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Old notes arrive and reveal worrying past

Case history

Brian, 39, is a new patient who disclosed depression when he registered, but his records have not yet been summarised.

You met him only once when he said that St John's Wort greatly improved his depression.

He openly admits to having smoked cannabis but says he has not used drugs for more than six months. He has been unemployed but says he is trying to get his life back together and is looking for work on the railways where he used to be employed.

You receive a request for a pre-employment medical report for a safety-critical post, to include an opinion of his suitability for this work.

While summarising his records you discover a thick bundle with two serious attempts at self-harm five years before, and a 10-year history of cocaine and amphetamine abuse.

A psychiatrist's report says Brian has a personality disorder with addictive tendencies.

Brian had been very aggressive during his last admission, expressing homicidal intent against health professionals. He has requested access to his medical report before you send it.

Dr Rachel Mckenzie

'I have responsibilities to society as a whole and I must be honest in filling in this form ­ I cannot ignore his medical history'

This is a real dilemma. It is possible that Brian has really sorted out his problems and is no longer taking drugs.

A previous diagnosis of personality disorder and his past behaviour should not prevent him from having a chance now. But his job involves responsibility for other people's safety and I cannot ignore his medical history. Although I wish to be his advocate I have responsibilities to society as a whole and I must be honest in filling in this form.

Another difficulty is I do not know Brian very well. He is a new patient to me and he may not have stopped his destructive behaviour. If I knew him better I would be able to make a fuller assessment. I would approach his previous GP to find out a bit more.

I obviously need to see him again now that I have summarised his notes. I will start the second consultation in a positive light, telling him I am impressed at how well he has turned his life around. I will show him the form and point out the sections that cause me some concern. I will try to get to know him better and discuss his past, attempting to develop a rapport. I will discuss the services that are available in the local area to support people with mental health problems.

It is possible this discussion might lead him to decide against applying for such a responsible job. As he is currently unemployed he might do better if he got back into the responsibilities of work more gradually.

If he is still determined to apply for this job I will try to get a form of words regarding his medical history he can agree to that explains he has had problems previously with depression and drug misuse but that he informs me he is no longer taking drugs and he is not receiving any medical treatment at this time.

I will also say I have not been his GP for very long and give details of his previous GP who the prospective employers can contact for further information with Brian's permission.

If Brian becomes upset with me it would be very enlightening, as would his being able to take responsibility for his past in an open and honest fashion.

Dr Patrick Wills

'The liberal in me asks if Brian should be barred from the job, but would I want to be on a train with him operating the signals?'

This is the classic situation of the GP's care for the patient colliding with their responsibility to the world at large.

Brian acknowledges he has had problems. The liberal in me asks if previous drug or psychiatric problems should bar a person from a responsible position on the trains, or indeed any job where public safety is an issue. But would I want to travel on a train with Brian operating the signals?

Brian has been less than frank with me, minimising the severity of his previous problems. I do not know him well enough to pass judgment but the psychiatrist's comments are damning.

I'm afraid I might well try to dodge things a little. I object to being asked to make recommendations for suitability for specific employment in a specialised area. Perhaps any decision of suitability should be made by an occupational health physician on the basis of information supplied rather than by me.

It could be argued his past history should not be held against him but his personality disorder implies ongoing and difficult-to-resolve psychiatric problems. There is no indication when his last psychiatric contact was, or if he is still receiving treatment, although this should be clear from the notes.

If he is still using recreational drugs then this should exclude him from this type of employment.

I would not want him to roll up in the surgery, look at the report and decide I am responsible for his downfall. I would hope to hold his violent tendencies at the end of the telephone by calling him to discuss things. I would make him aware there are issues in his records that could be held against him. I would also point out that obviously I couldn't lie. I would ask him how he wants me to proceed. It may be reasonable to suggest in my report that a specialist psychiatric assessment would be required.

Brian has presumably signed a consent form for the release of medical information. This means that for this report ­ with Brian's consent ­ I am working for his potential employers rather than for Brian.

Dr Lucy Free

'If I'd known him longer I might suggest the company tried him in a less-critical position ­ in the meantime I'd take the bus'

Poor Brian, is he reformed and unfairly labelled, or is he a danger to himself, health care professionals and the train-travelling public? Fortunately the handling of a case like this is clearly laid down ­ the form must be filled in with all information available, passed to the patient who may request changes, and then either forwarded intact to the employer, or with a note that amendments have been made.

I believe most employers' liability insurance requires vetting of prospective employees, and a decent pre-employment questionnaire should cover most potential problems. All will have a section asking for the examiner's opinion, sometimes a tick-box pass/fail, sometimes written comments.

Hopefully, this form will have the facility for referral on to the company's occupational health department for further assessment; this is the one situation where I am glad of a 'cop-out' option. I'm sure a safety-critical post would also entail a medical by an experienced company doctor anyway, where his past problems would inevitably be exposed for assessment, but if left to my own devices I would rightly or wrongly err on the side of the safety of the general public.

I would fill in the form accurately from the notes in my possession and the information given by Brian, both good and bad. I am expecting to have to justify my position and will write nothing unsubstantiated. Brian would be very naive to expect this to be plain sailing, and if asked to alter my original report I would of course do so, but make very sure the company realised this had happened, probably by telephoning, although without saying anything specific.

I would obviously try to avoid a confrontation in the surgery with him about it if at all possible by being totally neutral, and emphasising my role as a conduit of information rather than the judge and jury, but would not put any special security precautions into play.

Perhaps if I'd known him longer I might suggest the company tried him in a less-critical position, but in the meantime I'd take the bus!

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