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Dilemma: Recreational drugs

Your practice cares for many of the medical students at a local university. One of the third-year students comes to see you saying she feels ‘tired all the time’. Taking her history, you discover she uses recreational drugs such as ketamine in significant amounts at the weekends, and feels awful on Monday mornings. Are there any fitness-to-practise issues to consider, and how would you manage the consultation?

Explore her drug use and background in a non-judgmental way

The GP needs to balance a duty of confidentiality against the safety of patients, bearing in mind that the GMC is clear that patient safety takes priority (see Good Medical Practice and Medical Students: Professional Values and Fitness to Practise).

However, in the first instance you would want to explore the drug misuse in a non-judgmental and supportive way. Are there other issues, such as underlying depression or a history of abuse?

The GP should also discuss the risks associated with ketamine misuse to minimise harm.

There should then be a discussion about whether the student is in contact with patients when under the influence. If the current risk to patients is minimal, then with support and encouragement (plus, possibly, the involvement of outside agencies), the student may well be able to stop. Part of this process will require you to discuss the expected behaviours and responsibilities of medical students, as set out in the GMC’s Tomorrow’s Doctors.

If the student’s problems continue or escalate, then she should inform the medical school, which will have its own processes in place. That said, in my experience and that of colleagues looking after thousands of medical students over many years, it would be exceptional for the matter to reach that stage.

Dr Hugh Porter is a GP at the University of Nottingham Health Service, and chair and clinical leader of  NHS Nottingham City CCG

A low threshold for treatment and frequent review are key for drug misuse

I would take a pastoral approach to the consultation. I would want to know the reasons for the drug use and the student’s understanding of the health risks, the risks to colleagues, her career and her future employment prospects. Does she want to have a criminal record? Above all, what might be the consequences for patients of her drug use? Note, fatigue may be unrelated to drug use and needs consideration on its own merits. I would then highlight the hazards associated with ketamine use, such as cystectomy. Then I would offer appropriate advice.

Unless the student displayed a serious disregard for the consequences I would not, at this point, consider whistleblowing. It would be important to give her time to reflect, and avoid sending her into a panic and downward spiral by reporting her to authorities.

The key principles of managing substance misuse are empathy, a low threshold for entry and re-entry into treatment, early and frequent review at the start of treatment, and risk management. In this case, the balance of risk is the overriding principle, so having established that, it should be possible to support the patient without colluding with her, and to manage the situation by means of advice, empathy and early review.

Lastly, I would make it clear that failure to re-attend might require me to refer the matter to the deanery or medical school.

Dr George Ryan is the clinical lead for Shropshire Community Substance Misuse Team. He previously worked as a GPSI in substance misuse treatment

The patient’s behaviour might undermine public confidence

Medical students must be aware that their behaviour outside the clinical environment, even in their personal lives, may impact on their fitness to practise. Working with patients brings specific responsibilities, so medical students’ conduct must not undermine public confidence in the profession.

A student’s fitness to practise is called into question when their behaviour raises a serious or persistent cause for concern about their ability to continue on a medical course or to practise as
a doctor after graduation. Students who prompt serious fitness-to-practise questions must not put patients or the public at risk, and in some cases it may be necessary for a GP to raise a concern. However, the GP must also consider their duties under the GMC’s confidentiality guidance and decide whether disclosure would be in the public interest. They must support patients to care for themselves and should discuss the effects of drug misuse on health and wellbeing.

If the student has shown a persistent failure to meet the standards of good medical practice, it may be appropriate to raise a concern with the deanery or medical school – they are responsible for determining their students’ fitness to practise, and the use of illegal substances is normally a fitness-to-practise issue. Medical schools usually offer support alongside a fitness-to-practise process, encourage the student to continue to seek help from their GP and sometimes offer to refer the student to an occupational health service.

Paul Buckley is director of education and standards at the GMC


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