Physicians who work under the influence of alcohol unsurprisingly have a risk of poor outcomes, but patients and support staff may be reluctant to raise concerns about them, a review of 17 disciplinary cases suggests.

The review analysed proceeding taken agains 17 hospital physicians in Poland who collectively treated a total of 157 patients . There was direct evidence of harm in four cases, which included omissions in care, misdiagnosis and treatment complications.

However the review also showed that only 11 patients noticed signs of alcohol use and made a complaint , while 142 patients “had no significant objections to the doctor’s work and the quality of the health benefits provided”, according to author Dr Damian Sendler, an epidemiologist with an interest in medical malpractice  from the Felnett Health Research Foundation in New York.

Writing in Forensic Science International, Dr Felnett notes that  most of the treatments provided by doctors under the influence of alcohol were low-risk, requiring either a disposal of medications, follow-up treatment planning or a minor treatment execution, e.g. removal of sutures from one patient’s forehead.

Of the four patients who were harmed, one case involved a doctor missing an abnormality on a uterine ultrasound in a patient who subsequently experienced bleeding.

The other instances – improper treatment for a twisted ankle, a post-operative complication and a misdiagnosed pneumonia – resulted in lesser penalties with doctors able to return to work within six months.

His review highlights several common themes among the cases of doctors who were working under the influence of alcohol. Most were working in areas of doctor shortages and were working longer than usual hours. In addition, most doctors were working night shifts, although it was not clear of this was a conscious choice to try avoid detection. The review also shows there was poor communication between staff and with hospital management, which may have been a factor in the doctors’ alcohol use not being notified.

In particular, the review notes that support staff felt they were treated as inferiors and believed that voicing concerns would get them into trouble.

“Most nurses chose to remain complicit and not report intoxicated physicians to hospital administration. They also did not warn patients, widening the opportunity for harm,” Dr  Sendler writes.

Likewise, none of the four patients affected by malpractice filed a formal complaint.

The author argues that while there is “no specified reason justifying such inaction” it is apparent that patients frequently agree to receive  care from an intoxicated doctor, despite possible harm. This might be due to the “hallowed position” that doctors have in society, he suggests.

Dr Sendler concludes by saying that it is the duty of hospitals and healthcare services to  have systems in place to enoucrage notification of intoxicated doctors, and also to reach out to overworked and stressed doctors and offer them support and help.

In Australia, AHPRA data show that five out of 224 mandatory reports made about doctors to the Medical Board in 2016-17 were related alcohol or drugs.