Respond to this article

Doctors’ health

Healthy doctors make for healthy practice, says Joan M Brewster

Four recent studies in the BMJ from three countries look at the health of doctors (doi:10.1136/bmj.a2004; doi:10.1136/bmj.a2155; doi:10.1136/bmj.a2038; doi:10.1136/bmj.a2098). Their publication coincides with the International Conference on Doctors’ Health took place in November in London.¹ Frank and colleagues report on medical students’ use of alcohol and counselling of patients regarding alcohol in the United States.² Isaksson Rø and colleagues find a reduction in burnout in Norwegian doctors’ after a counselling intervention,³ and McLellan and colleagues present outcomes from doctors monitored for substance use disorders by 16 US state physician health programmes.⁴ Brewster and colleagues report outcomes for substance dependent doctors monitored by such a programme in Ontario, Canada.⁵ All of the papers, in one way or another, reflect a concern with the association between doctors’ health and their medical practice.

Impaired practice

The treatment of sick doctors has a history of association with a reduction in impaired practice.⁶ Indeed, the medical sociologist Gerry Stimson postulated that the “impaired physician movement” in the US arose as a method of professional control by defining problems such as alcohol misuse or drug misuse as diseases requiring medical treatment rather than discipline.⁷ As noted by McLellan and colleagues, current US physician health programmes have the dual purpose of treating ill doctors and protecting the public, with the assumption that doctors with substance misuse problems are a danger to their patients.⁴ The authors report a success rate of about 80%. This finding is strengthened by the inclusion of data from 16 programmes. All programmes use lengthy monitoring and contracts with contingencies that can lead to the doctor being reported to the regulatory authorities. The paper by Brewster and colleagues found a similar success rate in a substance dependence monitoring programme.⁵ Lack of variation among programmes makes it difficult to answer research questions about the factors leading to success and to compare different approaches. Also, focusing on these programmes excludes doctors who develop drug problems but seek treatment privately. We currently know little about treatment outcomes or practice outcomes in such doctors.

Isaksson Rø and colleagues assess one year outcomes after voluntary counselling for burnout in doctors.³ Here, practice adversely affects doctors’ health, rather than the reverse. The authors found that group counselling for a single day or week significantly reduced emotional exhaustion and the amount of time taken as sick leave. It also increased the use of psychotherapy after the intervention. The authors concentrated on doctors’ personal characteristics when looking for predictors of burnout and success after counselling. However, they found that it was the reduction in work hours after the intervention that was associated with a reduction in emotional exhaustion. We need to look at systemic factors that wear down doctors and their health as well as personal characteristics when making recommendations for action.⁸

Frank previously suggested a link between doctors’ personal health habits and their advice to patients.⁹ In the study reported here, the authors found that students who drank excessively were less likely to advise patients to drink sensibly than those who did not drink, but that doctors who received alcohol related education were more likely to give their patients such advice.² Participants in the study were medical students who had not yet built up real world experience in their chosen specialty, possibly making their reports of patient advice less predictive of future practice. More research is needed on the association between doctors’ health habits and their care of patients, but a healthy medical workforce is not sufficient to produce good doctors—motivation, knowledge, and skills are also needed. Frank and colleagues also found that a third of medical students drank “excessively.”² This rate is lower than in the US population of the same age group, but it raises concerns for the health habits of medical students.

The four studies fall along the continuum of doctors’ health and illness—primary prevention in medical school; secondary prevention in a voluntary intervention for burnout; and tertiary care for doctors with substance misuse or dependence. All along this continuum, research questions abound. How can we produce healthy doctors who will use voluntary programmes if they need help? When doctors become ill, are they always “impaired,” and how can they best be treated?

International approaches

Most previous studies were carried out in one country, which limits conclusions. Comparing countries that have different healthcare systems and working conditions for doctors would enhance our knowledge of their relation to doctors’ health. Globally, approaches to early intervention for sick doctors and treatment for them vary greatly.^{10 11} Comparisons would provide answers that cannot be obtained in the US alone, where programmes are relatively uniform in monitoring. The biennial International Conference on Doctors’ Health provides an ideal opportunity to forge international collaborations and advance doctors’ health research.¹

Competing interests: None declared.

This article was first published in the BMJ (2008;337:a2161, doi:10.1136/bmj.a2161).

See the research in the BMJ (doi:10.1136/bmj.a2004; doi:10.1136/bmj.a2155; doi:10.1136/bmj.a2038; and doi:10.1136/bmj.a2098).

Listen to the podcast at http://podcasts.bmj.com/bmj/2008/11/12/doctors-health/

Provenance and peer review: Commissioned; not externally peer reviewed.

Joan M Brewster assistant professor Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada
jmbrewster@sympatico.ca
Student BMJ 2008;16:425468-ISSN 0966-6494 | December

1. BMA. International Conference on Doctors’ Health. Doctors’ health matters—finding the balance, 17-19 Nov 2008, London. http://www.bma.org.uk/doctorshealthmatters?.
2. Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and alcohol counseling behaviours among US medical students: cohort study. BMJ 2008;337:a2155.
3. Isaksson Rø KE, Gude T, Tyssen R, Aasland OG. Effect on burnout of counselling intervention for doctors: one year cohort study. BMJ 2008;337:a2004.
4. McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008;337:a2038.
5. Brewster JM, Kaufmann IM, Hutchison S, MacWilliam C. Characteristics and outcomes of doctors in a substance dependence monitoring programme in Canada: prospective descriptive study. BMJ 2008;337:a2098.
6. American Medical Association. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA 1973;223:684-7.
7. Stimson GV. Recent developments in professional control: the impaired physician movement in the USA. Sociol Health Illness 1985;7:141-66.
8. Arnetz BB. Psychosocial challenges facing physicians of today. Soc Sci Med 2001;52:203-13.
9. Frank E. Physician health and patient care. JAMA 2004;291:637.
10. Oxley JR. Services for sick doctors in the UK. Med J Aust 2004;181:388.
11. Tyssen R. Health problems and the use of health services among physicians: a review article with particular emphasis on Norwegian studies. Indust Health 2007;45:599-610.

   

 Printable version     Download PDF    E-mail this to a friend    Respond to this article    Request Permissions