This 26-year-old GP Registrar, doing a year's supervised training in your practice, has moved to your area with his wife and baby. He is pleasant, but lacks confidence. Even after three months, he is seeing only 2-3 patients an hour. Seemingly unwilling to make decisions, he asks advice on most patients, even concerning relatively simple or common conditions. When he is given gentle feedback, he becomes upset and self-deprecating.

Dr New appears relieved when you suggest setting aside an hour for a chat in a private setting where you won't be interrupted. He tells you that he has been having panic attacks which are increasingly disabling. A panic disorder which developed in his teens had responded well to support and cognitive behavioural therapy. He had occasional panic attacks during his medical studies: one, in particular, was associated with a viva examination, but otherwise he managed quite well prior to graduation.

Being unable to see his psychologist since moving to your town, the attacks are becoming worse. He has difficulty sleeping, has been using temazepam regularly and is finding it less effective. One month ago, he self-administered pethidine from his doctor's bag supply, and has since done this twice. After the initial surge of relief from the panic, he returned to feeling anxious and depressed.

At the end of your discussion, he tells you that he is glad of the opportunity to discuss this openly. He says that he feels better, and asks permission to return to Sydney monthly to see the psychologist. He 'knows' that his pethidine use is 'in the past', and is confident that he won't self-administer again.

Comments on Dr New

You are aware of your mandatory reporting obligation in any case where you become aware that another practitioner has engaged in practice while intoxicated by alcohol or drugs. You express full support, but you cannot be sure that he has not already done this, and you are also concerned that he may be tempted to use pethidine again when his anxiety recurs. He eventually agrees to self-notify to the Medical Board, so that he can join the Impaired Registrants scheme and receive maximal support. You know that this represents his best chance of satisfactorily dealing with his dual problems of anxiety and substance abuse, and maximises his chances of continuing to work successfully.