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THE pendulum may have swung too far towards emphasising mental health issues and unsafe working hours for doctors to the detriment of their physical health, says a leading medical defence adviser.
Dr Sara Bird, manager of medicolegal and advisory services at MDA National, said the impact of physical illness, particularly acute illness, on doctors and their ability to work was often overlooked or not considered as important as mental health problems.
Dr Margaret Kay, a senior lecturer in the discipline of general practice at the University of Queensland, agrees, saying that some doctors will have mental health issues but probably all at some time will suffer with a significant upper respiratory tract infection (URTI) or other physical health issue.
Dr Kay, who is currently completing a PhD into doctors’ health, said medical educators currently teach about doctors’ health issues with a focus on impairment and mental health. This contributed to junior doctors’ reluctance to address their physical illness and often made them unwilling to take a day off when they were ill.
“Doctors’ health needs to be considered from a broader focus than [impairment and mental health]”, Dr Kay said.
Dr Bird said it did not help that most doctors treated physical illness with a sense of bravado — an attitude that was often passed onto junior doctors.
AMA president Dr Steve Hambleton said doctors had a professional obligation not to expose patients and colleagues to infection if they were ill.
“We tell patients to stay at home when they have the flu so they don’t infect us and our other patients, and the same should apply to doctors”, Dr Hambleton said.
The comments follow the publication of a research letter in Archives of Internal Medicine on presenteeism — working while ill — among physicians. (1)
A survey of 150 residents found that among those who chose to work when sick, the reasons most frequently given were an obligation to colleagues (57%), an obligation to patient care (56%) and fear that colleagues would think they were weak (12%).
An editor’s note on the research said that working while sick might demonstrate an admirable sense of responsibility to patients and colleagues, but doctors should worry about the real danger of infecting vulnerable patients as well as colleagues and staff. (2)
Dr Bird said a professional obligation not to work when ill was clearly laid out in the Medical Board of Australia’s code of conduct. It stated that doctors should not rely on their own assessment if “you know or suspect that you have a health condition or impairment that could adversely affect your judgment, performance or your patient’s health”. (3)
She said the code made it clear by referring to “health condition” that it was not just referring to mental health issues, and doctors should not be working when ill if it could adversely affect their patients’ health.
Dr Kay said doctors had a responsibility to “first do no harm”, although the difficulty was to determine the harm that could be done if a doctor had an URTI.
She said while all workplaces should have appropriate backup systems to enable a sick doctor to take time off, most places had very little capacity to offer support to doctors when they were ill, forcing doctors to decide whether the risk of attending work was greater than the risk of creating a staff shortage.
This was particularly unfair on junior doctors who could not be expected to be across all the issues to make such a judgement. “The person making this decision is also unwell and acculturated through years of medical school to soldier on”, Dr Kay said.
“Education around managing these issues in a holistic manner is important. When focusing on training issues, mentoring of healthy behaviours is equally important because most doctors learn their health behaviours through the hidden curriculum.
“Medical schools should ensure that doctors who teach junior doctors and students are aware of the importance of their personal health behaviours in their mentoring.”
Dr Kay said the issue highlighted the need for all doctors to have their own GP.
However, she said if doctors could not take time off to see their GP when they were ill, they could have the best GP but fail to benefit from this.
“Workplace interventions need to support doctors in maintaining their health”, she said.
– Kath Ryan
1. Arch Intern Med 2012; Online 18 June
2. Arch Intern Med 2012; Online 18 June
3. Medical Board of Australia: Good medical practice: A code of conduct for doctors in Australia
Posted 25 June 2012
I think the problem is at an institutional level. I work at a regional hospital where there is a medical registrar who covers the wards at night and a surgical registrar is on call for the whole period from Friday night to Monday.
A couple of weeks ago, the medical registrar was as sick as a dog and had to bail on Friday night shift, informing the admin before midday.
The administration failed to realize that they needed to find a replacement, and after a lot of bullying and harrassment, the SURGICAL registrar ended up having to work the MEDICAL registrar’s shift overnight, meaning he was working for 36 hours before being able to grab a few hours’ sleep (but remained on call and busy until Monday!).
He was forced to work dangerous hours, at a job he was not really qualified to do. And yet, nothing happens to rectify the situation, because junior doctors have no effective industrial representation. Makes me spew.
My post related only to the author’s third last paragraph “Medical schools…”. On the subject of Public Hospitals, I worked for several years in Public Hospital Emergency Departments and more than 8 years covering rural hospitals, and in those years worked with other doctors always supporting their colleagues when sick. I feel sympathy for Jonathan and his “public hospital co-workers” who “will continue to come to work sick” , as I feel it is Jonathan who is missing the point of the article , including the reference to the Code of Conduct.
I think Rose is missing the point. A medical certificate means nothing to our colleagues who have to cover twice as many patients when we are away, or to the patient who won’t be seen for 8 hours because the hospital refuses to hire a replacement doctor.
Although I hate writing medical certificates for patients in ED who are less sick than I am, I and all my public hospital co-workers will continue to come to work sick until hospitals commit to replacing sick doctors rather than leaving the wards empty.
I applaud the author’s article, including her statement that medical schools ..doctors….. students ..personal health behaviours.. mentoring. I see medical and nursing students from the local uni. When patients have clinical signs, including fever, tonsillitis, otitis media (such as a student today), I give them a medical certificate stating their illness. I would encourage mentors to advise students to seek a medical appointment and detailed medical certificate when ill. Furthermore, mentors should seek advice from their local public health unit regarding the risk that students with flu or pertussis symptoms pose to other students, staff and patients, as both influenza and pertussis have been reported from the local uni students, most of whom are neither medical nor nursing students, so are not required to have an immunisation record, and therefore may represent a reservoir of pertussis infection.
The real dilemma is that doctors get sick when we are most needed – just like the rest of the population. The winter virus season sees more people go to doctors and hospitals, more doctors and nurses get exposed, more absenteeism just at the time of greatest workload. And even worse, the ones who “soldier on” while sick, while others take time off, have to work even harder. I suggest the following solution: a hemispheric exchange of acute workforce – a body of people who work only in summer, with seasonal rotation between hemispheres. Anyone know if this has been tried?
I have this year been involved in teaching year 1 and 2 medical students, who are exhorted to attend clinical teaching even if unwell, as they will be penalised for absence (even if covered by a Medical certificate.)
If I tell my patients I have “a bit of a cold” or “a touch of the flu”, I often get the response “…but you’re a doctor”! I tell them yes, but I’m only human!
Thanks for this article, about time we review how we doctors treat and value our own health and that of our colleagues.
As an ICU registrar who worked 2×12 hour shifts this weekend with an URTI, I can definitely identify with the article! One feels torn between not wanting to infect people (and of course wanting the day off to rest) and not wanting to inconvenience others (including most of all one’s boss, who will have to find a replacement +/- stay much longer than they want to). In the end most people don’t want to be thought of as ‘selfish’ by staying home, and so soldier on.