Letters

Increase in staff numbers may reduce doctors' "presenteeism"

EDITORForsythe et al show, on the basis of self reports, that doctors regularly ignore BMA ethical guidelines that advise against self-prescribing or prescribing for colleagues or relatives.¹ Concerns about confidentiality were commonly reported. Proposals to address these problems include more "doctors' doctors" and an improved occupational health service for general practitioners.

The opportunities and anxieties that doctors face in their everyday lives may be important factors. For example, research in Edinburgh in which I participated found that many junior hospital doctors were doubtful that an occupational health service had an effective role for mental health problems.² Anecdotal experience also suggests that highly confidential information about colleagues' health problems can quickly enter the hospital grapevine. Doctors gossip: few in the medical profession will not have heard other clinicians completely disregard their duty of confidentiality to a doctor-patient. Either they believe that colleagues have an insatiable curiosity or else they seek to shareand thereby reducetheir personal burden of responsibility. The causes are likely to be multiple (being a doctors' doctor can be anxiety provoking), but every disclosure is a straightforward and serious breach of discipline.

Applying the vignettes we had developed in Edinburgh, Forsythe et al also reported on senior doctors' reluctance to stop working and consult others if they were to become ill. Applying the vignettes (all drawn from our personal experience of doctors' health behaviour) to junior doctors in training, we had found a similar stoicism.² In fact, we had decided to tone down the vignette on 12 hours' haematuria as it seemed too far fetched: the original was "developing anuria" (after which I had gone to work as usual!). Again the causes of doctors' stoicism are likely to be complex, some admirable and others commonplace (the anxiety about becoming ill, etc), but a recurring factor in many reports is the frequent difficulty that doctors describe in arranging locum cover when they become ill and the extra burden that then falls on already hard-pressed colleagues. ^{3 4}

Too narrow an examination of doctors' health behaviour risks overlooking these important organisational issues. Only a substantial increase in medical staffing may noticeably reduce doctors' "presenteeism." Otherwise, in the face of declining vigour or new health concerns, giving up clinical practice or taking early retirement may become senior doctors' main method of managing their workload.

R M Wrate, consultant psychiatrist. 
Working Minds Research Unit, Astley Ainslie Hospital, Edinburgh EH9 2HL

1.	Forsythe M, Calnan M, Wall B. Doctors as patients: postal survey examining consultants' and general practitioners' adherence to guidelines. BMJ 1999; 319: 605-608[Abstract/Free Full Text]. (4 September.)
2.	Baldwin PJ, Dodd M, Wrate RM. Young doctors' healthII. Health and health behaviour. Soc Sci Med 1997; 45: 41-44.
3.	Forsythe M, Calnan M, Wall B. Study into compliance by the medical profession with the BMA guidelines on being a doctor-patient. Canterbury: Centre for Health Service Studies, University of Kent, 1999.
4.	McKevitt C, Morgan M, Holland WW. Protecting and promoting doctors' health. London: Nuffield Provincial Hospitals Trust, 1997.