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AS doctors we are always trying to improve health literacy in the community. Access to knowledge via the internet may not always give our patients relevant, accurate information. Often, all it seems to do is provide some support to people’s misconceptions and their denial.
There is an enormous push to have patients actively involved in decisions about their own health – shared decision-making – which is difficult without some level of health literacy.
The paradox is that the one group with the best knowledge about health and the most potential to be involved in the management of their own health also has some of the worst, delayed health-seeking behaviours.
That group is doctors.
With the exception of smoking and exercise rates, as a group we underperform in our socio-economic group for almost every indicator of health compared to the average community member. But in spite of this, we somehow manage to provide an excellent level of health care to our patients.
Why are doctors vulnerable?
Doctors tend to have a variety of personality traits (here, and here). It is a matter of debate how this arises. Is it an inherent outcome of the selection process for medical students? Is it the outcome of training we undergo in university and in supervised clinical training? Is it the only way that we can meet the expectations placed on us as students and doctors in training?
We doctors are prone to being obsessional. If we can control our obsessions, it is an asset. A thorough doctor, after all, is a safe doctor.
If we cannot control our obsessions, that is a curse. It leads to excessive perfectionism, anxiety and depression when we recognise that we are not perfect but believe that we should be. This is magnified by the expectations of our patients, the law and our perceptions of what the Australian Health Practitioners Regulation Agency (AHPRA) expects of us. We can be conscientious to a fault.
We are prone to being avoidant and are afraid of giving the impression that there are things that we cannot or will not do. We hate to say no to people or we overcompensate and say no too easily.
We can feel guilty when we spend time on our own recreation. We also feel guilty when we do not give time to our own relationships and invest in our families.
The clash between our expectations and our perceptions of what is happening also contributes to anxiety, burnout and depression (here, and here).
A major reinforcement for our doing medicine is for us to feel special. But if we are dependent on the opinion of others for our self-esteem, this has several problems. We need to guard against being overly sensitive to criticism or the tendency to seek adulation from our patients. We need to encourage a healthy self-esteem to guard against violation of doctor–patient behavioural boundaries.
This all sounds miserable but unless we realise our challenges, we cannot deal with them. Self-awareness, gently given peer review and reflection are key. However, not all of the challenges belong to doctors alone.
It could be said that the “system of medicine” needs a check-up for its deficits, yet the medical–industrial complex is a far more difficult, costly and recalcitrant patient, even than doctors.
Vulnerable systems
There can be no mention of doctor’s health without an acknowledgement that the system that doctors work in is a major contributor to the expression of doctors’ vulnerability. The 2013 beyondblue National Mental Health Survey of Doctors and Medical Students clearly showed personal distress and burnout scores which were largely consistent with international literature.
What is not often mentioned is that, at least for personal distress, other age-matched, similarly tertiary educated professionals had very low levels of personal distress. It is hard to imagine that engineers, lawyers and academics are not at least personally as vulnerable as doctors. It would be interesting to consider the impact of the workplace itself as a significant factor in unmasking the vulnerability.
Doctors needing help have difficulty seeking help and, furthermore, once they access help they may not be treated as well as someone without a medical degree. For doctors treating doctors these are some important tips provided by the Doctors Health Services course recently held in South Australia:
- Being asked to treat other doctors is usually a sign of respect; that respect must flow both ways.
- As a patient, a doctor should consider several things. The following are suggestions:
- Always make a formal appointment with adequate notes; never do corridor consultations.
- Expect and offer to pay normal fees.
- Always book a long appointment; there is a lot more talking involved when dealing with colleagues.
- Establish and confirm professional boundaries; there is always the chance that your treating doctor may have issues of their own that they need to speak to a doctor about. As you asked first, it is appropriate that your doctor is your doctor, not your patient.
- Are you happy to have investigations or referrals done locally?
- Ask if your doctor is comfortable to send you copies of your investigation results; it saves a lot of time.
- Ask how your doctor would like to be contacted; SMS in hours is usually the most convenient and least obtrusive.
Beware that when doctors are patients, they are concerned about several issues:
- Fear of the possible causes of the illness.
- Fear that they are exaggerating their concerns.
- Embarrassment at being sick or not being in control.
- Fear of criticism for any element or aspect of their illness.
- Fear of disclosure of their illness to others.
- Lack of trust in other doctors’ abilities.
- Fear that they will need to stop working.
- Fear that they will be reported to AHPRA.
Beware that when doctors are patients, they often:
- Wish to organise elements of their own care; advise against this as we are no longer permitted to self-prescribe and we are being encouraged to avoid self-referral for opinions and investigations.
- Need lots of appropriate reassurance as they are often very scared.
- Present late in an illness.
- Have high levels of denial and can dispute the diagnosis especially if it involves mental illness, drugs, alcohol, sexually transmissible infections, any form of domestic violence and forensic issues.
- Totally misinterpret the symptoms and have an incorrect self-diagnosis.
- Still function at a high level even when physically, cognitively or mentally unwell.
There are other difficulties as well:
- In training we are taught to teach patients to be balanced in diet, exercise, rest, sleep and recreation.
- We expect each patient to put themselves first, that a job is just a job:
- What are we taught to do – directly or indirectly?
- We are taught and expected to put the patient first, to keep working until the tasks are done – even if it means unpaid and even unrecorded overtime.
- We are told that what we do is more than a job, it is a profession, a calling and a respected role in our community.
- We are taught to teach our patients to communicate with their families about their lives, to share what they do:
- We are taught that what we do is confidential, that we cannot even identify someone as our patient.
- In ward rounds, we are tested to destruction until we make a mistake and the next in line answers.
- Effectively, we are being taught to be positive, assertive, to pretend to always be correct and to always have a response.
Doctor-specific health services are available in every state. There is a list at the bottom of this article.
We need to ensure that every health practitioner has their own GP. Not only do GPs provide person-centred care and a large amount of mental health care, we can also provide whole-person care. GP care is confidential and connecting with your own GP provides insight for you, and a chance to establish your health literacy and your own circle of care for yourself.
Finally, we are mindful of Sir William Osler’s great quote: “The doctor who treats himself has a fool for a patient.” This might explain the great propensity for doctors to present late in an illness and to have a shared, partially completed management plan such as investigations already ordered. We can only encourage all doctors to treat ourselves with respect and to see a GP, who can also be our greatest advocate in a system which injures us.
Do yourself a favour and put your humanity first.
We acknowledge the Australian Doctors Health Service for the tips. We are indebted to a recent course on doctor’s health given in South Australia by Roger Sexton which has informed this article.
Associate Professor Chris Hogan has had many GP involvements including proceduralist, practice principal, GP advocate, researcher and academic. He is affiliated with the University of Melbourne.
Dr Karen Price is a GP and a member of the GPs Down Under Facebook group administrative team. She is Deputy Chair of RACGP Victoria, and a PhD candidate on the “Role of peer connection in general practice” at Monash University.
Doctors’ Health Advisory Service (http://dhas.org.au):
NSW and ACT … 02 9437 6552
NT and SA … 08 8366 0250
Queensland … 07 3833 4352
Tasmania and Victoria … 03 9280 8712 http://www.vdhp.org.au
WA … 08 9321 3098
New Zealand … 0800 471 2654
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
I have read all of your comments with great interest.
Doctors experience the same barriers finding and having access to a GP as our patients do, but plus a whole lot more. Access to another doctor ( let alone a doctor of choice) is almost impossible in some rural and remote areas and has become more difficult in urban areas too.
Billing is always controversial, but what matters is no matter how the patient is billed, they deserve to receive the full complement of your clinical skillset, with no corners cut. Unfortunately, there are too many examples of a discount being applied to the clinical content of the consultation as well as the fee! Not all doctors want to treat other doctors. That is a fact.
Self-treatment by doctors of themselves and family members, especially in rural and remote areas is common, out of necessity, for acute illnesses, especially infections. This is not ideal but is a compromise. It is certainly safer if another doctor reviews the management as soon as possible. This is only sensible.
I don’t ever want to be responsible for a clinical error involving a family member – the personal stakes are way too high and the impact can last a long time. But we can be drawn into this whether we like it or not.
There is no denying the ability of doctors (practising within their scope) to self-manage some things but a timely set of fresh GP eyes on the problem really is best, in particular where a doctor is managing their own chronic condition such as diabetes and hypertension or even depression.( yes, even depression ! …..).
As far as being an ‘expert’, devotion for over 25 years to the mission of improving the health of the medical profession for the good of the community does bring with it some knowledge and benefits – exposure to exceptional members of our profession, learning from the inspiring stories and conversations with hundreds and hundreds of doctors and students, opportunities to run doctors’ health programs with caring and motivated people and building the case to influence funders and decision-makers, the chance to problem-solve and offer innovative solutions which make a difference.
But it is my experience that we are members of a profession, some of whom like to diagnose what is wrong with your idea, seeing it as a diagnostic challenge to find fault!
Doctors are brilliant problem-solvers and we can and should collectively help ourselves. We have the capital and human resources to do so and not wait to be ‘rescued’ . I firmly believe the best doctor for another doctor in a general practitioner. GPs are central to the wellbeing of the profession and we must all lead on this.
If any doctor wishes to join the growing number of doctors who are persistently working to achieve the mission of a healthy profession, their devotion and sacrifice to help the profession would be very warmly welcomed. Your local doctors’ health program is a good place to start.
Finally, a most useful and very new education resource for doctors (and students) in the form of modules on the topic of doctors’ health for doctors is now available via the http://www.drs4drs,com.au website. The videos alone are worth a look. Best wishes to all for this coming year.
Having needed to find my own GP more than once on my later years when health concerns arose, there were no central lists/agencies and I found a direct approach to a respected local/nearby colleague was never rebuffed, and my choices always showed themselves worthy of my trust as I had expected. A personal request, outlining your respect for your colleague, and your understanding of their busy lives, is perhaps the greatest compliment you can give them, and I continue to be grateful for their care for my needs.
I have seen studies suggesting 85% docs treat themselves and family for minor problems, so AHPRA and Roger are kidding themselves when they try to eradicate this. Roger is not an expert just because he is or was on the SA Medical Board. he and I have argued for hours about this to no avail. My wife recently developed a shingles rash so I started an anti-viral straightaway without having to find a GP in a country town on a weekend. Later she developed post herpetic neuralgia so I referred her straight away to another GP who prescribed her Pregabalin. System worked safely and well because we were not in Victoria and could legally prescribe for family. By the way I’ve heard that Sir William Osler had a prostate problem and needed a PR when he said “The doctor who treats himself has a fool for a patient.”
Doctors not “treating” themselves or their family is a fine thought but is hopeless in practice. I just rang the NSW doctors health line from this article to ask for a list of GPs in my area who are prepared to have doctors as patients and was told, “well no, perhaps I could put you in touch with….” so thanks for not much. My wife had nausea recently so I went to the local chemist for some ondansetron and was told by the chemist he couldn’t dispense a script written by me anymore, so she put up with the nausea for the night. APRHA would suggest we go to the local ED and get a Nurse to see her…or call the ambulance and have a paramedic assess her!! I contend that my opinion and treatment is better than a nurse or paramedic. The subordination of doctors to nurses and paramedics is not related to the current topic but it does put pressure on doctors to “treat “themselves and their families, especially after hours. Perhaps a more enlightened approach would be to suggest that doctors regard themselves as a “registrar” in their relationship to their GP. Able to do a lot but always checking with and reporting back to their consultant. As one of my consultants said to me many years ago “you can do anything to my patients as long as it’s RIGHT”. Perhaps that should be the test for a charge of professional misconduct, that firstly the treatment, prescription, referral etc should be wrong.
Thanks Ian Hargreaves. It’s an interesting proposition. Not bulk billing Doctors. The bullet points were supplied as acknowledged from the SA Doctors Health course run by leading expert Dr Roger Sexton. The a Doctors health services do not recommend bulk billing other Doctors. During the course this was debated and every attending physician had a different view on it. Personally in my private practice I bulk bill my medical colleagues for the reasons you state. The Doctors health services don’t as they wish to address the complexity of care appropriately and perhaps they see it as a way of addressing the professional nature of the relationship and its boundaries.
Regarding phone calls emails (notably not secure) and SMS these are also debated as options. My preference is fine in selected circumstances and for selected patients. Consented and discussed. I’ve never had it abused.
Our clinic now sends out routine result notifications by SMS. It’s an emerging technical area of communication in practice and one in which I expect to see more change as we become more mobile and time pressures continue to engulf us. Payment models will need to adapt of course. As always practice boundaries.
The issue mostly is getting Doctors to access and prioritise their health care. I agree when working as a contractor in or in private practice taking time off is hugely expensive. However working when impaired by fever by pain or ill health of any sort might just cost you more and create immeasurable suffering for patients.
We are human. The stoic lone soldier indispensable to everyone needs to pass from our vernacular in all but the most extreme of circumstances. I feel for our remote and isolated rural practitioners. However would hope their communities can support them for long term sustainability and put up with minimal or zero clinic for recovery.
As many GPs in remote or rural places observed patients move on quickly when a Doctor dies.
I think the best thing I have learned is to care for myself as much as I do my patients and allow myself the same level of care.
As to the medical industrial complex well observing my daughter go through physician training I think we certainly need clinicians back in charge.
One thing not touched on in the article is that most doctors are self-employed or subcontractors, and even for those doctors in training (who have sick leave provisions) the threat of a gap in training hours can lead to having to repeat a year.
Many of the doctor-avoiding behaviours referred to in the article apply equally to a self-employed builder or musician, who cannot afford the time off their career development path to get their painful hand treated properly.
There are a few issues with your recommendations: To “Expect and offer to pay normal fees” is a break from the traditional Hippocratic principle of treating our colleagues for free, and teaching them for free. Neither do we patent our operations or therapeutic techniques and insist on a fee for intellectual property. Hippocrates knew that if we all treated (in every sense of the word) each other as family members, all would be well.
I am not sure who came up with the idea of: “Ask how your doctor would like to be contacted; SMS in hours is usually the most convenient and least obtrusive”, I can think of fewer nightmares worse than having my phone beeping continuously with SMSs from multiple patients to distract me while I am consulting with other patients – that is why I have staff who can handle all routine phone enquiries, and if necessary will organise time for a follow up appointment. I would rate an SMS consult as a lot worse in every way than a real live corridor consult!
The comments here should be enlightening. I used to refer to a Gynae Oncologist and assist at the ops on my referred patients but she lost me when she said “I’m a control freak”.
A few years ago I did delight (retrospectively) in developing a cluster of painful symptoms suggesting upper GI pathology or even pancreatic cancer (when the pain started to radiate through to the back). CT and endoscopy all normal (despite the large amounts of Nurofen I’d been taking), a surgeon couldn’t find anything surgical, with which I agreed. The afternoon I went home the shingles rash appeared.
Now retired, I had a hip replacement this month, the recovery is challenging to say the least.
Interestingly, or not, I resided in Osler House for part of my elective term, and it was the coldest place I have every inhabited, a little like the Medical Boards of every state except WA, where there in not obligatory reporting to the State Medical Board unless the treating Doctor see a risk to the patients that the depressed Doctor is treating or to the Treated Doctor themselves.
If you have read the BeyondBlue data regarding Suicide and Depression amongst Doctors the fact that Females Doctors have twice the incidence of Suicide of the General Population, is a totally unacceptable figure, the rate for Male Doctors is 25%.
I wait for data to find out whether this is Doctors in Primary Care or Secondary / Tertiary Care, perhaps as you are writing you might be able to assist this data, for the focus of all of the population and those educating Medical Students.
Thank you for providing this interesting, thought-provoking yet practical article. The subject of doctors’ health is always relevant and often brushed over, sometimes with grievous consequences. The more we as a health profession can converse about this, I believe in time, the less the fear and stigma.