Suicide Amongst Doctors Under Investigation: The Tip of the Iceberg

Over the last 15 years, the number of complaints against doctors to the GMC has quadrupled. In 2013 there were more than 8,500 complaints about doctors of which just over 3,000 went on to be investigated. More than a third of those are still under investigation.

Twenty-eight doctors in the UK have committed suicide whilst under investigation for fitness to practice, from 2005-2013, reports the General Medical Council (GMC) today. 'Doctors who commit suicide while under GMC fitness to practise investigation', is the internal review commissioned by the governing body of medical doctors in the UK, to determine whether there may be ways to reduce the impact on doctors being investigated.

Over the last 15 years, the number of complaints against doctors to the GMC has quadrupled. In 2013 there were more than 8,500 complaints about doctors of which just over 3,000 went on to be investigated. More than a third of those are still under investigation. Fitness to practice tribunal hearings reached a high of 326 in 2010, and from 2010 to 2013 an average of about 80 doctors per year were suspended or erased from the medical register (Civitas Report 2014,GMC State of Medical Education and Practice in the UK 2014)

During this period of investigation, the doctor may be placed on restricted, often supervised duties. Even medical activities done on a voluntary or charity basis may be prohibited. This undoubtedly has a profound psychological impact, as well as financial implications, with a knock-on effect to spouses and children. Mental health disorders and substance misuse were unsurprisingly documented to be contributing factors to many of the suicides recorded in the GMC report.

Following several high-profile cases of professional misconduct, such as Harold Shipman in the late 90's, there has been increased media scrutiny of the performance of doctors. Published stories are usually one-sided and invariably subjected to a degree of journalistic 'flair'. With a doctor's commitment to patient confidentiality, they are often unable to provide a worthy response. Mix life, death with an elite profession and there you have the recipe for a scandal to make papers fly off the shelves.

With such an intrusion beyond the professional domain, it is unsurprising that a doctor's life can fly from top to rock bottom faster than a Ferrari goes from 0-60mph. Of course any doctor who does not meet the high-standards set out in the Good Medical Practice document, should not be allowed to practice. Yet we now live in a culture where complaints are encouraged, and there is rarely any regard for the doctor who is invariably guilty until proven otherwise. This report should open our eyes to the catastrophic consequences of these investigations. The vast majority of doctors are exonerated, although less publically than when accused, and are left to quietly rebuild damaged personal and professional lives. In a minority of tragic cases it leads to death by their own hand.

The GMC have made a number of recommendations based on todays report, which acknowledges changes need to be made to protect these vulnerable doctors, to treat them as 'innocent until proven guilty'.

This long-awaited report has however come under scrutiny from key figures in the medical community. Christoph Lees, an Consultant Obstetrician at a London teaching hospital told me "The report is welcome but says more about what we know already that what we don't know. There are clearly many doctors who die under investigation for reasons other than suicide or become severely unwell and we need to understand the causes for this." Due to methodological flaws the report hides a significant degree of morbidity and mortality among the population in question. First and foremost, the figures only quote deaths where suicide was recorded as the primary cause. Other stress-related causes of death do not factor in the figures, and likely make a significant contribution to the 86 further deaths of doctors under investigation recorded in the study period. Furthermore, there are no data following-up doctors who were found to have no case to answer following investigation, and as such the 28 reported suicides are undeniably the tip of the iceberg.

Lees also said "This report comes at a time when the GMC is seeking even more punitive powers as outlined in a consultation exercise carried out in August. It has not yet responded to the new culture of openness, transparency and fairness that thankfully is now coming to define the NHS."

Clearly we all want healthcare systems that are open, transparent and where mistakes are learnt from. However it is hard to see how this can be attained when doctors exist in a culture of fear from the regulator. Referral to the GMC is the tip of the iceberg in the UK where parallel investigations often mean doctors are subject to double or triple jeopardy. Perhaps from the public's perspective, how doctors respond to this type of oversight may be of more interest. We know from studies that experiencing complaints and investigations leads to defensive practice - which is not in the interests of patients. It may seem counter-intuitive - but the regulatory structure designed to protect patients may have the unintended consequence of harming more patients than it protects.

This review by the GMC limited itself to 28 cases of suicide by physicians when there were investigations open and being carried out into their practice. So it excludes any events after a verdict has been given - which seems likely to mean a number of possible cases of harm to doctors may have been missed. The wider issue however is that this report only looks at 28 doctors who died. What of the hundreds of their colleagues who have survived the experience? The GMC's own report highlights the need for doctors under investigation to feel "innocent until proven guilty" and states such processes may stigmatise and "create a culture of fear and discrimination". Many would think it is time for an independent external review of the regulatory and complaints system in the UK.

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