Doctors as Patients

1. Doctors as Patients By MutazAldawoud July 2009

2. Health professionals’ health Aim to understand more about: • Health care for ourselves and our families • Looking after our colleagues

3. Objectives • Explain why doctors find it difficult to seek help when they are ill • Explain why doctors find it more difficult to care for professional colleagues than ‘ordinary’ patients • State the reasons why doctors are more prone to certain illness than other members of the population • Describe ways of looking after sick colleagues more effectively • Describe and evaluate more effective ways of recognising and managing ill health in professional colleagues and yourself.

4. Fact or Fiction?1(class vote) • Any doctor can write a private prescription, using headed notepaper • doctors can write private prescriptions for themselves for controlled drugs including diamorphine, pethidine etc. • Doctors can write private prescriptions for family members and NHS prescriptions if they are registered on their lists • No GP can be registered as their own patient • GPs are allowed to register their spouse / children as patients • Doctors are more prone to mental illness that the rest of the population • Doctors tend to be off sick less often than the rest of the population • When they are off sick, doctors tend to be off for longer periods of time than the rest of the population • There is no comprehensive occupational health service for general practitioners • Doctors do not receive formal training in the management of their colleagues as patients

5. All of these are FACTS1… • Any doctor can write a private prescription, using headed notepaper • doctors can write private prescriptions for themselves for controlled drugs including diamorphine, pethidine etc. • Doctors can write private prescriptions for family members and NHS prescriptions if they are registered on their lists • No GP can be registered as their own patient • GPs are allowed to register their spouse / children as patients • Doctors are more prone to mental illness that the rest of the population • Doctors tend to be off sick less often than the rest of the population • When they are off sick, doctors tend to be off for longer periods of time than the rest of the population • There is no comprehensive occupational health service for general practitioners • Doctors do not receive formal training in the management of their colleagues as patients

6. Intro • 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

7. Intro • 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 behaviour3

8. Doctors’ physical Health • It is well known that doctors are often reluctant to seek medical advice • One study revealed that 26% of doctors with a medical problem reported feeling inhibited consulting another doctor • Doctors enjoy a low standard mortality rate, however, this is a crude measure of health • Mortality data shows that most doctors die from physical rather than mental illness, yet most studies concentrate on their mental health. • 44% of doctors have chronic health problems 4

9. Doctors’ physical Health • Doctors are more than likely to suffer from one or more of ‘the three D’s’ – Drugs, Drink and Depression (including suicide) • Half of a group of 408 GPs in the United Kingdom had a serious illness or an operation as an adult5 • Illnesses experienced by doctors include all the expected categories for the population at large • 30% of doctors attending for psychiatric care were found to have a concomitant chronic physical illness5 • Doctors with physical illnesses have been reported to be at higher risk of suicide5 • In a follow-up study of a sample of UK GPs, 8.6% retired before 60 years of age because of illness5

10. Doctors’ physical Health - Summary • Studies of doctors’ health have emphasised psychological health, and limited data have been collected on their physical health status • Doctors often fail to follow current preventive health guidelines for their physical health. • The majority of doctors are now registered with a GP, but studies show that consultation rates were lower than the general population. Reasons given for this include ‘lack of time’ and ‘not being ill enough’. • Doctors are reluctant to take sick leave.

11. Doctors’ health behaviour • Only 55% of doctors have their own GP 5 • 26% of those in partnerships, general practitioners were registered with a partner in the same practice 5 • Hospital specialists are significantly more likely to advise sick doctors to consult specialists directly rather than their GPs 7 • In a 10 year retrospective study on 247 GP’s, over half had seen a specialist about their health - 51% had referred themselves. One third of medical investigations had been self-initiated 8

12. Doctors’ health behaviour • Doctors are more likely than other professionals to work through illness (1% vs 5% mean annual sick leave of all NHS workers (Seccombe and Patch, 1994); • Most doctors admit to working when they feel too unwell to be able to carry out their duties to the best of their ability • This may be symptomatic of a culture in which an image of invincibility is encouraged and vulnerability is denied . Also confidentiality issues as other doctors usually have access to personal data, leaving the sick doctor in a vulnerable position. • The direct result of this phenomenon is likely to be delayed presentations even for serious conditions.

13. Doctors’ health behaviour • From a study of 724 general practitioners and 427 consultantsin the South Thames region (1999) 6: • 71% of general practitioners and 76% consultants responded that they “usually” or “sometimes” self prescribed • 10% of general practitioners and 15% of consultants also admitted usually or sometimes self prescribing opiates, anxiolytics, antidepressants, or hypnotics • 83% of general practitioners and 70% of consultants prescribed for their family

14. Doctors’ 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

15. Doctors’ health behaviour • A questionnaire survey on 358 Doctors’ health-seeking behaviour (2003) revealed 3 : • 90% and 25% thought self-treating acute and chronic conditions respectively, was acceptable • 51% thought that it was acceptable to order a blood test on oneself for diagnostic purposes • GPs are significantly less likely than specialists to seek appropriate treatment across several situations

16. Doctors’ health behaviour • In a review of literature (2004),vaccination rates against Hepatitis B amongst doctors ranged from 49% - 87%. • Other occupational risk groups (e.g. dentists and pathology lab supervisors), achieved close to 100% hep B vaccination coverage in direct comparison 5 • One study showed that 93% of GPs had checked their blood pressure and 64% had checked their cholesterol level in the previous 3 years, consistent with preventive health guidelines.

17. Doctors’ health behaviour • Although preventive guidelines do not recommend screening prostate specific antigen (PSA) testing, studies have found that 26%–51% of male doctors over 40 years have tested themselves • If our personal screening habits influence the screening we recommend to our patients, does this have wider ramifications?

18. Advantages of having an independent GP • Better documentation • Better delivery of evidence-based preventive care • Opportunities for health promotion advice • Facilitates access to the healthcare system (often difficult for doctors - we do not really know why doctors have these difficulties ….. embarrassment, delusions of invincibility, inconvenience compounded by being so busy) • Finding a GP for routine health issues means that, when a problem arises, especially if the need is urgent (or embarrassing), a relationship with a trusted GP has already been established

19. Looking after doctors as your patients • Boundary issues, complex in any doctor-doctor relationship, become potentially even more complicated when the patient is also a fellow doctor • There can also be excessive emotional commitment and involvement with colleagues who are patients • Doctors may experience varying reactions ranging from over-identification or defensive under identification • Issues of lowered self-esteem and a heightened sense of vulnerability are not uncommon when treating senior or peer colleagues • The treating doctor may assume too much in terms of what their colleagues know or understand about the treatment • Intensity of handling life and death issues together may lead to intimacy or mistreatment

20. Looking after doctors as your patients • Dr. Walter Anderson (a VTS course organiser in Yorkshire for many years) identified useful steps in helping doctors look after their colleagues as patients 1: • See your patient in optimal circumstances (own consulting room ) - not the corridor, the bar, the surgeons' changing room, the golf course, or the fishing club • Make sure that your doctor patient is registered with a general practitioner who he or she trusts • When taking your doctor patient's history, include self medication . Don't forget to ask about drugs and alcohol.

21. Looking after doctors as your patients cont. • Ask about self diagnosis – can easily jump to conclusions and can be reluctant to confess their fears unless coaxed. • Veto any deviations from established procedures. • speak to a relative if your doctor patient agrees, to expand the history and explain • always write a full referral letter (and telephone if you wish). If you are telephoned by general practitioner colleagues, ask them to put the referral in writing as soon as possible.

22. Partner patients? • If a doctor consults as a patient with one of their partners, there is likely to be 1: • Mutual embarrassment and awkwardness • An increased risk of ‘corridor consultation’ • Less adequate notes than usual • Conflict of interest if the doctor-patient really needs to be off work. In this scenario, both parties may tend to collude to pretend that the doctor-patient is not really all that ill at all and is safe to be working – The Shadow Contract

23. Doctors as ‘better’ patients 1 • Register with a general practitioner you can trust • Never mention a symptom to a specialist without prior discussion with your general practitioner - you want a second opinion, not a first. ‘Rehearsal effect’. • Never take any medicines that a lawyer could not purchase over the counter, or give them to anyone in your family – note GMC’s new regulation about controlled drug prescribing. • Consult by appointment in appropriate surroundings - better service and access to your notes with your history • Meticulously follow the rituals and protocols that protect non-doctor patients – do not exploit ‘loopholes’ in the system.

24. Key tips • Doctors (and their spouses) should be registered with a GP where the only relationship between them is that of doctor and patient • When doctors are ill or are worried about symptoms they should see their GP • Doctors should not self prescribe or self-diagnose • Use occupational Health department

25. Occupational health • Competent to judge fitness to work, in doctors equally as in other members of NHS staff; they are able to advise management about fitness to work and recommend ways in which an ill doctor may best be introduced back to work after an illness • Can refer sick doctors for appropriate treatment if the doctor does not have a general practitioner, or liaise with the general practitioner when he or she does • Can recommend relocation, retraining or retirement on medical grounds as appropriate • Occupational health should be seen as an integral part of health care

26. Resources for sick doctors • National Counselling Service for Sick Doctors. (www.ncssd.org.uk. Tel: 0870 241 0535) • BMA 24 hour stress counselling service (0645 200169) • Overseas Doctors Association's health counselling panel (0161 236 5594) • GMC's Fitness to Practise division (0171 580 7642) • Association of Anaesthetists (0171 631 1650) • Sick Doctors' Trust national helpline for addicted physicians (01252 345 163) • The British Doctors' and Dentists' Group (via the Medical Council on Alcoholism on 0171 487 4445) • DrinkLine/National Alcohol Helpline (London: 0171 332 0202. Rest of the UK: 0345 32 02 02) • Department of Health UK Expert Advisory Panel on health care workers infected with blood-borne viruses (0171 972 4378) • Royal Medical Benevolent Fund (0181 540 9194/5) • Doctors' Support Network (0171 727 3738) Email: Lizzie.miller@talk.21.com) • Leeds Professional support group – a small group of GPs with interest and expertise in helping sick colleagues • ‘Hazlewood’ - organised by the Yorkshire faculty of the Royal College of general Practitioners - 24 hours of ‘time out’ in facilitated peer groups • Speak to one of the Course Organisers, in confidence

27. The End • Thank you for your time.