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Doctors’ health matters

April 2007

Introduction
It has been suggested that although doctors are physically healthier than the average person, they often do not follow their own healthcare advice [go to notes 1 and 2]. Furthermore, evidence suggests that doctors are more likely to have significant psychological vulnerabilities and are more likely than the average person to suffer from one or more of ‘the three Ds’-drugs, drink and depression (including suicide) [go to note 3]. It has long been debated whether this is likely to be due to the stress of the job or to pre-existing traits [go to note 4]. There is general agreement in the literature that some degree of obsessionality personality is common among doctors [go to notes 5 and 6] and that this ‘level of conscientiousness’ is often to the detriment of their own health needs. Coupled with this is the culture of ‘working through illness’ and ‘self-treating’ that has developed among the medical community. The perception that doctors are more likely than other professionals to work through illness may be symptomatic of a culture in which an image of invincibility is encouraged and vulnerability is denied [go to note 7].

International evidence suggests that doctors are at a higher risk than the general population of developing stress-related problems, depression, or suicide [go to notes 8, 9 and 10]. In particular, doctors have high standardised mortality rates in respect of cirrhosis, accident and suicide [go to note 11]. Suicide rates among female NHS doctors have been shown to be twice that of the general female population. Suicide rates also differ between specialties, with anaesthetists, general practitioners (GPs) and psychiatrists of both genders having significantly higher suicide rates than doctors in general hospital medicine [go to note 12].

Stigma of ill health
Many doctors who are sick do not seek help because of the stigma of ill health or because of peer pressure and professional loyalty. There are also the professional risks involved in the acknowledgement of ill health, in particular psychological illness and substance misuse. Concern about the response of colleagues, their fitness to practise, or losing the respect of patients are all reasons given for doctors ignoring their own ill health. Doctors in training, in particular, may feel vulnerable about their career prospects [go to note 13]. This stigma attached to ill health reinforces the perception that ill health is akin to inadequate performance and unacceptable conduct or the risk of stigmatisation as the ‘weak link’ in a supposedly ‘strong chain’.

Stress
It has been argued that stress in doctors is a product of the interaction between the demanding nature of their work and their obsessive, conscientious and committed personalities [go to note 14]. Several studies [go to notes 15, 16 and 17] have documented stress and higher than expected levels of psychiatric morbidity in doctors and medical students. Evidence shows that the proportion of doctors and other health professionals showing above average levels of stress has remained constant at around 28 per cent, compared with 18 per cent in the general working population [go to note 18]. It is suggested that stress and its related problems come from both the workplace and from the individual.

The main sources of work-related stress for consultants and GPs are excessive workloads, organisational changes, poor management and insufficient resources, dealing with patient suffering and mistakes, complaints and litigation and pressure of work [go to note 19, 20 and 21]. The data from the Doctors for Doctors Unit clearly shows just how much stress and depression feature in cases coming to the unit.

Drug and alcohol misuse
The misuse of alcohol and other drugs by doctors forms the major component of any concern about the health of the medical profession [go to note 22]. The largest group of doctors facing action through the GMC’s health procedures are those with addictive problems. Alcohol and drug dependency are characterised by denial and collusion, particularly from colleagues. Doctors are often reluctant to acknowledge their own problems of drug and alcohol misuse [go to note 23]. Failure to deal with the problem of alcohol and other drug misuse by doctors is largely due to its complexity and a culture that resists the recognition of psychological stress and is reluctant to constructively support or confront colleagues.

Mental illness
Evidence shows that doctors are more likely to suffer from work-related mental ill health than other professions [go to note 24], with the prevalence of any common mental disorder in doctors as high as 28 per cent, compared with 15 per cent in the general population [go to note 25]. Deep prejudices exist against people working in the NHS with mental illness. The myth that you cannot be a doctor if you are mentally ill is shown to be false and, although burnout and stress are important in medicine because of their frequency and disability caused, severe depression, near lethal suicide attempts and psychotic features are also all too frequent [go to note 26]. Other studies have identified the major factors in mental illness as the long hours worked, the high workload, the pressure of work and their effect on the personal lives of doctors [go to note 27].

Vulnerable doctors
The ‘macho medical culture’ has often been blamed by doctors for their own illness. Many hide their illness from colleagues, family and friends in an attempt to not appear vulnerable, while continuing to maintain a heavy workload [go to note 28]. It is suggested that the culture of the health service and the unwritten contract that doctors have with their colleagues makes it very difficult for doctors to take time off work because of ill health [go to notes 29 and 30]. Experience from bodies such as the GMC and National Clinical Assessment Service (NCAS) suggests that many of the cases being referred to them could have been avoided if a doctor had sought help for a health-related issue at an early stage [go to note 31]. However, anecdotal evidence suggests that many doctors are reluctant to seek help until the situation becomes serious because they are ashamed of failing and fear harsh judgement by colleagues and the GMC [go to note 32].

Self-treatment
The well documented stigma attached to ill health, often results in doctors self-treating. Self- treatment for doctors includes diagnosing and treating one’s own illness and prescribing for oneself. It also includes undertaking informal or ‘corridor’ consultations and self-referring to a specialist. Furthermore, self-medication avoids the human support element of treatment, and reinforces the withdrawl from others, particularly in relation to mental illness.

Evidence suggests that self-prescribing and prescribing for the family is prevalent among all groups of doctors [go to note 33], including medical students who learn such behaviour very early on in their careers [go to note 34]. A recent survey [go to note 35] found that a quarter of respondent doctors thought that it was acceptable to self-treat chronic conditions and an even higher proportion thought it was acceptable to order blood tests on oneself to monitor chronic conditions. Recent evidence from the BMA cohort study of medical graduates suggests that self-treatment and prescribing is not unusual, with around a fifth of respondents reporting that they self-prescribed to help cope with work and ill health and a further third of respondents were aware of colleagues who self-prescribed [go to note 36].

Constraints of the health system
A doctor with health problems often faces unique barriers to obtaining help. Evidence [go to notes 37 and 38] suggests that doctors are reluctant to seek medical advice through the usual routes and mechanisms and find it difficult to adopt the role of the patient [go to note 39]. The consequences of this include self-prescription, working through illness and self-referral [go to note 40]. GPs perceive that ‘patients and colleagues link good health in doctors with medical competence. Doctors feel compelled to portray a healthy exterior while being aware of their vulnerability’ [go to note 41].

Doctors are notorious for not being registered with a GP, or if they are registered, not seeking their advice and treatment when needed. A survey of GPs and consultants in the South Thames Region found that although most respondents were registered with a GP, consultation rates with the GP were lower than that of the general population [go to note 42]. Results from the BMA cohort study show that while the majority of doctors report that they are registered with a GP, more than half do not go and see them when they are ill [go to note 43]. Reasons given for this include lack of time or not ‘being ill enough’. Many doctors report that they deal with illness themselves, while others felt ‘too embarrassed to see colleagues’. Doctors may find it difficult to maintain objectivity in diagnosing and analysing their own ill health, often resulting in denial or panic. Doctors are also reluctant to take sick leave [go to note 44]. Although this reflects a tradition of ‘working through’ illness, it is also due to practical reasons, such as the absence of cover.

It might be argued that doctors themselves do not make ‘ideal’ patients. They may present late, after having sought opinions from various colleagues or tried to manage their illness themselves, including prescribing their own medication [go to note 45]. Furthermore, doctors with health problems face unique barriers in obtaining help and there is no single comprehensive pathway of care and support that exists for such doctors [go to note 46]. A recent survey of GPs found that more than half still do not have access to occupational health services [go to note 47].

It is difficult for health professionals to deal with colleagues. It may be seen to breach the usual borders between professional and personal communication with colleagues. Although professionals looking after a sick doctor may keep strictly to the rules of confidentiality, the fact that a group of local colleagues have access to personal details about a sick doctor puts that doctor in a vulnerable position, which may compromise future working relationships. Jones suggests that ‘it should be routine that doctors needing admission should be offered admission to a hospital they do not work in or, for GPs, refer to’ [go to note 48]. The traditional care pattern of commissioners of care, usually PCTs, is one of making decisions about admissions on an ad hoc basis. It is argued, that currently this system does not work well, because doctors are still being admitted to their own trust [go to note 49]. In many cases, PCT managers perform a ‘gatekeeper’ role, making it difficult for doctors to access out of area referrals. Previously, the system of referral was seen as being more flexible and out of area referral was done as a measure of goodwill from one doctor to another.

The BMA Doctors for Doctors Unit
The picture that emerges from much of the literature is one of doctors with high levels of stress, anxiety and depression who take very little time off work for ill health but who, when they are off work, tend to be off for longer periods [go to note 50]. A high quality occupational health service, a well publicised point of contact who could direct the doctor to the appropriate service, available NHS care out of area and an evaluation of pilot schemes and new mechanisms are suggested ways forward [go to note 51]. If the problems surrounding the health of doctors are to be addressed, confidential, non-judgemental support must be provided to doctors who require it. The BMA provides such support to members through the Doctors for Doctors Unit and the BMA Counselling Service. The Doctors for Doctors Unit provides confidential advice and support to doctors in distress or difficulty and deals with a wide range of problems including mental health issues, drug and alcohol problems