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When the doctor's on drugs.

You are both personal physician and friend to another physician, Dr. G. He has seemed withdrawn, irritable, and distracted recently. You have heard rumors through the hospital grapevine that not long ago he made a serious error in calculating a medication dosage, but that the error was caught by the pharmacist before the drug was dispensed.

Dr. G has resisted yur gentle explorations and expressions of concern during casual encounters, so you are surprised when he blurts out while seeing you for a routine office visit that he is using cocaine daily. You encourage him to enter a detoxification and addiction treatment program but he declines, saying that he can "handle it' by himself. Unfortunately, his personality changes peW and even though he assures you that he is now drug-free you strongly suspect that Dr. G's drug abuse continues. No further obvious medical errors occur, but stories are circulating in the hospital about his abusive responses to late-night telephone an When you directly confront him with your suspicions, he cuts off all further contact between you.

You wish to intervene, but are uncertain how to proceed. You believe you should at least raise your concerns to the quality assurance committee of the hospital medical staff or to the impaired physicians committee of the state medical society, if not to the state licensing board. Are you justified in doing so on the basis of your current information? Won't Dr. G just deny everything and accuse you of possessing an economic motive? Should his admission of cocaine use to you during a professional contact be kept confidential? What are the moral and legal implications of breaking confidentiality?

If you do not reveal everything that you know, you have no convincing evidence to present. You realize you have no proof that Dr. G has harmed any patient, but wonder if your social duty extends to protecting his patients from the possibility of future damage. What if you're wrong, and he is no longer using drugs? If being irritable is a crime, the hospital medical staff is going to be decimated! If you intervene, there is a real chance that Dr. G will end up the victim of rumors in the community and perhaps have his name listed in the National Practioner Data Bank. How can you sort through your duties to him as his friend, his physician, and his colleague, while remembering that you have duties to society as well?

In this wonderful country where the media are hungry for medical man-bites-dog stories and televised lawyers encourage every patient to consider himself a malpractice plaintiff, physicians are understandably reluctant to find fault with their colleagues. One never knows who else might be listening.

Doctors are particularly afraid to bring the faults of their colleagues to public attention. They are afraid that they will be sued, afraid that their own shortcomings will be revealed or that someone will accuse them of a self-serving economic interest. They are also afraid that they might unjustly deprive a person of his livelihood. When, as here, the faulty colleague is also a friend and a patient, someone who has put his trust and confidence in you, and when his faulty conduct arises out of a potentially reversible but addictive disease, one associated with manipulative and sociopathic behavior, an enormously complicated situation arises for the ethical physician.

What should be done?

In Dr. G's case the time for action would seem to be now. His behavior has changed noticeably. He has made a potentially serious mistake in prescribing, and his effectiveness as a clinician is being undermined by his abusive manner and the resulting rumor mill. Undoubtedly, patients will be injured by this physician should he continue to use cocaine.

The principle of primum non nocere (or nonmaleficence) incorporates the requirement that physicians prevent conditions likely to be harmful to patients. There is also the compelling duty to maintain the quality of the profession. A colleague who does drugs is not respectable, and a physician who may be perceived as covering up for him brings the profession into disrepute.

All of this said, it nonetheless seems that the duties arising from the doctor-patient relationship take precedence in this case. This relationship was established or to Dr. G's cocaine problem. Doesn't Dr. G also deserve compassionate care, especially for a disease that may have arisen by the stresses of his profession? Besides, there is the possibility that an effective plan may be able to resolve the problem of the cocaine use that renders Dr. G potentially harmful to patients.

If the physician caring for Dr. G has a therapeutic relationship with him, one that results in Dr. G becoming free of cocaine, then the physician can maintain confidentiality, and should not report him.

If there is no such therapeutic relationship, or if the therapeutic relationship breaks down, then I believe that the physician is obligated to report Dr. G to appropriate authorities. In some states, my own included, this is not only ethically correct but is also required by law. This action will result in Dr. G being reported to the National Practitioner Data Bank. In California, and perhaps other states, a specific "diversion" program exists, allowing treatment of the impaired physician in a program outside of legal or licensing processes. This would be an ideal step if Dr. G were willing to commit himself.

In this case it is not clear whether Dr. G is anyone's patient anymore. We are told that he has "cut off all further contact." In this situation, severance of the doctor-patient relationship should be more formalized. The physician should contact Dr. G immediately and insist on a clarification of their relationship, preferably in person, although telephone contact may be the only feasible way. The question for Dr. G should be framed simply: Are you still my patient?" Ideally, Dr. G's answer should be witnessed by someone impartial. If the answer is yes, then the physician should insist that Dr. G be enrolled in a program which would enable him to be drug-free, corroborated by urine testing to assure compliance.

If the answer is no, then the physician must insist on immediate referral to another competent physician to supervise Dr. G's drug-free rehabilitation. The physician should also insist that the copies of a record certifying Dr. G's compliance, preferably including urine testing results, be forwarded to him to insure that Dr. G is undergoing successful therapy.

The physician should not tolerate any half-way measures. Dr. G must understand unequivocally that anything short of immediate steps to becoming drug-free will result in his being reported. Herbert J. Keating III is associate chair and residency director, Department of Medicine, Medical Center of Delaware, Wilmington, Del.
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Title Annotation:case studies; physicians' opinions of what to do when a patient who is also a physician is abusing drugs
Author:Keating, Herbert J., III; Ackerman, Terrence F.
Publication:The Hastings Center Report
Date:Sep 1, 1991
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