Doctors as patients: a systematic review of doctors' health access and the barriers they experience

Literature search

A systematic search of the literature used the electronic databases MEDLINE® (1966–2007) and CINAHL (1982–2007). Keywords were identified through an iterative search strategy, including further search terms as relevant articles were found. Articles were also identified by hand searching citation lists and grey literature. Searches were restricted to articles whose full texts were available in English.

The final search strategy for MEDLINE® was: ((Physicians/ OR Physicians, Family/ OR Physician Impairment/ OR Internal Medicine/ OR Family Practice/) AND (Self Care/ OR Self Medication/)) OR ((Physicians/ OR Physicians, Family/ OR Physician Impairment/ OR Internal Medicine/ OR Family Practice/) AND (Health Behavior/)).

A similar strategy was used for CINAHL.

Inclusion criteria and validity assessment

• All articles needed to record some information related to health-access behaviour of doctors (for example, whether they had registered or consulted a doctor and the quality of the service they received) and/or a description of barriers that the doctors had experienced while accessing health care.

• All articles collected qualitative or quantitative data from medical practitioners (not students or allied health professionals) directly, through a survey, focus group, interview, or mixed methods (that is, both qualitative and quantitative methods).

Assessment of quality

An assessment tool was used to ensure studies were assessed in terms of their internal validity (identification of bias and confounding factors),6 reporting quality, and reliability (external validity).7 Criteria for questionnaire-based studies included having a response rate?≥40%. Although this is relatively low, this response rate was selected for this systematic review because medical practitioners are known to be difficult to survey.8^–10

Assessments for criteria and quality were made by two authors. Disagreements on inclusion were resolved by consensus.

Data abstraction and synthesis

Quantitative results were tabulated. Dominant themes were determined from the qualitative comments, and these were categorised and tabulated. Statistical meta-analysis was inappropriate because of the heterogeneity of study populations, methods, and outcome measures.

Data quality

The three qualitative studies were rated as high-quality studies meeting at least six of the seven quality criteria.6 The quality of the surveys, however, was affected by several factors: in the majority of cases insufficient information was available to assess the questionnaire form (given to the physicians), instructions, administration, and previous piloting of the measures used.7 Low response rates, retrospective self-reporting (without objective verification of data), and incomplete data available on non-responders also affected quality. Although some studies collected demographic data of the non-responders, it was not possible to obtain information regarding their healthcare access.8

Do doctors have their own doctor?

Table 1 shows that between one-fifth and nearly all responders were registered with a GP. This disparity reflects the different national health systems associated with each study. Some systems require compulsory patient registration with a GP, for example the NHS of the UK. Therefore, studies from the UK would be expected to have a greater than 90% registration (Table 1). The study populations also varied with regard to the specialties, age, and sex of the medical practitioners surveyed, and these factors may account for the differing responses reported. Choosing a GP is a complex process, often fraught with difficulty for doctors.11^–14 Female doctors were more likely to describe difficulty with this,10 but were more likely to find an independent doctor.15 Many doctors do not choose a GP who is independent (that is someone who is not a close friend or relative, including spouse, and who is not a practice partner) (Table 1). Regardless of whether or not they have a GP, most doctors are satisfied with their health care.10

Do doctors go to the doctor?

Some studies described how often doctors consulted other doctors, either formally or informally. This review used Pullen's definitions of formal and informal consultations.9 That is ‘in a formal consultation, the doctor sees his or her colleague as a usual patient would. An informal consultation may occur in passing; for example, as a “corridor consultation”’.9 Between 24% and 87% of responders stated they had consulted a doctor within the last year (Table 1). The higher rates probably included informal consultations with colleagues, although this was not clearly stated in some studies. Informal or ‘corridor’ consultations appear to be more common than formal care.16^,17 Over one-third of doctors used corridor consultations.17^,18 Even when the consultation was formal, the doctor may not have consulted their usual doctor.

Two studies found that doctors with a GP were more likely to have received preventive health care;8^,19 however, having a GP does not always ensure better health access for all medical conditions. Hypothetical vignettes showed that having a GP predicted an appropriate treatment choice in relation to physical health, but not for mental health issues.10^,17 Doctors with a chronic illness were less likely to access formal health care,18 even though they may be more likely to have a GP,17^,19 although the data are conflicting.18

A sex difference in relation to consultation with a doctor was also evident. Female doctors consult other physicians more frequently than male doctors,9^,12^,20^,21 although this may reflect a tendency to access more informal care, especially if they had a medical spouse.12

Self-treatment

Between one-quarter and almost all doctors reported ‘self-treatment’ (Table 1). Most doctors felt that it was acceptable to self-treat, especially for minor illnesses.10^,22 The variation in these reported percentages of self-treatment may lie in the definition of what constitutes ‘self-treatment’. This was not clearly defined in the majority of the studies. Self-treatment was more common for GPs than specialists.9^,23 Rosvold and Bjertness reported that even if a doctor had consulted another doctor within the past 3 years (68%), 76% still self-treated.12

Barriers

Table 2 lists the barriers reported by doctors. To facilitate interpretation, these barriers are grouped into categories and subcategories as described in Table 2. The ‘Patient’ category reflects the barriers specifically related to the doctor–patient seeking health care. The ‘Provider’ category details the barriers predominantly under the control of the provider of the medical care. The ‘System’ category reflects barriers within the medical system itself. Although these system barriers may be expressed in the individual behaviours of a patient or provider, they are barriers that are difficult for any individual to alter without the system itself changing.

Patient category

Provider category

The provider determines how confidential health information will remain, and this was a key issue. Confidentiality can also be considered an umbrella term reflecting different fears regarding how personal details will be handled in the medical setting. Doctors may be very aware of the limitations to confidentiality within a system where obligatory legal requirements for reporting and the closeness of social networks can make confidentiality difficult to assure.8 Having a professional partner as a GP further complicates this issue.13 Anxiety about confidentiality is greater for those with mental health problems.10 The provider also determines the quality of care provided, and it is concerning to see how frequently the personal experience of poor medical care was reported.11^,20^,22 This is consistent with the many personal accounts of doctors seeking health care.29^,30 A negative experience may reduce the future health access for the doctor–patient.

System category

Summary of main findings

This systematic review describes the current knowledge of doctors' health-access behaviours and the barriers they experience accessing health care. Firstly, this review demonstrates that very little information is available, despite the importance of this issue for doctors' health. Secondly, collation of these data enables comparison between doctors' health access and that of the general community.

Strengths and limitations of the study

It should be noted that despite the different styles of studies (descriptive and qualitative), the different populations studied, and the different countries where the data were collected, there was a high level of concordance in the health-access experiences described by doctors. The diversity of the study populations (different countries, specialties, age groups, and sex) also improves the generalisability of the data.

A number of the articles reviewed are relatively old. Ten papers are over a decade old. Many of these articles are still regularly cited and continue to inform the current debate on doctors' health. The two most recent studies in this review report similar findings to the earlier studies.21^,33 Uallachain surveyed younger doctors, who may have been exposed to more education about self-care in their training, yet the results are similar.21

The quality of the data does limit the conclusions that can be made. Imprecise definitions within the studies affect the interpretation of the results. Selective reporting of comments from the questionnaires may have caused potential reporting bias (Appendix 2). Care should also be taken when accepting hypothetical data, because doctors report how they should access health care differently from how they actually access health care.34

Comparison with existing literature

Implications for future research

This review highlights a significant gap in current knowledge of an important aspect of doctors' health — the health-access behaviours of doctors. Further research targeting the understanding of doctors' health-access behaviours is encouraged. Presenting future research within a broader context will add an important perspective to the doctors' health literature.