Doctors are more at risk of mental ill-health than the general population.1 The risk of suicide is higher than the general population, especially among GPs, anaesthetists, and psychiatrists.2 Studies from North America suggest that 8–18% of doctors will be affected by drug or alcohol abuse during their lifetime.3 So the way that doctors do or don't access health care is important — for them, their families, their colleagues, and ultimately, for their patients. An article in this issue4 reviews the literature on health behaviours of doctors and the barriers they experience in accessing care.
The review is timely in that the 2007 white paper, Trust, Assurance and Safety – the Regulation of Health Professionals in the 21st Century5 proposed a strategy for improving the health of health professionals. This will include appropriate prevention and early intervention for health concerns, promoting easier uptake of services and assuring confidentiality. In 2006 the Chief Medical Officer6 recognised deficiencies in the provision of care to doctors impaired by mental health and addiction problems. In addition, the Department of Health published a report this year on mental ill health in doctors;7 this was a response to the inquiry8 into the suicide of a young psychiatrist with serious mental illness who received suboptimal care.
Dating back to 1994, a variety of reports in the UK, from the Nuffield Trust,9,10,11 the General Medical Council (GMC),12 and the British Medical Association (BMA)13 have identified the particular health needs of doctors and the barriers they experience in accessing care.
The review by Kay et al4 notes that there is little data on doctors' health access behaviours and the barriers they experience. It does, however, provide some useful pointers. Factors that affect access to health care by both doctors and their patients include self-care, concerns about confidentiality, lack of time, costs in accessing care, fear, and embarrassment about the triviality of the condition. Those with mental health problems experience these barriers more severely.
Additional barriers for doctors identified in the review are concerns about the quality of care they may receive and that their specific needs as a doctor–patient will not be recognised. While most UK doctors are registered with a GP, some choose one who is a relative or practice partner. ‘Corridor consultations’ occur and doctors may not get preventive care or the care for chronic conditions that would be available to their patients. Doctors feel the pressure from peers and their community to be healthy. They lack training in seeking care for themselves or in treating doctor–patients.
To tackle these problems, it is important to identify current resources, and identify what more might be required.
What's available now?
Many doctors will choose to use their GP. Doctors using health services, like all other patients, need to be assured that the doctor who is treating them fully understands the limits of their competence and will refer on if necessary. Many clinicians do find treating their own peers to be uniquely challenging, and may experience real problems in probing those health beliefs which may lead doctor–patients to over- or under- diagnose their own illness, or to fear the worst (and rare) diagnosis from common symptoms. Ultimately, doctors need high-quality care like any other patient. While doctor–patients are of course not unique in being challenging, nevertheless there is clearly a place within training and education to discuss these concerns. As in any consultation, the good practitioner will probe the patient's ideas, concerns, and expectations, and this may require appropriate assertiveness, an ability to negotiate and a willingness to take responsibility where this is needed. The potentially difficult issue of knowing when and how to confront a colleague who may be ill needs to be considered in the training of health professionals in many specialties.
When doctors are sick they may need to take time away from work, as they would advise their patients to do, but there can be real difficulties in taking time off, particularly for GPs. A doctor treating a work colleague may feel a conflict when the advice they provide has consequences for his or her own workload. Personal and/or practice financial consequences may be serious and doctors may need help to plan for income protection and sickness insurance.
More use could be made of specialist services for doctors already in place. These include the BMA helpline, Doctors for Doctors, support schemes set up by some colleges, and peer support groups such as the Sick Doctors' Trust, British Doctors and Dentists Group, and the Doctors' Support Network. In addition some deaneries fund services, for example MedNet (London), House Concern (Newcastle), Take Time (Leeds), Medic Support (Oxford), and the Individual Support Programme (Wales). Local medical committees may also offer help.
Occupational health services are available to some doctors but are often poorly used. Their role needs to be clarified and promoted, and rules of confidentiality understood. Occupational health doctors also need good consultation skills to handle doctors, which some say are their most challenging client group.
What more is needed?
GMC guidance on doctors' health14 makes it clear that the GMC expects all doctors to be registered with a GP who is not a family member, but this could be strengthened to exclude registration with a work colleague (except where there is no alternative). The GMC could, and maybe should, advise that doctors attend for a formal consultation when they are unwell, rather than seek informal contact, and counsel against any form of self-diagnosis or treatment beyond that reasonable for any non-medical person. Sickness absence should be properly certified by an appropriate clinician — to do otherwise risks depriving both patient and employer of an optimum level of care.
Doctors need to be clearer about when they have a duty to report a colleague with a health problem to the GMC and when this is not required. Referral to the GMC purely on health grounds is required for only a tiny fraction of doctors who are sick — those cases where a doctor's illness poses a serious risk to the safety of their patients and the individual is unwilling to take sick leave and cooperate with treatment and monitoring of their condition.
The National Clinical Assessment Service has identified health concerns in 20% of cases referred to it.15 When a doctor is not working to the standard expected, or when their behaviour is difficult with colleagues or patients, there may be an underlying health problem — mental health, alcohol dependence, cognitive impairment, or some other condition. We need to be more aware of this and encourage the individual to seek help.
Medical students and postgraduate trainees should be provided with information about the risks of health problems among doctors, how to identify and manage them, and how the risk can be reduced. They should be warned about factors that may predispose them to ill health, for example, career transitions, workload, and job mobility leading to lack of support from family and friends. Mobility may also lead to difficulty in follow-up of chronic illness, with resulting risks, particularly for enduring mental health conditions. All medical students and postgraduate trainees should be required to confirm GP registration in their application for places. The GMC might reinforce this by setting out the expectation of registration with a GP in its guidance for medical students.16
While this is a worldwide problem, in the UK the GMC, the BMA, and the medical royal colleges could do much to raise awareness of the issues. They could help by openly acknowledging that doctors, like everyone else, become ill, that they need to look after their own health and encourage their colleagues to do so.
The BMA is hosting the International Conference on Physician Health in London, 17–19 November 2008. This will be an ideal opportunity to raise awareness about doctors' health in the UK and to promote the lessons from abroad. In the US almost all states have a physician health programme. A prototype service based on the Ontario model will open in London in October 2008 for doctors unable to access suitable local care for physical or mental ill-health or addiction. It should provide a great opportunity to address at least some of the barriers to health care identified in the review by Kay and colleagues.4
- © British Journal of General Practice, 2008.