Dodging a bullet

A few months ago I got a letter from the College. If you are like me you get a panic attack when even the College Quarterly arrives, but this time it was the one. By the grace of God more than good judgment, I have managed to practise blemish free for 30 years, but this was a "letter of enquiry." A patient of mine had died in a house fire and a concerned friend had written to the College expressing the conviction that her friend had died because her GP and I had oversedated her, making her unable to respond to the fire caused by the deep fat she had left overheating on the stove. This patient had indeed been on fairly high dosages of antidepressants and benzodiazepines—although within indications. I had struggled for years to reduce her intake or switch her to less dependency-producing medications, but without success. We had one stand-up row when her Ativan "fell into the toilet," remarkably sparing the antidepressant. Despite my best efforts she always managed to get back to her original prescription, claiming that it was the only thing that had ever helped her.

The College letter did concern me, though, and I spent considerable time preparing my response. Salvation eventually arrived in the form of a toxicology report. My patient had large amounts of heroin in her system and not a trace of the drugs I had prescribed. I had no idea she abused narcotics—or that she was presumably selling benzodiazepines for something stronger—but I was greatly relieved to learn that I had no part in her demise. I must admit that I found the College to be very sympathetic and supportive, though I have colleagues whose experiences have been different. For me the relief faded and anger arose as I considered some of the questions this incident raised.

Even if my patient had died in a benzodiazepine fog, does that make me responsible? Are physicians to be held accountable even for medication abuse? Are we responsible for the behavior of our patients after they have left our offices? I wonder if this could be a cultural phenomenon. Despite being a proud citizen, I find Canada to be a blame-seeking society. Whatever the crisis—Somalia, the Red Cross, Walkerton—there seems to be a concerted attempt to reduce it to a simple black-and-white analysis and find some poor sucker to nail to the wall. We in medicine are particularly vulnerable as the Canadian public continues to ignore the concept of individual responsibility. Their pioneering forebears would be horrified.

The practice of medicine is tough. To be held responsible for events not directly related to treatment makes it virtually impossible. This time I dodged the bullet. The next time I—or perhaps you—might not be so lucky.

—AFS