We all know them—the chief surgery resident receiving fluid boluses in an empty hospital room after vomiting throughout his call shift; the physician maintaining a busy clinic schedule despite a fever of 103°F; the faculty geriatrician working at his usual pace while his own elderly parent dies of cancer states away; the widowed physician returning to see patients to “keep her mind off things” following the death of her husband only 2 weeks before; the cardiac surgeon ignoring his own symptoms, which he would be quick to recognize in one of his patients. Despite our ability to care so diligently for others, to expect that the health and well-being of our patients come before anything else, we as health care professionals are notorious for being horrible patients.
Many factors are thought to play a role in this pattern. Stress, for one, has taken a large portion of the blame. Most surgical or medical residents use their time away from the hospital to maintain their marriages, spend time with their families, and repent for all the hours they have been away. Taking time for self-care seems almost laughable. The drive to and from the hospital may be the only time they get to themselves. The hectic pace of the physician life style, the emotional and physical stress of residency, and the fear of being viewed as weak all have been implicated in the inability of physicians to become patients. In 1987, Dr. Peter Marzuk wrote in the New England Journal of Medicine, “Doctors, it seems, are to treat sick people; they are simply not allowed to get sick themselves” (1). Twenty years later, despite significant progress and change, the phenomenon of physicians ignoring their own self-care remains.
The physician as a patient seems to undergo a two-step process—denial followed by acceptance, often when it is too late. The denial is initially strong and impressive. As physicians we often believe we are separated from our patients by more than a medical degree. We seem to think that the long hours of studying the science, its pathophysiology, and the diseases that result save us from being at risk of developing what we watch our patients struggle through every day, and that understanding the disease prevents us from becoming vulnerable to it because we could not possibly cross over to the other side, the side of our patients. Fewer things are more frightening to most physicians than the other side of the stethoscope. Annual examinations and routine screening tests, such as mammography and colonoscopies, often are ignored completely. Subtle symptoms are brushed away with intellect (if we can explain them, they do not exist). Often not until symptoms are too prominent to be ignored, until they interfere with our ability to take care of our patients, or until a concerned and respected colleague comments on them are we forced to seek health care ourselves.
Privacy remains a concern for many in health care. Most faculty physicians, residents, nurses, and medical students only have the option of health care within their own systems. This often offers the highest level of care, because most residency programs and medical schools are affiliated with tertiary care centers; however, the issue of privacy within the institution where they almost live is a sensitive one. The study by Dunn et al. (2) demonstrates through resident survey that, from a quality and accessibility standpoint, receiving care within one’s own institution is adequate. When health concerns arise of a more confidential nature, options outside one’s facilities are more appealing. Although intuitive, this poses a problem: the issues of higher significance, greater urgency, and greater impact on overall health and well-being are the ones that physicians are hesitant to address in their own institutions. It is easy to imagine how substance abuse, mental illness, or confidential health care concerns (such as HIV, new diagnosis of cancer, and obstetrics or gynecology) could be neglected in the schedule of a busy resident or staff physician. Simply finding the time to leave one’s hospital to see an outside provider can become a major hurdle for physicians, especially for those in training.
The culture of the doctor as strong, omniscient, and untouchable seems straight out of a 1950s film. Despite pleas from the public that physicians be more tender, more sensitive, and more emotional, the hospital often houses an altogether different set of expectations. General medical and surgical culture has required that physicians be stoic overachievers, ignoring their emotional and physical aches and pains to focus on the needs of their patients. These beliefs have propagated through generations of matriculating medical students, changing only minimally over the last decade.
In 2001 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required that identification and education of impaired physicians be mandated but separate from disciplinary action (3) and that all staff and resident physicians be educated on physician impairment and offered resources for psychiatric or substance abuse concerns and a referral to access these resources, all while maintaining confidentiality. Additionally, JCAHO mandated that patient safety surveillance be in place until physicians complete rehabilitation or necessary treatment (3). The American Medical Association mandates reporting impaired physicians secondary to substance abuse or mental illness (4). Annual resident lectures are required continually to address this issue, making it public and open for discussion.
Medical schools are also informing students early in their education that resources are available for psychiatric and substance abuse issues. Estabrook’s (5) study emphasizes early promotion of medical student well-being with the hope of imprinting the value and importance of physician self-care on young medical minds. Eventually and with our best efforts, the belief system and culture would change, resulting in faculty physicians with a personal history and practice of caring for themselves. The importance of this cannot be overemphasized, because it has been supported both through anecdotal evidence and observational study that physicians take better care of patients when they themselves are feeling whole (6, 7).
Physician stress is well known. Suicide rates in male physicians have been quoted as high as three times greater than that of the general public, and in women physicians, approximately twice as high (8). The U.S. Physician WorkLife Study evaluated more than 2,000 physicians through survey, measuring self-reported stress levels and factors that influenced stress overall. Excessive demands on time with patients, level of personal control over work environment and schedule, and support for a “person-centered environment” were the most influential factors in self-rated stress levels (9, 10). Understanding what caused physician stress gave health care professionals the tools to change it. Simple alterations in residency programs and clinical practices (such as personal time off during the week for medical and dental appointments and more time for each patient in a busy clinic) could decrease physician stress at the expense of minimal resources (11). Additional understanding and flexibility built in to a residency program so that the inevitable “unexpected” pregnancies, deaths of family members, influenza, depression, and ruptured appendices (otherwise known as life) would not cause disruption. Support of faculty, residents, and students during these times allows individuals to focus on themselves, their families, and their diseases.
Physicians need to be given the freedom to take care of themselves, both physically and emotionally. At the very least, we should practice what we preach to our patients.