Confidentiality vignette: alcohol concerns

Should a doctor report concerns about her patient's alcohol consumption?

Dr Okonkwo is a GP who has cared for Dr van den Berg, a consultant physician at the local general hospital, through a period of considerable stress, involving a complaint about his conduct at work and the breakdown of his marriage.

Dr van den Berg clearly values Dr Okonkwo’s support and discloses, in the strictest confidence, that he’s been drinking heavily. He is adamant that it is not affecting his work, but Dr Okonkwo is concerned at his level of alcohol consumption.

Dr van den Berg says he drinks most of a bottle of wine nearly every evening, often more at the weekend. His worry, and his reason for mentioning it to Dr Okonkwo, is that he has occasionally found it difficult to stop drinking, especially after a stressful week. Dr van den Berg says he never drinks before or during work hours or when he’s on call, and that he’s never allowed his work to suffer as a result of his alcohol consumption.

Dr Okonkwo uses the AUDIT-PC questionnaire to screen for alcohol misuse, in which Dr van den Berg scores 15 (a cause for increasing concern). She gives him some literature and advice about strategies to limit his alcohol consumption; but she is worried about the effects of Dr van den Berg’s alcohol consumption on his work and urges him to seek assistance from the hospital’s occupational health service. Dr van den Berg refuses, insisting his work has not suffered and that he can handle the situation himself, with Dr Okonkwo’s help. During their discussions, he makes it clear that, if Dr Okonkwo were to approach the hospital directly, he would deny there was any problem.

It is clear that Dr van den Berg would regard any direct approach to the hospital as a breach of confidence and of trust. Dr Okonkwo fears that that could lead to a breakdown in their good relationship and that Dr van den Berg’s alcohol consumption and his health might deteriorate without continued engagement.

But Dr Okonkwo is also concerned that Dr van den Berg’s patients would be at risk if he were to work while intoxicated, and that his judgement could be impaired by the effects of his alcohol consumption even if he abstains immediately before and during working hours. On the other hand, she appreciates that, when doctors are patients, they have the same right to confidentiality as other patients, and she has no reason to disbelieve what Dr van den Berg tells her about his abstinence before and during work hours and when he’s on call.

Dr Okonkwo decides that Dr van den Berg does not pose a danger such that a disclosure without consent is warranted. She provides him with information about the Doctors’ and Dentists’ Group and Alcoholics Anonymous and encourages him to make contact in an effort to moderate his drinking. She also discusses the case on anonymous basis with a consultant psychiatrist colleague who specialises in alcohol misuse after the consultation and is satisfied by his advice that she has taken the right approach. With his advice, she resolves to keep the situation under review so that a decision to raise concerns can be taken quickly, if necessary, to protect patients.

GMC Guidance

• There is a clear public interest in a confidential medical service, which is central to trust between doctors and patients (paragraph 6).
• The duty of confidentiality is not absolute, and there can be a public interest in disclosing information, e.g. to protect others from risks of serious harm which may be posed by healthcare professionals with health, conduct or performance problems (paragraphs 36 and 53 to 55).
• Doctors must protect patients from risk of harm posed by colleague's conduct, performance or health (Good Medical Practice paragraph 43).
• Doctors should be clear, honest and objective about the reason for raising a concern about a colleague’s health, which should usually be addressed to their employing or contracting body’s occupational health service in the first instance (Confidentiality: disclosing information about serious communicable diseases paragraph 5). (pdf, 114kb)