How do doctors care for their own health?

Marie-Eve Muller

 

Introduction

Research, mainly in English speaking countries (US, Canada, the UK, Ireland and Australia), has shown that physicians behave towards healthcare-seeking differently from the non-medical community. Medical culture pushes physicians towards thinking that they should not be ill and that they are fully capable of self-treating. Physicians do rarely consult a primary care doctor and ask for an informal consultation (between doors) rather than a formal visit [1, 2]. As many as 99% of physicians may choose to self-medicate for benign diseases and even sometimes chronic conditions (hypertension, diabetes, asthma, psychiatric diseases). Indeed, self-medication is considered normal in the current medical culture [3], despite medical association guidelines promoting the opposite [4–6]. Furthermore, self-medication is a risk factor for substance abuse, especially in anaesthesiology, emergency medicine and psychiatry [3].

Several countries (mainly the US, Canada, the UK, Ireland and Australia) have developed specific healthcare networks for physicians in order to prevent self-treatment by doctors. In Switzerland, the Swiss Medical Association supports a programme offering help for psychological issues in doctors, but there is no organisation caring for their physical health. One study was conducted in 2007 on health of Swiss doctors but focused on primary care physicians only [7]. Information about hospital doctors was lacking.

Hence, a study aiming at bringing information about healthcare access in university hospital physicians was conducted in 2017 at the Centre Hospitalier Universitaire Vaudois – CHUV – in Lausanne. Six hundred and thirty seven physicians, of both sexes and from all specialties, answered an online questionnaire that aimed to evaluate their use of a general practitioner (GP), self-medication and barriers to medical visits as a patient. Their mean age was 38 years, which is consistent with the fact that 56% of doctors at the CHUV are still training for their specialty [8]. Respondents showed interest in the study and confirmed that the topic of doctors’ health was something which needed to be worked on.

To have or not to have a general practitioner

The rate of physicians having a GP varies greatly (from 19–100%) [1, 9] depending on the healthcare system. Half of the physicians at the CHUV reported having a GP, which was much higher than the 21% found among Swiss primary care practitioners [7]. However, it was still lower than the 88% found in the Swiss Health Survey (SHS) conducted in 2012 among the general Swiss population [10].

The first reason for not having a GP declared by physicians at the CHUV was feeling perfectly healthy. The great majority of doctors (87.9%) assessed their health as “very good” or “good”, which is quite similar to the SHS results [10]. Being one’s own doctor was the second reason. Lack of time or difficulties in finding an available GP were less frequent reasons. Thus, not having a GP does not seem to be the result of an organisational barrier. Physicians mostly chose not to have a GP because they did not feel the need to have one, which is an issue already described in literature, not only for doctors but also for the general population [1, 11, 12]. Being one’s own doctor was still considered a danger by some participants, as it prevents a standard healthcare process and could lead to diagnostic omissions or bad follow-up of chronic conditions.

Literature show that physicians tend to choose a GP who is related to themselves, and many national medical associations [4–6] have recommended against it, as caring for close relations is believed to be unsafe. This seemed not to be an issue for doctors at the CHUV, as only a few declared a GP who was also a family member. By the way, neither the Swiss Medical Association nor the Swiss Academy of Medical Sciences give any recommendation about a doctor’s own health care.

Furthermore, having or not having a GP does not seem to influence the number of medical visits to a specialist or for informal counselling. Compared with the SHS, being a university doctor did not drastically modify the number of medical visits, which was about two per year. A few studies have shown that doctors are used to taking informal counselling rather than visiting a doctor [13]. Thus, working in a university hospital with easy access to specialists could favour possibilities for informal counselling. However, in this population, the rate of informal opinions was not higher than formal visit rate.

Self-prescription

Self-medication was high among doctors at the CHUV (fig. 1). Nonopiate pain killers were the most frequently self-administered drugs, which was expected as this is also very common in the general population. Based on the SHS, 23% of people between 25 and 64 years old had taken nonopiate pain killers in the previous seven days [10]. More surprisingly, a third of doctors took proton pump inhibitors, 21% antibiotics, 14% antifungals and 10% psychotropics. This is a rather notable drug consumption for self-declared healthy people, which may show either some kind of banalisation of their illnesses or at least another threshold for determination of illness. There was no information about drug consumption by drug class in the SHS and literature about physician’s drug consumption is too heterogeneous for direct comparison. However, banalisation of illness has been demonstrated among physicians and puts them at risk of insufficient health care [14].

Research showed that doctors consider self-medication as acceptable for minor illness or emergencies [3]. The drugs classes that were taken more often after self-prescription than on another doctor’s prescription seem to be mostly those treating acute conditions (pain killers, anti-infectives, proton pump inhibitors, topical immunosuppressants), whereas drug classes taken more often after another doctor’s prescription are more for chronic conditions (hormonal therapies, anticoagulants and antiplatelet agents, blood pressure and cholesterol lowering drugs, cardiotropics, neurotropics and antidiabetics). Emergencies were also mentioned by a third of the doctors at the CHUV to explain self-medication. Sufficient knowledge is still the principal reason for self-medication, followed by lack of time for a medical visit. Financial reasons only play a minor role in this matter.

These results can be linked to the question of self-prescription regulation. Self-prescribing is allowed in almost all countries, but some English-speaking countries have decided to limit or strongly regulate this right of physicians [15–18] owing to the hazards linked with this practice. In Switzerland, dispensing of opioids and psychotropics are monitored, but there is no regulation of self-prescription by doctors, neither in the state law nor in the medical code of ethics. It has not been shown that stronger regulation of self-prescription changes the rate of this practice [19]. The general population self-medicate with over-the-counter drugs on the basis of their knowledge. Doctors do the same at a higher level. Hence, prevention through empowering doctors to recognise limits of their knowledge should be more successful than stronger regulation.

 

Rate of drug administration in the past year. Violet bars: self-prescription. Orange bars: prescription by another doctor. ACT = anticoagulant therapy, APT = antiplatelet therapy

 

Barriers to medical visits

Only a quarter of physicians saw no reason that could prevent them from visiting a doctor if needed. For the others, the first declared reason for avoiding a medical visit was lack of time. Financial issues were the second. Based on literature, both reasons are major barriers found similarly in the general population [1]. The Swiss Health Observatory indicated that in 2016, 19% of the population of the French-speaking part of Switzerland was prevented from visiting a doctor in the past year for financial reasons [20]. It is worrying that even 25.5% doctors would give up a medical visit because of costs. Furthermore, some participants also admitted having poor follow-up of chronic conditions for this reason. Someone suggested a discount on insurance policies, given that doctors have lower use of the healthcare system. However, the study showed no real difference in terms of medical visits between doctor-patients and the general population, and it is not possible to draw conclusions about consumption of drugs. Hence, this suggested discount could not be supported by the results.

Lack of time is a common reason to avoid medical visits, mostly by independent physicians who have no possibility of a substitute [1]. In a hospital, it would be expected that doctors could more easily be replaced by a colleague, given that they have the right to see a doctor for health purposes during their work time. Other reasons evoked were worry about consuming the time of a colleague, of a common diagnosis or of being judged on one’s knowledge, which are also reasons commonly evoked by patients [1]. Finding a reliable colleague in terms of knowledge and confidentiality was also presented as difficult, as some respondents had the feeling that most doctors are not skilled enough, lacked knowledge of “off label” indications for drugs, or had never tried themselves the drugs they prescribed, which was perceived as prejudicial to the patient. On the other hand, one respondent reported having received successful care from a vet, which confirms that the skill or hierarchy level required can be very different from one doctor-patient to another.

Confidentiality was also evoked, as one could meet patients or colleagues in the waiting room, which was considered to be uncomfortable.

Finally, avoiding medical visits because a doctor should not be ill was mentioned by 21 participants. Nevertheless, it remains a minor barrier to medical consultation in comparison with the before mentioned items.

Hence, major barriers to address in order to improve healthcare access for doctors are the same as those for the general population, that is to say time constraints and costs of healthcare, which prevail over cultural aspects linked to their status.

Conclusion

The behaviour of doctors regarding their own health is a growing issue. Half of the physicians working at the CHUV had a GP; the other half thought themselves capable of self-treating, which correlated with their good health self-assessment. Nonetheless, the rate of self-medication was high and tended to be linked with acute disease or emergency cases and did not depend on having or not having a GP. Lack of time and high costs of health care are the two major reasons for self-medication. Hence, self-treatment is due to the opportunity to do so and accessibility of drugs on self-prescription, rather than to barriers linked to medical culture. These findings suggest that a healthcare system dedicated specifically to doctors would not change the rate of self-treatment. Thus, prevention of inadequate self-treating should rather be focused on helping doctors to recognise their limits.

Disclosure statement

No financial support and no other potential conflict of interest relevant to this article was reported.

 

Dr Marie-Eve Müller, MD: Längmatt 3, CH-3280 Murten

Memueller[at]citycable.ch

 

References

1. Kay M, Mitchell G, Clavarino A, Doust J. Doctors as patients: a systematic review of doctors’ health access and the barriers they experience. Br J Gen Pract. 2008;58(552):501–8. doi:https://doi.org/10.3399/bjgp08X319486. PubMed
2. Rogers T. Barriers to the doctor as patient role. A cultural construct. Aust Fam Physician. 1998;27(11):1009–13. PubMed
3. Montgomery AJ, Bradley C, Rochfort A, Panagopoulou E. A review of self-medication in physicians and medical students. Occup Med (Lond). 2011;61(7):490–7. doi:https://doi.org/10.1093/occmed/kqr098. PubMed
4. BMA. Ethical responsibilities in treating doctors who are patients. London: British Medical Association; 2010.
5. MBA. Good medical practice: A code of conduct for doctors in Australia. Medical Board of Australia; 2014.
6. CPSO. Physician Treatment of Self, Family Members, or Others Close to Them. Toronto: College of Physician and Surgeons of Ontario; 2016
7. Schneider M, Bouvier Gallacchi M, Goehring C, Künzi B, Bovier PA. Personal use of medical care and drugs among Swiss primary care physicians. Swiss Med Wkly. 2007;137(7-8):121–6. PubMed
8. DirectionGénérale. Rapport d'activité 2017. Lausanne: Centre Hospitalier Universitaire Vaudois; 2018.
9. Schulz S, Einsle F, Schneider N, Wensing M, Gensichen J. Illness behaviour of general practitioners-a cross-sectional survey. Occup Med (Lond). 2017;67(1):33–7. doi:https://doi.org/10.1093/occmed/kqw135. PubMed
10. OFS. Enquête suisse sur la santé 2012. Neuchâtel: Swiss Federal Statistical Office; 2014.
11. Davidson SK, Schattner PL. Doctors’ health-seeking behaviour: a questionnaire survey. Med J Aust. 2003;179(6):302–5. doi:https://doi.org/10.5694/j.1326-5377.2003.tb05552.x. PubMed
12. Chen JY, Tse EY, Lam TP, Li DK, Chao DV, Kwan CW. Doctors’ personal health care choices: a cross-sectional survey in a mixed public/private setting. BMC Public Health. 2008;8(1):183. doi:https://doi.org/10.1186/1471-2458-8-183. PubMed
13. Campbell S, Delva D. Physician do not heal thyself. Survey of personal health practices among medical residents. Can Fam Physician. 2003;49:1121–7. PubMed
14. Lam ST. Special considerations in the care of the physician-patient: a lesson for medical education. Acad Psychiatry. 2014;38(5):632–7. doi:https://doi.org/10.1007/s40596-014-0138-3. PubMed
15. defenceupdate.mdanational.com.au/articles/drug%20prescribing. (Accessed 26 October 2018).
16. Moberly T. Physician, don’t heal thyself: the perils of self prescribing. BMJ. 2014;349(dec08 1):g7401. doi:https://doi.org/10.1136/bmj.g7401. PubMed
17. www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/need-and-objectivity. (Accessed 26 October 2018).
18. www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/self-treatment_and_treatment_of_family_members. (Accessed 26 October 2018).
19. Kay M, Del Mar CB, Mitchell G. Does legislation reduce harm to doctors who prescribe for themselves? Aust Fam Physician. 2005;34(1-2):94–6. PubMed
20. Merçai C. Expérience de la population âgée de 18 ans et plus avec le système de santé – Situation en Suisse et comparaison internationale. Obsan dossier 56. Neuchatel: Swiss health Observatory; 2016.