Physician heal thyself

aIt's a routine viral illnessa, Dr. Kumar said. I explicitly remember this conversation while I was posted with him for a month during my Internal Medicine training. Dr. Kumar was perceived as a very dynamic, charismatic, and energetic physician with a passion for patient care. That day I found him not being his self, with a runny nose, lethargy, and he was losing concentration quite easily. aHe must be having flu,a I thought as he continued to browse his list of patients for that day, sniffing his nose intermittently. His next patient was a 38-year-old software engineer who interestingly was having a similar illness. Dr. Kumar explained to me that he suspects respiratory viral illness in this young gentleman and prescribed him antipyretics after a set of blood work came normal. He also advised him to adrink lots of fluida and atake rest from work for 2 days.a I could not recollect when was the last time Dr. Kumar himself adrank lots of fluida and he certainly was not taking rest.

Soon I realized that there is a Dr. Kumar within each one of us (doctors). Doctors by virtue of being human have similar rates of acute as well as chronic illnesses and are expected to undertake similar preventative measures as age/gender-matched population. Still, data consistently show doctors defaulting on these aspects. A study¹ found that while 80% of studied doctors had one or more illnesses, only 35% of them sought a professional opinion. A majority of such aprofessional opinionsa are informal in nature, such as consulting with their friends, families, or colleagues over the phone, in the corridor and so forth. Underplaying their symptoms, added to lack of proper evaluation during acorridor consultationsa provide a false sense of security. Doctors are likely to advise their patients to take rest for the same ailment that they themselves might be suffering while reporting to work.

It is counter-intuitive to think why doctors, who presumably are well versed with disease processes and their repercussions, do not seek health care in a manner they expect their patients to do so. If this idea is explored further, many factors can be identified which act as a barrier for doctors to seek health care. Such barriers can be loosely grouped into aindividual/personala factors or ainstitutional/systema factors (Table 1). There seems to be a societal belief system that doctors do not get ill. Doctors themselves do not accept their own illness with the fear that it may be perceived as a sign of weakness (both to society and to their colleagues). It is often engrained to a doctor that he/she is immune to damaging effects of extended forms of physical or mental exhaustion in forms of extended work hours, graveyard shifts, or psychosocial stress. Doctors take pride in not taking any sick leaves for a number of years. There is a psychological and social stigma associated with doctors seeking medical care, particularly mental health. Loss of privacy and/or being treated by one's own colleagues is other commonly cited reasons. I know of friends who despite getting benefits in their own hospital would choose a different hospital for clinical evaluation citing privacy reasons. I know a friend of mine who got tested and was found anemic. Over the next few weeks, more than 20 people at her workplace inquired about her anemia. Doctors are less likely to seek urgent care as well because it puts them up for a cumbersome task of adjusting their clinical schedules.

Table 1.

Barriers to seeking healthcare among doctors

Individual or personal factors 1.Exposing self to peers, both emotionally and physically 2.Confidentiality 3.Feel a failure as should be able to cope up with 4.Feel embarrassed to bring a atriviala illness to a doctor 5.Worried about imposing on a busy doctor 6.Worried if self-treatment is wrong and ashamed of revealing 7.Mental health issues 8.Lack of time 9.Money/insurance 10.A shift of alocus of controla from oneself to other 11.Perceived responsibility for patients 12.Awareness of the deficits of the medical system System or institutional factors 1.Pressure from colleagues or community to be healthy 2.Burden on colleagues for additional work 3System promoting self-treatment 4.Partners/peers tend not to intervene in illnesses 5.Lack of normal cues to health seeking 6.Less flexible and long duty hours 7.No systematic backup in one's absence for sickness 8.Lack of medical training on both aspects: training doctors to act like a patient, as well as training doctors on how to treat other doctors

Adapted from the study by Kay et al.⁵

Mental illness among doctors is by far the most important and neglected one. A systematic review and meta-analysis published in the Journal of American Medical Association found that one in four medical students² or medical residents³ has experienced depression, an incidence that is about three times higher compared with general population. Almost 10% of them are reported of contemplating suicide. Things only get worse as they progress in their careers. Male physicians are 1.41 times likely to commit suicide compared with nonphysicians (male). The data are worse for female doctors in which the suicide rate is 2.27 times that of the general female population.⁴ When a doctor tells a patient's family that their loved one is no more, a system geared towards providing psychological support to patient's family is activated. An empathic doctor, who by virtue of being human, may have developed emotional bonding with the patient, is typically assumed to be free of any psychological repercussions of the mortality and is not offered any psychological support. There simply is no perceived need for it. His/her psychic state goes unchecked. Anxiety, mood disturbances, insomnia/nightmares, guilt, addiction, mental illness, and so forth prevail. These eventually get compounded and lead to mental illnesses and high suicide rates among doctors that often crosses cultural boundaries.

To have a healthy work pool of doctors, we need to understand and remove the barriers that prevent doctors from seeking medical attention. While individual barriers seem obvious, it is the systemic barriers to health-care access which were found to be more significant in recent studies.⁵ Individual barriers, seemingly specific to a particular person/situation, are difficult to change without changing system or culture. For example, a doctor may not seek health care because of the concern of burdening colleagues with extra work in his/her absence. Such scenario is unlikely to change unless the system has adequate redundancies to fill in for the absentee. Changes at institutional level coupled with behavioral modifications and education are likely to improve doctors' healthcare-seeking behavior. Society should be receptive to doctor's physical and mental illnesses and support in their health-seeking behavior. The message has to go loud and clear: aIt's ok for a doctor to seek medical help.a Doctors have the right to receive an unbiased medical care in the most nonjudgmental way. Doctor-patients expect to be treated like a general patient, yet the treating physician often fails to satisfy that expectation.⁵ This, to a certain extent, can be addressed by formal education. Effective training should involve excellence in self-care as well as in caring for doctor-patients. Topics such as physician burnout and medical cynicism need to be taught in a more formal manner.

Systemic barriers should be handled at the institutional level and are the crux of this discussion. Issues related to confidentiality can be managed by mandated protocols whenever a doctor-patient visits his/her own hospital. Formalized sick leaves with adequate redundancies and backup should be put in place. Such system should be free of major bureaucratic challenges and thus easy to be triggered in times of need. Barriers are often created when role models fail to normalize health-care access.⁵ Leadership should audit employees' health periodically. It calls for establishing a system that identifies doctor-patient problems early on and provides help in a timely fashion. Mandated employee health reviews every few months may be one way to achieve this. The system should recognize doctors' unhealthy behaviors and intervene early to promote health. This can be in the form of regulated work hours, structured work schedules, ensuring optimal breaks in between high-intensity tasks, identifying countertransference, providing psychological support and so forth. Engaging in high precision activities such as surgery after extended work hours should be discouraged to reduce medical errors which in turn may disturb doctor's psyche.

At a personal level, doctors should challenge the notion that they can take a higher degree of physical or mental assault without any ill effects. Doctors should be encouraged to seek medical and preventative care as they would advise their own patients to do. While self-diagnosis is inevitable, doctors should seek professional opinion to evaluate their problems in a more systematic way. It is time to ditch the doctrine of adoctors heal thyselfa. Doctors should not be embarrassed about a wrong self-diagnosis that they have made (preventing them to seek formal professional opinion). Data suggest that even after a professional consultation with another health-care provider, doctors continue to self-treat themselves. Doctor-patients should behave the same way they expect their patient to. Rather than being ashamed of their illness, doctor-patients should be upfront about the issue and actively discuss it with concerned providers. They should shed their own biases (typically related to their personal knowledge, belief system, and specialty) and conform to the professional advice given. While dedication toward their patients is well appreciated, no amount of clinical duties should be ranked higher than one's own health. Doctors should engage in healthy behaviors such as balanced diet, exercise, smoking cessation, limited alcohol intake, and so forth. While doctors should seek out for healthy food choices, institutes should make healthy food available in their cafeteria. Doctors should insist on having a predictable work schedule so that their body is prepared for things to come and should strive for 8 h of uninterrupted sleep daily. Long work hours should be followed by periods of rest. Engaging oneself in recreational activities is essential to maintain a healthy psyche.

Doctors as care providers to doctor-patients should be formally educated for their added responsibilities. They should respect their clients' personal and emotional integrity. Patient confidentiality is more important than ever in these situations. They should treat doctor-patients in the same way as what they would do to other patients. They should strive to explore additional barriers and resolve to the extent they can. They need to be good counselors as well.

aDoctors are bad patientsa is an artificial phenomenon. While the problem is real and multifactorial, the solutions at times lie within us. I urge doctors to take control of their own health. In fact, taking the command entails shifting the locus of control from oneself to another professional health-care provider. As a patient, they should seek health care in the most unbiased form, and as a doctor, they should take care of their colleagues in the most respectful and confidential manner.

Conflict of interest

No conflict of interest.

Appendix A. Supplementary data

The following is the supplementary data related to this article: