Legend has it a doctor’s worst fear is relayed in the form of an A4-sized envelope.
In my case, however, it was one particular email, buried within my inbox that had caught my attention. It was titled ‘Re: General Medical Council’ – and it had an ominous serial number attached in the header section.
As I took a deep breath, and with my heart pounding frantically, I knew the contents of the email would make this particular downcast December day, somewhat darker.
I learnt that I was subject to a provisional inquiry from the GMC regarding a clinical decision I had taken some months earlier. In short, I had seen a lady privately who relayed numerous symptoms on the background of a past history of thyroid cancer.
She appeared irritated in clinic and her frustrations, in particular, were directed towards her NHS general practitioner. She revealed she had made a complaint to the GMC about the care she had received from her doctor. Although slightly taken aback by this, I tried my best to address her concerns.
As part of my assessment, I noted that she was significantly clinically and biochemically thyrotoxic and subsequently advised a small-dose reduction in her thyroxine replacement.
I knew the contents of the email would make the day somewhat darkerGP
Several months passed before I became embroiled in the investigation.
Although the GMC had closed the case against the patient’s usual practitioner, there were concerns expressed regarding the unilateral decision I had taken in reducing her Levothyroxine dosage. I had not at the time fully appreciated the importance of complete TSH suppression, for differentiated thyroid cancers.
Furthermore, the GMC wanted to establish whether I had knowingly contravened specialist advice in altering her replacement dose.
After an independent expert reviewed my clinical notes, I was eventually exonerated of the latter charge, as it was clear that I was not in receipt of any hospital correspondence when reviewing the patient.
Most importantly for me, no harm had come to her as she was advised to remain on the lower thyroxine replacement dose after specialist review. I was obviously relieved by the decision of the GMC to end the investigation at the preliminary stage after six weeks.
Consumed by fear
Those few weeks, though, had felt like nothing short of an eternity as time around me lost its linearity.
I had become so consumed with fear that I managed to conjure up a reality where being struck off, penniless and destitute was an inevitability. I was unable to motivate myself to leave the house and my appetite and sleep had become interrupted.
Prior to my GMC inquiry, I was fortunate to have only ever received one frivolous complaint in the preceding 12 years. I did not – naïvely perhaps – think of myself as someone who would fall foul of the regulator as I prided myself on being conscientious, reflective and extremely patient-focused.
Given the wide knowledge base required in being a competent generalist, I had always been receptive to the dangers of the unconscious unknown. With that at my forefront, my armament was attempting to stay up to date where possible across all areas, as well as completing numerous and varied clinical diplomas.
Furthermore, I had always thought the GMC’s remit was only to investigate issues of probity that might bring the profession into disrepute, or reprimand reckless doctors who repeatedly cause patient harm. But I believe the threshold is lower than that.
In the last few years, the GMC has considered around 8,000 to 9,000 FTP (fitness-to-practise) inquiries each year, with around 1,500 proceeding to a full investigation. Put another way, there is a reasonable chance that a doctor might expect to have their practice called into question at least once in their career.
While there was of course immense relief on my part, that I would not be subject to any further action, the expectation of a rapid transition to normal duty did not materialise.
In the subsequent months, I found myself naturally gravitating towards the practice of defensive medicine.
I was now starting to subconsciously over-investigate my patients and was referring more of them into secondary care services.
I was not prepared to deal with uncertainty and found the concept of risk extremely anxiety provoking. Indeed, my greatest asset as a generalist had now become a significant weakness and with that my confidence to do the job effectively had all but deserted me.
As the ruminations became even more unpleasant, so did my mind’s ability to catastrophiseGP
As my irrational thoughts grew, I started to ruminate on clinical encounters from many years before.
Had I undertaken the correct management plan for patient X? Did I refer patient Y on in a timely manner or did they fall into the ether?
Why did I ever choose to prescribe remotely for an online pharmacy all those years ago and will it come back to bite me?
These whispering thoughts did not just limit themselves to the clinical arena, but also transgressed into my private life.
As the ruminations became even more unpleasant, so did my mind’s ability to catastrophise. On seeing an ambulance blue light in the vague direction of my primary care practice, I would presume the paramedics were attending a desperately ill patient that I had misdiagnosed.
If a patient did not come for their review appointment as instructed, then they must have died owing to my gross negligence.
Desperate need of help
I was not capable of offering myself any kind of logical explanation to circumstances that I had no control over. A seed of doubt would quickly snowball into an obsessional intrusive thought, and with that a compulsion to seek reassurance at the earliest opportunity.
Like the itch-scratch cycle, any relief was short-lived, before the next implanted seed would perpetuate the same cycle of futility.
I was now on a downward slope into the abyss and it was my family who would ultimately bear the brunt as the self-consumption translated into my absence as a dad, husband and son.
In short, I became a dishevelled and emaciated shadow of my former self and would ruminate on everything until I reached what I can only describe as some sort of ‘pseudo-catatonic’ state.
I was now on a downward slope into the abyssGP
I was in desperate need of help and was put in touch with NHS Practitioner Health, a confidential free service tailored for doctors and dentists with mental health problems.
I was reassured to learn that I was not alone and that many doctors had felt a similar crisis of confidence when being the subject of a GMC inquiry or investigation.
It has been nearly three years since my brush with the GMC and although I was scathed by the process, I am glad to have been able to finally close this particular chapter.
As I reflect upon my experience, I feel a sense of sadness as well as surprise that I had allowed my mind to wander into such depths of despair; especially over a provisional inquiry that never escalated.
Clearly my perceived resilience was in short supply given my inability to cope with the fallout. Clichéd as it may sound, it truly is enlightening what one learns about themselves during their darkest days.
While I recognise the GMC’s statutory role to protect patients through the regulation of doctors, the over-representation of doctors from minority ethnic groups in FTP referrals is perturbing.
I, like many of my colleagues from minority ethnic backgrounds, worry incessantly about complaints arising, including the possibility of unconscious biases playing out.
Fairness in question
In the case of a recent ruling of discrimination brought against the GMC by a surgeon of mixed racial heritage, the tribunal found that ‘there was a level of complacency about the operation of discrimination in the work of the GMC’ and that they were ‘looking for material to support allegations, rather than fairly assessing matters’.
Doctors from minority backgrounds are not always treated in an even-handed mannerGP
This will not surprise many of us who have long felt that doctors from minority backgrounds are not always treated in an even-handed manner. And finally, as we negotiate our way out of the pandemic, an already demoralised profession faces unprecedented challenges after many years of underfunding.
General practice is no exception as demand for primary care services has never been greater. Juggling increasingly complex medical problems with ever diminishing resources, coupled with longer waiting lists has unsurprisingly culminated in diagnostic delays and the potential for patient harm.
Given my own particular obsessive personality trait, working within such a fragmented health system on a full-time basis feels entirely unsustainable going forward. This has led me to contemplate working abroad or leaving the profession altogether – a situation I could never have envisaged just a few years ago.
The GP, who is from the West Midlands and wishes to remain anonymous, worked with Peter Blackburn on this piece
The BMA is also supporting legal action taken by the family of Sridharan Suresh, who took his own life when facing a GMC investigation.