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Sunday, December 16, 2001
Keeping fit

When doctors become patients

In spite of relatively easy access to medical aid, doctors are reluctant to seek help when they are unwell and find it difficult to assume the role of a patient. They delay seeking attention and work through illness. They also indulge in self-prescription, self-referral and often inappropriate treatment. It is well known that doctors are prone to certain ailments like viral hepatitis, tuberculosis, liver diseases, anxiety and depression, says B.K. Sharma

IN his famous novel Doctor’s Dilemma, George Bernard Shaw wrote that every doctor should write below his name plate that he is also a mortal. It does appear, however, that doctors often face a dilemma about their own health and the health of their families. In over 40 years of my professional career, I have had the painful experience of watching brilliant colleagues neglecting their health and not attending to themselves as they would attend to their patients. The subject is sensitive in nature. I have picked up the courage to write on this subject after seeing a recent report in British Medical Journal on the subject.

Medical professionals are exposed to intense physical stress and psychological distress both during their training and their careers. In spite of relatively easy access to medical aid, they are reluctant to seek help when they are unwell and find it difficult to assume the role of a patient. They delay seeking attention and work through illness. They also indulge in self-prescription, self-referral and often inappropriate treatment. It is well known that doctors are prone to higher levels of certain ailments like viral hepatitis, tuberculosis, liver diseases, anxiety and depression. The picture that emerges from earlier reports from Britain also paints the picture of both general practitioners and senior hospital doctors having higher level of stress, taking very little time off their work during illness and exhibiting rather unrealistic healthy images both about themselves and their colleagues. As a result, the British Medical Association in 1995 produced a set of recommendations about the ethical responsibilities of doctors towards themselves and their families (see box).

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Acute abdominal emergency: A ticking bomb
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Notwithstanding the impressive nature of these guidelines, a survey done by a team of doctors from the University of Kent in 1999, about adherence to these guidelines showed that both general practitioners as well as consultants were not following these guidelines or very few of them were doing so. This report reinforces the earlier observation that doctors prefer self-treatment, carry on working when they are unwell and consult their colleagues only informally. Self-prescribing and prescribing for family was also prevalent. This, unfortunately, also contributed to a relatively higher rate of suicide among the doctors.

The above quoted reports originated in Britain, but my impression is that in general doctors behave the same way all over the world. In India there are no specific studies available but enough experience leads one to believe that doctors in India too behave in a similar manner. What propels the medical professionals to follow this paradoxical course of action? Is it the underlying fear because they have medical knowledge? Is it the pressing need to appear healthy all the time? Is it to protect their patients? Is it not to let their colleagues know? Is it professional egoism? Or may be it is a combination of these factors. Coming back to the report in British Medical Journal, important observations have been made about the attitude of doctors.

— Although most doctors were concerned about the increasing illness in doctors, particularly increasing incidence of myocardial infarction at an early age, most of them were reluctant to talk about their own illness.

— Many of them said that self-employment particularly made it difficult for them to look after their own health.

— There is psychological pressure to appear physically healthy as "nobody wants to go to a doctor who is himself sick". This reflects the unwritten belief that their patients equate a doctor’s competence with has health.

— Many doctors agreed that they did not look after themselves and worked through their illness and expected their colleagues to do the same.

— Acknowledging psychological illness was particularly difficult. Although to their patients they would say "it is just another illness".

—Professional culture appeared to discourage discussion of personal illness with colleagues.

— Many agreed that self-care was not taught either during undergraduate or postgraduate training. This appears to be a very important lacuna in the training of a doctor.

— Medical knowledge made them prone to swing between panic and denial when they experienced symptoms of certain illnesses. A headache may appear to be just nothing or to be a brain tumour.

— A sense of obligation to the colleagues, the department or the institute made them feel guilty if they took leave for medical reasons for a long time.

— For strange reasons this attitude also reflected in the care of their families. They did not want to believe that their own kith and kin could also fall sick.

— Many agreed that they played down the evidence of their colleagues being unwell because they did not want to interfere or make a premature observation which may not turn out to be right. This has been referred to by somebody as "a conspiracy of friendliness".

Based on these evidence, the authors synthesised a contract among the doctors which runs like this:

"I undertake to protect my colleagues from the consequences of my being ill. I will protect them by working through my illness up to the point of my being unable to walk. I expect my partners to do the same in order to keep the contract. I will act on the assumption that all of my partners and myself are healthy enough to work all the time which may mean that from time to time it is appropriate to ignore evidence of distress and physical illness. I also expect my partners not to remind me of my any illness when I am working while sick".

This contract is obviously a delibrate overstatement but does hide a lot of truth. Hard work and dedication never harm anybody but all professionals, including doctors, need to remember that they are all vulnerable and they are all human. A report from Wall Street Journal about ambitious young executives working till midnight shows how they are playing havoc with their health and family life. Let’s strike a balance between the two extremes.

Ethical responsibilities of doctors towards themselves and their families (BMA 1995)

1. It is not advisable for doctors to assume responsibility for the diagnosis and management of their own health problems or those of their immediate family.

2. All doctors should be registered with a general practitioner. All hospitals with resident staff should ensure that staff have access to primary care services.

3. As with all other patients, the responsibility for overall care and continuity of treatment for doctors and their families should rest with their general practitioner. Referral for consultant advice or care should be made through their general practitioner.

4. It is preferable that a doctor’s general practitioner should not be a relative nor, if at all feasible, a partner of the doctor.

5. It is not advisable for doctors to prescribe themselves anything other than over-the-counter medicines.

6. Doctors need to be aware that they become the patient in the doctor-patient partnership when they are receiving medical care.

7. Doctors have an ethical duty, to themselves and to their patients to ensure that their own health problems are effectively managed; to seek competent professional advice particularly on their ability to work; and to follow this advice.

8. Doctors should not take advantage of the access they have to medical records to look at the records of their family and friends without previous consent.

9. Doctors have a responsibility to ensure that they are protected against infectious diseases such as tuberculosis and hepatitis B.

10. Doctors should not undermine the confidence that their relatives have in their own general practitioner by disparaging the advice and treatment that they are given.

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