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.
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.
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.