Doctoring doctorsBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7205.2 (Published 31 July 1999) Cite this as: BMJ 1999;319:S2-7205
Like anyone else, doctors can have problems with their health. General practioner Walter Anderson outlines some principles to avoid getting on the wrong end of a corridor consultation
Most people seem to think that doctors get better treatment than everyone else when they are ill, but in my experience doctors and their families often get worse treatment than other patients. I first met this problem when I was a medical student working in anaesthetics. When I arrived at the hospital one morning I found the anaesthetist very upset. A doctor's wife had been admitted 15 minutes before her hysterectomy. Everyone else was admitted the day before so that a proper history could be taken and any necessary preoperative investigations performed. During my career I have come across many other examples.
A newly appointed senior house officer was chatting to a surgeon in the corridor and casually showed him a lesion on her forearm. He advised her to have it removed and put her on the end of the afternoon list. A few days later she was informed brusquely over the telephone that it was a malignant melanoma and would need wide excision and grafting. She was absolutely devastated and, as she was not registered with any general practitioner in the district, ended up talking to a friend of mine for several hours.
A few years ago we discovered that an anaesthetist, a patient of ours, had been treating himself for 10 years for diabetes and hypertension. Both conditions were badly controlled. He said he did not like to admit to other doctors that he was ill.
A surgeon was well known by all his colleagues to have an alcohol problem, but no one did anything about it until he was convicted of drunken driving. He lost his driving licence and was referred to the General Medical Council. He was suspended for 12 months on condition that he accepted treatment.
Another example was the tragic case of a general practitioner who committed suicide. He was registered with one of his partners and never told anyone of his distress. Several years later, his partners have still not recovered from the shock and feelings of guilt.
These are just a few examples of the problems faced by doctors who are ill, but similar anecdotes abound. There have been official pronouncements about doctors' health (see below), but I do not find them of much help when dealing with individual doctors.
What can be done?
To improve this situation, we should first keep in mind those diseases that are commoner in doctors than in the general population. These include depression, suicide, alcoholism, and drug dependency. Next, we should remember that our jobs involve a high degree of stress and that diseases which may affect performance (such as schizophrenia and dementia) are just as common among doctors as in the general population.
It should be noted that this is us we are talking about - you and me. We usually seem to deny that any of these problems apply to us, presumably because of the macho image instilled during our training. We therefore tend to choose our doctor on the basis of convenience of obtaining anti- biotics for a sore throat or repeat prescriptions for oral contraceptives or getting our children immunised, whereas I believe we should choose our doctor in recognition of the diseases we are prone to.
Robin Steel was a general practitioner in Worcester who formulated a set of rules about doctoring doctors (personal communication). He pointed out that looking after doctors and their families is never easy but that there are a number of things that both the doctor physician and the doctor patient can do to make it easier.
See your patient in optimal circumstances. This is not the corridor, the bar, the surgeons' changing room, the golf course, or the fishing club. Ideally, it should be in your own consulting room, where you have all your own equipment, but at least it should be a place where you can take a blood sample, perform a rectal examination, measure blood pressure, test the urine, or do any other test that you would normally do as a routine.
Make sure that your doctor patient is registered with a general practitioner who he or she trusts. If not, your doctor patient should get registered with such a person as soon as possible.
When taking your doctor patient's history, include self medication. Few doctors have not taken an antibiotic for an infection or used powerful corticosteroid creams for a skin rash, and many will have taken strong analgesics. Don't forget to ask about drugs and alcohol.
Ask about self diagnosis. Many doctor patients will have consulted old textbooks and jumped to conclusions. They may be reluctant to confess their fears unless coaxed.
Veto any deviations from established procedures. Shouldn't your doctor patient have consulted his or her general practitioner first?
Steel recommends that you should try to speak to a relative if your doctor patient agrees, to expand the history and explain. A puzzling diagnosis may become clear when a spouse mentions that a close relative has recently died of a dissecting aneurysm or, for example, if depression or alcoholism has not been admitted.
When referring your doctor patient to another doctor, always write a full letter. Many doctors referred to hospital have no letter because it has been arranged informally by telephone. If you are telephoned by general practitioner colleagues, ask them to put the referral in writing as soon as possible.
Be a good doctor patient
Register with a general practitioner who you feel would help you if you developed any of the problems mentioned above. It is relatively easy to find someone who will deal with trivial illnesses, but try to find someone you feel you could talk to about depression, drug misuse, stress, or alcoholism. It is unlikely that this person will be your partner - he or she will have too many conflicting interests. This may cause some difficulty in remote country areas, but I have found that doctors are often prepared to look after a colleague even if they are out of the usual practice area. If you move to a new job in a different area, get registered with a new general practitioner as soon as possible.
Never mention a symptom to a specialist without prior discussion with your general practitioner. It seems obvious that rectal bleeding goes to a proctologist and haematuria to a urologist, but who will take a holistic view of your problems? If direct referral works for doctors, why not for all patients? If not for all patients, why only for doctors? Seeing your general practitioner has a rehearsal effect. Remember that when you see a specialist you want a second opinion, not a first, and that you want someone with whom you can discuss the specialist's recommendations.
Never take any medicines that a lawyer could not purchase over the counter, or give them to anyone in your family. Most general practitioners' families get the latest sample from the last pharmaceutical representative who called. Is this really the best treatment to give to your family?
Consult by appointment in appropriate surroundings. If possible, see the doctor in his or her own consulting room like everyone else. If you make an appointment you are likely to get a better service than if you try to catch a doctor just as he or she is dashing off to make a few calls before going to the theatre or is rushing off to a clinic. At an appointment, the doctor will have access to your notes with your history and, if a specialist, your doctor's referral letter.
Meticulously follow the rituals and protocols that protect non-doctor patients. The reasons for going into hospital early or staying in hospital for five days after certain procedures have been worked out for the average human; doctors get complications like everyone else, so it is foolish to short cut he system.
Sometimes doctors do not realise that they are ill. It is obvious that this may result in harm to patients. The GMC therefore requires every doctor to try to help an ill colleague and to “blow the whistle” if the person does not respond to expressed concerns and seek help. Many general practitioners now have a clause in their partnership agreement which states that if a partner's behaviour or performance causes concern the other partners can insist that he or she has a medical examination. I have been surprised at how many doctors do not know about the “three wise men” arrangements in hospital.
Doctors forget the power of the consultation process and often bypass or short cut the usual arrangements. If we followed the above advice we might see fewer serious health problems among doctors, with their sometimes devastating effects. Why not discuss these guidelines at your next departmental or practice meeting?
Useful phone numbers
National Counselling Service for Sick Doctors (0171 935 5982).
BMA 24 hour stress counselling service (0645 200169)
Overseas Doctors Association's health counselling panel (0161 236 5594)
GMC's Fitness to Practise division (0171 580 7642)
Association of Anaesthetists (0171 631 1650)
Sick Doctors' Trust national helpline for addicted physicians (01252 345 163)
The British Doctors' and Dentists' Group (via the Medical Council on Alcoholism on 0171 487 4445)
DrinkLine/National Alcohol Helpline (London: 0171 332 0202. Rest of the UK: 0345 32 02 02)
Department of Health UK Expert Advisory Panel on health care workers infected with blood-borne viruses (0171 972 4378)
Royal Medical Benevolent Fund (0181 540 9194/5)
Doctors' Support Network (0171 727 3738)
Some official publications
Taking care of doctors' health - Report of a working party. Nuffield Provincial Hospitals Trust, 1996.
Occupational health services for GPs - a National Model. London: Royal College of General Practitioners, General Medical Services Committee of the BMA, 1997.
Brandon S, Oxley J. Getting help for sick doctors [career focus] BMJ 1997;Classified section:17 May
Armstrong E. Rehabilitating troubled doctors [career focus] BMJ 1997;Classified section:7 Jun