Impairment in the medical and legal professions

Journal of PsychosomaticResearch, Vo|. 43, No. 1, pp. 27-34, 1997 Copyright © 1997 Elsevier Science Inc. All rights reserved. 0022-3999/97 $17.00 + .00

ELSEVIER

S0022-3999(97)00025.1

I M P A I R M E N T IN THE M E D I C A L A N D L E G A L PROFESSIONS DEBORAH

BROOKE

Abstract--Male doctors and lawyers are among the job groups with high mortality from alcohol-related diseases, although the prevalence of substance misuse among these groups is not known. Both professions have occupational risk factors. This article describes aspects of the work environment which have facilitated substance misuse by doctors and lawyers, and describes the professional consequences of addiction. Data will be presented from two studies: a retrospective casenote survey of doctors treated for substance misuse; and a questionnaire survey of lawyers in recovery from alcohol problems. Mechanisms for assisting impaired professionals into treatment have been developed in the UK and the USA. The most successful models separate health procedures from disciplinary procedures as much as possible, and offer a confidential evaluation and treatment program. Self-help groups play a crucial role in these therapeutic processes. © 1997 Elsevier Science Inc.

Keywords: Doctors; Lawyers; Professional impairment; Drug misuse; Alcoholism. INTRODUCTION O v e r a d e c a d e has passed since Bissell and H a b e r m a n ' s l a n d m a r k study which surv e y e d professionals in r e c o v e r y f r o m alcohol misuse [1]. T h e y d o c u m e n t e d the similarity of drinking histories across professions, the rarity of c o m m e n t or intervention f r o m colleagues or superiors, and the efficacy of abstinence-based t r e a t m e n t approaches. This article describes substance-related p r o b l e m s in the medical and legal professions in the U K and reports current therapeutic initiatives. It will include data f r o m studies of doctors and lawyers with addiction-related problems [2-5].

WHAT SORT OF IMPAIRMENT? A n indication of the diseases of occupations can be f o u n d in the O P C S ' s publication of occupational mortality tables [6]. B o t h male doctors and male lawyers appear in the list of j o b groups that have a high mortality f r o m alcohol-related diseases, such as cirrhosis of the liver. T h e General Medical Council Annual Report gives a b r e a k d o w n of the reasons why doctors a p p e a r before the H e a l t h C o m m i t t e e [7]. O f 97 doctors appearing before the H e a l t h C o m m i t t e e b e t w e e n 1981 and 1993, 57 (59%) had a diagnosis of misuse of alcohol and/or drugs, either alone or in com*Addiction Research Unit, Institute of Psychiatry, London, UK. Address correspondence to: Deborah Brooke, Bracton Centre, Bexley Hospital, Old Bexley Lane, Bexley, Kent DA5 2BN, UK. Tel: 01322 294300; Fax: 01322 293595. 27

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bination with another diagnosis. In 1988, the American Bar Association determined that 27% of all nationwide disciplinary cases involved alcohol misuse [8]. It appears that substance misuse problems, particularly alcohol, are a significant cause of morbidity in these two professions. HOW LARGE IS THE PROBLEM? Sources of information about the amount of substance misuse by doctors and lawyers include surveys, clinical case series, disciplinary reports and interviews with selected groups. All of these are subject to bias in terms of the selection of subjects and the information collected, so the prevalence of alcohol and drug problems in these professions is uncertain. DOCTORS Three reports of postal surveys illustrate the current situation well. All three achieved response rates of over 75%. Two, both based in Ontario, found that alcohol and drug use reported by Ontario hospital doctors did not exceed that reported by the general population [9], and that the uptake of treatment for drug and alcohol problems within a sample of the physician population was less than might be expected from general population figures [10]. On the other hand, a Finnish study of doctors' drinking habits found that doctors consumed more alcohol per person than the general population, and that heavy drinking correlated with smoking, benzodiazepine use, and suicidal thoughts [11]. To compound the difficulties in interpreting results, work correcting for social class is very scarce. Three studies have done this: Murray's survey in Scotland showed that first-admission rates for alcoholism were 2.7 times higher among male doctors than among social class one controls [12]. Conversely, a prospective study of American college graduates showed that those who qualified in medicine subsequently drank alcohol and smoked cigarettes to the same extent as their non-medical peers, although they used more psychoactive drugs. This excess psychoactive drug use appeared to be due to self-prescribing [13]. Bissell and Haberman interviewed 407 professionals recovering from alcoholism and drug addiction in Alcoholics Anonymous. They found that the difference between medical and nonmedical professional groups reporting addiction to a drug in addition to alcohol was not substantial--39% and 32%, respectively. Narcotic misuse was higher among physicians [1]. These conclusions are similar to a recent postal survey of 9600 physicians in the US, which concluded that physicians were less likely to have used cigarettes and illicit substances during the preceding year than ageand gender-matched counterparts in the National Household Survey on Drug Abuse. They were more likely to have used alcohol and two types of prescription medications--minor opiates and benzodiazepine tranquilizers [14]. The literature on prevalence of drinking problems among medical students and doctors has been comprehensively reviewed by Clare [15], who concluded that these groups did not differ from comparable professionals. In summary, it seems that, for doctors compared to social class one controls, drinking-related problems were more common and are now as common, and misuse of pharmaceutical preparations was always more common and remains so. If alcohol consumption by doc-

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tors mirrors the national average, there are 3600 men and 200 women doctors drinking dangerously [16]. A district general hospital employing 100 male and 20 female consultants could expect to find seven with "drinking problems." Added to this is the special problem for the medical profession of access to mood-altering drugs. Doctors, particularly general practitioners, commonly medicate themselves. Richards [17] reported levels of self-prescribing among GPs of sleeping pills (24%), antidepressants (4%), and opiate painkillers (3%). Such evidence of self-treatment, sometimes inappropriately, has contributed to the suggestions that an occupational health service for GPs is long overdue [18]. Hospital doctors also have access to drugs from a variety of sources, including prescribing. Clark et al. [19] circulated a questionnaire on patterns of prescribing for non-patients to 565 house officers in Cincinnati, Ohio, 339 (60%) of whom responded. Twenty-three percent of the respondents had written at least one psychoactive drug prescription for a non-patient in the previous 8 months. The largest number were for family members and friends, and the second largest were for fellow house officers. Narcotic analgesics were the most frequently prescribed psychoactive drug. A study of 144 doctors who had received treatment for alcohol and drug problems showed that, of the 83 who had misused drugs, only 5 % had ever used illicit supplies [2]. LAWYERS In the UK, most of the published evidence for drinking problems in the legal profession is contained in the findings and orders of the Solicitors' Disciplinary Tribunal. Some solicitors facing disciplinary proceedings will explain and seek to mitigate their conduct by mentioning their past drinking and claiming that they are now sober [20]. However, many complaints against solicitors are dealt with by the Solicitors' Complaints Bureau without publicity. Thus, the extent to which misconduct is associated with drug or alcohol addiction can only be guessed at. Even if the prevalence of high-risk drinking among lawyers also mirrors the national average of 6% of men and 1% of women [21], this applied to the number of solicitors in England and Wales (66,123; figures supplied by the Law Society) and the number of barristers (8935; supplied by the General Council of the Bar) suggests that there are about 3000 male and 200 female lawyers engaging in high-risk drinking. (That is, over 50 units per week for men and over 36 units per week for women; a unit contains about 8 g of alcohol, the amount contained in a half-pint of ordinary strength beer, a glass of wine, or a single measure of spirits.) How do addiction problems develop among professional groups who, one might imagine, would be protected to some degree by seeing the medical and social consequences of addiction in their daily work? PATHWAYS Alcoholism has a multifactorial etiology, to which genetics, opportunity, and social patterns all contribute [22]. Furthermore, perhaps some personalities are less able to manage the organizational stresses unique to each occupation; for doctors, some studies have examined the genesis and maintenance of anxiety [23, 24]. It has

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been suggested that, for some, the decision to study medicine is motivated by an unconscious wish to compensate for childhood experiences of emotional neglect [25]. The drinking stories of lawyers in recovery from alcoholism attest to the importance of personality and situational factors [5]: "I was an inadequate and oversensitive young man, without any "common sense," and generally a mess as a result of a traumatic childhood." "I was articled to a seriously alcoholic senior partner whose drinking patterns I followed." Some reported specific aspects of the practice of law that facilitated heavy drinking: "I was the partner responsible for a large amount of entertaining clients which increased my alcohol intake." "I started in a small firm as an advocate mixing with clients and police in pubs etc. and gradually spending more and more time in pubs." Similarly, there were aspects of working in medicine which facilitated drinking, as the following comment from one doctor's drinking history illustrates [4]: " . . . regularly drunk as a house officer--within social norms." CONSEQUENCES For most people, the consequence of untreated addiction is chaos. From an occupational point of view, the most remarkable thing about addicted doctors and lawyers is the length of time that they can carry on practicing in the face of an all-consuming addiction; one study of addicted doctors found that this was, on average, over 6 years [2]; some of these subjects had progressed their alcoholism all the way to delirium tremens while still practicing. They experienced increasing isolation-alienation from staff, stepping sideways, taking contracts abroad, and dissolution of professional partnerships. This last issue is especially noteworthy. In both our lawyer and doctor studies, single-handed solicitors and general practitioners were overrepresented relative to their proportion in the professions. Furthermore, for those lawyers in recovery from alcoholism, single-handed solicitors had a shorter period of sobriety than barristers or solicitors who were employed or in partnership. Sole practitioner solicitors were the highest risk group within the legal profession for serious professional problems related to alcohol. The professional consequences reported by alcoholic lawyers are shown in Table I. Some of these consequences only apply to solicitors, and others only apply to barristers. Therefore, they are more common within the relevant professional group than the table suggests. The most common consequences reflect a personal loss of enthusiasm and efficiency. One third had problems with finding and keeping a job. However, decreased effectiveness was infrequently followed-up by colleagues; only about one third of this sample reported receiving warnings and perhaps one tenth experienced more formal interventions. Some respondents remarked on a pervasive decline in interest and commitment: "A tendency to give negative advice to clients which was an easy way out of having to do work which deep down I did not then feel up to."

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Table I.--Professional consequences reported by lawyers with alcohol problems (n = 61) Problem Lunchtime drinking Sickness absence Missed appointments/court hearings Trouble with the police Losing interest in remaining up to date with the law Warnings from employers/partners/clerk/members of chambers Losing license for drinking and driving Losing job/partnership/place in chambers Losing clients Inability to meet fee targets Unable to perform effectively in court Difficulties in finding a job/chambers tenancy Other problems Employers, partners, or clerk reluctant to provide good work Study difficulties and/or failing exams Being ostracized by fellow practitioners Breach of accounts rules Disciplinary proceedings Loss of confidence of instructing solicitors Negligence claims Reprimands from professional body or criticisms from j udge/magistrate Complaints to the Law Society or Bar Council Insolvency Intervention under the Solicitors Act 1974

Number

Percent

47 38 31 29

77 62 51 48

25 22 22 21 18 18 17 16

41 36 36 34 30 30 28 26

15 13 10 8 8 7 7

25 21 16 13 13 12 12

6 6 5 4

10 10 8 7

"Not getting best results owing to lack of knowledge of file, poor presentation of c a s e . . , letting down colleagues who had to cover up for me." "Misleading clients about progress on matters, fictitious timesheets showing time spent on client matters, covering things up on job applications." For some, the need to avoid withdrawal symptoms had become a preoccupation which overwhelmed other commitments: "I feel towards the end of my drinking, I really couldn't care what result I obtained for a client. I wanted to negotiate quickly, 'at the door of the court,' so that I could get to a nearby pub." There were some instances of colleagues making well-intentioned interventions, and their subsequent frustration when the situation failed to improve: "Three years ago my partners expressed concern. I admitted I had a problem, and sought medical help. I returned to work, but the drinking crept up and finally I was asked to resign." "I was suspended to "sort myself out." I spent 6 weeks alone in my fiat drinking heavily. I went back to work and was sacked." "I was given a "second chance" but I then committed a very serious offence."

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Resignation or being asked to leave was a common outcome. Many tried sole practice at this stage, but without effective treatment for their addiction the results were not encouraging. Occasionally, colleagues' responses were reported as helpful. For example, colleagues had been instrumental in levering at least four subjects into treatment. Two of these were partners in large firms and the third a lawyer employed in industry. The organizations of which they were members were, accordingly, better placed than most to carry a colleague whose earning power is suspended for a significant period: "Under pressure from my senior clerk and with exceptional support from my head of chambers I dried out in a private clinic." "My partners gave me no choice but residential t r e a t m e n t . . , their generosity and understanding cannot be overstated."

EARLY DETECTION OF SUBSTANCE MISUSE PROBLEMS These pathways operate for long periods; alcohol and drug problems develop slowly. Their progress is marked by milestones, such as drunk-driving convictions and lost relationships. Throughout this progression there is potential in the workplace for intervention, before even more severe problems develop. Denial is likely to be part of the clinical picture, so the onus is on colleagues to insist on change. The implications of this are that colleagues need to be aware of the presentation and management of addiction problems. Advice and support must be readily accessible.

MANAGEMENT It is difficult to initiate change in the face of denial. Crosby and Bissell have described a structure for sympathetic, yet firm, intervention with the aim of encouraging the practitioner into treatment [26]. Once in treatment, both doctors and lawyers, being experienced in arguing their case, can wriggle away from reality unless their therapist is prepared for such defenses: "I saw a doctor, but only mentioned my drinking briefly. I did not want to appear to be too much of a fool. I was putting on an act and my own professional experience made me all too successful." Similarly, there are a number of pitfalls in treating the addicted physician, some of which are applicable to any fellow professional [27]. The physician-therapist may be reluctant to reveal a relative ignorance about substance misuse to a fellow physician. The therapist may be subject to countertransference influences such as wishing to protect the patient from public exposure, and the therapist may be uncomfortable with the use of sanctions that threaten the activity that they share, for example, the practice of medicine. There is a general need among doctors for improved skills in managing addiction, as illustrated in this poignant comment from a lawyer who had achieved abstinence through Alcoholics Anonymous (AA):

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"I see aspects of alcoholism in my work every day. Indeed at this moment I am sitting in court mulling over the fact that a local GP told me it had not occurred to him that his patient [the battered victim of an assault] was alcoholic. This was despite a 10-year history of accidents, depression, anxiety attacks, blackouts, brain scans, etc. I told him about AA and he said that his patients were often unhappy about it because it was generally attended by 'social class groups 4 and 5.' He tended to refer them to therapy groups where controlled drinking was advocated." The health procedures of the General Medical Council assist sick doctors into treatment and monitor their progress. Because the procedures are administered by the profession's licensing body, most doctors comply. The Law Society is to establish a support program with the dual aims of educating the profession about addiction, and assisting individual solicitors with this problem. In the USA, virtually all states have an impaired physicians program and the most populous have a lawyers' assistance program; these vary in their degree of formality. The usual components include [8]: * confidentiality and separation from the disciplinary authority, to encourage candor; * prevention and education; * mechanisms for the identification, assessment, and treatment of distressed lawyers. Self-help groups, offering abstinence-based programs and run by recovering members of the profession contribute beyond measure to the recruitment and retention in treatment of afflicted colleagues. Examples in the UK are the British Doctors' Group and the Lawyers' Support Group. There are particular problems attending professional rehabilitation. Opportunities to practice in a "protected" capacity are few, in either profession, and there may have been adverse publicity prior to entering treatment. Such "second penalties" were experienced by both legal and medical practitioners: "I was 48. Most jobs are aimed at solicitors qualified for not more than five years--unless they have a client following." PROGNOSIS Experience with addicted doctors in recovery has shown that their outcomes are rather better than unselected clinic populations [28]. There are grounds for optimism. This is implicit in this comment by the personnel director of a major law firm: "I am pleased to say that all the cases [of alcoholism] we have had to date have emerged at the other end of the t u n n e l . . , we have begun to develop a culture at the partnership level where it is legitimate to discuss these things in a reasonably open way without fear of ridicule, or recrimination." The development of this culture throughout both professions would facilitate the acknowledgment and management of alcohol-related problems, to the benefit of afflicted practitioners, their clients, patients, and families.

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Acknowledgment--Mr. Jonathan Goodliffe contributed information about the Law Society's plans for a support program for impaired solicitors.

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