaviour may be subtle and over a period of time may go unnoticed until there is a dramatic departure from normal. Sometimes immediate colleagues may not notice much, being too close and “not seeing the wood for the trees”.
We are often looking at changes in health which are not immediately obvious such as the onset of mental illness, for example stress, depression, substance abuse, and the types of illness where the doctor themselves may not acknowledge their condition. Signs of worsening health or reduced standards of practice can take time to develop. Also we have to be cautious when relationships have been difficult over a period of time to ensure that concerns about a colleague’s health are not unfair criticisms disguised as health concerns.
From our experience at MDDUS, by the time a member gets in contact there are a range of observed factors. For example, in cases of substance misuse this often includes noting the smell of alcohol, signs of medication overuse such as drowsiness or detachment, and deterioration in general function, such as being habitually late, lack of care with appearance and taking too long to complete normal tasks.
The tasks left incomplete are frequently related to administration and can often go unnoticed by colleagues. Sometimes there is an avoidance of more high risk practical procedures.
It is important to explore the reasons for the member’s concern and the ways in which their colleague’s work has changed. There may have been observations as mentioned above, a spate of complaints from patients, a failure to complete part of their work or complaints from colleagues who have found the doctor to be unusually short tempered or slow to respond to requests for assistance.
The first step is to try to look at the events causing concern as objectively as possible. Are the concerns shared by other healthcare professionals in the team? Can the observations be discussed with the colleague directly? Usually in a hospital setting this would be undertaken by a line manager and in general practice a nominated senior partner. Clearly any discussion must pay due regard to the sensitivity of the subject and requires care and support for the colleague.
It is essential to remember that the main issue is patient safety and any behaviour that could threaten it must be addressed promptly.
Where a colleague accepts they have health problems, there are various ways in which to proceed, from providing support at work to offering a period of sick leave. Any measures should also include appropriate healthcare input for the doctor involved.
This approach means patients can be protected from the potential errors of a doctor who is not functioning properly whilst the doctor also obtains remedial input with a view to a safe return to work in due course.
Difficulties arise when the colleague fails to accept there are health concerns, or challenges the extent and impact of their behaviour, and so refuses to engage in local intervention. If concerns are genuinely held, supported by adequate evidence, further steps are then necessary. These include wider local reporting (both in the hospital and GP setting) and are likely to include occupational health. All of this requires cooperation on the part of the doctor in question. Failure to engage with local processes is one of the main reasons for referral to the GMC – which is the next step. In cases of serious health matters the GMC should normally be consulted at an early stage.
The MDDUS experience is that careful assessment of concerns about a colleague and discussion with us at an early stage can put matters into context and allow determination of a proportionate response. This usually means using local procedures to protect patients and allow appropriate healthcare input for the doctor in question. In most cases, once a health issue has been acknowledged by the doctor they can obtain treatment and expect to return to practice once fit to do so.
Failure to act on concerns about a colleague’s health can create a serious threat to patient care. The risks are significant and at MDDUS we continue to be notified of errors in patient care which then lead to a doctor’s health problems being uncovered – some of which have gone unnoticed for some time. The risks associated with a failure to act on genuine concerns about a colleague’s health are significant to various parties:
(1) The doctor themselves
For failing to follow the GMC’s guidance: “Protect patients and colleagues from any risk posed by your health. If you know or suspect that you have a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients.”
(2) Medical colleagues
For not acting in accordance with the duty set out at paragraph 25c of Good Medical Practice (see above)
MDDUS cases show a range of harms ranging from falsified medical records to serious delays in diagnosis (failures to refer) and serious surgical errors leading to significant harm and death. In these cases the doctors not only face sanction by the regulator but also negligence claims and in some cases criminal investigation.
This is a difficult area but one which cannot be ignored. MDDUS advisers are happy to discuss any issues related to this sensitive subject and offer objective and fair advice.