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Each of these "case histories" is an amalgamation of individual stories characteristic of the problems encountered by our colleagues.
1. Dr New and his pethidine
2. Dr Wonderful "burns out"
3. Dr Predictable becomes depressed
4. Dr Everlasting lacks insight
 1. Dr New and his pethidine
This 26-year-old GP Registrar, doing a year's supervised training in your practice, has moved to your area with his wife and baby. He is pleasant, but lacks confidence. Even after 3 months, he is seeing only 2-3 patients an hour. Seemingly unwilling to make decisions, he asks advice on most patients, even concerning relatively simple or common conditions. When he is given gentle feedback, he becomes upset and self-deprecating.
Dr New appears relieved when you suggest setting aside an hour for a 'chat' In a private setting where you won't be interrupted, he tells you that he has been having panic attacks which are increasingly disabling. In his teens, he had developed a panic disorder, which responded well to support and cognitive strategies instituted by a clinical psychologist. He had occasional panic attacks during his medical studies: one, in particular, was associated with a viva examination.
Being unable to see his psychologist since moving to your town, the attacks are becoming worse. He has difficulty sleeping, has been using temazepam regularly, but finds it no longer effective. One month ago, he self-administered pethidine from his doctor's bag supply, and has since done this twice. He found the effect exhilarating, but then felt anxious and depressed.
At the end of your discussion, he tells you that he is glad of the opportunity to discuss this openly. He says that he feels better, and asks permission to return to Sydney monthly to see the psychologist. He 'knows' that his pethidine use is 'in the past', and is confident that he won't self-administer again. You express full support, but remind him that it is likely that he will be tempted to use pethidine again when his anxiety recurs. He eventually agrees to self-notify to the Medical Board, where he can join the Impaired Registrants scheme and receive maximal support. This represents his best chance of satisfactorily dealing with his dual problems of recurrent anxiety and substance abuse, and maximises his chances of continuing to work successfully.
2. Dr Wonderful 'burns out'
This 32-year-old single woman has been an associate in a general practice for 2 years, and is considering a partnership. She lives in a rented unit. She is popular with staff and patients, and is an 'asset' to the practice. She attends to patients extremely well, although she might be fostering their dependence on her. On a number of occasions over a period of some months, she becomes upset and tearful. She copes by 'working harder' (ie longer hours). At a Monday morning debriefing meeting, she announces tearfully that she has decided that she doesn't 'have what it takes to be a doctor' and is giving up Medicine.
Dr Wonderful demonstrates many features of 'burnout', a response to stressful occupations usually associated with providing services to others. It can have a number of components:
a reduced sense of personal accomplishment ('No matter how hard I work, it doesn't make any difference in the end');
emotional exhaustion, ie investing considerable emotional energy in providing care, without replenishing emotional reserves through rest, relaxation and attention to personal needs. This exhausts emotional resources, and is often accompanied by feelings of depression and failure. It is commoner in doctors with much direct patient contact, particularly patients with complex psychological needs, and is common in rural GPs. It also seems commoner in females;
depersonalisation, 'switching off' our sensitivity to the emotional aspects of a patient's problems. This adaptive defense mechanism is common with constant high stress levels. The danger is that, when the stress abates, the doctor continues using depersonalisation to cope with interactions with patients. This component of burnout is commoner in males, and may explain the stereotypical male doctor who 'is a great technician, but has a lousy bedside manner'.
Dr Wonderful needs help to develop strategies to prevent and manage burnout. If she succeeds, she is likely to find her work rewarding and fulfilling again, and to have a more positive self-image.
3. Dr Predictable becomes depressed
This 48-year-old man has been in a four-person stable GP partnership for 16 years. He is increasingly critical of his partners and staff, complaining of unequal rosters and poor practice management. Eventually a staff member resigns, claiming through her solicitor that she was 'harassed' by him. When you tackle him gently, he becomes angry and starts to criticise you, citing instances where he thinks you have shown poor clinical judgement.
This is a difficult situation, partly because of his aggressive responses to even gentle enquiries. He is at high risk of becoming impaired, probably through substance abuse (alcohol or narcotic abuse are most likely at his age), or through behaviour which could risk his professional reputation. If he fails to respond to your interest, you might seek advice from the Doctors' Health Advisory Service.
It transpires that there is a strong family history of depression. He has himself had two major episodes of depression, one at University, and one eight years ago, when he took an overseas 'sabbatical' for several months. His current depression has been manifesting, over several months, as anger and low tolerance of frustration.
This is often a time of life when close personal relationships are re-evaluated, as children become more independent. Relationship problems may be either a cause or effect of his current depression. A sensitive history would include questions about financial stress and risk-taking behaviour (including drugs, alcohol and sexual adventurism). Even though this appears intrusive, it is important to enquire with the same level of concern and care as we would with any patient.
Ultimately Dr Predictable needs a supportive medical carer (or carers). If he accepts this advice, he might choose a known colleague or someone who doesn't know him. His individual preference is perfectly reasonable. Even though we feel uncomfortable 'dobbing on a mate', failure, at this stage, to enlist support risks worsening his situation.
4. Dr Everlasting lacks insight
This 72-year-old woman is running a solo practice. Your practice has covered for her on the rare occasions she takes leave. On her first visit as a patient, she tells you of arthritis in both knees, particularly the right, of her need for a knee replacement, and which orthopaedic surgeon she prefers. She rejects your suggestion that she reduce her workload, as her youngest dependent son is still at university. You persuade her to have some routine tests, which show a significantly elevated gamma GT and a Hb of 9.9. You discover that she is self-prescribing largish quantities of Panadeine Forte and NSAIDS for her pain and Rohypnol 'to sleep'.
Dr Everlasting has signs suggesting impairment. As with many older patients, she has several medical problems and major psychosocial problems. It transpires that she has not submitted a tax return for six years ('I don't have time for that nonsense. The patient's needs have to come first'). Your further history reveals definite emotional, and possibly physical, abuse in a dysfunctional relationship with her son. You have real concerns as to the level of care that she is providing to her patients, even though she cares a great deal about them.
A rapid intervention is needed to avert a potential physical or psychosocial disaster. Despite allowing you to be her 'treating doctor', Dr Everlasting refuses to alter her practice or other behaviours. It would be reasonable to seek advice from the DHAS. Ultimately, she will probably require notification to the Medical Board, since she appears to lack insight. While this might seem draconian, punitive, and in breach of your doctor-patient relationship, the best opportunity to assist her will be to discuss her (even anonymously) with the only body with the legislative authority to enforce an intervention. Remember that many states also have Medical Benevolent Associations, which assist distressed doctors, particularly those with financial problems.
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