Illness in doctors and dentists and their fitness for work—are the cobbler's children getting their shoes at last?

Doctors and dentists with health problems face unique problems in obtaining help [1]. It has been reported widely that mental ill-health and substance abuse problems are particular issues for a large percentage of doctors and dentists who become ill and the stigma associated with such problems might explain, in part, their difficulty in obtaining assistance. However, the explanation is likely to be much more complex. A number of confidential support services have been made available to doctors for several years. Oxley [2] has reviewed the services available for sick doctors in the United Kingdom and has highlighted the provision of both local and national services. Local services include National Health Service (NHS) occupational health services and counselling services, but often exclude dedicated specialist treatment services for addiction [1]. National services include the National Counselling Service for Sick Doctors, a counselling and a ‘doctors for doctors’ service provided by the British Medical Association, the British Doctors and Dentists Group and the Sick Doctors' Trust, which provide assistance for addicted doctors and the Doctors' Support Network for doctors with mental health problems. There is also the Doctors' SupportLine, which is a first step telephone help line for personal or work-related problems. Some medical royal colleges have established support for their members in the form of confidential advice or mentors. Yet despite these and other support services, doctors and dentists continue to run into difficulties that may culminate in a referral to either the General Medical Council (GMC) or the National Clinical Assessment Service (NCAS).

From an occupational health perspective, it is, perhaps, not surprising that the provision of confidential services that are remote from the employing organizations has not been the complete answer. It is disappointing that doctors have been reluctant to access local occupational health services because they are seen as too close to management [2]. Whilst acknowledging that NHS occupational health services have been patchy, this attitude is likely to be a reflection of the issues facing doctors when they become a patient. Taub et al., writing in this issue [3], discuss the ethical difficulties for doctors who develop an impairment, which might affect their ability to practise. Doctors might find it difficult to accept diagnoses made by colleagues and might have concerns about the confidentiality of their treatment. Nonetheless they have a duty to recognize the implications of their ill-health and take appropriate action. Similar guidance has been given by the GMC for UK registered doctors. Taub et al. also argue that the medical profession has a duty to promote health and wellness among physicians, to establish appropriate mechanisms to detect impairment, to intervene in a supportive fashion and to refer and/or report impairment if necessary. Whilst such behaviour would address the need for preventive action as well as better case management, this should not obviate the need for doctors' employers to provide better occupational health for them.

There are many reasons why a doctor's performance at work might be affected [4]. They can be grouped into individual factors, factors associated with the work environment and factors relating to education, training and continuing professional development. Work-related factors include teamwork, organizational climate and culture and leadership as well as workload, sleep deprivation and shift work. Medicine is a 24-h discipline and it is well-known that doctors work long hours. However, the workload of doctors does not just relate to hours worked, but a combination of the demands of the tasks performed, the resources available for support and the effort that must be expended in performing tasks. Doctors may be affected by on-call commitments or the new shift patterns that have been introduced. The long-term effects of sleep deprivation may be lower mood and psychological well-being, as well as poorer attitudes to work performance and safety. The lack of proactive occupational health and safety arrangements for doctors has been contrasted with those of pilots [5]. Both professional groups are involved in the performance of safety critical tasks where the lives of the general public are at risk. For pilots, team working is highly developed, there are planned programmes of professional development and there is continual evaluation of performance. The number of flying hours is restricted and overnight accommodation is of high quality. There are regular health assessments to ensure fitness to fly. For doctors, teamwork is not well developed, training is often fitted in around the demands of the job and formal objective evaluation of performance at work is only just being developed. Health checks for doctors usually occur only at the start of a new job. It is to be hoped that the publication of a new book [6] reviewing the evidence on the various factors affecting doctor's performance will stimulate a review of the current arrangements.

The lack of effective arrangements for dealing with problems related to doctors' ill-health were highlighted by Donaldson [7] over a decade ago. Quoting a hypothetical example of a consultant pathologist with a bipolar illness, the issues raised demonstrated not only the complexity of the problem but also the lack of organizational structures and systems to deal with it. The so-called ‘three wise men procedure’, whereby a panel of medical consultants sat in secret to intervene when patients were at risk of harm due to a doctor's illness, was another example of the separate arrangements that existed for doctors without any occupational health input. Subsequently, new arrangements were introduced with the creation of the National Clinical Assessment Authority, recently renamed as the NCAS. The NCAS is part of the National Patient Safety Agency and it takes referrals from NHS Trusts when there are long-standing problems with the performance of hospital doctors, general practitioners or dentists. There are three parts of the assessment: an occupational health assessment, an occupational psychology assessment and a clinical assessment of practice. This approach acknowledges the contribution of health, behaviour and work context on a doctor or dentist's performance. The NCAS assessment is formative culminating in a report to the referring body identifying both strengths and weaknesses and providing advice on remediation. A new ‘BACK ON TRACK’ project has been launched by the NCAS based on the lessons learned since its inception. The project espouses a set of principles and a framework for return to work programmes for doctors and dentists. Only a minority of doctors and dentists who are referred to the NCAS have health problems. However, physical and mental ill-health problems have been identified in the referees, including impaired cognitive function. The aim of the NCAS has been to help doctors and dentists resume their jobs unless there were irremediable factors that would prevent this. BACK ON TRACK addresses the complex issues surrounding a return to work, where there may have been long-standing organizational problems or a breakdown in professional relationships. The work of the first stage of this project is now out for consultation [8].

Oxley [2] quotes a statement by a group of European experts (PAIMM—Integral Care Programme for Sick Physicians) describing doctors as ‘one of the most unattended populations in terms of health’. It is ironic that this should apply to a group who have a leadership role in health care provision. It is unacceptable that this professional group does not enjoy good occupational health care but there is an opportunity for occupational physicians to work with the medical profession and their employers to redress the situation.

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