Doctors in Difficulty or Difficult Doctors?

Edna Astbury-Ward

March 10, 2020

How do you distinguish between 'difficult doctors', who are a real problem, and doctors who are just in difficulty?

Difficult doctors tend to be those who lack insight into their behaviour, especially if it falls below what is expected of them, whereas doctors in difficulty tend to be those who are struggling with their career progression or may have external factors in their personal lives, which may negatively affect their performance or capability.

 A look at the General Medical Council (GMC) website 'Search the Register' area makes interesting reading. Medscape UK looked at a sample of 60 names from the 84 doctors given warnings by the GMC in 2019 and up to and including January 2020. Below is a breakdown of the types of behaviours that warranted the GMC issuing warnings in 2019/2020.

GMC Reasons for Warnings 2019 & JAN 2020

(TOTAL SAMPLE = 60)

PERSONAL REASONS = 37 (61.7%)

All Driving Offences: 23

  • Drink Driving: 17

  • Drug Driving: 3

  • Reckless Driving: 3

Improper Relationships/Sexual Conduct:7

Possession of Class A & B Drugs: 6

WORK RELATED = 23 (38.3%)

Poor Medical Practice/Poor Patient Care/Incorrect Diagnosis: 15

Miscellaneous: 5 (Including Threatening Behaviour/Violence/Breach of the Peace)

Breach of Confidentiality: 3

Personal Issues

It is immediately clear that nearly 62% of poor behaviour in doctors was linked to personal issues as opposed to poor medical practice, whereas a report published for the GMC in 2015 showed 87% of reasons for being struck off the medical register were 'work' related'. It must be noted however that 36% of that figure comprised inappropriate personal relations, which one could argue is both a personal and a work-related matter. A full list of fitness to practise issues is available on the GMC website.

The numbers of complaints against doctors has risen from 5773 in 2010 to 7388 in 2019 but we need to keep in mind this represents a very small overall percentage (2.4%) of the 312,916 doctors who are currently registered to practise in the UK.

Doctors today more than ever before are working in challenging times. Health care is faster paced, technologically complex, financially driven, and doctors are expected to do more with fewer resources.  According to the Office for National Statistics report Healthcare expenditure, UK Health Accounts: 2017, while health spending grew by 3.3% between 2016 and 2017 (in current prices), when these figures are adjusted for general price inflation, government expenditure on health increased by only 0.04%.

Culture of Avoidance and Denial

Given such stringent times is it any wonder that a small percentage of doctors go off the rails? 'Going off the rails' and spectacular falls from grace, as in the case of Ian Paterson, are at opposite ends of poor professional practice. Doctors are, after all, human, like the rest of us. Except that the consequences of rogue doctors such as the disgraced breast surgeon Ian Paterson leave a devastating impact on their victims. How is it that the scrutiny of regulatory gaze didn't identify Paterson's crimes until 14 years later? 

A culture of avoidance and denial, together with his 'God complex' meant Paterson was left unchallenged to continue operating, despite growing concerns about his behaviour both inside and outside of medical practice. Concerns about Paterson are understood to have been noted but not shared between the private and NHS practices in which he worked. It is hoped that a new framework developed by Sir Bruce Keogh (former NHS England Medical Director) will go some way to prevent cases such as this happening again.

Medscape UK went along to a conference held in London to find out more about what is being done and how we are supporting doctors in difficulty and difficult doctors. We interviewed Dr Andrew Long, deputy medical director at Great Ormond Street Hospital for Children and responsible officer, lead for remediation with the Academy of Medical Royal Colleges.

Dr Long has worked with doctors who have experienced professional challenges for more than 20 years, and was appointed associate Dean at the London Deanery (now The London and South East Postgraduate Medical and Dental Education) at the time of the MTAS (Medical Training Application Service) crisis.

Q&A

Why do you think Ian Paterson wasn't picked up sooner?

I suspect it's because people didn't want to tackle him.

Why was that?

I think because of his persona, apparently, he presented as a very friendly guy. But it doesn't mean that if you're friendly to people, you're not doing harm to patients. Different systems (between NHS and independent sectors) were less well recognised then, so I think we have improved remarkably since, especially the introduction of responsible officers. There's a lot more sharing and we want to ensure that our organisations are fit for purpose. We must embrace the process, so we make sure that doctors have regular opportunities to review their own practice.

Have you seen changes in the types of behaviour over the years?

Oh yes, there's much less deference to people in positions of power or authority, and I think generations X, Y and Z aren't going to tolerate the types of work patterns that we experienced.

What challenges have you faced along the way?

I suppose for me it's making sure that our work environments are designed to support all health professionals, and everybody who works there. But what I want to see is our particular responsibility to doctors and making sure that we have avenues within all our work locations to identify doctors who are struggling, and obviously, to try to put into place a system so that they don't find that they are pushed to the severe ends that some doctors are, but to step in early and try to help when necessary.

How do doctors react when they're confronted about the issue of their conduct?

The vast majority are upset, some are embarrassed, some are defensive and some are angry, so there are a variety of ways in which doctors express themselves when confronted.

Do you think by the time they arrive at your door they have any insight?

I think the majority probably do, but there are a percentage who clearly lack insight into what impact their behaviour is having on other people and the organisation.

How do they generally come to you? Do they self-present, or do they come because somebody made a complaint?

They present either as a result of a complaint, or the result of a serious incident, or as a result of a colleague saying, “I think they need your help and support”.

How do doctors find the process?

Obviously, most of them find that once the process is explained to them it is clear and straightforward. Although the process is supposed to be short-lived, often they go on for a long period of time, and we are dealing with issues that haven't been addressed for a long time. So, you know, depending on the extent of the severity of the conduct disorder, either it's something which is brief, which we can deal with fairly quickly, or else it takes a long time to sort out.

How do you start the conversation with the doctor?

It's normally a difficult conversation. You need to tell them that something has come to the attention of the organisation. We are robust about making sure that we don't start this process without a genuine information source. What we don't want to do is to rely on gossip and there's a lot of that in hospitals!

What do you think are the root causes of unacceptable behaviour in doctors?

Poor team structures and intensity of workloads do not support doctors in the ways they wish to work. Also entrenched behaviours such as a great sense of self-importance or arrogance.

Would you say you see more complaints about behavioural issues rather than capability issues?

I'm fortunate to work in a very high performing organisation. We do have a lot of international experts in the field. Unfortunately, when you are an international expert in the field, you often behave like one and that sometimes leads to an inflated impression of your own self-importance. However, we do get some doctors who have capability issues, so we need to deal with those slightly differently.

Do you get dispirited when you have to deal with doctors whose behaviour falls below what's expected?

No, I don't, because we feel that we are doing important work, which is designed to be in the best interest of patients. So anything which is done to make patient care better in the organisation is not dis-spiriting. And the thing is, sometimes, you know, I'd like to say that all our doctors in hindsight, look on it, favourably, but that's not always the case. I think most of them do realise when we take action that there was an issue that needed addressing.

Not Trained to Deal With Difficult Doctors

Dr Long said in his lecture that it was the responsibility of all Trusts to provide a supportive environment, to prevent undermining and bullying, and to encourage a 'no blame' culture and foster the ability to 'Speak Up' freely.

He said it was important to learn from serious and untoward incidents and vital to offer a confidential support service. Often, he said the source of the problem wasn't just down to an individual doctor but to dysfunctional teams who may collude to hide the problem. Indeed, a delegate suggested that, "It all gets lost in a big Trust but in a small Trust it’s incredibly visible".

During discussions with delegates - most of whom were senior clinicians - taking on an advocacy role such as responsible officer was not for all. One delegate said, "I was trained to care for patients, not deal with difficult doctors." However, others understood the need for support. Another delegate said, "We all need to pay attention to it and remind each other of the importance of kindness and support."

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