|
AN
OCCUPATIONAL HEALTH PROBLEM
Lecture to the
Scottish Society of Occupational Health Doctors, Glasgow, March 2004
Dr P.J.Tomlin,
Secretary to SCP
Doctors Suspension Study Group
There is an
industry which has a little used process. The problem with this process is that
for the workers involved it makes half of them ill. Some of them become
seriously ill and need hospitalisation and almost three percent of the
workforce involved die as a direct result of this process. Management knows
all about it. They have known for years and apart from a few token words and
the odd crocodile tear have shown not the slightest interest in making the
process safer. Instead they are constantly seeking the increase the use of
this process on grounds of increased efficiency. The Health and Safety
Executive know all about it and refuse to intervene because of the politics
involved. The Government knows all about it and have known for more than ten
years but there are no votes in this and so they ignore it.
For the workers
involved, the death risk is greater than the death risk faced by the citizens
of any British City during the height of the bombing during the war. That
Industry is the National Health Service. The poor bloody infantry who are the
victims are the doctors. The illnesses and death are quite deliberate in that
they are not Acts of God but the result of an indifferent and callous
management. All this illness and mortality is completely preventable.
Here are some
examples. A young consultant anaesthetist had severe dental phobia. He needed to
go to the dentist. So he took an ampoule of Valium and a syringe and needle and
went to a dentist. He was seen injecting himself with the Valium. He was
suspended. At the disciplinary hearing he described his dental phobia. He was
called a liar, a thief, a drug addict and a disgrace to the profession. He was
summarily dismissed He committed suicide the next day. That death was
because of a 5p. ampoule of Valium plus a tuppeny syringe. The bully who
made those allegations was a senior member of the hospital Board.
Another
example. Another anaesthetist. One of the bravest men I have known. He
volunteered and worked for a year as a civilian doctor treating the victims of
battle atrocities in Vietnam from both sides, in the middle of that war.
He then came to England and trained to become an
anaesthetist. He got a job as a consultant. There was then a dispute as to who
was failing to fill in the DDA book in the operating theatre This is a
register of who gave what narcotic to which patient. All anaesthetists use
powerful narcotics and often there is delay in signing the book until after the
operation or operating list is over. He was the only ethnic minority
anaesthetist and was accused of misusing the drugs. He committed suicide.
Another example. A consultant was convinced that key public
health figures were being manipulated by her seniors and blew the whistle.
The consultant was promptly suspended and as a result became acutely depressed.
She was admitted to hospital. Eventually she was allowed to return to work, but
down graded to SHO - and then received a letter of dismissal. The doctor
committed suicide the next day.
The
SCP
Doctors Suspension Study Group
was set up by the Society of Clinical Psychiatrists some sixteen years ago to
look into the health problems of suspended doctors. The remit was to look at
suspended senior doctors in the Hospital Service.
[TABLE ONE]
We have
information on three hundred and fifty 0ne senior hospital doctors, that is
doctors in final career grades, collected over the last sixteen years. It was
amongst these doctors that we identified two patterns of morbidity. We found two
principle illnesses; depression and stress induced heart myocardial
infarction. The severity of the depression varied. For some it was a rather
severe "fed-upness", but for others it could grow into morbid depression, with
destruction of self worth, intense apprehension as to their professional
future, and indeed whether they would be driven from this country into exile,
that is become economic migrants. For cultures where Face is significant, they
suffered much more. And of course for some the depression was made worse by
mangled accounts leaked from management to the media, local or national. Words
such as "we are examining over 100 dossiers that have been compiled that involve
this doctor". Or where Management quite deliberately obstructs the resolution
of the case. They want that doctor out and don't care who gets hurt in the
meantime. The depression was such that half of all the suspended doctors had
to be treated by another doctor, either the GP or, if the depression was
bad, then a consultant psychiatrist was called in. We have information on about
160 such patients. Some needed to go to a place of sanctuary, a place of
quiet and rest in sympathetic surroundings - that is, some form of care outside
the NHS, in the private sector. Others were admitted to acute psychiatric
units in the NHS. And their case notes were available to be examined by
the Management who was responsible for this illness, in case there was a legal
suit! That is, there was, and is, a profound distrust that normal patient
confidentiality would be observed.
As a result we now advise all suspended doctors that they must not try to cope
with things on there own but to consult with their family doctor. And have
done so for the last ten years. It was my proud boast that we had prevented all
the suicides from the doctors who consulted us, although the suicides were
still occurring in the suspended doctors who did not get in touch with us.
Sadly, last year we had our first suicide among our own group..
The other source of morbidity is stress induced myocardial infarction. This is
usually rather late, that is after the doctor has been under continuous stress
for more than three months, maybe for more than a year. Incidentally, this
problem occurs not only among the doctors, but also with their wives. We have
had four deaths from acute and unexpected myocardial infarction, and another
eight where the myocardial infarct was not fatal. It actually provided an
escape out of the deadlock, in that the doctor could then be retired on grounds
of ill health. Whether they wanted to or not, I regard it as deeply unethical
that management should so stress their workers and then use the resulting
myocardial infarction as an excuse for getting rid of someone.
What are the factors involved in suspensions?
Race
discrimination
and sex discrimination are there.
Taking Sex Discrimination: of the 57 suspended female doctors, for some
16 we do not have the outcome, either because the doctor refuses to answer
our letters, or because the case is still outstanding. But where the case has
been resolved only 1 in 9 was the suspension ever shown justified and the
doctor dismissed BUT fewer women got their jobs back Instead they were
"bought out" in some kind of settlement.. Whereas for the men it was 1 in 5.
That is, female doctors were twice as likely to be wrongly suspended as male
doctors.
Race discrimination is rife. Almost one third of suspensions were doctors
from ethnic minorities, although they make up less than 20% of the population
of consultants. And again, the white doctor is more likely to be reinstated
than the black doctor. But the ethnic minority doctors are fighting back.
There have been six cases of racial discrimination against ethnic minority
hospital doctors; four have been won. The most expensive award for racial
discrimination was over £900,000, in Manchester. In addition at least two
other cases have been settled out of court. There are another six cases
pending.
If you look at the various specialties, against the relative number of doctors
in each specialty, gynaecologists are seven times more likely to be suspended
than physicians. There is also some bias in that 1 in 3 suspended
obstetricians is likely to be dismissed. This is so far outside the normal
range as to suggest that something quite specific is occurring.
When we looked at whether the suspended doctor was whole time or part time with
a private practice we discovered that among the suspended gynaecologists it
was the ones with the biggest private practice locally who were suspended.
Usually as the result of a complaint by a colleague.
We looked next at the variation across the regions, to see who was "trigger
happy"
[TABLE TWO]
Three
regions stand out. Trent, The West Midlands and South East London. There has
been a notable change over the years. Trent used to be the worst region by far,
and then they had a change in Management and in more recent years have had a
relatively low rate of wrongful suspensions. On the other hand Wales and the
South West, who were originally very good about not suspending people wrongly,
have roared ahead! I am not sure whether this is a result of a change in
management or whether they have taken on a more aggressive firm of solicitors -
who obviously have a vested interest when consulted about whether a doctor
should be suspended.
We then looked at the accusers and reasons for suspension
[TABLE THREE]
Less than half
are because of alleged professional incompetence. In only 18 out of 351
suspended doctors was professional incompetence established as proven, and
that was at the low standard of the balance of probability. It is quite clear
that there are no standards of what constitutes professional incompetence - all
one gets is opinions from the great and good of what they think it might be.
Yet the data is available. Every one is doing audit. Therefore it should be
possible to compare like with like.
Where this has
happened, it has been very enlightening. Here is Scotland a few years ago; a
neurosurgeon was accused of being a bad surgeon. So he looked at the audit
data and found that his accuser had a worse mortality than he had. When this
was pointed out the allegation was dropped. Another, a cardiac surgeon, was
accused of incompetence, but curiously his excess deaths only occurred when
he had a junior, half-trained anaesthetist at the head of the table. Another
surgeon was accused of having double the death rate following cholecystectomy
than his colleagues. Audit showed that he was doing three times the number
of cholecystectomies than his colleague. What is clear is that management,
personnel officers, chief executives and medical directors do not know what
constitutes professional incompetence in all the various specialties. It is
therefore very easy to pull with wool over the eyes with an overblown
allegation. The reflex "let's suspend" then occurs, and after that
management are left with trying to justify the wrongful suspension.
What is
particularly interesting is that you would think that a doctor accusing a
colleague of professional incompetence would know what he was talking about.
But there is no difference between colleagues making all the running with the
complaint and administrators who, as a result of some complaint, decide to
trawl through hundreds of case notes to justify the suspension.
Our advice to any administrator, to avoid being taken to the cleaners, is to
ask certain simple questions of the accusers. Tell them to produce the
statistical detail of comparison from your departmental audit to show comparison
between colleagues doing the same kind of work. The other question is to ask
the accusers and the experts for documentary published objective statistical
data to justify their allegations or opinions. Otherwise refuse to suspend,
but warn the doctor that his work is being examined. There can be no
justification for locking out the doctor from the hospital, because there could
well be a hidden agenda behind the allegations. It might be private practice,
it might be a desire to be head of department, it might be simple professional
jealousy. But suspensions are costing the NHS over £50m. p.a. by the time
you factor in the cost of retraining or the cost of training the
replacements, plus the golden handshakes That money would save more lives
if spent on patient care than the lives potentially put at risk for allowing
a suspect doctor to continue practising, particularly if the doctor was
warned to pull his socks up. Only in 5%, 1 in 20 of all suspensions does the
doctor pose a threat to patients. It is costing nearly £50m a year to
identify one doctor a year who could be a threat to patients. You could save a
lot of lives with £50m.
So now we warn all doctors who are suspended, and who are over the age of
40 to take half an aspirin a day, every day, and to continue with that
until at least three months after the case has been resolved We believe that
there is a rebound risk when the stress is suddenly reduced but I cannot
prove that.
The role of the Occupational health physician is a troublesome one. The
experience of our group is bad, although not uniformly so. In essence there
is commonly a breach of patient confidentiality, and far too much personal
data is passed to the management. For example, details of obstetric
complications, miscarriages, gynaecological surgery, fertility treatments are
given to management, to be circulated among the administrative secretariat
The suspended doctors find that disturbing. They cannot see why more
medical information is given to hospital management than they would give to the
managers of a car factory. What is also apparent to our group is that
occupational health doctors seem to lack the insight of the effect of the
suspension on the doctor, that his whole way of life, and his career are on the
line, that suspensions can and have caused breakdown of marriage, and that the
occupational health doctor is not being a doctor in the true sense of the
word, that is someone who puts the patient first. To give an example, a
doctor was not in favour with his colleagues who fundamentally wanted him out.
He had a domestic crisis, his engagement was broken off, he made a feeble
attempt at suicide; but vomited up the tablets. He told the hospital the next
day what had happened and that he was feeling low . The day after he was
admitted to a psychiatric unit. After a period he was discharged. The Consultant
psychiatrist, who is on the GMC medical board which assesses psychiatrically
disturbed doctors as to whether the individual doctor poses a risk to
patients, said he was no risk. An independent consultant psychiatrist, another
member on the GMC board also said he was no risk. But the occupational health
doctor would not sign him up as saying he posed no risk and the so the doctor
remained on indefinite gardening leave.
It is the opinion among our group of suspended doctors that occupational health
doctors are too much under the influence of management in assessing the health
factors surrounding a suspended doctor. That unhappily is their opinion,
which means in turn that Occupational Health Doctors will have to work very
hard to regain the trust of their wrongly suspended colleagues.
There are
proposals to reform the system. Some of you may have seen the leading article
in the BMJ earlier this year. So far, the proposals do not amount to a row of
beans. They propose time limits, but these have been proposed before and
ignored. The Public Accounts Committee of the House of Commons is due to make
a report in the House about the waste of money over suspensions. Given the
public mood, I do not think they will be kind. Next Monday there is to be a
brief debate in the House of Lords, initiated by Baroness Jill Knight. One
proposal that is being circulated is that chief executives, together with
the chairman of the board and possibly the director of Human Resources,
should be held financially responsible for the cost of any suspension where
they have deliberately broken the rules. Some of you may recall the case of
Dame Shirley Porter who, as chairman of Westminster City Council, broke the
rules concerning the selling of council property. It was held that it was
unfair for the taxpayer to pay when she knowingly broke the rules. She now has
a bill of several million pounds.
The suggestion going around is that it is unreasonable for the taxpayer to pay
when hospital trusts deliberately break the rules concerning suspensions, and
therefore the highly paid chief executives ought to pay out of their own
pockets. That should make everyone more careful about suspending doctors.
It might even save a few doctors' lives.
DISCUSSION
Following the presentation there was a very lively debate. What clearly
emerged is that suspended doctors do not know or understand the role of
the occupational health doctor, that it is not one of being a personal
physician who happens to practice in the suspended doctor's workplace.
What also emerged is that occupational health doctors do not realise the
misconceptions in the mind of the suspended doctor as to their role. It is
assumed that, because they are hospital doctors, they know the function and
application of the occupational health doctor.
It was also stressed that occupational health doctors have a strict code of
conduct about what is passed on to the employer, even if that employer is
medically qualified and wants further particulars. It was suggested that
before any suspended doctor sees an occupational health doctor he should be
given a written sheet describing the purpose of the attendance, and a
guarantee of confidentiality.
PETER TOMLIN
Tables 1, 2 & 3 available on request from
Hon.
Secretary Suspended Doctors Group: Dr P J Tomlin
Radnor House, The Heathlands, Downton, Wiltshire SP5 3HJ
Telephone/Fax: 01725 513367
|
