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You stumble across a report that reveals your partner has Hepatitis C

Three GPs share their approach to a practice problem

Three GPs share their approach to a practice problem

Case history

While looking for the practice accounts in your partner's room, you find under a bundle of papers a medical report about your partner. It is dated last month and discusses his recent medical problems which seem to centre around his infection with hepatitis C. This comes as a shock to you as you knew nothing about this. Should you mention it to him?

Dr Alison Lennox

'I'd be concerned that he hadn't confided in the other partners'

Finding a letter like this would be a shock, and I must not panic. Having found it, I would read it carefully and try to gauge the gravity of the situation. If the partner has been diagnosed and treated, all well and good. It is likely that he has already informed the PCT and he must have discussed his situation with the specialist who is treating him.

He is only a possible risk to his patients if he is performing exposure-prone procedures and these can be avoided fairly easily as a GP without stopping work. No minor surgery; IUCD insertions would be marginal as nothing sharp is involved but are probably best avoided. Probably injections and phlebotomy should be avoided too.

You would want to avoid any possibility of blame (or litigation) if someone claimed that you had infected them. Having been treated he must be monitored at six-month intervals for one year to make sure his serology stays non-infective. After considering the facts, I would find it very hard not to talk to the partner. I would like to offer my support and help to manage his workload around his restrictions.

(I had a partner once who had been banned from driving for a year. We managed to work around this and evade patients' inquiries as to why he was being chauffeured around.)

I would be concerned he hadn't confided in the other partners – it's always possible I am the only one who didn't know! But the partnership dynamics would be a concern. I would engineer an opportune moment and come clean about my discovery, have a sympathetic discussion and reassure myself that everything was being done correctly.

Alison Lennox is currently working as a GP locum in Staffordshire

Dr Des Spence

'Your partner may need support and you have a duty of care to protect patients'

Does it matter if a doctor is hepatitis C positive? My understanding is that the epidemiology of hepatitis C is poorly understood with little long-term data.It has a low infectivity, especially if viral RNA is not present. In summary, it presents no risk to patients unless the doctor carries out invasive procedures like surgery.

So what to do with my partner, as he does not seem to present a risk to patients? It is very tempting to bump my head as the door shuts quietly behind me, causing amnesia. 'It's not my problem' is society's modern catch phrase. But you can't do that!

First he may need support, but also you have a duty of care to protect patients even if the risk is very low. Believe me, it really helps if you can sleep at night. You're going to have to deal with this and in my opinion on your own – that means no discussions with your spouse, partner or significant other.

Don't put this off, do it the next day. Get the partner alone and tell them how you found out. Reinforce that you will keep this all confidential, be open and supportive. Hopefully the whole story will spill out. It may be that this is a needle-stick injury, that they are having treatment and occupational health service and the trust are fully aware. End of story – keep your mouth shut for ever and sleep easy.

If the meeting goes pear-shaped and they go ballistic, that's a different matter. Do they have a drug problem? Frankly that is the most common cause of infection.

The bottom line is, this must be dealt with and the occupational health service must be involved. If your partner is not willing to deal with this issue on a voluntary basis then you need to consider breaking confidence in the name of public safety. You could contact your defence union as a first step.

Des Spence is a GP in Glasgow and a tutor in general practice at the University of Glasgow

Dr Joanna Harris

'I'd take him aside as a friend, say what I had seen, and ask him to tell me more'

You undoubtedly must say something to him, but the question is when and what? Partnerships should be based on trust and something like this not only affects the health of your partner but may have an impact on the health of the patients.

The GMC guidance on serious communicable diseases says you must always take action to protect patients if you feel a colleague's health may put them at risk. Also your partnership agreement may have a clause on illness of a partner and the recommended course of action.

However, I would take him to one side as a friend and mention what I had seen and ask him to tell me more. After all, he had left the paper lying around in his room and possibly wanted to broach the subject but was not sure how to begin. He may be relieved that it is all out in the open. I would ask about his current state of health and whether he is seeing a specialist or receiving treatment. I would ask if he knew how he might have caught it.

Intravenous drug abuse is a common route and this may bring up the subject of other issues regarding his health. But it is possible to have contracted hepatitis C from blood transfusions before 1991 when screening began and in fact half of people with the disease are unaware of their route of infection.

The actual risk to patients may be very low since this is a mainly blood-borne route of infection. If the partner has been performing minor surgery there is a risk that he may have infected some patients through needle-stick injuries, etc, although this is slight. Once it is out in the open, I hope he would agree to see a local occupational health physician and take further advice regarding the risk to patients.

Joanne Harris completed VTS in 1995 and is a part-time partner at a practice in Ealing, west London – she teaches medical students from Imperial College

Learning checklist

Law on hepatitis C

  • Staff must be provided with information and training about measures to reduce the risk of occupational exposure
  • Health care workers who perform exposure-prone procedures where there is a risk that injury to the worker may result in the exposure of the patient's open tissues to the blood of the worker should be tested before professional training, if they know they have been infected with hepatitis C or if they have been successfully treated for hepatitis C. If they have antibodies to hepatitis C virus, they should be tested for hepatitis C virus RNA, and if positive for hepatitis C virus RNA, should not carry out exposure prone procedures
  • A health care worker who performs exposure-prone procedures and believes they may have been exposed to hepatitis C infection should promptly seek and follow confidential professional advice (eg from an occupational health physician) on whether they should be tested for hepatitis C. They should cease performing exposure-prone procedures if they are carrying the virus
  • Under GMC 'Duties of a Doctor', if you discover a health care professional may possibly be putting patients at risk, you cannot keep such information confidential. Before breaching this confidence, discuss it with a partner, LMC member or your medical defence society
  • Circular HSC 2002/010 'Hepatitis C Infected Health Care Workers', Department of Health (2002)

What points should the partnership agreement include?

  • Sickness absence: how much, on what terms, who pays, certification required?
  • Locum insurance for sickness absence – level of cover, deferred period
  • When partnership can be terminated through ill-health of partner
  • Action to be taken if patients', staff or colleagues' health or safety is jeopardised by partner's behaviour
  • Requirement for partners to declare their hepatitis B and C immune status (positive or negative)?
  • Pre-partnership occupational health assessment (rare?)
  • Partners to behave with good faith towards each other

What points should be included in a salaried GP's contract?

  • Sickness absence – providing certification, practice policy on sickness absence, sick pay
  • Termination of employment on health grounds; adherence to health and safety regulations; duty of care to patients and colleagues
  • Action to be taken in event of needle-stick injury
  • Proof of hepatitis B immune status (positive or negative)
  • Pre-employment occupational health assessment
  • Disability Discrimination laws

Doctors as patients

  • How can doctors be reassured that their treatment is confidential?
  • Good Medical Practice says that doctors whose health may put patients at risk should seek independent advice
  • All doctors should be registered with a GP outside their own practice

Doctors can get confidential advice and support from:

  • BMA Doctors for Doctors 08459 200 169
  • Sick Doctors Trust (Addicted Physicians Programme) 0870 444-5163

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