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Do not heal thyself

Self-treatment and self-prescription by doctors are widespread across Europe and North America in spite of clear guidelines proscribing such behaviour, which evidence shows poses severe risks to clinicians’ well-being

Doctors in several countries continue to self-prescribe, self-treat and provide medical care to loved ones despite knowing it is risky and against strict guidelines.

The widespread nature of this phenomenon was explored at a research seminar at the ICPH (International Conference on Physician Health) in Montreal, Canada, last October.

Researchers from country after country — the USA, Canada, Norway and Spain — presented findings that showed significant numbers of doctors continued to self-prescribe and self-treat.

Ontario Medical Association physician health programme medical director Michael Kaufmann suggested that doctors were guilty of ‘cultural hypocrisy’.

‘Officially, Canadian physicians espouse the principle that doctors should not treat themselves or family, but most do so anyway,’ he told the meeting.

CMA (Canadian Medical Association) policy on physician health and well-being ‘recommends that physicians not treat their own illnesses or self-prescribe’.

Guidance ignored

However, Dr Kaufmann cited a 2009 article (‘Health practices of Canadian physicians’) from the journal Canadian Family Physician, stating that three-quarters of Canadian clinicians take care of their medical needs when they can, and 15 per cent do not know what resources to turn to if they have mental health or substance abuse problems.

The conference, which was jointly hosted by the BMA, the CMA and the American Medical Association, also heard echoes in research from other countries.

Oslo occupational health specialist Karin Isaksson Rø presented a paper called ‘Physician self-prescribing in Norway’, revealing that three-quarters of Norwegian physicians had self-treated but 13 per cent thought they should not have done so.

Also, of the two-thirds who took prescription drugs, 12 per cent used anxiolytics and hypnotics, and between 73 and 90 per cent of these were estimated to have self-prescribed.

Barcelona psychiatrist Pilar Lusilla reported that 80 per cent of Spanish doctors self-prescribed, and 60 per cent didn’t have a GP. Dr Lusilla also referred to a study involving 335 impaired doctors being helped at the Barcelona Integrated Care Programme for Sick Physicians and Nurses.

She said 63 per cent had been self-prescribing psychotropic drugs such as benzodiazepine, antidepressants and hypnotic drugs before seeking help.

Associated dangers

Dr Lusilla told the conference: ‘Self-prescription might lead to delays in seeking help, and is associated with addictive behaviour, dual diagnosis and poorer outcomes.

‘As self-prescription appears early during medical school, more education and preventive strategies should be developed to raise awareness among physicians of the dangers associated with [it].’

Dr Kaufmann says: ‘We set out to examine cultural differences in this regard but found only cultural similarities.

‘In the North American and European countries we examined, there was a general policy acceptance, at many levels, that doctors should only prescribe for themselves or family in situations that were trivial or urgent, [and] if access to emergency care is not available.

‘But research shows that doctors’ self-treatment is widespread and does not strictly adhere to those guidelines.’

So why is this so? And should there be a debate about whether the guidelines are fit for purpose?

BMA pilot

London forensic physician Meng Aw-Yong has been involved in a pilot project with the BMA Doctors for Doctors unit, assisting clinicians undergoing GMC fitness to practise procedures.

He points to cultural issues, saying doctors can feel that they do not have the time to take care of their health, or that they can feel ashamed to be unwell and wish to conceal their ill health.

Doctors for Doctors head Michael Peters concedes the issue can be controversial and one that gets a mixed reaction from doctors.

He says a GP who is also a parent faced with a child with a bad ear infection in the middle of the night might well be tempted to give their offspring antibiotics instead of waiting for four hours in the emergency department. But this temptation should be resisted.

The GMC’s Good Medical Practice guidance advises that doctors ‘wherever possible … should avoid providing medical care to anyone with whom [they] have a close personal relationship’.

Paragraph 77 adds: ‘You should be registered with a GP outside your family to ensure that you have access to independent and objective medical care. You should not treat yourself.’

Risk of drug misuse

The GMC’s 2008 Good Practice in Prescribing Medicines guidance adds: ‘Controlled drugs can present particular problems, occasionally resulting in a loss of objectivity leading to drug misuse and misconduct.’

Controlled drugs should only be self-prescribed or given to someone close to the doctor if no other prescriber is available and the person would otherwise be in uncontrollable pain or at risk of death or serious deterioration, the GMC advises.

Afterwards, any such incident should be recorded, setting out the personal relationship and emergency circumstances.

Dr Peters points out that self-prescribing is not illegal (even though it is contrary to GMC guidance), and this adds to a sense of mixed messages perceived by the profession.

He acknowledges that self-prescribing and self-treatment do still occur, and this is why it remains so crucial to ensure that doctors feel they can access appropriate healthcare when they need it.

Cultural issue

He says: ‘Part of this is a cultural issue that stretches back decades. It may have something to do with our tradition of professional independence, and wanting to hold on to that, or it may just be [a matter] of convenience.

‘However, there is a culture shift as doctors become more aware of the importance of taking care of their own health, and having their own GP.

‘We need to make sure that doctors, because of their busy schedules or perhaps a perceived stigma about being ill or seeking help, do not face difficulties accessing healthcare.’

Dr Peters suggests that doctors might feel there is a big difference between prescribing controlled drugs such as diamorphine and pethidine, and other non-addictive drugs for minor ailments.

There is a perception that they are facing more stringent GMC checks on the issue, he adds, pointing to a MDU (Medical Defence Union) analysis of self-prescribing cases between 2008 and 2011.

The MDU found it had handled one-fifth more self-prescribing cases over that three-year period than in the three previous years.

Rise in investigations

Moreover, GMC figures on the number of closed cases that featured allegations of self-prescribing, self-treatment or informal treatment of family and colleagues between 2010 and 2012 increased from 36 in 2010, to 82 in 2011 and 98 in 2012.

However, a GMC spokesperson says this was likely to reflect a general rise in investigations. Over the three years, these resulted in 13 voluntary erasures, 10 undertakings, 12 warnings and 28 cases referred to fitness-to-practise hearings. A further 111 cases merely involved giving advice to the doctors to avoid similar actions in the future.

And out of the 28 cases referred to hearings, only 10 resulted in suspensions and five in erasure. Even these outcomes did not relate solely to allegations of self-prescribing, as some cases involved multiple allegations.

However, Dr Peters is quick to add that in seeking informal care from colleagues, doctors are sometimes ‘side-stepping’ the fact that they might have serious health problems.

With a colleague, Dr Peters produced a series of video ‘clinical vignettes’ with actors simulating awkward consultations to encourage doctors to explore such issues. These were presented at the ICPH at a seminar entitled Discomfort in the Doctor-to-Doctor therapeutic relationship.

Loss of objectivity

He says: ‘You lose objectivity if you are treating yourself or you are treating family. It is complex enough understanding patients, what is going on and what’s not being told. I think doctors should not self-treat. It is a recipe for disaster.

‘It is important that a doctor has a formal trusting relationship with their own doctor. The whole issue of self-prescribing is an area that can benefit from further research.’

Dr Kaufmann agrees: ‘I and my colleagues are in the business of responding to the needs of doctors with a range of personal health problems, including psychiatric and substance use disorders.

‘It is common for us to see that these doctors have attempted self-treatment without success — often with antidepressants and with powerful sedatives or opioid analgesics as precursors to substance abuse and dependence.

‘From that anecdotal and experiential platform, I’m sure none of us in this business would support a more liberal approach to doctors’ self-prescribing.’

In the meantime, the issue continues to spark debate.

Dialogue needed

At the ICPH, doctors heard about research from the CPHP (Colorado Physician Health Programme) based on responses from 600 physicians in the US state, showing that 15 per cent had self-treated and self-prescribed for serious matters such as the management of acute life-threatening illnesses, performing potentially life-threatening procedures, management of MI, major GI bleed, major surgery or even delivering their children.

Sixty per cent said they had self-prescribed and self-treated for serious or chronic illnesses, such as diabetes, cancer and depression, or had prescribed anti-depressants, anti-hypertensives and insulin.

And one-third reported that they had self-prescribed addictive medications or office samples.

CPHP medical director Michael Gendel said the figures suggested the ‘need for profession-wide dialogue on guidelines for appropriate self-prescribing’. (Read more.)

Work by the BMA and others, so evident in the ICPH debates, could be seen as part of this dialogue, which will hopefully support doctors in turning to others rather than themselves for the care they deserve.

London consultant psychiatrist Julia Bland gives an insight into what doctors want from the colleagues who treat them

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