Abstract
Referral of doctors to the General Medical Council concerning their fitness to practise is an important subject, not only because of potential risk to patients, but because of its impact on the mental wellbeing of the doctors concerned. This paper is based on the case histories of 124 doctors (1990–2015) reported to the GMC and for whom I was requested to undertake a psychiatric assessment. My findings are summarised under three headings: psychiatric problems, substance misuse and inappropriate sexual behaviour. Nerve-wracking though GMC referral is for any individual doctor, most investigations do not proceed beyond the triage stage, after which the case is closed. I also reflect on the changing pattern of doctors’ professional identity and how this might help them seek help for mental disorders at an earlier stage than in the past, thus preventing referral to the GMC.
Keywords
Introduction
Over the 25 years from 1990 to 2015, I was one of a number of psychiatrists who assessed doctors referred to the General Medical Council (GMC), in order to give a psychiatric opinion on their fitness to practise. My work in this capacity came about because of long-standing medico-legal interests, including with the Parole Board (1992–1998), and as a member of council and psychiatric adviser (1978–1996) of the Medical Protection Society and chairman of council (1988–1996). Requests to me to undertake assessments came from the medical defence organisations, solicitors and the GMC. I was a GMC associate and health examiner for the Medical Practitioners Tribunal Service between 1999 and 2015. For this paper, I reviewed the case histories of the 124 doctors whom I had assessed, all paperwork having been filed securely since doing so. I consider the main clinical and behavioural problems of those doctors. I do not relate this to the final outcome of the GMC’s deliberations for each individual because I was not privy to that information.
The role of the GMC is that of official register and regulatory body of medical practitioners in the United Kingdom (UK). Its chief responsibility is to “protect, promote and maintain the health and safety of the public by controlling entry to the register and suspending or remove members when necessary”. Referral to the GMC is an important subject which we need to better understand, in particular because it has a profound impact on the doctors concerned. It is a tragedy that the GMC reported that five doctors died by suicide while under investigation or during a period of monitoring, during the three years from 2018 to 2020. 1
Inevitably, when a doctor discovers that he or she has been referred to the GMC, the spectre of erasure will always be at the forefront of the individual’s mind. They seek the support of their defence organisation and, if necessary, legal representation for any GMC hearing. They may also seek peer support from the British Medical Association’s (BMA) GMC investigation support – doctor support or Wellbeing service. 2
The GMC commissions this BMA service to provide emotional support to doctors undergoing investigation. The service does not provide expert or legal advice. Importantly, the doctor accessing it does not need to be a BMA member. Concurrent with undertaking psychiatric assessments of doctors referred to the GMC, I have also worked with the BMA doctor support service. I mention this as a potential “conflict of interest”. However, there was no overlap between this work and the psychiatric assessments for any individual doctor.
The GMC receives concerns about doctors’ practice from various sources, including from their colleagues and their employing authorities, from patients, and from the police following conviction for an offence. Thirty-two of the 124 doctors in my sample were referred to the GMC following convictions for a variety of offences, ranging from one-off drink-driving, shoplifting or illegal prescribing, to fraud or sexual assault. Two doctors had served custodial sentences, one for fraud and another for forgery, while three others were awaiting investigations for manslaughter, supply of drugs, or theft from a NHS Trust account.
The GMC publishes statistics relating to concerns raised regarding doctors’ fitness to practise. In 2015, coinciding with the last year of my series, there were 273,767 doctors on the register and the GMC received 9,418 communications regarding their fitness to practise. Of these, 6,208 cases were closed with no further investigation, after initial triage assessment to decide if the information received could ever raise a concern about fitness to practise. Of the 2,306 doctors subject to full investigation, 351 underwent a provisional enquiry and 553 were referred to their employer or “Responsible Officer”, the person within a healthcare organisation accountable for local clinical governance focusing on the conduct and performance of doctors. Of 239 who proceeded to medical practitioner tribunals, 72 were erased from the GMC register, and 95 suspended. A further 25 were subject to registration conditions and undertakings to help remedy clinical or other difficulties. 3 Nerve-wracking though GMC referral and investigation is for the individual concerned, in reality, most doctors return to clinical practice.
The subject of fitness to practise is also topical, given the media attention to This Is Going to Hurt, 4 Adam Kay’s book based on his diaries about his experiences as a junior hospital doctor between 2004 and 2010. Together with his seven-part television drama series of the same name, Kay gives a graphic account of a junior doctor’s life, mainly in an obstetric unit which appeared to be understaffed and poorly managed. He describes the junior doctors as being exhausted and demoralized, and one died by suicide. There is reference to a GMC referral but apparently the complaint was withdrawn. Kay later decided that life as a doctor was not for him.
Clinical and behavioural problems
Findings from my case histories are summarised under three headings: psychiatric problems, substance misuse and inappropriate sexual behaviour.
Psychiatric problems
I assessed a total of 56 doctors referred with suspected psychiatric disorders, organic and functional. Their behaviours had been sufficiently abnormal to cause concern to colleagues, patients, or health authorities and to warrant their referral to the GMC. However, at the time of my examination, the disorders were not necessarily apparent: some had already accepted treatment, some had recovered, and some showed no evidence of having had any psychiatric disorder.
The majority (36) had a history of severe mental illness, with at least four warranting detention under the Mental Health Act 1983 (section 2), at some stage. Although not exhibiting any signs indicative of psychosis at the time of my examination, at least four had experienced psychotic episodes diagnosed as schizophrenia or schizoaffective disorder. Others had had bouts of severe depression or the depressive phase of bipolar disorder. Only one was diagnosed as having suffered from mania. One had been newly diagnosed, by an expert in the field, with attention deficit hyperactivity disorder, deemed to have been aggravated by recent stressful life events.
I also assessed five doctors aged between 62 and 88 who were referred to the GMC by medical or nursing colleagues concerned that they showed signs of cognitive impairment. One of these doctors lacked insight into his limitations, which led to him being exploited by drug addicts requesting prescriptions to satisfy their drug dependency.
I examined 15 doctors suffering from anxiety and depression, apparently stemming from professional or personal problems or working conditions, whose behaviour had caused concern. I found no evidence that any of these doctors had a psychiatric condition making them unfit to practise. Common symptoms were often those seen in burnout: poor concentration, sleep problems and anxiety, often with a feeling of emotional flatness, and loss of drive and enthusiasm for the work as a medical practitioner. For all of them, I felt that some form of counselling, support or retraining would be appropriate. With more recent understanding about doctors’ depression, anxiety and burnout associated with stressful work environments, 5 if I was in the same role today, I would be looking more towards responsibilities of employers towards their staff. The symptoms described may also be associated with risk taking behaviour as an emotional panacea. Alcohol or drugs may be used to relieve symptoms, and activities such as speeding, shoplifting and sexual indiscretions may lead to prosecutions. Four doctors had a history of convictions while suffering from a mental disorder, including two for shoplifting while in a state of depression and one for assault on relatives while psychotic. Another served a prison sentence following writing inappropriate prescriptions and supplying medication. He had a history of auditory hallucinations, but this did not appear to be relevant in terms of his offence.
Substance misuse
Thirty-two of the 124 doctors I assessed had problems of substance misuse: 20 were referred because of alcohol-related concerns and 12 with problems due to drug taking. Doctors have relatively easy access to addictive drugs, either by self-prescribing, prescribing for fictitious patients or by stealing from hospital supplies. The drugs most frequently used by the doctors in my sample were all opioids: fentanyl, pethidine and tramadol. Nine of the 12 in my series had been prosecuted.
The GMC’s advice on the matter of any prosecution and conviction is clear: “You must tell us without delay if, anywhere in the world”, “you have accepted a caution from the police” or been “charged with or found guilty of a criminal offence”. 6 In the UK, doctors found driving above the legal alcohol limit are reported to the GMC by the police if the driver is identified as a medical practitioner. The GMC will invite these doctor-offenders for a fitness to practise examination by a psychiatrist and appropriate physical tests. Twelve of the 20 cases referred to the GMC in which alcohol was a factor were in the drink drive category. Two cases appeared to have been “one off” offences with no evidence of any alcohol problem. In contrast, one doctor who had been convicted of drink driving was also referred to me for an opinion about his fitness to practise. Unfortunately he came to my consulting room and admitted that he had just had two pints of Guinness, and he appeared drunk. He was ponderous, facetious, his speech was slurred and his conversation rambling. At that point in time, he was manifestly unfit to practise.
Of the other eight doctors I assessed with whom alcohol was a factor, three were referred because the smell of alcohol on their breath while at work had raised suspicions. However, on examination, as in the two drink drive cases, there was no evidence of any alcohol problem or psychiatric disorder. In the remaining five cases there was some evidence of depression with intermittent use of alcohol.
It is heartening that, by the time of my examination, nine of those whose alcohol problems had led to GMC referral had addressed this issue and were attending either Alcoholics Anonymous (www.alcoholics-anonymous.org.uk) or the British Doctors and Dentists Group (www.bddg.org) and were abstinent.
Inappropriate sexual behaviour
Twenty doctors in my sample were referred because of inappropriate sexual behaviour, with nine resulting in conviction. Two of the convictions were incurred while on holiday abroad. One was for voyeurism with a camera on a holiday campsite and another for impulsive homosexual behaviour while staying in a backpacker’s dormitory. Both these cases were reported to the GMC by the offenders themselves, in accordance with GMC rules. One doctor had been arrested after being observed by the British Transport Police taking photographs under the skirts of women travelling on an escalator. Another had engaged in risk taking behaviour by sending erotic emails to non-medical colleagues while in a state of moderate depression, while three others were disciplined by hospital or practice authorities for using computers to access pornographic sites. Another was convicted of accessing child pornography by using his credit card.
A few complaints, usually from female patients about male practitioners (although one was from a male homosexual patient about a male homosexual doctor), were allegations of sexually motivated behaviour following what appear to have been routine physical examinations when a chaperone had not been present. 7 At least three doctors had sexual relationships with patients who were under their care. Another had a sexual relationship with the wife of a patient, and another with a former patient.
Discussion
Despite the GMC’s roles to register and regulate medical practitioners in the UK to ensure the well-being of the public, those who are referred to it may see it primarily as a disciplinary body. It is worth keeping in mind that suspension or erasure are rare, counselling or retraining may be advised, and that over 80% of referrals to the GMC are closed and do not proceed beyond the triage stage.
Illnesses, life events and professional and personal stresses may interfere with a doctor’s professional medical skills without causing alarm to that individual, until colleagues, patients or health authorities realize that their fitness to practise may be impaired. Poor concentration, loss of drive and risk taking behaviour and self-medication with drugs or alcohol may lead to problems in clinical practice or even to prosecutions. Examining psychiatrists and the ensuing tribunal panel may decide that the individual practitioner is fit, but, in some cases, failure of the doctor to seek help when they are struggling with psychological symptoms can lead to deteriorating mental health and serious problems.
Dame Clare Gerada, medical director of NHS Practitioner Health (www.practitionerhealth.nhs.uk), has pointed out that doctors have a deep rooted sense of professional identity which allows them to do jobs that society expects from them, but it also acts as a barrier to seeking care when unwell. She has also noted that the training and power which doctors have is changing, becoming more egalitarian and multi-professional. With these changes, it is hoped that doctors can both retain their strong identity to their chosen profession and unchain themselves from the conviction that they are invincible, with the result that they may better recognise that they too may need help and guidance at times. 8 This shift may help doctors seek help at an earlier stage than they would have done previously, and prevent referrals to the GMC.
Footnotes
Permission details
I am submitting original work, and have the rights in the work. I am submitting the work for first publication in the MLJ and it is not being considered for publication elsewhere and has not already been published elsewhere. No permissions are required for citations. No visual art work is included.
Acknowledgements
I am indebted to Dr Claire Hilton, Resident Historian to the Royal College of Psychiatrists, for her untiring encouragement throughout my preparation of this review.
Consent
I have had no contact with the doctors since assessing them between 1990 and 2015. It has therefore not been possible to seek consent, but care has been taken to remove all possible identifying information, including names, ages, specialties and location.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.