Clincal case study: Underperforming colleague

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Colin is a 62 year old GP partner in a two GP rural practice. The practice nurse has come to you to indicate that she is concerned that Colin is not well. You are Colin's GP partner and you have noticed he has been a little weary lately, and has been talking about his workload. He has also brought up the issue of retiring from his full-time partnership and returning on reduced hours.

Colin has been the lead GP partner in the practice for 30 years and knows his patients well. His GP records have always been a little scant, which has made sharing patients a little trickier for you, but Colin has always maintained that he has a good memory and doesn't need detailed records.

The practice nurse is relatively new to the practice. She reports that she is reluctant to raise her concerns, but states that Colin has been late starting his clinics over the last couple of months. In addition, she has had to transfer a few patients that had initially seen Colin to your clinic, as they reported that Colin seemed vague and uninterested in their reason for attendance. The practice nurse has indicated she doesn't want to make her concerns formal and will leave it to you to deal with as you see fit.

You are also aware that Colin's six year old granddaughter has recently had a serious illness with an extended time as a hospital inpatient.

What are your initial thoughts on how to handle the information from the practice nurse?

• You need to be independent, impartial and fair in handling the situation
• Are there any immediate patient safety issues?
• Is there a hidden agenda, e.g. conflict between the practice nurse and Colin?
• Is Colin suffering with any health issues, e.g. physical, mental, substance misuse?

What initial actions would need to be undertaken by you or the practice manager?

Further information needs to be collected. This should be carefully collected from other staff members who work with Colin (without breaching confidentiality about any concerns). This information should include the following:

• Check the clinical activity, e.g. review case records of patients he has seen
• Are there any immediate patient safety issues?
• Look into Colin's general work activity, e.g. time keeping, concerns, complaints
• Try to determine if there is a pattern of issues/concerns.

You make use of a meeting already arranged to opportunistically enquire about how Colin feels things are going and to give him the opportunity to talk about how he is in terms of his health and general wellbeing.

Colin expresses some concerns as to how target-driven GP work has become and refers to the 'tick box' approach to work that seems to be required on a day-to-day basis. He seems anxious; however he reports that the family members are relieved that his granddaughter is recovering well.

Out of the blue, Colin mentions that he has recently received a letter of complaint from a patient's daughter. She has complained that Colin had not noted deterioration in her mother's health and that he had been dismissive of her long-standing gynaecological concerns.

You think that Colin's breath smells of alcohol.

What do you say to Colin?

• Express sympathy and show empathy with how he is feeling
• Ask Colin if he has acknowledged and responded to the complaint. If not, ask why he hasn't, and when he plans to do so.

Colin states that there may have been a couple of other complaints, which he didn't deal with as they were minor and didn't merit any response.

• Tell Colin that concerns have been raised about his time-keeping and apparent lack of interest in some patients, and feed any information back to him that you have obtained from your investigation
• Raise your concern regarding his alcohol use
• Ask him to see his own GP.

Colin reacts with anger and becomes very upset. He refuses to follow your advice.

What would you do before you inform your Health Board/Clinical Commissioning Group (CCG)?

• Take advice from your Defence Union.

You make a referral to your Occupational Health (OH) service on the advice of the Health Board/Clinical Commissioning Group (CCG).

What important background issues would you need to provide in your referral to the OH service?

Give a full account of your findings including details of staff concerns, which should include that:

• The practice has had several written complaints over the past six months that Colin had simply filed in his desk drawer
• On at least one occasion Colin was noted to smell of alcohol at work, but he denies recent or excessive alcohol intake
• Colin has appeared anxious and low in mood at times
• Any other relevant information on Colin's past medical history, including physical and mental health
• Biopsychosocial information
• A job description for his role as a GP partner in your practice.

What specific questions would you like the OH service to address?

• Does Colin have a health problem that is affecting his work performance?
• Does Colin have a problem with his alcohol intake?
• Is Colin fit for work and is there any need for workplace adjustments and/or restrictions to his practice?
• Is Colin fit to attend meetings with managers and the medical director at the CCG/Health Board?

A GP with a special interest (GPwSI) at your local NHS Occupational Health service arranges to see Colin following your referral. Colin has been advised to be take time off work pending an OH opinion.

The referral indicates concerns with regard to Colin's health and any potential impact on work performance.

What will be the strategy and format for the OH assessment by the GPwSI?

• Clarification of Colin's perspective of the reasons for the referral
• Explore his current health, past medical history, current medication, social history
• Explore thoroughly his pattern of alcohol use and if it has led to accidents/incidents, problems (e.g. with relationships)
• Investigate any use of recreational use of drugs or abuse
• Psychological history including current symptoms, self-harm, suicide risk
• Current job information including workload, relationships with colleagues and patients
• Job history including any problems or triggers that may affected him
• Current pressures
• Physical assessment including signs of alcohol excess and/or drug use
• Consider the need for psychometric testing and alcohol and drugs testing.

What mental health assessments should the GPwSI undertake on Colin?

• Mental state examination
• Anxiety and depression questionnaires (such as Patient Health Questionnaire (PHQ-9) and Hospital Anxiety and Depression (HAD) scale questionnaire).

What important screening should the GPwSI undertake on Colin as part of the mental state assessment?

• A suicide risk assessment - an example is shown here. This can also be done by using scoring scales.

The GPwSI assesses Colin and finds him to be suffering with anxiety and depression with features of panic attacks.

What is the recommended treatment?

• The recommended treatment should be in keeping with NICE Guidance CG90.

Also:

• Guided self-help such as a leaflet on depression and anxiety
• A psychological therapy (counselling or CBT is best, but is likely to take some time to organise and be effective)
• Pharmacological therapy (an SSRI licensed for panic such as paroxetine (Seroxat), usually up to 40mg daily).

Colin denies any history of alcohol excess. He becomes angry when the GPwSI specifically questions him about this.

What specific blood markers could the GPwSI undertake in order to determine if Colin is misusing alcohol?

• FBC - low platelets; raised MCV
• LFTS - deranged liver function with raised gamma GT
• CDT (carbohydrate deficient transferrin) - a raised level suggests a pattern of alcohol excess within the last 2 weeks
• Blood ethanol - a positive indicates recent alcohol use/excess within the last 24 hours
• Low B12.

The GPwSI takes blood samples for alcohol screening. They are consistent with recent excessive alcohol intake.

The GPwSI feels that Colin has been able to provide a satisfactory history and he understands the severity of the allegations against him. There is no suggestion of psychosis.

Is Colin fit to return to work? Additionally, what criteria would the GPwSI have used to assess fitness to attend meetings with management and is Colin fit to attend these meetings?

• Colin is unfit to return to work due to his psychological symptoms and alcohol misuse but he is fit to attend investigatory interviews.
• He has given a good account of himself and he understands the severity of the allegations against him. There is no suggestion of psychosis and he is 'fit to plead'. The fitness to plead criteria are relevant here.
• OH can recommend that he is accompanied to the interviews by a representative or advocate (friend, union representative) and adequate breaks should be allowed during proceedings.

Colin wants to see a copy of the OH report before it is sent to the Clinical Commissioning Group (CCG) – how would the GPwSI handle this?

The GMC guidance on confidentiality states that Colin has the right to see the OH report, so he should be permitted to view a copy. The GPwSI should set a clear timescale by which comments should be received before the report is sent out to the referrer. Colin can ask the GPwSI to alter any factual errors contained within the report, but Colin cannot alter the opinion expressed by the GPwSI. However, Colin can withdraw consent for the GPwSI's report to be sent to the referrer.

Colin contacts the GPwSI at the OH Service to say that he does not feel able to attend any investigatory interviews. Colin subsequently obtains a medical certificate from his own GP which says he is unfit to attend any interviews with management. Colin also talks to the GPwSI from the OH service on the telephone and asks the GPwSI to say that he is unfit to attend interviews or meetings with management.

Should the GPwSI alter his opinion based on the medical certificate from Colin's own GP?

No. The GPwSI should stick to his professional independent opinion if it was based on a thorough initial assessment. Also, if Colin refuses permission for the report to be sent to the CCG then the GPwSI must honor Colin's decision and the report should not be sent. However, the GPwSI can inform the CCG that consent to release the report was denied.

What are the possible outcomes for Colin? What factors may impact on their suitability?

Potential outcomes include:

• Successful return to work
  Providing Colin is accepting of the fact that he has problems that need to be dealt with/treated and is able to subsequently show that he has achieved and sustained better health, he may be able to return to work. A psychiatric or psychological opinion may be needed. His progress will require monitoring by an occupational health practitioner.
• Return to work to a modified job (semi-retirement)
  Again, provided health issues are accepted, managed and show sustained improvement, with a satisfactory psychiatric/psychological opinion, Colin may be able to return to work in a modified role that is less pressured.
• Retirement
  Colin may not be able to improve his health in a timely manner, in which case he will not be able to return to work, or he may decide to pursue retirement.

NB: The Medical Director of the CCG may choose to involve NCAS (National Clinical Assessment Service) or the GMC in the case and, if so, the occupational physician may well be asked to respond to their queries.

• Fitness for work, 5th Edition, pp 275-276. Editors: KT Palmer, I Brown, J Hobson. Oxford Medical Publications (OUP) Oxford.
• Good Medical Practice, GMC 2013.
• Guidance on alcohol and drug misuse in the workplace. Faculty of Occupational Medicine, July 2006.
• Alcohol, drugs and the workplace. The role of medical professionals. BMA, February 2014.
• BMA guidance: Concerned about a colleague.

Acknowledgements: Dr Donald Menzies and Dr Aloke Sen