I have applied the 24-hour rule. The 24-hour rule is to reflect on something for 24 hours before writing about it.
A clinical colleague has been so critical of the way I am managing a patient, that this person told a family member of my patient that my management was so poor that I "should be shot".
I have a reasonably thick skin. From time to time I do dish out criticism. So I should be able to take it. In a sense I have taken this criticism on the chin as I do not plan to take my response any further than here.
Jobbing Doctor is just that: a Jobbing Doctor. I cover a large practice area that encompasses pretty much all parts of the population - I can't predict if my next patient is going to be a barrister, a doctor, an asylum-seeker or a drug addict. That is the joy and the challenge of the job.
Over the last few years I have developed a small clientele of drug addicts that I see regularly. I have spent a lot of time establishing rapport and trust, assessing all their psychological and physical needs, and establishing a regular pattern of prescribing for them that enables them to re-establish a more ordered existence. Most of this handful of patients are now leading regular and more fulfilling lives, and no longer take dangerous substances from unreliable sources.
One of my proudest achievements is to keep one of my patients out of jail for 10 years now. I have spent hundreds of hours dealing with this difficult group of patients. Each individual patient is treated as such, an individual; I use my professionalism to manage them in the way that helps them to function and keep healthier and safer than they were before.
One particular case, however, has been difficult. When I first registered Steve* as a patient, he was still smoking heroin regularly. He and his girlfriend were both keen to get off street drugs (she was injecting Heroin), and I agreed to look after them. Over the succeeding months I was able to establish them on a pattern of treatment (which I discussed with the local drug treatment project) and I thought things were going well.
Both were on a combination of long-acting Dihydrocodeine and Zopiclone: Steve was also on a stable dose of Diazepam. I would prescribe weekly, and see them both regularly. So far, I think, so good.
These patients' pasts have a habit of catching them up, and Steve got involved in a serious incident for which he has been arrested, and is likely to be kept in prison for more than 5 years. I do not condone what he did, although it was as a reaction rather than premeditated.
Into prison, on remand; the magistrates would not do any different with his past.
The prison medical services ask for his medical details to be faxed to them. This I do.
They decide to take him off all of his medication, with the exception of a small dose of Diazepam. Steve immediately experiences withdrawal effects: these are so bad that he attempts suicide by slashing his wrists. He is now in a shocking state. This makes me cross, as the medical service clearly have their "protocols" and are only allowed to prescribe a certain amount of Diazepam (about 20% of what Steve was on). That is the charitable interpretation.
The other possibility is that they think that Jobbing Doctor is incompetent, should not have been prescribing at this dose, and has been highly irresponsible. In view of the comments of the prison medical service that "I should be shot" for what Steve was on, I am inclined to believe the latter is the case.
I don't mind being criticised - I happen to believe that I have dealt with Steve very well; but to have this kind of comment made about me in front of a patients' relative is wholly inappropriate. It has undermined me, and I feel is unacceptable.
There will be people who will agree with the prison medical service - they might suggest that I am merely feeding drug addicts' habits at the public expense. I am prepared to have that debate, especially as I feel that public policy on dealing with drug addiction is wrong-headed (the classification of drugs and the David Nutt affair are examples of this).
I will not be happy to be criticised by an anonymous colleague like this.
21 comments:
Your colleagues action is a blatant breach of para 47 of the GMC good practice guide. I am not saying you should report him to the GMC but you could perhaps politely point out this breach to him.
In my experience the prison medical services do not exactly attract the cream of the profession.
Dear JD -join the club, I am being investigated by the Australian equivalent of the GMC. For quote "Prescribing Benzos to Drug Addicts" - I am judged by what my peers would do (other GPs), so I am in trouble. Welcome to my world.
Benny
He shouldn't have made this remark, but perhaps there is a bit of good in it too - maybe it is time for reflection on your own professionalism and how you can make it better.
From a logical point of view, a steadily decreasing dose of DHC seems like a really good way to go about things.
I would suggest you privately bring this up with the doctor in question. It may be a result of his years in the prison service, but it's no excuse.
it seems you think that whatyou are doing in prescribing term s is outside of the norm. i dont condone the criticism but if you practice in unusual ways i think you have to expect it.
is there some dependency (on you) and some transference that has you feeling personally upset about this?
bw
You just do nothing about it JD, Just forget it.
you know more than 50 % of humans are lying evil bastards?
i only have to take a quick glance at linkedin to note lots of people claiming to have designed things I FUCKING DESIGNED, or claimed to have led teams THAT I FUCKING LED, or had successes THAT WAS 100% DOWN TO ME, or indeed claim to have led teams i was part of when they were just little shits and no positive impact on the project
sadly however the recruitment industry and general lazy fuckers running what laughingly passes for british industry at the moment tend to take the lies on linkedin and CV's without asking a few sensible questions
largely cos british industry is largely led by overpromoted salespeople
fuck the prision service its just a symptom of fucked up human nature, lies, and fashions in views of the world
The prison service often has dodgy ten day and seven day detoxes which are a recipe for disaster for most addicts. Ironically many prisons used to refuse to prescribe methadone and followed a protocol very similar to your patients regime but using horrendously high doses of dihydrocodeine!
This sounds like good prescribing based on the individual, certainly not a shooting offence :-)
Psych nurse
Perhaps you should have left it 48 hours.
I have some sympathy for the prison medical service in this case. There are unquestionable risks with detoxing people in prison - one of them is an increased risk of suicide. The past use of forced detox with no option for continued prescribing was reprehensible.
However, I can see very little way they can continue prescribing dihydrocodeine as maintenance in prison. Frankly, there are very few doctors who are prepared to do it in the community. At the recent RCGP/SMMGP conference in Glasgow the issue of DFs was discussed. We had a big room full of people with a vast amount of experience in treating heroin addiction and although a few would entertain it most wouldn't touch it with a bargepole. Given it can't be supervised and the prison service have no way of knowing if 'Steve' was actually taking it there isn't a prayer of them continuing it in prison. They could and should be able to offer some kind of opiate substitution therapy - methadone or buprenophine. However, the conversions are also a horror story. I still think it has a place for carefully selected patients and I would applaud anyone that is prepared to give a full personalised service to patients tailored to their needs. But you have to be prepared to accept that there wasn't much wriggle room for the prison service on the issue of the DFs.
Equally, let's consider benzos. Most prisons will offer a benzo reduction - I wouldn't offer more than about 30mg for a community detox and you haven't stated what dose he was on. Everyone knows that the withdrawal can be awful (check out www.benzos.org.uk for a full doctor-hating perspective on benzos) and it's done far quicker in prison. However, there are known long term problems, including cognitive decline, with benzos and I think you say you've had years to do a slow reduction.
If he was on a big dose I can understand why the prison GP might have struggled. Again, they are not supervised and, like DFs, there is a massive diversion problem. So, the prison medical officer can’t even be sure he is taking any. Not prescribing the full dose isn’t about what you disparagingly refer to as “protocols” – it’s about simple commonsense. Of course, very few GPs think it is their patients diverting them... but someone does it.
Clearly, the response of the prison medical officer is crass and unhelpful but there are significant drawbacks to prescribing DFs and benzos – one of the known ones being that they won’t be carried on in prison. It is the prison that face the abuse when they can’t, justifiably as often happens, continue these meds and that may have coloured his reaction.
This whole post has caused me some serious irony overload issues. As has been pointed out, the prison service have been pisspoor at dealing with users in the past - slow improvements are being made and, yes, they have used dihydrocodeine to detox people. And I love it that you've used an anonymous blog to criticise a complaint from an anonymous colleague. Genius.
Northern Doc - are you suggesting that prescribing habits (outside of prison) should be determined by the sort of service one might expect on the inside?
It goes without saying that no maintenance therapy is without risk - in fact some commentators have even gone so far as to question the entire paradigm upon which medicine and certain forms of addiction are founded;
http://www.telegraph.co.uk/culture/books/non_fictionreviews/3670042/Addicted-to-getting-it-wrong-about-heroin.html
I never criticise a colleagues management in the way this prison doc apparently did. It is worth bearing in mind that second hand tales from relatives often have little basis in the truth of a consultation.
Even when doing medicolegal work I am careful to stress only the options at the time, the retrospectoscope has no place.
In time the patient will form a judgement of who gave better care, I doubt that his opinion will be the prison doc.
@ the a&e charge nurse
No - ideally, there should be exactly the same medical service on offer in prison than in the community. Of course, there are safety issues with any opiate substitution therapy (OST) but the risk with unsupervised treatment is considerably greater. However, prison isn't the same as the community and unsupervised OST would cause serious problems. If someone is at high risk of going back to prison it is only sensible to consider that when treating them.
I think I've seen you quote Dalrymple before. You can go ahead and question the 'paradigm' but you may wish to consider reading the extensive literature on the benefits of OST, including recent extensive articles in the BMJ and Lancet, if you wish to balance out Dalrymple's dubious viewpoint.
I agree that the prison doctor was completely wrong to criticise in this fashion but I would agree with @drphilyerboots that I wouldn't rely on the secondhand tales either.
not shot hot snot lelőni.
Your anger at the criticism is understandable and even justifies. For a doctor to criticise the practice of a colleague, particularly such a personal criticism, when they haven't had to deal with the clinical situation in the particular clinical setting with all its frustrations and limitations is disrespectful and narrow minded.
I'm a drug & alcohol doctor in Australia, so I'm commenting without first hand experience of the system in the UK. For any doctor, prescribing drugs of dependence outside of guidelines is fraught with risk of criticism and censure. Realistically and objectively looking at the pharmacology, any long acting oral opioid can be used as a substitution treatment for opiate dependence. In Australia, the only opioids registered for use for the treatment of dependence are methadone and buprenorphine, and the use of other opioids for drug treatment can get medicos in serious hot water with the authorities.
Playing the devil's advocate - the treatment setting within a prison would have different challenges to community based treatment. Certainly one of the issues I come across in dealing with patients in prisons is the risk of diversion of medication to other prisoners and the risk of "standover" situations with other inmates seeking to obtain medication by intimidation. I have worked with a remand centre that refused to start buprenorphine treatment because they were unable to contain the risk of diversion, and only had methadone available as it is easier to check that the dose has been taken appropriately. Providing ongoing dihydrocodeine treatment and higher doses of diazepam for your patient may well not have been logistically possible in the prison setting. Just a thought anyway...
I can, and do question, our approach to both drug taking and the way treatment of addiction, or concepts about 'disease' are framed.
The first thing to say is that drug use is endemic in our culture - my own children (from a middle class suburb in London) tell me that no night out is complete without methadrone, cannabis, ecstasy, ketamine, etc, etc.
Perhaps for this reason I was most interested in Angus MacQueen's trilogy of films, currently being shown on C4, which demonstrate all too clearly what a dreadful mess we've got ourselves into when we examine current drug policies, especially those relating to enforcement.
http://www.channel4.com/programmes/our-drugs-war/4od#3109766
The banning of mephedrone, for example highlights why the authorities are simply digging a deeper hole for themselves in part because they have such a blinkered attitude to the level of drug taking that goes on nowadays (leaving aside the big killers cigarettes and alcohol).
With regard to the treatment of addicts I think it would be much simpler if doctors admitted that they are complicit with a form of social engineering (albeit for honorable reasons) rather then pretending they were treating an actual disease because the way I see it if drug taking is a disease then everybody is sick.
Now I expect some will say, ah yes, but addicts are different and their problematic drug use qualifies them for disease status - this is the fundamental position that Dalrymple objects to, and although you may think it a rather dubious, you do not say why?
You mention OST but lets not forget that although methadone may reduce harm it also;
*kills a % of patients taking it.
*has low success weaning addicts off opiates.
*reinforces a powerful message that 'the disease' is the problem, rather than bad choices made by a growing number of addicts.
Dalrymple cites an interesting analogy - supposing the state introduced a new scheme intended to wean car thieves off their 'habit' by supplying them with a slightly less powerful vehicle than the models repeatedly stolen (and this approach was able to demonstrate that the number of thefts was slightly lower).
Would it be in society's interest to roll out a programme on a much wider scale, especially if an MRI scan could demonstrate abnormal brain activity when images of a ferrari, or top of the range BMW, was flashed before the eyes of a prospective car thief?
After all fewer cars would be stolen and fewer people would end up in jail, while at the same time the car substitute programme would require an infra-structure, hence jobs would be created and the economy would be stimulated - a win-win situation, surely?
Worrying about what somebody says somebody else said about you is a waste of energy. May have been a quite different comment really.
I disagree with what you are doing in managing these patients. I would not be prescribing for them as you are.
BUT, I agree that the prison service has no right making such comments about your treatment to the patient or the family. That is completely inappropriate and does not help the situation.
AussieGP
Your comments do not surprise me, AussieGP - there is already evidence to suggest that fault lines exist amongst GPs trying to look after patients who are dependent on opiates - not least because of their predilection for polypharmacy
http://www.ncbi.nlm.nih.gov/pubmed/9173454
Some authorities have argued the case that dihydrocodiene can used instead of methadone.
According to Dr Robertson 235 people requiring treatment for opiate dependency in Edinburgh found that dihydrocodeine was just as effective as methadone - the cost of dihydrocodiene was 50% less.
http://www.medicalnewstoday.com/articles/58487.php
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