Doctors as Doctors as PatientsPatients

By Mutaz AldawoudBy Mutaz Aldawoud

July 2009July 2009

Health professionals’ healthHealth professionals’ health

Aim to understand more about:Aim to understand more about: Health care for ourselves and our familiesHealth care for ourselves and our families Looking after our colleaguesLooking after our colleagues

ObjectivesObjectives Explain why doctors find it difficult to seek help Explain why doctors find it difficult to seek help

when they are illwhen they are ill Explain why doctors find it more difficult to care for Explain why doctors find it more difficult to care for

professional colleagues than ‘ordinary’ patientsprofessional colleagues than ‘ordinary’ patients State the reasons why doctors are more prone to State the reasons why doctors are more prone to

certain illness than other members of the certain illness than other members of the populationpopulation

Describe ways of looking after sick colleagues Describe ways of looking after sick colleagues more effectivelymore effectively

Describe and evaluate more effective ways of Describe and evaluate more effective ways of recognising and managing ill health in recognising and managing ill health in professional colleagues and yourself.professional colleagues and yourself.

Fact or Fiction?Fact or Fiction?11 (class vote)(class vote)

Any doctor can write a private prescription, using headed Any doctor can write a private prescription, using headed notepapernotepaper

doctors can write private prescriptions for themselves for doctors can write private prescriptions for themselves for controlled drugs including diamorphine, pethidinecontrolled drugs including diamorphine, pethidine etc. etc.

Doctors can write private prescriptions for family members and Doctors can write private prescriptions for family members and NHS prescriptions if they are registered on their listsNHS prescriptions if they are registered on their lists

No GP can be registered as their own patientNo GP can be registered as their own patient GPs are allowed to register their spouse / children as patientsGPs are allowed to register their spouse / children as patients Doctors are more prone to mental illness that the rest of the Doctors are more prone to mental illness that the rest of the

populationpopulation Doctors tend to be off sick less often than the rest of the Doctors tend to be off sick less often than the rest of the

populationpopulation When they are off sick, doctors tend to be off for longer When they are off sick, doctors tend to be off for longer

periods of time than the rest of the populationperiods of time than the rest of the population There is no comprehensive occupational health service for There is no comprehensive occupational health service for

general practitionersgeneral practitioners Doctors do not receive formal training in the management of Doctors do not receive formal training in the management of

their colleagues as patientstheir colleagues as patients

All of these are FACTSAll of these are FACTS11…… Any doctor can write a private prescription, using headed Any doctor can write a private prescription, using headed

notepapernotepaper doctors can write private prescriptions for themselves for doctors can write private prescriptions for themselves for

controlled drugs including diamorphine, pethidinecontrolled drugs including diamorphine, pethidine etc. etc. Doctors can write private prescriptions for family members and Doctors can write private prescriptions for family members and

NHS prescriptions if they are registered on their listsNHS prescriptions if they are registered on their lists No GP can be registered as their own patientNo GP can be registered as their own patient GPs are allowed to register their spouse / children as patientsGPs are allowed to register their spouse / children as patients Doctors are more prone to mental illness that the rest of the Doctors are more prone to mental illness that the rest of the

populationpopulation Doctors tend to be off sick less often than the rest of the Doctors tend to be off sick less often than the rest of the

populationpopulation When they are off sick, doctors tend to be off for longer periods When they are off sick, doctors tend to be off for longer periods

of time than the rest of the populationof time than the rest of the population There is no comprehensive occupational health service for There is no comprehensive occupational health service for

general practitionersgeneral practitioners Doctors do not receive formal training in the management of Doctors do not receive formal training in the management of

their colleagues as patientstheir colleagues as patients

IntroIntro

Reduced well-being may lead to health problems for GPs, difficulties in coping at work and a reduction in quality of care to patients.

Unhealthy doctors cannot be expected to deliver high-quality healthcare

Doctors are reluctant to seek health care through usual mechanisms, and find it difficult to adopt the role of the patient 2.

The pressure to appear physically well – “nobody wants to go and see a doctor who is sick” 2

IntroIntro GPs report that their medical knowledge made

them more prone to swing between panic and denial when they experienced symptoms 2

Many studies show that, when doctors experience ill health, they disregard the advice they give their patients 3

The medical community has developed a culture in which working through illness and self-treating is the norm

When doctors do seek external care, evidence suggests they receive a lesser quality of care than lay patients 3

Previous studies have found differences between GPs and specialists in their patterns of health-seeking behaviour 33

Doctors’ physical HealthDoctors’ physical Health

It is well known that doctors are often reluctant It is well known that doctors are often reluctant to seek medical adviceto seek medical advice

One study revealed that 26% of doctors with a One study revealed that 26% of doctors with a medical problem reported feeling inhibited medical problem reported feeling inhibited consulting another doctorconsulting another doctor

Doctors enjoy a low standard mortality rate, Doctors enjoy a low standard mortality rate, however, this is a crude measure of healthhowever, this is a crude measure of health

Mortality data shows that most doctors die from Mortality data shows that most doctors die from physical rather than mental illness, yet most physical rather than mental illness, yet most studies concentrate on their mental health.studies concentrate on their mental health.

44% of doctors have chronic health problems 44% of doctors have chronic health problems 44

Doctors’ physical HealthDoctors’ physical Health Doctors are more than likely to suffer from one or Doctors are more than likely to suffer from one or

more of ‘the three D’s’ – Drugs, Drink and Depression more of ‘the three D’s’ – Drugs, Drink and Depression (including suicide)(including suicide)

Half of a group of 408 GPs in the United Kingdom had Half of a group of 408 GPs in the United Kingdom had a serious illness or an operation as an adulta serious illness or an operation as an adult 55

Illnesses experienced by doctors include all the Illnesses experienced by doctors include all the expected categories for the population at largeexpected categories for the population at large

30% of doctors attending for psychiatric care were 30% of doctors attending for psychiatric care were found to have a concomitant chronic physical illnessfound to have a concomitant chronic physical illness 55

Doctors with physical illnesses have been reported to Doctors with physical illnesses have been reported to be at higher risk of suicidebe at higher risk of suicide 55

In a follow-up study of a sample of UK GPs, 8.6% In a follow-up study of a sample of UK GPs, 8.6% retired before 60 years of age because of illnessretired before 60 years of age because of illness 55

Doctors’ physical Health - Doctors’ physical Health - SummarySummary

Studies of doctors’ health have emphasised Studies of doctors’ health have emphasised psychological health, and limited data have psychological health, and limited data have been collected on their physical health statusbeen collected on their physical health status

Doctors often fail to follow current preventive Doctors often fail to follow current preventive health guidelines for their physical health.health guidelines for their physical health.

The majority of doctors are now registered The majority of doctors are now registered with a GP, but studies show that consultation with a GP, but studies show that consultation rates were lower than the general population. rates were lower than the general population. Reasons given for this include ‘lack of time’ Reasons given for this include ‘lack of time’ and ‘not being ill enough’.and ‘not being ill enough’.

Doctors are reluctant to take sick leave.Doctors are reluctant to take sick leave.

Doctors’ health behaviourDoctors’ health behaviour Only 55% of doctors have their own GP Only 55% of doctors have their own GP 55

26% of those in partnerships, general 26% of those in partnerships, general practitioners were registered with a partner in practitioners were registered with a partner in the same practice the same practice 55

Hospital specialists are significantly more likely Hospital specialists are significantly more likely to advise sick doctors to consult specialists to advise sick doctors to consult specialists directly rather than their GPs directly rather than their GPs 77

In a 10 year retrospective study on 247 GP’s, In a 10 year retrospective study on 247 GP’s, over half had seen a specialist about their over half had seen a specialist about their health - 51% had referred themselves. One health - 51% had referred themselves. One third of medical investigations had been self-third of medical investigations had been self-initiated initiated 88

Doctors’ health behaviourDoctors’ health behaviour Doctors are more likely than other professionals to work Doctors are more likely than other professionals to work

through illness (1% vs 5% through illness (1% vs 5% mean mean annual sick leaveannual sick leave of all NHS of all NHS workers (Seccombe and Patch, 1994)workers (Seccombe and Patch, 1994);;

Most doctors admit to working when they feel too unwell to be Most doctors admit to working when they feel too unwell to be able to carry out their duties to the best of their ability able to carry out their duties to the best of their ability

This may be symptomatic of a culture in which an image of This may be symptomatic of a culture in which an image of invincibility is encouraged and vulnerability is denied . Also invincibility is encouraged and vulnerability is denied . Also confidentiality issues as other doctors usually have access to confidentiality issues as other doctors usually have access to personal data, leaving the sick doctor in a vulnerable position.personal data, leaving the sick doctor in a vulnerable position.

The direct result of this phenomenon is likely to be delayed The direct result of this phenomenon is likely to be delayed presentations even for serious conditions.presentations even for serious conditions.

Doctors’ health behaviourDoctors’ health behaviour• From a study of 724 general practitioners

and 427 consultants in the South Thames region (1999) 66 : • 71% of general practitioners and 76%

consultants responded that they “usually” or “sometimes” self prescribed

• 10% of general practitioners and 15% of 10% of general practitioners and 15% of consultants also admitted usually or sometimes consultants also admitted usually or sometimes self prescribing opiates, anxiolytics, self prescribing opiates, anxiolytics, antidepressants, or hypnotics antidepressants, or hypnotics

• 83% of general practitioners and 70% of consultants prescribed for their family

Doctors’ health behaviourDoctors’ health behaviour• A recent (2002) study of 300 junior doctors 9:

• half self-referred to consultants or treated themselves for conditions that warranted a medical consultation;

• 30% agreed that they had suffered from a medical condition they would have discussed with a doctor, but had not done so because they were doctors themselves.

• 22% admitted to requesting a prescription from a work colleague;

• More than 50% of respondents said they felt uncomfortable about being asked for a prescription by a colleague

Doctors’ health behaviourDoctors’ health behaviour• A questionnaire survey on 358 Doctors’ on 358 Doctors’

health-seeking behaviour (2003) revealed health-seeking behaviour (2003) revealed 33 : :

• 90% and 25% thought self-treating acute and 90% and 25% thought self-treating acute and chronic conditions respectively, was acceptablechronic conditions respectively, was acceptable

• 51% thought that it was acceptable to order a 51% thought that it was acceptable to order a blood test on oneself for diagnostic purposes blood test on oneself for diagnostic purposes

• GPs are significantly less likely than specialists GPs are significantly less likely than specialists to seek appropriate treatment across several to seek appropriate treatment across several situationssituations

Doctors’ health behaviourDoctors’ health behaviour In a review of literature (2004),vaccination rates In a review of literature (2004),vaccination rates

against Hepatitis B amongst doctors ranged against Hepatitis B amongst doctors ranged from 49% - 87%.from 49% - 87%.

Other occupational risk groups (e.g. dentists and Other occupational risk groups (e.g. dentists and pathology lab supervisors), achieved close to pathology lab supervisors), achieved close to 100% hep B vaccination coverage in direct 100% hep B vaccination coverage in direct comparison comparison 55

One study showed that 93% of GPs had One study showed that 93% of GPs had checked their blood pressure and 64% had checked their blood pressure and 64% had checked their cholesterol level in the previous checked their cholesterol level in the previous 3 years, consistent with preventive health 3 years, consistent with preventive health guidelines. guidelines.

Doctors’ health behaviourDoctors’ health behaviour Although preventive guidelines do not Although preventive guidelines do not

recommend screening prostate specific recommend screening prostate specific antigen (PSA) testing, studies have found antigen (PSA) testing, studies have found that 26%–51% of male doctors over that 26%–51% of male doctors over 40 years have tested themselves 40 years have tested themselves

If our personal screening habits influence If our personal screening habits influence the screening we recommend to our the screening we recommend to our patients, does this have wider patients, does this have wider ramifications?ramifications?

Advantages of having an Advantages of having an independent GP independent GP

Better documentation Better documentation Better delivery of evidence-based preventive care Better delivery of evidence-based preventive care Opportunities for health promotion advice Opportunities for health promotion advice Facilitates access to the healthcare system (often Facilitates access to the healthcare system (often

difficult for doctors - we do not really know why difficult for doctors - we do not really know why doctors have these difficulties ….. embarrassment, doctors have these difficulties ….. embarrassment, delusions of invincibility, inconvenience delusions of invincibility, inconvenience compounded by being so busy)compounded by being so busy)

Finding a GP for routine health issues means that, Finding a GP for routine health issues means that, when a problem arises, especially if the need is when a problem arises, especially if the need is urgent (or embarrassing), a relationship with a urgent (or embarrassing), a relationship with a trusted GP has already been established trusted GP has already been established

Looking after doctors as your Looking after doctors as your patientspatients

Boundary issues, complex in any doctor-doctor relationship, Boundary issues, complex in any doctor-doctor relationship, become potentially even more complicated when the patient is become potentially even more complicated when the patient is also a fellow doctoralso a fellow doctor

There can also be excessive emotional commitment and There can also be excessive emotional commitment and involvement with colleagues who are patientsinvolvement with colleagues who are patients

Doctors may experience varying reactions ranging from over-Doctors may experience varying reactions ranging from over-identification or defensive under identificationidentification or defensive under identification

Issues of lowered self-esteem and a heightened sense of Issues of lowered self-esteem and a heightened sense of vulnerability are not uncommon when treating senior or peer vulnerability are not uncommon when treating senior or peer colleaguescolleagues

The treating doctor may assume too much in terms of what The treating doctor may assume too much in terms of what their colleagues know or understand about the treatmenttheir colleagues know or understand about the treatment

Intensity of handling life and death issues together may lead to Intensity of handling life and death issues together may lead to intimacy or mistreatmentintimacy or mistreatment

Looking after doctors as your Looking after doctors as your patientspatients

Dr. Walter Anderson (a VTS course organiser in Dr. Walter Anderson (a VTS course organiser in Yorkshire for many years) identified useful steps in Yorkshire for many years) identified useful steps in helping doctors look after their colleagues as patients helping doctors look after their colleagues as patients 11::

See your patient in optimal circumstances (own consulting See your patient in optimal circumstances (own consulting roomroom ) - ) - not the corridor, the bar, the surgeons' changing not the corridor, the bar, the surgeons' changing room, the golf course, or the fishing clubroom, the golf course, or the fishing club

Make sure that your doctor patient is registered with a Make sure that your doctor patient is registered with a general practitioner who he or she trustsgeneral practitioner who he or she trusts

When taking your doctor patient's history, include self When taking your doctor patient's history, include self medicationmedication . . Don't forget to ask about drugs and alcohol. Don't forget to ask about drugs and alcohol.

Looking after doctors as your Looking after doctors as your patients cont.patients cont.

Ask about self diagnosisAsk about self diagnosis – can easily – can easily jump to jump to conclusions and can be reluctant to confess their conclusions and can be reluctant to confess their fears unless coaxed. fears unless coaxed.

Veto any deviations from established procedures.Veto any deviations from established procedures. speak to a relative if your doctor patient agrees, to speak to a relative if your doctor patient agrees, to

expand the history and explainexpand the history and explain always write a full referral letteralways write a full referral letter (and telephone if you (and telephone if you

wish). wish). If you are telephoned by general practitioner If you are telephoned by general practitioner colleagues, ask them to put the referral in writing as colleagues, ask them to put the referral in writing as soon as possible. soon as possible.

Partner patients?Partner patients?

If a doctor consults as a patient with one of If a doctor consults as a patient with one of their partners, there is likely to be their partners, there is likely to be 11::

Mutual embarrassment and awkwardnessMutual embarrassment and awkwardness An increased risk of ‘corridor consultation’An increased risk of ‘corridor consultation’ Less adequate notes than usualLess adequate notes than usual Conflict of interest if the doctor-patient really needs Conflict of interest if the doctor-patient really needs

to be off work. In this scenario, both parties may to be off work. In this scenario, both parties may tend to collude to pretend that the doctor-patient is tend to collude to pretend that the doctor-patient is not really all that ill at all and is safe to be working not really all that ill at all and is safe to be working – – The Shadow ContractThe Shadow Contract

Doctors as ‘better’ patients Doctors as ‘better’ patients 11

Register with a general practitioner you can trustRegister with a general practitioner you can trust Never mention a symptom to a specialist without prior Never mention a symptom to a specialist without prior

discussion with your general practitionerdiscussion with your general practitioner - - you want a you want a second opinion, not a firstsecond opinion, not a first. ‘Rehearsal effect’.. ‘Rehearsal effect’.

Never take any medicines that a lawyer could not Never take any medicines that a lawyer could not purchase over the counter, or give them to anyone in purchase over the counter, or give them to anyone in your familyyour family – note GMC’s new regulation about – note GMC’s new regulation about controlled drug prescribing.controlled drug prescribing.

Consult by appointment in appropriate surroundingsConsult by appointment in appropriate surroundings - - better service and access to your notes with your historybetter service and access to your notes with your history

Meticulously follow the rituals and protocols that protect Meticulously follow the rituals and protocols that protect non-doctor patientsnon-doctor patients – do not exploit ‘loopholes’ in the – do not exploit ‘loopholes’ in the system.system.

Key tipsKey tips

Doctors (and their spouses) should be Doctors (and their spouses) should be registered with a GP where the registered with a GP where the only only relationship between them is that of doctor relationship between them is that of doctor and patientand patient

When doctors are ill or are worried about When doctors are ill or are worried about symptoms they should see their GPsymptoms they should see their GP

Doctors should not self prescribe or self-Doctors should not self prescribe or self-diagnosediagnose

Use occupational Health departmentUse occupational Health department

Occupational health Occupational health Competent to judge fitness to work, in doctors equally as Competent to judge fitness to work, in doctors equally as

in other members of NHS staff; they are able to advise in other members of NHS staff; they are able to advise management about fitness to work and recommend management about fitness to work and recommend ways in which an ill doctor may best be introduced back ways in which an ill doctor may best be introduced back to work after an illnessto work after an illness

Can refer sick doctors for appropriate treatment if the Can refer sick doctors for appropriate treatment if the doctor does not have a general practitioner, or liaise with doctor does not have a general practitioner, or liaise with the general practitioner when he or she doesthe general practitioner when he or she does

Can recommend relocation, retraining or retirement on Can recommend relocation, retraining or retirement on medical grounds as appropriatemedical grounds as appropriate

Occupational health should be seen as an integral part Occupational health should be seen as an integral part of health careof health care

Resources for sick doctorsResources for sick doctors National Counselling Service for Sick Doctors. (National Counselling Service for Sick Doctors. (www.ncssd.org.uk. Tel: . Tel:

0870 241 0535) 0870 241 0535) BMA 24 hour stress counselling service (0645 200169)BMA 24 hour stress counselling service (0645 200169) Overseas Doctors Association's health counselling panel (0161 236 5594)Overseas Doctors Association's health counselling panel (0161 236 5594) GMC's Fitness to Practise division (0171 580 7642)GMC's Fitness to Practise division (0171 580 7642) Association of Anaesthetists (0171 631 1650)Association of Anaesthetists (0171 631 1650) Sick Doctors' Trust national helpline for addicted physicians (01252 345 163)Sick Doctors' Trust national helpline for addicted physicians (01252 345 163) The British Doctors' and Dentists' Group (via the Medical Council on The British Doctors' and Dentists' Group (via the Medical Council on

Alcoholism on 0171 487 4445)Alcoholism on 0171 487 4445) DrinkLine/National Alcohol Helpline (London: 0171 332 0202. Rest of the UK: DrinkLine/National Alcohol Helpline (London: 0171 332 0202. Rest of the UK:

0345 32 02 02)0345 32 02 02) Department of Health UK Expert Advisory Panel on health care workers Department of Health UK Expert Advisory Panel on health care workers

infected with blood-borne viruses (0171 972 4378)infected with blood-borne viruses (0171 972 4378) Royal Medical Benevolent Fund (0181 540 9194/5)Royal Medical Benevolent Fund (0181 540 9194/5) Doctors' Support Network (0171 727 3738) Email: Doctors' Support Network (0171 727 3738) Email: Lizzie.miller@talk.21.com) ) Leeds Professional support group – a small group of GPs with interest and Leeds Professional support group – a small group of GPs with interest and

expertise in helping sick colleaguesexpertise in helping sick colleagues ‘‘Hazlewood’ - organised by the Yorkshire faculty of the Royal College of Hazlewood’ - organised by the Yorkshire faculty of the Royal College of

general Practitioners - 24 hours of ‘time out’ in facilitated peer groupsgeneral Practitioners - 24 hours of ‘time out’ in facilitated peer groups Speak to one of the Course Organisers, in confidenceSpeak to one of the Course Organisers, in confidence

The EndThe End

Thank you for your time.Thank you for your time.