“Throughout my career as a doctor, I was trained to believe I was infallible. As far back as medical school, we were told that, no matter what, you don’t call in sick; you show up. So, even though I knew I was in trouble, I didn’t ask for help.”
So writes Darryl Gebien, one of the 10-15% of medical professionals around the world who, at some point in their careers, find themselves addicted to drugs. Some turn to illegal substances; others abuse the prescription drugs to which they have unparalleled access. Most start out managing stress, or pain from long-term injuries, and are motivated by that sense of responsibility: “no matter what, you show up.”
A concern to maintain their fitness to practice ends up compromising it.
Fitness to practice
The General Medical Council (GMC) regulates doctors working in the UK. It ensures they are fit to practice, not just as safe and competent doctors but that they can establish effective relationships with patients, so as to maintain confidence in the medical profession.
This is underpinned by the principles described in good medical practice which sets out the standards of competence, care and conduct expected of doctors.
In exercising this guidance, the old saying holds true: prevention is better than cure. Detecting issues when they do occur is also a serious responsibility, but it’s important to see the regulator as protectors of the profession, not a punitive force.
Professional stress
Living up to the high standards of conduct expected by the medical professions is not easy, and the tension begins at training. Medical students report higher than average levels of stress and emotional distress, with one in ten experiencing suicidal ideation.
As a consequence of their stressful, challenging and competitive study environment, stimulant use is exceptionally high among medical students. Around 20% use stimulants to enhance cognitive performance. That figure doesn’t include the most commonplace stimulant of all, caffeine, which is associated with short-term overuse during periods of intense mental effort. Relaxation brings further substance abuse problems; there is a strong correlation between binge drinking and burnout among medical students.
These habits carry forward into practice: 25% of doctors rely on drinking and prescription medication to cope with stress, while around 10% actively abuse drugs. This can create multiple fitness to practice concerns. In the short term, there is the possibility of intoxication while working; in the longer term there is an underlying concern about mental health and conduct, which overlaps with the duty of care medical institutions have to their staff.
The GMC uses chemical testing in appropriate fitness to practice cases, to establish if and what substances have been/are being misused and if the doctor has complied with restrictions. Blood testing is used for alcohol abuse, while a hair drug test is the default method for identifying commonly abused drugs.
Hair testing: the best bet for screening
Hair testing has become the GMC’s standard for commonly abused substances because:
- Hair testing gives a clearer picture of drug use in the long term, over a matter of weeks rather than days and from single tests, not a repeated cycle.
- Hair testing is non-invasive, not vulnerable to donor anxiety, and difficult to subvert by dilution or short-term drug fasting.
- Hair testing is accurate over time - it indicates sustained usage and short-term spikes, while fluid samples are accurate in the short term but may be indicating a one-off use.
- Hair testing can highlight anything; laboratories are accredited for a wide range of illegal and legal substances, carrying out discrete tests to identify specific usages.
The exact model of hair testing can vary. Targeted tests for professionals who display signs of substance addiction, habitual use, or the stress that leads to these states are one; regular workplace testing as a detection measure is another. It’s worth noting, the GMC doesn’t conduct regular workplace testing; employers, on the other hand, might.
It’s important to remind professionals and students that the goal is not to catch them out, but to identify problems before they become problems. Likewise, it’s important to follow up positive tests with caution - occasional or recreational usage, outside a professional context, does not automatically equate to impaired fitness to practise. Hair testing must be carried out and interpreted by toxicologists, and in the case of the GMC, interpreted by the medical professionals who report on doctors health.
At present, UK medical institutions use regular (but not routine) hair testing in addiction cases to ensure continued abstinence, emphasising the value of hair testing for long-term substance use tracking. Establishing fitness to practice demands this kind of observation, determining if the trainee or practitioner is able to uphold their standards of conduct and self-care over extended periods.
Some drug tests can be ‘gamed’ through temporary abstinence, which is why we recommend hair testing for drugs, which provides a long-term picture, distinguishing between sustained and irregular substance abuse. The goal is not to detect and police drug and alcohol consumption, but to identify those students in need of the care and development that the GMC guidelines suggest - saving money, time, and potentially lives.
Thanks go the GMC for their insights for this piece. For more information on their good medical practice guidelines, head here.
