The Impaired Colleague on Nights
You are the medical registrar on a busy night shift. A foundation doctor (FY2), whom you have worked with for six months, arrives for the night shift smelling strongly of alcohol and is visibly unsteady. He insists he is 'fine' and that he 'only had a couple' at a leaving do. He is due to cover 40 patients on the medical ward, including a patient with a rising NEWS score. You are the only senior doctor on site, and the consultant is off-site and contactable by phone. There is no other doctor available to cover. The FY2 has previously been reliable and well liked.
1. What are your immediate priorities, and what is the reasoning?
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Patient safety comes first. Immediate priorities:
- Do not allow the FY2 to assume clinical duties. An impaired doctor is a risk to patients. This is non-negotiable regardless of staffing pressure.
- Ensure the deteriorating patient is covered - you personally review the rising NEWS patient while arranging cover.
- Escalate - phone the on-call consultant immediately and inform them of the situation and the staffing gap.
- Arrange safe transport home - the FY2 should not drive. Ensure he gets home safely (taxi, colleague, family).
- Document the facts objectively: what you observed, time, what you did.
Reasoning: the duty to protect patients overrides collegial loyalty and the discomfort of challenging a colleague. Staffing shortages do not justify allowing an impaired doctor to work. The consultant and hospital management must solve the staffing gap, not you alone.
2. What are your professional obligations regarding reporting, and to whom?
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You have a professional duty to report concerns about a colleague's fitness to practise that pose a risk to patient safety:
- Local level first: inform the on-call consultant and the clinical director/medical director. This is the immediate line of accountability.
- Formal incident reporting: complete a clinical incident / patient safety report describing the concern factually.
- Regulatory level: if there is a pattern or the colleague continues to practise impaired, this may need to be referred to the medical regulator (in Malta, the Medical Council; in the UK, the GMC). Referral is mandatory where patient safety is at risk and local measures have not resolved it.
- Occupational health: refer the colleague to occupational health for assessment and support - this is both a duty and a route to help.
The key reasoning: reporting is not punishment; it is a patient-safety duty. You must act on reasonable concern, not wait for harm to occur. Balance this with confidentiality - share information only with those who need it (consultant, medical director, occupational health), not with the whole team.
3. The FY2 later apologises and says it was a one-off. How should you respond, and what follow-up is needed?
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Respond with compassion combined with clear boundaries:
- Acknowledge the apology and treat him with dignity - substance problems are health issues, not moral failings.
- Be clear that the concern has been reported and why: patient safety, not personal judgement.
- Encourage engagement with occupational health and any support services; this is the constructive route.
- Do not collude in minimising the event or agree to 'keep it between us' - that would breach your duty.
- Follow-up: ensure the incident is reviewed, that there is a plan for monitoring fitness to practise, and that the colleague is supported. If there is any recurrence, escalation must follow.
Reasoning: the exam tests whether you can hold both compassion for a colleague and an uncompromising commitment to patient safety. The 'one-off' framing is a common pressure point - it does not remove the duty to report and support.