Volume 181 Issue 7

Promoting psychological wellness in doctors requires tailored interventions Doctors’ health and wellbeing seems to be attracting increasing international attention by the medical profession. 1,2 Is this because doctors’ health is worse than it used to be? Is medicine becoming too overwhelming for its practitioners? Does health promotion targeted at the profession work? And what is the profession doing about the health of its members? Unhealthy doctors cannot be expected to deliver high-quality healthcare Doctors are physically healthier than the average person in the community,3 even though they do not always follow their own healthcare advice (see Kay et al, page 368). 4-7 At the same time, they have significant psychological vulnerabilities,8 and are more likely than the average person to suffer from one or more of “the three D’s” — drugs, drink and depression (including suicide). Whether this is predominantly due to the stress of the job or to pre-existing personality traits has long been debated (see Riley, page 350). 9 The relatively small proportion of doctors who experience mental illness or substance misuse are described as being impaired. Many of them ultimately come to the attention of state medical boards, usually through referral by concerned colleagues. The New South Wales Medical Board has established an Impaired Registrants Panel, whose members work with impaired doctors and medical students to decide on how they can continue to work or study while the public interest is being protected (see Wilhelm and Reid, page 372). Troubled doctors are a larger group who are significantly affected by stress, although their disability may not be such that they cannot practise. Screening Australian doctors for anxiety and depression using the General Health Questionnaire has revealed a high level of stress among general practitioners;10 similarly, in New Zealand, severe stress symptoms are much higher among GPs than in the general population. 11 This troubled group is at risk of becoming impaired in due course. The most visible group are the dissatisfied doctors. They complain about “the system” and its demands, and contemplate leaving the profession. 12 Nevertheless, they are able to function quite well and do not have a “health problem” in the strictly medical sense. Whether they can be said to have “hypo-wellbeingness” is an interesting philosophical question. Whatever one’s viewpoint, these doctors may be at risk of “burnout”. Strategies aimed at promoting health and wellbeing among doctors must firstly consider which of these three groups is being addressed, and then tailor the intervention accordingly. The impaired doctor needs an early intervention and rehabilitation program; the troubled doctor needs a preventive approach to stress, plus an easily accessible referral pathway;13 and the dissatisfied doctor needs social support together with reform of “the system” so that known deficiencies (eg, workforce shortages, excessive paperwork, low remuneration levels) are adequately addressed. What has been done in Australia to reach these groups of doctors? Most states have the equivalent of a doctors’ health advisory service (DHAS), which often has little funding and depends on considerable goodwill by a panel of treating doctors. However, in May 2004, the DHAS network formed an Australasian doctors’ health planning and reference group, which may help to coordinate and refocus efforts in this area. Since 1999, there have also been national doctors’ health conferences every 2 years. To try to provide a more sustainable service in Victoria, the Australian Medical Association (Victoria) and the Medical Practitioners Board set up the Victorian Doctors’ Health Program in 2001. The aim of the Program is to provide confidential medical services to doctors, as well as referrals to specialists, such as psychiatrists, if required (see Warhaft, page 376). However, Australia is some way short of the US model of Physician Recovery Networks, which, although having no statutory role, intervene in situations where doctors are considered at risk (see Brown and Schneidman, page 390). Several specialist colleges have established their own support services for members who are experiencing difficulties. For example, the Australian and New Zealand College of Anaesthetists has been particularly active in supporting colleagues, especially in the area of substance misuse. Similarly, the Royal Australian and New Zealand College of Psychiatrists has assisted its impaired practitioners to obtain help through colleague support panels. Divisions of General Practice have taken up various wellbeing programs covering areas such as stress management techniques, improving skills in the business aspects of running a medical practice, and providing opportunities for social support through peer networking. 14 Unfortunately, the causal links between the impaired, the troubled and the dissatisfied are not very clear, and this has implications for the type of preventive programs being pursued. For example, do the various “docs-4-docs” programs run by Divisions of General Practice (with the aim of supporting GPs to better withstand the stresses of their profession) do anything to prevent impairment?15 This seems unlikely, as doctors with psychological problems are less likely to engage in the relatively open forums that the Divisions organise. The challenge has also been taken up by several Australian universities, which have developed “personal and professional development” programs to deal with self-care for health professionals. 16 An innovative way of promoting psychological health has been introduced at Monash University, where first-year medical students undertake a single-semester subject that teaches “mindfulness”-based stress management techniques that they can practise on themselves. 17 Similar courses are also being offered at postgraduate level. We need a better understanding of which programs work best for which groups of doctors. In the meanwhile, we can use liberal doses of common sense to guide us on what is worthwhile. Useful approaches are likely to include the provision of well advertised but confidential referral pathways for medical students and doctors who need help, the enhancement of a “no blame” culture that accepts and supports those who are starting to falter (see Hayhow, page 365), and attention to solving defects within the healthcare system. Unhealthy doctors cannot be expected to deliver high-quality healthcare. The increased attention to this issue in recent years is timely for doctors, their families and their patients.

Peter Schattner MD, MMed, FRACGP · Sandra Davidson BA, Grad Dip Behav Studies Hlth Care · Nathan Serry MB BS, FRANZP

Stress in doctors is a product of the interaction between the demanding nature of their work and their often obsessive, conscientious and committed personalities. In the face of extremely demanding work, a subjective lack of control and insufficient rewards are powerful sources of stress in doctors. If demands continue to rise and adjustments are not made, then inevitably a “correction” will occur, which may take the form of “burnout” or physical and/or mental impairment. Doctors need to reclaim control of their work environment and employers need to recognise the need for doctors to participate in decisions affecting their working lives. All doctors should be aware of predictors of risk and signals of impairment, as well as available avenues of assistance. Relevant medical organisations (eg, the Colleges, hospital administrations, and medical defence organisations) need to develop and rehearse effective response pathways for assisting impaired doctors.

Geoffrey J Riley MRCPsych, FRACGP, FRANZCP

All of us fear crossing the invisible line that separates “us” from the less fortunate “them” Recently, seated in the audience of Michael Moore’s film Fahrenheit 9/11, I was struck, yet again, by a thought that has inspired much of my writing over the years — that life is a protracted exercise in defining the line between us and them. In the case of Fahrenheit 9/11, the us and them refers to the haves and the have nots, or — according to Moore’s central thesis — those, on the one hand, who wield power and those, on the other, whose sacrifice on the battlefield secures that power. The intriguing thing about the line between us and them is that it is fluid. With a simple smile on the part of Fortune, it is possible for “one of them” to become “one of us” — or, in this case, for a have not to become a have. The maddening thing about such fluidity is that it is exceedingly rare for a nouveau-have to imbue their new-found havitude with the attributes of have not-edness. In other words — and this time in accordance with the rules of grammar — those who have the good fortune to cross over that thin line tend to travel light, rarely thinking to pack their ethics. Power corrupts. Absolute power corrupts absolutely. Orwell’s “Animal Farm” lives and breathes. In the world of medicine, we see the phenomenon of the thin line operating at its most poignant in institutions that practise “ageing in place”, where the haves are possessed of their faculties, while the have nots are not. (“Ageing in place” refers to the practice, in some institutions, of allowing residents whose condition has declined to below hostel level to remain at the same institution, rather than being uprooted to a distant nursing home.) In a strange inversion of the traditional social structure, it is the resident haves within this community who are the most dissatisfied. They are dissatisfied because they perceive themselves to be both besieged and beleaguered, by day and by night, by the frightening, zombie-like intrusions of the have nots, for whom they profess pity, while at the same time expressing fear, loathing, disgust and contempt. But, more to the point, they are dissatisfied because they know that the only thing that can possibly save them from an eventual slippery descent into the same loathsome condition is death. And yet, as sincere and as heartfelt as may be the pity and empathy felt for these poor creatures by both their peers and their carers, there is no denying the doggedness and the sheer ferocity of the contempt. “He’s lost it”, we caring professionals say, shaking our heads with what passes for concern. The terminology is crucial. — Lost what? — What the rest of us still have. — How could he have been so careless? — He’s no longer to be trusted with anything of value. Take away his car. Remove him from his home. Take away his independence. Remove him from his family. — This person is no longer fit to enjoy the privileges earned by those cautious enough not to lose what they still have. And all of this masquerading under the banner of care. It is not something that we are aware of doing, nor is it the sort of behaviour we would ever admit to. But, if you listen carefully, you will hear a thousand examples of it every day. But why? Why do we interpret as active and negligent a loss so utterly passive and ill-deserved? The answer is the same answer that comes back to us every time we question the iniquity of humankind — fear. We fear illness. We fear incapacity. We fear loss. We fear death. And what we humans do with the things we fear most is to subject them to the rigours of our most virulent contempt. But there is another, far more prickly and elusive example of the us and them mindset that pervades medicine, and this is the dichotomy that exists between doctor (have) and patient (have not). In this context, the terms have and have not are used not so much in a socioeconomic sense as in the sense of having knowledge and empowerment. Nowhere does the dichotomy between doctor and patient express itself with a more powerful sense of irony than in the mind of that most singular of individuals: the medico. For it is only within the person of the medical practitioner that doctor and patient meet head-on — buck naked and unadorned — with not so much as a privacy screen, a desk, a computer, a stethoscope or even a gusset behind which either can hide. This doctor can hide no secrets. No matter how dire or how remote the possibility, no diagnosis is withheld from the patient, no potential side effect hidden, no sequelae suppressed. The burden of fear and concern is not lifted by the professional hand but, rather, transmitted by it. Unexpurgated. For, regardless of the best efforts of the sundry medical bodies and boards to encourage doctors to seek arm’s-length professional help for their illnesses, each doctor consults daily, hourly, momentarily with his or her own inner patient. We engage in this nefarious practice under the shameful cloak of daily living. We do it as we chew on our toast, or as we strain at stool, or cleanse our bodies, or fall, exhausted, onto our beds. We do it when no one else is looking, or listening, or paying us the slightest attention. For we know that it is unseemly. Unforgivable. But we cannot help ourselves. Pain is no sooner suffered than interpreted, dyspnoea no sooner experienced than analysed, fever no sooner endured than investigated. But even the most ambitious, astute and adroit of procedural cardiologists remains powerless in the face of his or her own unremitting chest pain. And even the most introspective of haematemetic gastroenterologists baulks at the prospect of visualising his or her own entrails. There comes a time when the psychological defences crumble and the half of the medico that remains a practitioner must cross that thin line, thereby joining the frightened half that screams “patient!”. No amount of prodding and reassurance from the Medical Board can remove the stigma from this crossing. We are now become the object of contempt. And the more strenuously the opinion-makers of the medical fraternity deny it, the more corrosively the contempt seethes beneath the surface. For this is the nature of the human condition. Whatever we cannot control, we fear. Whatever we fear, we strive to control. Whatever we seek to control, we subject to the most heinous contempt. It is endemic, among patient and doctor alike. Nothing has changed since the coming of the first bubo.

Ron Elisha MB BS

Doctors as patients Is an ill doctor still a doctor, or a patient, or both? If he consults no one other than himself, he is both. If he consults a colleague and accepts his or her advice, he is a patient. If he argues with or rejects his colleague’s advice, he remains to some extent a doctor. Doctors choose a colleague to look after them to complement the role they prefer as patients. Those who feel they know almost everything and feel they must remain in control will choose a doctor who will do as they ask. So my father, a very experienced internist, chose as a GP a kind friend whom he had known for many years, but always considered his intellectual inferior. When my father was aged 85 and his GP 82, my father needed a certificate that he was still fit to drive a car. The GP thought it would be a terrible deprivation if he could no longer drive, and so signed it. Soon afterwards my father drove into another car without noticing it, and left the scene of the accident, and after that his licence was taken away. Those who are ready to trust a competent colleague, who understands them, are content to let him take the responsibility. That’s what I prefer, though when it comes to the use of drugs I want my opinion to be respected — and usually followed — because I am a clinical pharmacologist, and it is I who will have to take the drugs. Perhaps I am not so very different from my father. We all need a good doctor whom we trust, respect and like, who will listen to us but is not too close to us and not in awe of us, and will make his or her own independent judgements. When we find such a friend, we are in good hands.

Andrew Herxheimer

Objective: To determine the prevalence of psychiatric morbidity and burnout in final-year medical students, and changes in these measures during the intern year.Design: Prospective longitudinal cohort study over 18 months, with assessment of psychiatric morbidity and burnout on six occasions.Participants: All 117 students in the first graduating cohort of the University of Sydney Graduate Medical Program were invited to participate in the study; 110 consented.Outcome measures: Psychiatric morbidity assessed with the 28-item General Health Questionnaire and burnout assessed with the Maslach Burnout Inventory.Results: The point prevalence of participants meeting criteria for psychiatric morbidity and burnout rose steadily throughout the study period.Conclusions: Internship remains a stressful time for medical graduates, despite initiatives to better support them during this period. The implications for the doctors themselves and for the communities they serve warrant further attention, including programs specifically aimed at reducing the rate of psychological morbidity and burnout during internship.

Simon M Willcock MB BS(Hons), FRACGP · Michele G Daly BSc(Hons), MSc · Christopher C Tennant MD, MPH, FRANZCP · Benjamin J Allard BA, MB BS

Objective: To explore the attitudes of Australian medical students to the balance between work, family and other aspects of lifestyle, within a broader exploration of the issues that they regard as important to their decisions about future career.Design: Qualitative study using semistructured focus groups and individual interviews.Setting: The three medical schools in New South Wales and a national conference for students interested in rural practice.Participants: First- and final-year medical students who volunteered for focus groups held between March and August 2002 (82 students in 10 groups) or for individual interviews held between July and December 2003 (48 students).Main outcome measures: Emergent themes relating to the balance of work, family and other aspects of lifestyle.Results: Most students referred to a balance of work, family and lifestyle as an important factor in their career decisions. While indicating they were committed to medicine, they were unwilling to work to the exclusion of all else. Most saw family commitments as a high priority, and many saw “time out” as important in maintaining their health. Female students spoke of part-time work as essential for future happiness, while some male students expressed a preference for working part-time. They would seek to achieve balance by choosing to work in disciplines, locations and structures where limited-hours work is available, and would negotiate support from their partners and parents in caring for children.Conclusions: It is important that the medical profession continue to develop working and training structures that allow a balance of work, family and lifestyle.

Helen M Tolhurst FACRRM · Stephen M Stewart BMed(Hons)

A medical student poses some searching questions Recently I’ve been thinking a lot about the issue of supporting junior medical officers in distress, and I can’t help coming back to the thought that the lack of a sense of “community” in the workplace is an important contributor to the problem. In some ways, this is a vague and idealistic observation to make — let alone act upon — but it is strength of community that so strongly springs to mind when I consider the difference between institutions in which people are seen to flourish and those in which they are not. Perhaps this problem is especially acute for the professional. It strikes me that a key value of community — interdependence — grates against some doctors’ perceptions of themselves as exceptional, independent and self-determined. I think the competitive spirit of traditional medical education (both undergraduate and postgraduate) tends to engender a cautious, if not fearful, attitude towards one’s behaviour in the medical system. In particular, I think many doctors fear being identified for their human weaknesses, their academic shortcomings, and their occasional (but inevitable) clinical failures. Our clinical teachers are often better at pointing these things out than giving advice on how to cope with them, and we have all, at some time, felt small beside the consultant who takes perfection in his stride. Clinical uncertainty and human fallibility are facts of life and, at any level, it takes a special effort to deny that this has a personal impact. Yet this is clearly happening when so many doctors fail to seek help despite experiencing deep personal distress. A renewed emphasis on the values of community and the institutions that enact them may prove protective against such maladaptive behaviour. While this is probably a broader issue than the Council for Early Postgraduate Training in South Australia (CEPTSA) is likely to address, and although the huge scale of the healthcare system may work against our efforts, it still seems to me that we should encourage positive cultural changes in our hospital work environments. Big institutions can lack a sense of connectedness between the individuals that comprise them; this is unfortunate, as connectedness can produce a network of support that works between the lines of formal (often vertical) avenues of redress. The redress models we discussed recently were steps towards a better system for identifying and managing junior doctors in distress, but I wonder if it struck anyone else that one disadvantage of a system that attempts to maintain anonymity as its first priority is to reinforce the perception that to be seen to have a problem is the worst of all outcomes. Will it not, in other words, reinforce the underlying fear that perpetuates these problems? As in medicine more generally, treatment has its place, but prevention is preferred. A broad intervention aimed at changing the culture in which problems arise ought to be implemented alongside more direct strategies for supporting our doctors. Although they require further specification, I consider the proposition that we work on parallel cultural solutions practical and tenable. I was impressed, for instance, by the degree to which community spirit was fostered by administrators during my pre-clinical years at medical school. While recognising, once again, that the more widespread engineering of such initiatives may fall beyond the scope of CEPTSA, it may be something CEPTSA can contribute to in concert with other agencies such as the Australian Medical Students Association, the Australian Medical Association, other interest groups and hospital management. These thoughts seemed rather too abstract to raise during the last meeting of our group, but I was prompted to write to you after a cynical friend (also a cynical psychiatrist) suggested I enjoy the last of my youthful idealism before it is eroded during my own years as a junior medical officer. I prefer to imagine that anyone who cares to stop and consider the environments in which they too have felt supported to work creatively and effectively will find themselves imagining an instance of something similar to what I’ve tried to outline above.

Brad Hayhow BA(Hons)

Sharps injuries experienced by surgeons are common, but are under-recognised and under-reported. The overall risks of transmission of blood-borne viruses to surgeons are low, with hepatitis C posing the greatest transmission risk. Recent trials show that early treatment of acute hepatitis C results in a cure rate approaching 100%. Surgeons and theatre staff should be encouraged to report and follow up sharps injuries to allow early detection and treatment. Additionally, because exposures to blood-borne viruses may be unrecognised, surgeons should have regular tests for blood-borne viruses. There should be no restriction of practice in the “window period” between potential exposure and obtaining results of testing, because of the overall low risk of transmission.

Katrina J R Watson MB BS, FRACP, MPH

Studies of doctors’ health have emphasised psychological health, and limited data have been collected on their physical health status. Doctors often fail to follow current preventive health guidelines for their physical health. About half of doctors do not have an established relationship with an independent general practitioner. This would enhance their health and provide a means of ready access to the healthcare system should a problem arise.

Margaret P Kay FRACGP, DipRACOG · Geoffrey K Mitchell MB BS, FRACGP · Christopher B Del Mar MD, FRACGP, FAFPHM

Giving and receiving peer-group support After coming to terms with the stress in my life as a busy suburban GP, I joined my local Doctors’ Health Advisory Service in 2002. One of the events this group organised late that year was a doctors’ health information evening. A panel of experts was arranged to speak on topics such as substance abuse, depression and suicide among doctors. Despite a thorough marketing campaign, only the organisers showed up! From this experience I concluded that doctors, probably like most people, prefer a positive message to a negative one. One of the consequences of that evening was my development of a self-care workshop for doctors that I have conducted for three medical groups in Australia and New Zealand over the past year. The main objective of the workshops was to raise awareness of relevant stress and lifestyle issues (doctors have been shown to be a highly stressed group, with long working hours and poor habits in areas such as exercise). Other goals were to provide an experience of peer-group support and to help individual doctors develop strategies for changing their health behaviour. At the most recent event, doctors were asked to identify two areas of self-care they wished to improve. They were then divided into three groups, based on what they perceived to be the principal barrier to making change: about half the participants chose to be in the group who lacked motivation, while equal numbers of the remainder chose either the group who feared change or the group who could not move past the expectations of others. No one felt that a lack of knowledge or skills was a barrier to making the changes. Often after some heated dialogue, each of the groups came up with several strategies to overcome their perceived barrier to change. Many of those who lacked motivation felt all they needed was help and encouragement from a “buddy” to get them started. Others felt they would be more likely to succeed if the change process included a reward. The group that feared change reported that they needed to have more confidence to say no, to review their priorities with regard to earning money, and to stay on top of their overdeveloped work ethic. The group who felt the burden of others’ expectations concurred with the importance of learning to say no, and also perceived a need to clarify their priorities with regard to patients and family and to manage their time better. Both of these latter groups reported that the core issue seemed to relate to managing guilt rather than being controlled by it! My most lasting memory of these events has been the great enthusiasm and resourcefulness of the doctor participants, who generally found the workshops enjoyable and helpful. It was good to see the notorious reluctance of doctors to seek help put aside and to note the ease with which warm and intelligent collegial support can be offered and received.

Richard S Hetzel FRACGP

To the Editor: Duggan’s recent article on coeliac disease1 is a timely reminder of the complex manifestations of this common but under-recognised condition. I write as a patient diagnosed with coeliac disease at the age of 80. Throughout my life I have had aphthous ulcers, all sorts of abdominal pains, diarrhoea and constipation, dermatitis herpetiformis and profound fatigue. The extraordinary fact is that — apart from missing the diagnosis myself — I come from a medical family and have worked in a variety of medical environments both in Australia and overseas. My physique and weight were obviously substandard. Over the years, I consulted many physicians, surgeons and general practitioners. They diagnosed hiatus hernia (a fundoplication was done), gallstones (a cholecystectomy was done), irritable bowel syndrome, and, of course, psychoneurosis. I consulted three gastroenterologists, two of whom performed gastroscopy but did not take a duodenal biopsy. As I entered the rooms of a fourth, the secretary said, “I know your diagnosis” — and she was right. A duodenal biopsy showed flattening of the villi. Since going on a gluten-free diet, I have gained weight, the pains have gone, and the rash and ulcers have not recurred. A second biopsy, performed 6 months later, revealed restoration of the intestinal surface to its normal appearance. Not only is it a disease of malabsorption, but also one of malnutrition. This accounts for its widespread manifestations. Brain and nerve cells require adequate nutrition, just as any other cells of the body. I found, at times, difficulty in focusing attention, comprehension and cognitive processing. The spoken and printed word were meaningless on occasions. The fatigue was sometimes overwhelming. Galen first described the illness in 2 ad, but it took Dicke, a Dutch paediatrician, to trace the culprit to gluten in 1950. He found that children with coeliac disease fared better than usual when deprived of wheat during the Occupation. Other grains subsequently found to contain gluten were barley, rye and oats. Duggan points out that coeliac disease, like syphilis, is a great imitator. Not only is it a condition that can vary widely in its ramifications, it is the only illness treated by lifelong diet restriction. A pathologist colleague, diagnosed at a late age like myself, shares with me the fear of developing lymphoma — a not uncommon sequel to untreated coeliac disease.

William Woods

The New South Wales Medical Board has developed the Impaired Registrants Program to deal with impaired registrants (doctors and medical students) in a constructive and non-disciplinary manner; the program is now well established. The Program enables the Board to protect the public, while maintaining doctors in practice whenever possible. Disorders that commonly lead to referral of impaired doctors include alcohol and drug misuse, major depression, bipolar disorder, cognitive impairment and, less commonly, psychotic and personality disorders and anorexia nervosa. Pathways in the program are individualised according to the impact of the specific disorder, the registrant’s career stage, stage of involvement in the program, insight and motivation. Critical points in the program include entry, easing of conditions, breach of conditions, return to work after suspension, and exit from the program. Decision-making at these points takes into account the nature of the impairment, compliance, professional and personal support available and the registrant’s insight and motivation.

Kay A Wilhelm MD, FRANZCP · Alison M Reid MHA, FAFPHM

The Victorian Doctors Health Program (VDHP) was established in November 2000 to provide a confidential and compassionate service for doctors and medical students with health concerns, including alcohol, other drug and mental health problems. Although funded by the Medical Practitioners Board of Victoria, the VDHP is completely independent of the Board. Its staff include a director with experience of North American Physician Health Programs and a case manager/psychologist. In its first 3 years of operation, the VDHP had 438 contacts: 218 requests for advice and information, and 220 contacts resulting in provision of services (to 92 doctors and students with alcohol or other drug problems, 82 with psychiatric problems, and 40 with stress-related or emotional problems). 99 participants received standard care (assessment, referral and up to two consultations with the program) and 56 extended care (three or more consultations with the program). 65 participants (most with substance use disorder) entered the more intensive Case Management, Aftercare and Monitoring Program (CAMP); 57 of these have had outcomes considered satisfactory, with 50 returned to work.

Naham (Jack) Warhaft MB BS, GradDipSustanceAbuse, FANZCA, FAChAM

While some cases of sexual exploitation involve predatory doctors, many other cases represent the culmination of a series of boundary crossings (non-exploitative departures from usual practice). The deliberate move to reduce formality in medicine has increased the likelihood of boundary crossings and violations. There are also individual doctor risk factors; boundary violations appear more likely when doctors are under stress, with insufficient emotional support. Preventive strategies include continuing education about ethics and the management of professional boundaries, along with appropriate psychological support structures for doctors. Doctors are often involved in other professional relationships as teachers, supervisors and team leaders; inappropriate sexual behaviour in these relationships is harassment. Public pressure for more punitive responses is likely if the profession is not seen to be doing all it can to deal with these issues effectively, and to be cooperating with other responsible agencies.

Cherrie A Galletly FRANZCP, PhD

I am on leave at present. The leave was planned but not voluntary. In May 2000 I received a writ concerning a woman with cerebral palsy, who was born 20 years ago. I had been the general practitioner obstetrician who attended her mother until I handed over to a specialist obstetrician for a caesarean section. At first I felt confident that my management was proper and there could be no case. Two years ago, however, a court settlement of $14 million changed everything. Since then I have been through intensive examination of everything I did during the 4 hours she was under my care. The notes and written answers to highly detailed questions now fill a 12 cm deep file box and I have become totally disillusioned with medicine and the law. The only records that exist from that time were the notes I wrote during her labour. Instead of providing a solid basis for my defence, as I thought, my notes have been dissected, with every nuance of each word explored and even the punctuation and layout questioned. The lawyers even questioned the fact that notes at different times during the labour were written in different pen. This threw me until I realised the event took place late at night into the early hours and I had probably attended in a tracksuit without a pen, and had used whatever I could borrow at the time I wrote each note. As the case approached I was forced to question and requestion everything. The stress began to take its toll on me, but I believed it would not affect my family and practice partner. How conceited! In retrospect my relationship with my wife, my children, my colleagues and staff all suffered as they each tried to support me. My practice has changed. I am constantly asking myself: “Did I miss anything? Have I performed all the tests?” — beyond any sensible practice of good medicine. Of course, I quit delivering babies two years ago. GP obstetrics was never a well paid practice, but I loved it. I had undertaken extensive training overseas as well as in Australia so that I could fulfil my role as a rural GP, caring for women in labour. When I found myself doubting everything I could no longer continue. From time to time, the lawyers would iterate that I would be judged by the standards of my peers. However, the repeated examinations made it plain that only a specialist obstetrician could be considered competent. The plaintiff’s lawyers couldn’t find an obstetrician in Australia to criticise my care, so imported one from overseas. The case was scheduled to start on a Monday (nearly 4 years after the initial writ had been served) and run for 4 to 6 weeks. I am a country GP and have only once had 6 weeks’ leave. On that occasion I had major surgery. At least I was given 3 months’ notice of the court schedule, so had time to find a locum and to refinance against our home to cover the loss. Most readers will be aware how difficult and expensive this is. Then at 12:30 on the Monday, my former partner and long-time friend telephoned to congratulate me that the case had been settled. He had been subpoenaed by the plaintiff’s lawyers to give evidence as to her disabilities and they had telephoned him to tell him he would no longer be required. I immediately called my solicitor and he confirmed the news. My wife and I cried. When I investigate a patient with a breast lump, I telephone her as soon as I have the result. As a caring doctor I never allow a third party to give sensitive results to my patients. Part of our contract with our patients is to be sensitive to their feelings and the effect our diagnoses can have. So I am disillusioned with the law. We are now having a few days to recoup. My sense of humour is returning and my practice partner and I shared a bottle of red wine last night and debriefed each other. I am not ready to return to work, but hope that catching up on correspondence, as well as the many odd-jobs I never had time to do, will give me a chance to regain my desire to be a good doctor. Kerr’s story highlights all that is wrong with the adversarial civil litigation process. The plaintiff can choose whether or not to bring a claim. However, once the writ is served, the defendant has only two options — settle or defend. In a cerebral palsy case, the potential multimillion-dollar cost of the claim means it is not an option to settle “for convenience”, or on commercial grounds, or to spare the defendant doctors and their families the psychological, professional and financial trauma of a protracted defence. If the best advice obtained for the defendant is that the plaintiff’s claim is weak, then the claim must be defended. The defendant doctor is locked into a “Clockwork Orange” scenario — nothing he or she can do can end the nightmare. The problem of course is that it is only “grey” claims that become protracted. If the expert evidence obtained by the defendant’s lawyers is that the plaintiff’s case is sound, an early settlement will be attempted. If the claimant has an inflated estimate of what their claim is worth, there may be a protracted argument about “quantum”, but otherwise the claim will be settled and everyone can get on with their lives. If the plaintiff receives advice that there was no departure from acceptable care and skill, or an important fact not known to the claimant’s lawyers and the experts commissioned by them emerges which makes that clear, the claim will be abandoned. Neither side will pursue a lost cause. The most painful part of this story is reading of the settlement “at the door of the court”. It is customary tactics, if the parties can’t agree, to bluff their way right to the door of the court. The barristers are there, fully kitted up in gowns and wigs. The clients hear the opposing barrister say, “Look over there — I’ve got my experts lined up ready to go. This is your last chance to talk sensibly.” That tactic of brinksmanship is what caused this country doctor the most distress. Three months beforehand, he was told that the case was unlikely to settle and that he should prepare for a 4- to 6-week hearing. Hence, the expense of a locum, and the need to refinance his home. Would even his own lawyer understand that a locum never pays his or her way; that even with a locum in the practice, the doctor would suffer a substantial loss of income? How can the courts be managed efficiently when court time is set aside on the parties’ estimate that a case will run for a number of weeks, but it collapses either just before starting, or on the first day? What an appalling waste of resources!! But this cri de cœur is closer to the bone. All parties to litigation suffer severe distress during the process. The medical indemnity insurers offer collegiate support to defendant members during the process. One (the Medical Defence Association of Victoria) offers access to confidential counselling services by an external psychologist at the fund’s cost. Litigation has the same emotional impact as a major illness, loss of a loved one, or a severe career setback. The stages of grief (as described by Elisabeth Kubler-Ross1) were transparently apparent in the members whose claims I managed. Some were clinically depressed, but were reluctant to admit it and seek help. None committed suicide, but I have heard of that happening overseas. Further, the protracted course of the litigation, and the accompanying incessant questioning about minutiae, has caused this doctor to second-guess his own competence. All I can offer is the platitude that an accusation of “negligence” is not an accusation of “incompetence”. Being sued, even successfully, does not mean that you are a “bad” doctor. The vast majority of claims I settled for doctors represented the one-off lapse or slip or error of a perfectly competent doctor. Most medical indemnity funds offer collegiate support. A senior clinician associated with the fund is assigned to the claim, not to manage it legally, but to be kept up to date on its management and, more importantly, to be available to discuss the medical aspects, at length and repeatedly, with the doctor. Even when a member is told that the case must be settled because the circumstances meet the legal test of negligence, mentoring can help the doctor learn from the case, put it in perspective, and then move on. Perhaps writing up his experience will have a psychologically cathartic effect on the author. It is no consolation to him that very few doctors go through his experience. At least 90% of claims brought against doctors are either settled or abandoned by the plaintiff. Very few get to the final stages of preparation for trial, even fewer actually go to trial, and even fewer go to verdict. Litigation leaves deep scars on defendant and plaintiff alike. Rumpole and his supporters might think the gladiatorial adversarial model of litigated compensation for personal injury represents the highest form of justice, but it has been abandoned for injuries arising from workplace and road accidents. Why has it not been abandoned for medical accidents?

Charles D Kerr FRACGP · Paul Nisselle AM, MB BS, FRACGP

To the Editor: International medical graduates on temporary residency visas now make up a substantial proportion of the rural medical workforce. Anecdotal reports suggest that many make the transition to professional life in Australia reasonably well, in terms of both cultural adaptation and applying their professional skills, even though the level of educational assessment and support may vary considerably. However, there are some disturbing reports of a few such medical practitioners who perform poorly and are moved on, perhaps to another state. A survey conducted for Tropical Medical Training, the regional general practitioner training provider for North Queensland, found that international medical graduates were often the only doctors in some rural communities, and their lack of teaching confidence and connection to a medical school was a significant barrier to expanding medical student and registrar training in the region. 1 As part of a follow-up project that aims to identify the educational needs of international medical graduates in rural northern Queensland and design support programs for them, several organisations were approached to gain access to this group, rumoured to be perhaps 50–100 individuals. Because of the Privacy Act, the survey was to be distributed by one or more organisations that knew how to contact these doctors. However, no single organisation appeared to have an accurate database that included the target group. Queensland Health, a major employer of international medical graduates, had no central record. Divisions of General Practice stated that few international medical graduates joined them, and most were ineligible to join a college. The Queensland Rural Medical Support Agency probably had the largest database, but its accuracy cannot be verified. The lack of access to international medical graduates will place constraints on the research project (there is no denominator and response rates cannot be measured). However, the broader issue is that international medical graduates, at least in rural and remote communities, appear to have no single organisation monitoring their recruitment, educational qualifications and needs, or retention. They appear to be an almost invisible workforce. This somewhat chaotic situation cannot be in the best interests of either the workforce or the quality of Australian healthcare.

Richard B Hays

Prevention and intervention programs are up and running, but the work is far from over The sudden acute respiratory syndrome (SARS) epidemic in Canada exposed the vulnerabilities of our public health system, and demonstrated the strength of its caregivers. In addition to the devastating effects of this illness on patients and their families, SARS also highlighted the importance of professional health. The impact of SARS on healthcare professionals was high, with key factors for doctors including the potential risk of death, placing one’s family at risk of infection, and being treated differently by others because one worked in a hospital setting. 1 Before SARS, there had been increasing recognition and awareness of the health and wellness needs of Canada’s doctors and medical students. In 1997, the Canadian Federation of Medical Students (CFMS) produced a position paper on the health and well-being of medical students,2 and others quickly followed. 3 Our healthcare system continues to struggle with constraints on financial and human resources in the face of ever-increasing need and expenditure. Indeed, as funders and providers struggle to manage, doctors are reporting rates of advanced burnout approaching 50%. 4 This struggle has been acknowledged at some of the highest political levels, including the head of the recent Commission on the Future of Health Care in Canada, former Premier Roy Romanow, who, in an address to the General Council of the Canadian Medical Association in August 2003, stated, “If we don’t look after the health care of our providers, they can’t look after the health care of [us].” Overall scope of doctors’ health initiativesPhysician health is being tackled nationally, provincially and municipally. At a national level, the Canadian Physician Health Network (CHPN) was founded in 2001 and represents a working alliance of the Canadian Medical Association (CMA), provincial physician health programs, the Canadian Association of Interns and Residents (CAIR), the CFMS, and academic faculty wellness programs. Its purpose is to develop and strengthen a network of informed individuals involved with doctors’ health, and facilitate ongoing evolution and improvement of physician health initiatives. In 2003, the Canadian Medical Association launched the CMA Centre for Physician Health and Wellbeing to be an information resource for physicians, medical students and their families, to help them maintain health and prevent illness, and to provide national leadership and advocacy. In 2003, the Centre also announced $C100 000 for research into doctors’ health. These collective national efforts are proving to be powerful and critical components of an overall strategy to help the culture of Canadian medicine evolve. Each Province and Territory has access to a Physician Health Program (PHP), each of which has its own unique attributes and format. The largest PHP is based in Ontario, and is one of many services offered to members of the Ontario Medical Association. Since the program began in 1995, over 1100 doctors have used it. Like many physician health programs in Canada, the Ontario program reports that service needs have moved from a primary focus on substance use and substance-use disorders to include services for broader mental health problems. Canada’s Atlantic provinces (Newfoundland and Labrador, Prince Edward Island, Nova Scotia, and New Brunswick) are home to a small number of doctors spread over a large and diverse geographic area. While each province’s medical association operates a form of doctors’ health program, the region has elected to investigate the possibility of evolving a unique regional program to maximise limited resources, and provide services appropriate to local practice styles and sensitive to local culture. Finally, there has been innovative growth in doctors’ health at the grass roots, municipal level. Canada’s cities have partnered with doctor organisations to enhance recruitment and retention by acknowledging and recognising the value doctors have in their communities. In Ottawa, Physician Appreciation Day has been celebrated since 2002. This effort was designed to encourage the community’s citizens and institutions to recognise and acknowledge the various roles physicians play, from healers and advocates to parents and partners. Ottawa is also home to many national doctor organisations, many of which use the day to recognise the efforts of their physician-employees. Ottawa’s hospitals host events for their physicians, and the University of Ottawa has an event for its medical faculty members. Many Ontario communities are developing their own versions of this event. The impact of such initiatives on physician health is unknown, and warrants evaluation. In addition, in May 2004 the Ottawa Academy of Medicine launched a unique “Code 99” program to develop a network of physicians who are comfortable caring for their colleagues, and to help physicians and medical students find a family physician or specialist. 5 This program is already proving to be a well used resource. Special target groupsOne of the biggest drivers of change in Canadian medical culture has been resident associations. Each province has an organised association, the Provincial Housestaff Organization (PHO), which negotiates salary and working conditions for postgraduate trainees with the provincial teaching hospitals. These discussions have facilitated significant system changes, including improvements in working conditions, salaries, benefits, educational expectations, leave entitlements (illness, disability, parental, educational, and vacation), and work hours (including on-call demands). One natural outcome of these changes is a workforce of early-career and mid-career doctors who view their identity and obligations to the profession differently than preceding generations, and strive to balance personal, family, and professional obligations. Indeed, data suggest newer generations of doctors are working fewer hours. 6 There is also a growing body of data on the impact of work on the health and wellness of trainees. An observational study of 11 paediatric fellows working within Ontario guidelines revealed they worked an average 69 hours a week, and roughly 25.5 hours per shift. Per shift they received an average of 41 pager calls, slept 1.9 hours, and walked 6.3 km. Physical tests showed that 7 developed ketonuria, and 6 developed heart rate abnormalities. 7 These data have led to calls for further investigation into the impact on sleep deprivation and other factors on physician health and patient care. 8 The Canadian Association of Interns and Residents is also leading a national “Happy Doc” study to better understand resident health and well-being. Student health and wellness has been promoted with great vigour by the Canadian Federation of Medical Students (CEMS). One of their initiatives, at Dalhousie University’s faculty of medicine, helped students gain access to a unique peer support program, which sponsors activities focused on the humanism of medicine and themes of personal health and wellness. In addition, CEMS also focuses on the role of partners and family members during an annual “Significant Others” night. 9 Another program, at the University of Ottawa, offers access to a mentorship program, and a student health initiative. One of the greatest challenges for Canadian medical students is skyrocketing tuition costs and massive student debt. As tuition approaches $C20 000 per year in some provinces, students are increasingly reporting financial distress. 10 The impact of such debt is largely unknown, but it has been linked to the decline in interest in family practice. 11 Women comprise 59% of medical students in Canada, and 30% of physicians in practice. In spite of many successes, women in Canadian academic medicine struggle to balance work and family responsibilities. 12 In response, Canadian medical schools have been creating increased opportunities for women in leadership; increasing sensitivity to issues such as gender and equity; and looking seriously at the need to provide harassment-free work environments, work flexibility, and daycare. Indeed, there is a growing recognition that these issues increasingly affect both sexes, particularly given the changes in the role of men and male doctors in Canadian society. University initiativesThe Faculty Wellness Program at the Faculty of Medicine, University of Ottawa, the first program of its type in Canada, was founded to promote the well-being of all members of the faculty. 13 Since its inception in 2000, it has served an average of 150 individuals per year with a broad array of physical and mental health concerns. The program also participates in the development and evaluation of workshops and presentations on physician health, and is increasingly being used to help divisions and departments of the faculty of medicine. Current initiatives include the development of a standard policy on doctors with disruptive behaviour, development of strategies to assess resiliency of applicants to medical school, and promotion of physical fitness. Other Canadian medical schools are also developing their own programs. The Association of Canadian Medical Colleges has been helping to develop a national network of academic wellness programs since 2002, with a goal of increased collaboration between academic physician health programs and those operated by physician organisations. Canada has launched an innovative initiative — the Northern Ontario Medical School — to train physicians to work in Canada’s rural areas for the long term. While rural training experiences are important, rural doctors are also reporting that other factors, such as recreation, employment opportunities for their partners and educational opportunities for their children, are not as good as they were in the early 1990s. 14 Given the importance of recruitment and retention of doctors in Canada’s rural regions, the issue of physician wellness warrants attention. ConclusionA revolution in physician health is taking place in Canada. Since early efforts at policy development, the profession has created national networks, centres of excellence, research opportunities, and educational programs. Yet, a recent survey by the Canadian Medical Association showed that up to 46% of Canadian physicians are in an advanced state of burnout and 58% felt their family life suffered because they had chosen medicine as a career. 15 While the nation’s physicians have begun to develop prevention and intervention programs, it is clear that the work is not over.

Derek G Puddester MD, FRCPC

Despite the many services now on offer, doctors’ special problems in seeking healthcare advice and treatment remain unsolved Since the 1970s, when the Association of Anaesthetists responded to much-publicised suicides by setting up the first dedicated service for its members, much has changed in the provision of special help for “sick doctors” (those stressed and in need of professional psychological support, as well as those with physical and mental illness) in the United Kingdom. Now there are over a dozen national “sick doctor” services (details can be found at www.ncssd.org.uk) and many more local ones. This growth has led to increased choice, but has also raised questions about why they are all needed and how effective they are. Local servicesDoctors in the UK are entitled to use the National Health Service (NHS), and, as most provide services to patients under the NHS, are also entitled to use the NHS occupational health service. Their past reluctance to do so lay in the perceived closeness to management and general lack of availability. This was compounded by incorrect and unsubstantiated concerns about confidentiality. Local services are largely provided by government-funded organisations, including primary care trusts (which are responsible for the governance of primary care services provided by general practitioners and other healthcare staff) and postgraduate deaneries (which are responsible for doctors in training). 1,2 These local entities usually contract with an independent body, usually staffed by professional counsellors and sometimes by doctors, to provide services for discrete groups of doctors. The services often emphasise psychological counselling for those experiencing difficulties at work. National servicesAlthough many of the national services concentrate on problems related to drugs, alcohol, stress and mental health, they vary considerably in their characteristics. None receives permanent government funding, although several had start-up support from the Department of Health. The National Counselling Service for Sick Doctors (NCSSD) was established in the mid-1980s through the vision and leadership of the eminent psychiatrist Kenneth Rawnsley. It was set up partly to provide an alternative to the statutory health procedures operated by the profession’s regulatory body, the General Medical Council (GMC). 3 The NCSSD was the first, and remains the only, independent doctor-to-doctor service dealing with all health issues, and available to all doctors. 4 In the mid-1990s, the NCSSD was receiving about 400 calls per year and had a panel of about 80 medical advisers (now it receives 250 calls per year and has 50 advisers). The NCSSD’s main aim remains helping doctors gain access to appropriate healthcare before their health problems prejudice their ability to work safely. It does not provide a healthcare or (despite its name) a formal counselling service for doctors. Its advisers and management committee are volunteers. Other national services have been set up to meet specific needs. The medical defence organisations provide support for their members who get into difficulties over professional matters. The British Medical Association (BMA) has a counselling service, established in 1996, which receives about 200 calls a month from members, who are provided with 20–35 minutes of telephone counselling by a professional counsellor and, if necessary, given help in gaining access to further one-on-one counselling. The BMA has recently developed its own “doctors for doctors” service, which primarily supports the BMA’s industrial relations officers in their dealings with BMA members in difficulty, and also provides a signposting service to other sources of help. A distinctly different approach is adopted by other organisations which rely on volunteers who have themselves been ill and are in recovery. These include the British Doctors and Dentists Group (a support group for addicted doctors and dentists, reached through the Medical Council on Alcohol, which also provides information about alcohol-related problems and promotes alcohol education in medical school curricula); the Sick Doctors’ Trust,5 which helps addicted doctors; and the Doctors’ Support Network,6 which helps doctors with mental health problems. These organisations provide direct interventions, one-on-one, and group support. The Doctors’ SupportLine is a telephone helpline staffed by trained volunteer doctors, which provides a first step for doctors in getting help with personal or work-related problems. Two medical colleges have recently identified the need to provide extra help for their members — the Royal College of Surgeons of England has launched a national, confidential support and advice service providing surgeon-to-surgeon telephone and face-to-face help, and the Royal College of Obstetricians and Gynaecologists offers the services of members and fellows who are trained mentors. The British International Doctors’ Association also provides mentors and a health panel for doctors whose problems may be caused by cultural or linguistic factors. A web-based service has been created through British Medical Journal Careers, part of the BMJ publishing group, offering mentors for doctors with chronic illness and those who have suffered discrimination in their careers. Finally, the Royal Medical Benevolent Fund provides much-needed financial help to sick doctors and their families. All these organisations maintain appropriate confidentiality, but operate within the governing ethic that patient safety is a pre-eminent consideration. Doctors who continue to practise, but whose state of health is a danger to patients, should be reported by their colleagues to their employer and/or to the General Medical Council. It is the NCSSD’s experience that this sanction is rarely needed, and, once doctors are helped to recognise that they are ill and to seek appropriate treatment, they respond well. Challenges and the futureThe need to preserve confidentiality about doctors as patients has made evaluation of the effectiveness of services difficult. In future a more open approach may be needed. The smaller organisations rely heavily on the unpaid commitment of enthusiasts and long term funding is always a problem. Their future is not secure. The plethora of services presents a confusing picture. Some rationalisation is probably needed. And still there are unmet needs. Doctors often remain reluctant to acknowledge their need for help. Despite GMC policy to the contrary,7 they continue to self-diagnose and self-prescribe,8 and to present late when they are ill. Virtually all the services are reactive, becoming involved only after problems have arisen. A statement produced by European experts in 2000 describes doctors as “one of the most unattended populations, in terms of health”. 9 Certainly, in the UK, it is often difficult to arrange appropriate care for sick doctors away from the area where they work. A new initiative by the umbrella organisation the Clinicians’ Health Intervention Treatment and Support (CHITS)10 to provide dedicated addiction treatment centres for healthcare professionals may help, but substantial government funding is required. The NHS occupational health service is being strengthened, but this will take time and gaining doctors’ trust may take even longer. Where specialist services have been established for some time, use by doctors has increased, although the changing climate of medical practice may also be a factor. In some occupational health services, use by doctors is now greater in proportion to the numbers of staff than by any other occupational group (Kit Harling, Consultant Occupational Physician, Director, NHS PLUS, personal communication, 2004). The ability of specialist occupational health services to influence employers to make job changes to facilitate return to work after illness is a key benefit. There is now a greater knowledge of the stressors that doctors have to cope with,11,12 suggesting primary prevention is possible. The shortage of doctors in the UK and the high cost of early retirement13 may provide incentives for better services. The GMC’s statutory health procedures will soon cease to exist as a separate entity and, whatever happens in terms of independent sick-doctor services, it is essential that all organisations that employ, support, guide and control doctors have clear policies and practices that take full account of the impact of stress and ill-health on doctors’ performance. The special problems that doctors have in seeking healthcare advice and receiving timely and appropriate treatment have not yet been solved. Doctors require services that they trust, will use and that meet their diverse needs. Doctors themselves could help greatly by continuing to explore their attitudes to their own healthcare needs and those of their colleagues. 14

Jolyon R Oxley MA, MB BChir, FRCP

Despite a still small evidence base, programs throughout the country are tackling doctors’ illness and doctors’ health In 1973 the American Medical Association’s (AMA) Council on Mental Health published The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. While a handful of programs were already operating, this report is generally regarded as the watershed for doctor health programs that now exist in nearly all states across the United States. The report noted that “the [profession’s] primary responsibility for ensuring safe, competent care to the patient population affected must be reemphasized.” In December 2003, the AMA’s Council on Ethical and Judicial Affairs (CEJA) issued a report to provide “guidance in the area of physician health and wellness insofar as it affects physicians’ professional activities, including patient care and trust in the profession.”2 In this article, we discuss what transpired with physician health in the United States in the 30 years between these two reports. State programsThe most visible effect was the development of programs in nearly every state. These programs typically evaluate doctors who may have problems and monitor them after treatment. They operate to ensure that a doctor complies with the provisions of treatment and is able to practice; few programs provide care per se, and a number have wellness programs. There are a variety of models, with some under the auspices of the state licensing board (generally known as diversion programs, as the doctors are diverted to treatment rather than to disciplinary action), and some being programs of the state medical society or independent agencies, which generally have ties to their respective medical societies or boards. Considerable variation is found with other aspects of the programs. Some are largely restricted to doctors (including doctors in training), while others deal with virtually all healthcare professionals, including veterinarians, chiropractors, nurses and medical students. The types of problems dealt with also vary, but substance-misuse disorders are routinely addressed in all programs. Other issues, such as malpractice stress, physical disabilities and behavioural (personality) disorders, are less frequently included. The level of funding and range of sources for program funding are even more disparate. Details of program comparisons are available on the Federation of State Physician Health Programs (FSPHP) website. 3 What do the programs share in common? There is unquestionably an emphasis on professionalism in the sense used by sociologists (ie, the programs are developing specialised knowledge along with special skills to apply to the problems they encounter). 4 Before 1990, the state programs were loosely associated with the AMA’s impaired physician program, which facilitated communication among the various state programs by means of a subscription-based newsletter, and encouraged the adoption of consistent policies (such as model legislation that would sanction cooperative relationships between licensing boards and the medical society), and hosted regular conferences on the impaired physician. In December 1990, as the AMA was refocusing its program on doctors’ health rather than impairment, the FSPHP was formed. The Federation of State Physician Health ProgramsThe FSPHP’s mission is “to provide a forum for education and exchange of information among state programs, to develop common objectives and goals, to develop standards, to enhance awareness of issues related to physician health and impairment, to provide advocacy for physicians and their health issues at local, state, and national levels, and to assist state programs in their quest to protect the public.”3 It offers state programs (44 states are full members, as membership is voluntary), regional and national meetings and an electronic forum (open only to those with direct involvement in state or provincial programs) for discussing issues such as drug screening, monitoring agreements, treatment options, and program policies, particularly in dealing with refractory cases. Despite program differences, consensus on key issues is the norm. For example, recently completed are guidelines for doctors’ health program development and enhancement, despite a limited evidence base. Gathering the evidenceRecognising the lack of good evidence on many of the issues, the AMA and the Canadian Medical Association jointly sponsor, in cooperation with the FSPHP, the Federation of State Medical Boards and the Federation of Licensing Authorities of Canada, a biennial conference on doctors’ health, the program of which includes plenary sessions and papers that are peer reviewed. Though small, the conference attracts an international audience, including Australian doctors. Divergent international norms have generated many discussions on the merits of some program standards. For example, abstinence from all psychoactive substances, including alcohol, is the norm for a physician recovering from a substance-misuse disorder in North America. 5 In a presentation at the 2002 conference, Jack Warhaft, of the Victorian Doctors Health Program, commented that abstinence from alcohol is not necessarily required for narcotic misuse or dependency. This is an area where the science needs to expand in support of practice. One effort to advance the science of physician health has been the establishment of a loosely formed physician-health research group, a process encouraged by the AMA, the FSPHP and other organisations. The group has developed a tool to collect reliable and valid data, which is based on well validated instruments used in psychiatric epidemiology, and will allow researchers to compare cases across programs while protecting doctors’ confidentiality. At the same time, doctor wellness is vital, with many examples of topics worthy of investigation, possibly for their effects on overall public health. 6-8 Future directionsAn emerging issue is the future direction of the state programs. Over the years, some have separated from their respective medical associations, largely for financial reasons. A more recent trend is outsourcing. Programs operated by licensing boards or those operating as independent corporations with financial support from the licensing board are being outsourced, with bidders most likely to come from the for-profit sector. The recent revelation that Vice President Dick Cheney’s personal doctor was being monitored by the physician health program of the Medical Society of the District of Columbia and that his care had been kept confidential9,10 may have as yet unknown effects. One might anticipate, for example, efforts to breach confidentiality for physicians undergoing treatment or a move to mandatory disciplinary actions such as licensure suspension or revocation. This matter was the subject of numerous editorials, although at least one of these advocated a system used in the New Jersey state physician health program, in which information is shared with the licensing board in a way that maintains confidentiality. 11 Less newsworthy perhaps will be the development of hospital-based committees that were established as required by the Joint Commission on Accreditation of Healthcare Organizations in 2001. In some states, hospitals are working with state programs, while in others services are probably duplicated. The value for doctors and their health is unknown. Progress has been fitful over the past 30 years, but things are moving forward. Today, the AMA and the various state programs deal with health issues, not just illness, and they support a variety of treatment models, recognising that the evidence base for this work is really just beginning to be built. As the evidence base expands, progress will be swifter.

Roger L Brown PhD · Barbara S Schneidman MD, MPH

Marital challenges are ubiquitous in the relationships of doctors. Common issues include overwork, a need for control, self-neglect, perceived and felt stigma, being a “wounded healer”, trouble with boundaries, chemical dependency, depression, and more. Knowing the hallmarks of a healthy relationship, recognising warning signals of trouble, and taking action through suggested strategies can be salutary. As a specialist in doctors’ health, I have noted that relationship concerns constitute one of the most common complaints in my practice. 1 Although there are no empirical data on the prevalence of marital problems in doctors, there are some data on divorce, albeit mixed. Doherty and Burge2 reported that divorce rates in doctors are lower than in other occupational groups. In contrast, Sotile and Sotile3 describe divorce rates among doctors as 10%–20% higher than those in the general population. Historically, the call of medicine has given short shrift to our personal and family lives. It is refreshing to observe today’s younger doctors giving much higher ascendancy to their relationships. 4 A healthy relationship is an alliance of two mature individuals who are developmentally ready to form a union that will meet their individual needs and ensure their personal growth in the years that lie ahead. 5 The texture of this “coming together” depends on many factors: love, affection, sexuality, companionship, communication, financial security, intimacy and commitment. When we feel intimate in a relationship, we are describing notions of connection, trust, mutuality, and a sense of being loved and honoured. 6 Given our humanness, our personal pasts, and the demands and responsibilities of a career in medicine, is it any wonder that all of us, in greater or lesser measure, struggle with our intimate relationships? Common problemsThe following are some common characteristics of doctors and their intimate relationships. Overwork as normative. The number of hours worked per week varies enormously from one doctor to another, and is influenced by the branch of medicine and the doctor’s sex and life stage. The bottom line, though, is that we work hard and this affects the quantity and quality of time left for our partners. It is hard to be relaxed, interested, energetic, creative and fun with loved ones if we are tired or preoccupied with the residue of our work day. And our intimates are masters at detecting this, despite our protests, denials and defensiveness. Overwork in doctors seems to be a result of both the doctor’s personality and the culture of medicine. Escape into work. Overwork is not always the cause of relationship difficulty, but may be the result. We may deliberately stay at work late or go in to work to avoid the painful awareness of tension or unhappiness at home. Medical work can be seductive — and there is usually plenty of it. Further, it may be easier to solve clinical dilemmas than domestic problems. A need to be in control. Our work requires being in control and taking charge if we are to be effective in our patient management skills. In greater or lesser measure, this attitude or personality trait may colour our intimate relationships. Other traits commonly seen in doctors are compulsiveness,7 perfectionism,8 and pessimism, passivity and self-doubt. 9 Most spouses do not appreciate feeling controlled by their doctor-partner or not respected as an equal. To quote one wife of a cardiologist: “My husband forgets that the kids and I are not always going to step to attention like his office assistant. Nor do we hold him in awe like his patients do. My philosophy is that we’re all equals in this family.” Self-neglect. Many other professionals take better care of themselves than we do. 10 If they are ailing, they consult their general practitioner. Many of the best doctors do not have their own GP, live lives that are desperately out of balance, diagnose and treat themselves (sometimes incorrectly), and do not recognise the pain and suffering of their partners. For example, a psychiatrist who came to me for a consultation began with these words: A month ago, when I concluded that I was depressed, I started myself on antidepressant A. I didn’t feel any better after about 10 days, but, instead of increasing the dose, I decided to try another sample, antidepressant B. Well, after 2 days, I was really anxious and my sleep was worse so I stopped it and put myself on antidepressant C. About a week later, when the anxiety hadn’t gone away and my sleep was even worse, I decided to double the dose. Then I got really sick. I didn’t know if it was the drug, the flu, or my depression getting worse. Then the pharmaceutical rep came by with some samples of antidepressant D. So I stopped what I was on and started it. I don’t like it though — I feel strange on it. But I feel strange these days anyway. I am so glad to be here. Relieved that I’ve got someone to look after me. I feel dreadful. Do you know how hard it is to treat yourself properly when your cognition is off and you’re worrying constantly and you can’t make proper decisions and you don’t know if you’re going to recover? I would never treat my own patients like this. Stigma. Most doctors admit to fearing judgement or disrespect if they admit to relationship problems or psychiatric symptoms in themselves. 11 Fear of stigma is why so many doctors refuse to seek help, or delay consulting others for a long time, or treat themselves. It is aligned with rugged self-determination, not wanting to bother others, a strong capacity for denial of trouble and problems, and mistrust of other caregivers. Sadly, these beliefs are too often reinforced by a culture of medicine that elevates us to “gods” and renounces our humanness. “Wounded healer” notion. 12 Many doctors are “wounded healers” who have themselves faced one or more of the following: poverty, hunger, war, forced migration, torture, family heartache, alcoholism, divorce, suicide deaths of loved ones, physical/emotional/sexual abuse, racial or ethnic discrimination, religious persecution, gay-bashing, life-threatening disease, or other traumas and losses. While these “sticks and stones” often strengthen us and enable us to practise better medicine, they also make us vulnerable and subject to the same problems as any other human being. Lack of firm boundaries between work and home. Despite the fact that medicine is rarely a “nine-to-five” job and, by its very nature, extends into our personal and family lives (especially when we’re on call or making weekend hospital rounds), we should strive for some demarcation. Here’s a quote from the 14-year-old son of a doctor-patient of mine: My dad and I have a pretty close relationship, but I don’t know why he wears his pager when he’s not on hospital call. It really bugs me. We often do sports together on Saturdays — I worry that our fun is going to get interrupted if his pager goes off with something that’s not an emergency. Unrecognised substance use disorders and/or mood disorders. The culture of medicine accords low priority to doctors’ mental health, despite evidence of untreated mood disorders and an increased burden of suicide. 13 Our proneness to alcoholism and other substance misuse is not diminishing. These maladies have pernicious effects on our intimate relationships, especially communication, sexuality, and trust. Listen to the plaintive words of one doctor’s wife: I’m really worried about my husband, a family physician. I think that he’s quite depressed and burned out. He’s drinking a lot. Our marriage is the pits. I’ve asked him to come in to see you and he refuses. He says he’s fine, that all doctors are burned out these days. His father was also a doctor — he had a nervous breakdown at this age. What should I do? Warning signs of a relationship in troubleDoctors need to ask themselves, and answer honestly, the following questions about their intimate relationships: Do you feel bored or lonely, especially when the two of you are alone? Does your partner complain that you don’t share enough of yourself? How does this criticism make you feel? Defensive? And do your reasons — “I’m tired” or “I don’t have anything new to tell you” or “I was born this way” — seem unsatisfactory or tend to fall short? Are you arguing without resolving the issues? Do you argue about the same matters over and over? Do your arguments leave you feeling exhausted, frustrated or demoralised? Are your arguments increasing in frequency or in intensity (eg, are they escalating to verbal or physical fights)? Are you not arguing at all but are silently seething, withdrawing into yourself, or using passive-aggressive manoeuvres (forgetting to meet requests, being stubborn, disappearing, coming home late, responding with sarcasm)? Or, if you aren’t doing this, is your partner? Do you make a beeline for the liquor cabinet when you get home, and not talk about your day at work — or present only a very abbreviated version once the alcohol takes effect? Are you working so hard that you can’t find the time to talk with your partner? Is it possible that immersing yourself in your medical work has become preferable to talking with your partner? That you find practising medicine more fun, rewarding, and ego-boosting than spending time alone with your partner? How is your sex life? Do you find that your sexual relationship doesn’t seem very intimate? That you “have sex” but don’t “make love” anymore? Strategies to create and maintain relationship intimacySafeguard time for communication in your busy life. Experiment with venues and situations in which you communicate in a more open and relaxed manner — kitchen or living room? at home or outside the home? while out for a walk or a bike ride together? morning or evening? sitting opposite each other or beside each other? with food/beverage or not? The vast majority of couples whom I see tell me that their best talks occur outside the home, away from distractions, interruptions and undone tasks. And if you go for a walk or ride, and you’re not on call, leave your pager, mobile phone, personal digital assistant, etcetera, at home! Read up on relationships. Visit your local bookshop or library and pick up one of the many manuals on improving communication techniques in relationships. Or browse the Internet for material. Try some of the exercises together for a month or two. Consider a marital enrichment weekend. Most faith communities offer these, as do community college continuing education programs and private corporations. What works in many of these endeavours is the basic message that you give to each other: “I care enough about us to go away with you and try to learn new ways of renewing our relationship”. Go for marital therapy if you feel that your personal efforts are not working, or are having limited success. It helps tremendously to have the expertise of a trained professional who can diagnose the problems, explain the “why”, appreciate the positions of both partners, relieve anxiety and sagging spirits, and offer guidance and hope. Take care of your health. If you don’t have a GP, get one today. Concluding wordsCaring for our relationships is good medicine. Having someone to love and nurture is an integral part of being human. Doctors with children find the challenges more manageable and the joys more intense when their primary relationship is happy. And doctors living with illness find the experience much less frightening and lonely when they are fortunate enough to have a loving partner at their side.

Michael F Myers MD, FRCPC

Doctors know many things, but mothers know best The daycare centre will never know. Three-hourly paracetamol through the night at double the recommended dose, a couple of shots of chlorpheniramine and a bit of leftover amoxycillin from the last bout of otitis media thrown in (never mind that it was for a different child). This medical mother is free to face the fully-booked day ahead. School days begin and shrink the working day. First it’s school drop-off; then cramming a 10-hour work day into six; spending the next three running between music, sport, and playing at a friend’s house; and stealing 10 minutes to buy some food for dinner — all conducted with efficiency and alacrity. Nothing more, really, than a long day of appointments and housecalls, with a twist. Adolescence hits the household and it’s not quite so simple. All those refined counselling and negotiation skills, the wisdom so often shared with concerned parent patients and with adolescent patients themselves, somehow get lost in the dirty underwear and half-eaten lunches that have decorated the teenager’s bedroom floor for the past three weeks. Still, life hums along on autopilot, with only the occasional interruption of a sleepless night caring for a sick child, or worrying about a patient — the suicidal teenager, the unwell infant, the bad news I have to break. I suppose there’s a selflessness that comes with both job descriptions; it passes unnoticed, almost always. But there are times when being a medical mother hits me in the face. My first-born arrived 10 weeks early, not long after I had completed six months as a paediatric registrar in neonatal intensive care. Despite the panic, fear, grief, delight and excitement, the irony didn’t escape me. As I watched my baby fail to thrive, the mother and the doctor in me started fighting one another. Doctors make terrible patients, and medical parents are particularly neurotic about their own offspring. I knew these as medical facts. The vaguely smug expressions on the faces of the hospital staff every time I asked a question reinforced the fact that I fitted the medical mother stereotype. But the mother in me eventually won. She made a fuss, and a new diagnosis forced a change in my child’s care that should have happened two weeks earlier. I learned a lesson about medicine that I haven’t forgotten: mothers know best. Becoming a mother changed the way I understood the practice of medicine. Intuition can be as powerful a diagnostic tool as a battery of expensive medical investigations. Empathy takes on a whole new meaning. “Treatment” becomes a limiting concept in the light of real people with real lives, like the lives of my children. And when I start to forget what day it is and who I am, I remember something that happened years ago. I had taken the two oldest children, then four and five years old, into work. One said, “This looks like Dr Phill’s (their GP’s) room!”. “Yes! It’s a doctor’s office, just like Dr Phill’s.” “But you’re not a doctor! You’re a mummy!”

Melissa S-L Kang MB BS

Issues confronting doctor-parents include the impact of parenting on career choice, special challenges faced by women doctor-parents, leave entitlements, and the unique strengths and challenges of two-doctor families. Experience from one Canadian doctors’ health program suggests that unique themes include communication within doctor-families, insight into doctor-parent dynamics, the relationship between doctor-parents and their child’s doctor, and potential boundary crossings and violations within the doctor-family. The relationships between medical workforce sustainability, medical human resources, and issues related to doctor-parents need further consideration and analysis.* My husband and I recently adopted a little boy. We’ve fallen in love with him, and have been rediscovering our play skills, singing voices, and sources of patience. It’s been life-affirming. We’ve also had a crash course in the medical politics of parenting — and so far so good. I am fortunate to have access to parental leave, and, in combination with holiday leave and unpaid leave, I can have almost 8 months to be with our son and maintain a reasonable income. My husband works in the private sector, but has access to almost a year of federally-funded parental leave. Equally important, we live in a community with early childhood centres, free playgroups, and accessible advice about nutrition and development. Professionally, we worry about the impact of our choice on our careers. While in different professions, we both feel pulled between roles and commitments. We are aware of reports from some authors that those who try to balance these roles are slammed, on the one hand, for lacking professional seriousness and, on the other, for lacking parental selflessness. We are also sensitive to some suggestions that doctor-parents are constrained by social assumptions about gender roles, and that parenting and children are undervalued. 1 We’re learning that we can’t be everything to all people and that we need to establish goals, have strategic priorities, and focus on our current life stage. We’ve also realised that we are proof that issues related to doctor-parenting are of equal importance to both women and men,2 are present in doctor-families of all forms, and are, in fact, human issues. The literature on doctor-family issuesCareer choiceParenting, in combination with gender, greatly influences workforce choices for doctors with young families, while gender alone has little impact on those choices. 3 In one US study of surgeons,4 women were more likely to delay having children, and, when they did have children, were more likely to take parental leave. During surgical practice, 12% of the male surgeons and 64% of the women surgeons had taken parental leave. Half of the institutions surveyed in the study had no formal parental leave policy. Studies like these suggest that parenting may have an impact on medical students’ choice to enter the profession, and that formal policies are required to accommodate the needs of doctor-parents. 4 Parenthood also influences the choice of whether to enter academia. Academic doctor-parents spend more than 90% of the time devoted to family responsibilities on child care. Women doctor-parents also have less institutional support (eg, research funding, secretarial support) than their male counterparts. Academic mothers have fewer publications, slower self-perceived career progress, and lower rates of career satisfaction. There appears to be much work to be done to achieve equity in academia. 5 Parental leaveThere has been an evolution in parental leave provisions in some parts of the world, particularly in Canada. Recently, the federal government began to provide 15 weeks of maternity leave and 35 weeks of parental leave (including adoption leave), for a total of 50 weeks of support. In Ontario, an agreement between the Ontario Medical Association and the provincial government provides for 17 weeks of maternity benefits for doctors not eligible for federal funding. Since its inception in 2000, over 900 doctors have taken advantage of the program, which has cost $11.2 million. Calls for paternity and adoptive leave have been less successful. Surveys of doctors who take parental leave suggest it can adversely affect their careers. 6 Institutional and academic culture may influence parents to take less leave than they are entitled to. Academic staff are concerned about the impact on their colleagues of taking leave, and fear that any substantial period of absence may impair their career advancement. One key strategy for easing this dilemma would be to employ temporary locum staff. 6 Given these tensions, parental leave must be a critical part of any discussion about medical resource planning. Any policy that reduces the tension between a doctor’s professional and personal lives should be part of a healthy recruitment and retention strategy. 7 Women doctor-parentsAs the doctors’ health movement evolves, it parallels significant changes in societal perspectives of gender roles. Not only are more women taking on leadership roles in medicine, but men are taking on more childrearing and domestic duties. 8 In spite of these social forces, women doctors, although spending the same amount of time at work as male doctors, spend twice as much time on family and household work. Women doctors are less likely than male doctors to recommend parenting, less satisfied with the time available for parenting, and more interested in flexible working hours. Women are also more likely to claim that the best time to have children is at the end of postgraduate medical training. 9,10 Compared with childless female academic staff and compared with male staff, female academic staff with children face major obstacles in pursuing an academic career. Some of these obstacles could be modified relatively easily (eg, by eliminating after-hours meetings and creating part-time career paths). It has been strongly advocated that medical schools address these obstacles and provide support for academic staff with children. 5 One review of women doctors over an 80-year period found that 82% of women doctors became mothers, and that women doctors without children were more likely to be in surgical specialties, less likely to be in primary care, and more likely to work full-time than their female colleagues with children. Although the length of formal maternity leave increased over the eight decades, the level of satisfaction with leave duration fell. 11 A US study of otolaryngologists revealed that women surgeons were more likely to be divorced or separated and to have fewer children than male surgeons. Women reduced their work hours in conjunction with having more children, while men relied more on their partner for household responsibilities and child care. Women earned less money for performing similar jobs, yet had increased family responsibilities, which potentially affected their career advancement. 12 One study that formally evaluated the time women doctors spend on non-medical work noted that they spend little time on domestic activities that can be done for them by others, such as cooking, housework and gardening. Women doctors spend less time on child care and substantially less time on housework than do other US women. In contrast to other studies, this study concluded that measures of career satisfaction and mental health were not adversely affected by time spent on domestic obligations. 13 Two-doctor familiesUp to 50% of doctors may be married to other doctors. 14 Both men and women in these partnerships earn less money individually, less often feel that their career should take precedence over their spouse’s career, and more often play a major role in childrearing compared with other married doctors. Benefits include more frequent enjoyment from shared work interests and higher combined incomes. In general, two-doctor families achieve their career and personal goals as frequently as other married doctors. 14 Men in two-doctor families tend to work fewer hours than other married male doctors. 15 Keeping things in balanceIn this section I describe some specific solutions that clients of our program, clinicians involved in clinical work with doctor-families, or attendees at our workshops have reported as valuable. The doctor-families we meet come from a wide array of medical backgrounds and represent different cultures, family compositions, and support systems, reflective of families around the world. What makes doctor-parents different?In general, doctor-parents have unique access to health information and knowledge. They are also trained in assessing normal and abnormal development in children. Most have strong career demands. Some need to carefully balance their public versus private roles (depending on the type of clinical work they practice) and their role in the community. Many work longer hours than most parents, including on-call demands. Many are self-employed, without benefits, and need to ensure that they set up and monitor financial safeguards. Finally, sources of rebellion, confusion, and tension can be unique to doctor-families as children gain insight into the elements of medicine that interfere with their ideal family life. Doctor-parents are often high achievers. They seem to be under-represented in the health consumer population, possibly because of their awareness of health promotion and disease prevention strategies. However, there are reports of doctor-parents having reduced quality time with their children, feeling guilt and remorse over their limited parenting roles, and having different attitudes towards childcare and rearing depending on their gender. CommunicationMany doctors report that their long work hours result in reduced contact with their children, particularly if they leave home before their children rise, and/or arrive home close to bedtime. This appears to be a common regret, with some doctor-parents feeling it is too late to learn how to communicate with their children. On-call duty is a common source of tension within doctor-families. Some doctors set their pagers to remind them to make a good-night phone call, while others leave a note in the bathtub, under the pillow, or next to an evening snack. Children of these doctors tell us such gestures send a strong and positive message. Some doctors who come to us about family problems report that they didn’t recognise the red flags of poor communication, and encourage us to emphasise that lack of spontaneity, silent shared time, or hearing of problems through others should raise a doctor-parent’s concerns and prompt intervention. Doctors’ children have emphasised their need to be able to contact their parents directly in a time of urgency. Yet, they feel uncomfortable asking for this, as they know how busy work is for their doctor-parents. Ensuring that children know clinic or hospital staff (particularly assistants or secretaries) is felt to be helpful, and some families have established a code word or phrase that sends the message that the doctor-parent is required urgently. Several doctors have taught their children how to responsibly page or email them, or carry a beeper or mobile phone just for their children to access. InsightMost parents have a healthy fantasy of how they want their children to grow and develop. However, some doctor-parents have disclosed to us that they wished they had been more careful in the expectations they projected onto their children. Some have made the link between being part of a profession that attracts perfectionism, dedication, determination, and obsessiveness, and subsequently expecting their children to follow a competitive path of education and training, enter a profession of parental choice, or engage in activities that meet parental approval. Doctor-parents also report that the combination of work and home responsibilities contributes to isolation from the broader community. A useful intervention has been to help the doctor find time to reconnect, gain support from other parents, access recreational resources, and develop insight into their children’s development outside the home. Working with your child’s doctorDoctor-parents, like all parents, need access to competent general practitioners and paediatricians. Yet, the unique information and knowledge doctor-parents have can be as much of a curse as a luxury. Usual defenses of intellectualisation and minimisation are no longer helpful, and doctor-parents report they are often surprised by the emotions they feel in a routine health scenario. Doctor-parents often have additional anxiety driven by the knowledge of the worst possible outcome. Some feel a need to “do something”, and are uncomfortable with both giving up medical control to a colleague and remaining within the parental role. Some doctor-parents feel guilt and a sense of failure at “allowing” their child to become ill. In addition, some are painfully uncomfortable with finding themselves on the other side of the white coat. Doctor-parents also need to recognise that their child’s doctor may feel intimidated by the parents’ dual role. In these cases, it seems to be helpful to frankly discuss boundaries, acknowledge the skill set and role of colleagues, avoid jargon and “shop talk”, include children and partners in all discussions, and respect advice given. It is also helpful to acknowledge the value of medical skills, such as asking good questions, being an advocate, negotiating access to resources and services, having insight into early warning signs of problems, and being aware of potential sources of solutions. Monitoring boundariesThere have been no large studies on the phenomenon of doctor-parents treating their partners or children. However, it is widely acknowledged that such behaviour occurs and that it can be linked to difficulties with boundaries in medical practice. Few would argue with a doctor-parent’s right to treat his or her child’s superficial abrasion or fever. But ethical overtones shift if doctor-parents treat their own children for such problems as cosmetic, mental, reproductive or oncological health. Yet, paediatricians and staff of doctors’ wellness programs have seen cases of such complex boundary violations, some of which resulted in the involvement of children’s protective services. Some Canadian regulatory bodies are drafting policy to discourage doctors from treating family members. Studies are also in progress to estimate occurrence rates, improve understanding of the issues involved, and promote healthy debate in the profession. ConclusionAs the doctors’ health movement continues to evolve, there is increasing awareness of the importance of the role of doctors in their families and the importance of family members to doctors. Women doctor-parents continue to face unique issues in their professional and personal lives, and male doctor-parents are also taking more of an active role in their personal and family lives. These trends pose opportunities and challenges to medical workforce planning, models of care, academic systems, and remuneration models. There is also a need to increase research into the sociology of doctor-families. Research data are urgently needed to develop strategies to promote doctor-family health and wellness, which is a critical factor in recruitment and retention efforts. In the interim, case and anecdotal data may be of value in helping doctors better balance the tensions between their important, and competing, identities.

Derek G Puddester MD, FRCPC

Addiction is a treatable disease and patients can enjoy rather than endure recovery My work is regarded in various ways by my colleagues. Some see me as a quixotic figure ranting futilely against the impregnable world of alcohol and other drugs, as in the cartoon. Others see me as a sort of medical Mother Teresa on Sydney’s North Shore, devoted to a life of cleaning others’ mess. I think most simply shake their heads, believing that I am delusional and beyond help. This article seeks to define and refine this “delusion”: that addiction is a disease, that it is treatable, and that patients enjoy rather than endure recovery. Do addicted doctors need special treatment?I sometimes feel that all the hard work and inconvenience of gaining a medical qualification is worth it for one short sentence: “Doctor is busy.” As doctors, we have a wealth of privileges not afforded other members of the community. Not only are we excused for lateness, we also have access to a wide range of medicines (many of them dangerous, even in prescribed doses), and are permitted, even expected, to examine people’s bodies and to ask intrusive questions. With these privileges come ethical dilemmas that are not new to the profession — abortion, euthanasia, inappropriate relationships with patients, confidentiality, and commitment to training the next generation of practitioners. All rate a mention in the Hippocratic Oath. However, Hippocrates did not have a protocol for addicted colleagues. The saying that addicts and alcoholics are just like other people except more so is attributed to Sylvester Minogue, a psychiatrist influential in the introduction of Alcoholics Anonymous to Australia. I believe that alcoholic and addict doctors are just like other alcoholics and addicts, except more so. The issues of shame and guilt, of inability to believe that an intelligent person could perform such irrational and obviously unintelligent actions, still abound. Furthermore, colleagues who are patients know and have opinions about many interventions, reducing any chance of a placebo effect and virtually eradicating the impact of medical advice. They’re in the club, and they look carefully for any hint of superficiality in explanations and advice. Are addicts simply adults behaving very badly?Understandably, the moral stance has been the traditional first response by families, communities and medical boards when learning of a doctor’s addiction. Attempts to keep the community safe from addicted doctors have traditionally involved the law and lawyers, in a process that selected out, then deregistered, the “bad apples”. The problem is that addiction also occurs in undeniably “good” colleagues, whose work and track record make it both unacceptable and unhelpful to deal with them punitively (Anecdote 1 and Anecdote 2). Addiction is not “like” a disease — it is oneThis is the heart of my fortifying “delusion” and a debate in which I participated in the Journal in 1992. 1,2 Then, as now, I believed that addiction is a disease because it has definable clinical features, a substantial genetic influence, a reasonably predictable natural history, effective treatments, and even potential biological markers. More recently, others have compared addiction with medical conditions like asthma, diabetes and hypertension. 3 These comparisons have yielded remarkable similarities in genetic heritability, pathophysiology, role of personal responsibility, and treatment response. The effectiveness of drugs such as naltrexone4 and acamprosate5 in the short- and medium-term course of alcohol dependence, and methadone in opiate dependence,6 also argues strongly for medical involvement. The issue of hopelessnessEven more important than whether addiction is a disease is the fact that prognoses are not nearly as hopeless as most medical colleagues believe. The natural history of alcohol addiction can include remission, mostly through long-term abstinence, and often associated with attendance at Alcoholics Anonymous (Anecdote 3). 7 However, the fact that psychosocial interventions work (as they do for many medical conditions) does not render addiction a “non-medical” problem, as some have argued. Sustained abstinence is not an end in itself. If prolonged abstinence merely resulted in a desert of joylessness, as so many people in active addiction fear, then my job would indeed be difficult. In fact, real recovery takes off once abstinence becomes comfortable. New relationships are formed or old ones improved. Central issues, such as what constitutes meaning in life, are addressed. That common core belief of self-inadequacy begins to wither. If addiction is a disease and resetting one’s neural “reward” pathway from the ventral tegmental area to the nucleus accumbens of the brain is a key feature,8 then the treatment is only complete when ego-syntonic activities are fully rewarding — that is, previously enjoyed experiences, such as the joy of relationships, work and recreation, are fully enjoyed once more. Patients of mine in longer-term recovery do not continue to mourn for the moments of pleasure experienced at the end of a needle or a drinking binge. Instead, they are grateful for each sober day. Often, they gladly provide me with assistance with newer patients. Rehabilitation: a more enlightened attitudeThe progress made in treating doctors’ addiction is obvious over my 20 years of practice. Medical or licensing boards worldwide have come to recognise that the safety of the community is enhanced by having a rehabilitative attitude to alcohol and drug dependence. 9 Unidentified doctors still drinking or using drugs pose a greater danger to the community than those who have been identified, are seeking treatment, and are supervised by a stringent medical board program. Medical boards have also come to recognise that monitoring impaired doctors in a process independent of the treatment process is likely to be more beneficial for both doctors and the community. Both treatment and monitoring are important and neither should interfere with the other. The NSW Medical Board was at the vanguard of this movement in developing the Impaired Registrants Program (IRP). Under this program, doctors identified as having breached laws or regulations (such as the NSW Poisons and Therapeutic Goods Act 1966 through self-prescribing of drugs of addiction) make certain voluntary undertakings, such as to attend for assessment by a Board-appointed psychiatrist (whose only role is to provide detailed feedback for the Board’s use). 10 One of the conditions imposed by the IRP is for the practitioner to concurrently undergo treatment. Soon after the establishment of the IRP, I decided that I would be a treating psychiatrist and never a Board-appointed one. I have become much more disposed to referring my medical colleague patients to the IRP, as I have found that assessments by independent psychiatric colleagues can augment and monitor my own assessments and treatment. My other (non-medical) patients do not have the back-up of an independent assessment every 6 or 12 months. My involvement in this process also means I receive regular reports from the Medical Board about my patients and any changes to their conditions. My own frisson of anxiety at receiving an unexpected piece of mail from the Board reminds me of just how trying this process is for my patients. Issues of concern for doctors on monitoring programsMany problems can loom larger than usual for doctors in medical board monitoring programs. For instance, confidentiality is absolutely paramount (Anecdote 4), a drug test result that has gone astray may be misconstrued as a deliberately missed test, and false-positive test results can be especially trying for someone in recovery and working hard to comply with every condition of the IRP (Anecdote 5). All NSW doctors in the IRP are identified as such on their medical registration cards, which bear the word “conditional”. This can be a great source of agitation, and, as some suspect, of prolonged unemployment. Lest I be seen as advocating greater freedoms for doctors on the IRP, let me also say that some doctors may show enough change to satisfy their supervisors, but seem to gain little real insight into their problems. The NSW program is unable, in its present form, to deal with this issue of reluctant compliance. The futureTrends in the United States are for programs that manage identified addict and alcoholic doctors to be handled by systems outside medical boards. These newer programs (including one in Victoria) are called “Doctors Health Programs” (DHP). Most of these are funded in much the same way as medical boards, by medical registration fees, but these programs are independently involved in monitoring, often at four levels (individual, group, workplace and pathology), leaving the medical board to perform disciplinary functions. These programs are probably more intrusive than the ones run by the medical boards, but, while disciplinary procedures may still be imminent if compliance with the DHP is found wanting, many find it an advantage that the term “conditional” is not emblazoned across the registration papers of a doctor in early recovery. Anecdote 1 Dr A was a trainee physician who had been practising in another jurisdiction. He returned to Sydney, unregistered, and was referred by a senior specialist. A had developed an addiction to pethidine in the context of major social upheaval while working, and had been found diverting some from the hospital. His registration was suspended for 9 months, but no treatment was offered. On his return to Sydney and referral to my care, he was only able to gain the benefit of the NSW Impaired Registrants Program (IRP) after his suspension elsewhere ended. He responded to a regimen including counselling, urine testing and regular review by the IRP. Initially, he worked in unfashionable posts, but later returned to his previous level, passed his specialist exams, married and had children. Anecdote 2 Dr B was an influential specialist who referred himself, saying that his principal problem was migraines, but he had begun to self-medicate with a variety of opiates, including pethidine. Representatives of the Pharmaceutical Services Section of the Department of Health (which monitors the dispensing of Schedule 8 drugs in New South Wales) had visited him and informed him that it would be best if he voluntarily surrendered his right to prescribe S8 drugs. On taking a history, I discovered that, some 20 years before, he had been identified as having misused opiates, been reprimanded by the Medical Board, and been sent for treatment, which was unconventional, unmonitored, and, as his current presentation showed, ineffective. Anecdote 3 A 22-year-old medical student’s drinking habits and poor exam results were a source of concern to his supervisors. He was called before the warden of the clinical school and reprimanded. He resentfully disregarded this advice, but soon after was serendipitously placed as a medical student at a drug and alcohol treatment facility, where he identified himself as an alcoholic. He became a member of Alcoholics Anonymous and has remained sober and happy for many years without treatment. I know of his story because he sometimes helps me in supporting my medical patients. Anecdote 4 Dr C, a Resident Medical Officer from another hospital, rang to say that he desperately needed inpatient treatment under my care. I agreed, not learning until later that he was due to commence a term at Royal North Shore Hospital in the 12 months after his discharge. Subsequently, a colleague and rival of C was found to have enquired about gaining access to C’s inpatient medical records. C’s initial distress was well managed, he became a dedicated Narcotics Anonymous member, and has now graduated from the Impaired Registrants Program and been drug-free for more than 5 years. Anecdote 5 A colleague referred his patient, Dr D, who had been self-injecting benzodiazepines and lying about his alcohol use. After a brief negotiation, D informed the Impaired Registrants Program. He began urine testing, attending the Doctors Recovery Group and Alcoholics Anonymous. D became distressed when, despite a month of abstinence, his urine was still testing positive for benzodiazepines. He sought detailed quantitative analysis of his urine benzodiazepine levels allowing for the urine concentration, which subsequently showed an exponential decline consistent with abstinence. After only a year, his work, marriage, parenting, physical health and leisure pursuits have all improved dramatically.

Stephen M Jurd MB BS, FRANZCP, FAChAM

Despite suffering bouts of deep depression at certain times of her life, Helen Tolhurst has survived to tell the tale. With the help of close friends and a caring and supportive therapist, she is learning to find a balance between pursuing her medical career and taking time out to relax and experience life’s small pleasures My first memories of depression are of black periods as a child during which I hated myself and would hide under the blankets at night, thinking that if I held my breath for long enough maybe I would die. Having had many further episodes of depression since that first childhood experience, I often think how fortunate I am to have been born in the latter part of the 20th century rather than the earlier part, like my grandmother. Not for the reasons that you might at first think — such as the convenience and ease of so many aspects of modern life — but because of the wonders of modern psychiatry. My grandmother (see Box) had her first “nervous breakdown” at the age of 17, when her brother was killed at Gallipoli. From that time on, her life was punctuated by episodes of disabling depression for which she was admitted to hospital and often given electroconvulsive therapy. Her life was transformed by the advent of tricyclic antidepressants in the 1950s — at last there was an effective medication to treat her illness. Like me, several of my family members have inherited a vulnerability to depression, with which some of us have struggled for much of our lives. Different events have triggered each episode of depression. There was an episode of feeling desolate and losing a lot of weight because of problems in a relationship in my late teens, but mostly I just got on with life, studied medicine, married in 1973, and graduated in 1975. We moved to Alice Springs in 1978 and soon had two beautiful daughters. However, all was not well. After returning to work when I had a 2-year-old and a 6-week-old baby, I found the struggle to balance work and family overwhelming and, after a miscarriage, fell into a black hole of depression. Because of past severe hyperemesis gravidarum, I had not wanted another baby and felt guilty about what I saw as my failures as a mother. I can remember thinking, as I drove around the town, that deliberately crashing into a telegraph pole would be a way out of the blackness. I felt as if I was desperately hanging on to life only for the sake of my husband and children. It is difficult for a doctor to seek help for mental health problems in a remote community like Alice Springs. I felt ashamed of my inability to cope and unable to talk to my colleagues about the desperation I was feeling. My practice partners were totally overloaded with work, and I felt that to tell them how miserable I was would just sound like whingeing. So I struggled through my depression, trying to hide how I was really feeling from those around me. Looking back, I sometimes wonder how I survived. Recognising our need for family support, we moved closer to my parents in 1984. Again, just getting on with life, I bought a general practice, while my husband worked as a teacher and our girls started school. But, feeling torn between work and family, I slipped again into the black hole of depression. Help was now more readily available, and I saw a psychologist who suggested I take antidepressants. Too embarrassed to consult any colleagues, I committed the cardinal sin of self-medicating. By 1995, I realised that, although I had always loved general practice, I was completely “burnt out”. I sold my practice so I could pursue interests in research and teaching. However, there were now problems in my marriage and difficulties coping with the needs of my teenage daughters and the demands of a stressful situation at work. For 6 months I scarcely managed to sleep more than 3 or 4 hours a night, waking in the early hours of the morning, feeling completely alone in the darkness, tortured by black thoughts. I felt guilty about my inability to cope with work and family life and my failure to be the perfect doctor, perfect wife and perfect mother. There were also conflicts at work that recalled past unhappy times during my childhood. As I woke each morning, I felt like a wrung-out rag and it took enormous effort to get out of bed. By this time, I had admitted to myself that I needed professional help. I recovered from this episode of depression with the help of a psychologist and antidepressants prescribed by my general practitioner. The tremors, sweating and increased appetite caused by the antidepressants were a small price to pay for relief from the depression. For the first time, on the advice of my therapist, I took some time off work when the depression was at its most severe. Although I was relatively well by now, I realised that just wishing to remain so would not make the depression go away. I needed some long-term expert help. Finding a psychiatrist with whom I felt comfortable and confident was more difficult than I had anticipated. I was initially referred to a senior psychiatrist who had an angry and aggressive manner and, without taking a proper history, told me to stop taking the antidepressants, at a time when I was quite suicidal. I think it can be difficult for psychiatrists to find the right balance between empathy and professional objectivity, and I found some psychiatrists so distant that they made me feel as if I were carrying some sort of contagious disease. But at last I found a skilled, caring doctor, who treats me like an intelligent human being and is empathic and understanding about the pain I feel. Thanks to his help, I have recovered more rapidly from subsequent episodes of depression. Recently, after almost 30 years of marriage, my husband and I separated, and, grief-stricken, I plunged again into deep depression. As I worked my way through many past hurts, I wept and wept until I wondered why I wasn’t dehydrated. The wound inflicted by the end of my marriage is slowly healing and at last I am well, but I know now that staying well will take more than just medication. There are many things I need in my life to manage my depression: loving, supportive relationships; the right balance between work and other parts of my life; enjoyable work and leisure pursuits; regular exercise; meditation; and even the company of my cats. I am still learning how much work I can manage, having recently courted a relapse by working 7 days a week for 3 weeks. I need to anticipate stressful events in my life and think about ways to best cope with them. I am learning to be kinder to myself. I am coming to accept that for me there will be side effects with a therapeutic dose of medication. Hoping to reduce the stigma that members of the community and even the medical profession attach to depression, I am now more open and honest about my condition. The responses of my colleagues to this vary. Some who also have depressive illnesses welcome the opportunity to share their experiences with a fellow depression sufferer, while some offer support and sensible advice. But others react with awkward silence, or rapidly attempt to change the subject with looks that say “Don’t mention the war”. I wonder why they find open discussion with a colleague about her experience of a mental illness so difficult. Is it so different from diabetes or asthma? Do they think emotional difficulties are too private and personal to discuss with a colleague, or do they really see depression as a manifestation of weakness that I could overcome if I tried a bit harder to “pull myself together”? Still, I continue to hope that being more open about my illness will make life easier for my family members who also suffer from depression. If I had had some say in the matter I would never have chosen to have a depressive illness — yet, at the same time, I don’t regret it. There are two reasons for this. The experience of depression has given me some understanding of the pain my patients suffer when they descend into that black hole, and has made me more able to be empathic about their illness. And emerging from the blackness into normality, which sometimes seems like dazzling light, I have discovered joy in the smallest of life’s pleasures. So, how can a depressed doctor find much-needed help? For me, a supportive relationship with a therapist has been one of the most important factors in getting well. Sometimes you may know of a GP, psychiatrist or psychologist whom you like and trust, or about whom you have heard good things. Sometimes it requires enormous effort to take that first step in seeking help — but you can’t, and shouldn’t, treat yourself. If you think you need professional help, don’t hesitate to seek it. If you don’t know someone appropriate you may prefer to contact an organisation such as the NSW Doctors’ Health Advisory Service (tel: [02] 9437 6552; website: www.doctorshealth.org.au) that can refer you to an appropriate therapist. There are other helpful resources, such as the website (www.beyondblue.org.au) and the book Beating the blues, by Tanner and Ball. But paramount in recovering from depression is the help of a competent and caring therapist. A familial illness A: The author’s grandmother, who suffered crippling bouts of depression before the advent of tricyclic antidepressants. B: The author enjoying life, with the help of antidepressants and a supportive therapist.

Helen M Tolhurst MB BS, FACRRM

Forty-five years as a doctor with diabetes has given Alan Stocks personal insight into how to manage life and practice when living with a chronic illness. Diabetes has proved beneficial to his career, rather than a disadvantage. As a final-year medical student in 1959, over a 2-week period I experienced increasing thirst, polyuria and lassitude, and lost 5 kg in weight. Suspecting diabetes, I performed a urine test using Clinitest. The test was negative for glucose, and, believing my symptoms were caused by pre-examination stress, I took no action. Golden Jubilee meeting of Diabetes Australia – NSW, 1987 The meeting marked the 50th anniversary of the foundation of the first Diabetes Association in Australia. Shown in the photo are John Townend, Chairman of Diabetes Australia – NSW; Phyllis Lush, the first person to receive insulin in Australia; Kempson Maddox (her physician); and the author. Over the next 4 weeks my symptoms worsened rapidly, and I failed a pathology examination. I was so ill that, like all medical students at some time or other, I was convinced I had some sort of malignancy. Finally it dawned upon me that the first test might have been wrong. A repeat test showed high glucose and acetone levels — a random blood glucose level of 25 mmol/L established the diagnosis. Immediate admission to a diabetic ward was advised, but I asked if I could delay admission until the next morning, as I had a date that evening (diabetics often rebel against their condition, but not usually as quickly as that!). There followed a hurried discussion, and my request was granted, provided I first gave myself an injection of insulin. This accomplished, I had a most enjoyable evening, and can still remember being able to sit through the first act of an opera without having to visit the toilet. Already I had learned several valuable lessons about clinical medicine, and diabetes in particular: Urine-testing equipment has a limited shelf-life (in retrospect, that first test tablet must have deteriorated); Always trust your clinical judgement, rather than laboratory tests alone; People with insulin-dependent diabetes should take immediate responsibility for their condition, and should give their own first insulin injection; self-injection is easy, and not to be feared; The effect of insulin is dramatic; Wherever possible, diabetes management should be adapted to fit the patient’s lifestyle. Given my initial fears, to learn that I had a treatable condition came as a great relief, and since that first day I have never resented my diabetes, regarding it more as a constant companion than an illness. In fact, diabetes has proved beneficial to my career, rather than a disadvantage. I had originally hoped to become a surgeon, but was advised at the time that this path would be unwise, in view of the unpredictable hours and mealtimes it would entail. Therefore, I decided to specialise in diabetes. This has allowed me better to understand my own condition. Moreover, I believe that many patients derive comfort and confidence from knowing that their diabetes specialist, who also has diabetes, is apparently in good health! Now semi-retired, I walk 30–60 minutes daily, and am much fitter than when I worked 12-hour days. Apart from some symptomless vascular calcification, I am completely free of long-term complications. I look after the day-to-day management of my diabetes myself, but visit an endocrinologist once a year (for a full medical check-up and complications screen) and an ophthalmologist every 1–2 years. Speaking personally, my wonderful wife has been of inestimable support over the years, and we have two splendid children and two grandchildren. I play golf, which is an ideal sport for the diabetic, as the amount of exercise is moderate and predictable (unlike tennis or cricket) and safe (unlike football). I am also active in madrigal singing. Although I am interested in motor racing, my diabetes precluded me from holding a racing licence; I also had to surrender my glider pilot’s licence on diagnosis. However, I have been able to enjoy membership of a Beefsteak & Burgundy Club, learning to adjust my insulin doses to cope with some remarkable dining extravaganzas! I have found it easy to deal with most of the usual problems of living with diabetes. The need to eat regularly and diet carefully has lessened in more recent years with the advent of ultrashort-acting insulin and the basal-bolus insulin regimen. I am able to avoid jetlag on long trips by travelling business class and combining alcohol and temazepam to ensure 12 hours’ sleep (contrary to textbook advice!), plus aspirin to prevent deep venous thrombosis. My biggest problem is the ever-present risk of hypoglycaemia — in particular, the problem of hypoglycaemia unawareness, which remains the “Achilles’ heel” of type 1 diabetes. Perversely, the harder one tries to avoid hyperglycaemia and achieve an HbA1c level low enough to prevent vascular and neurological complications, the greater becomes the risk of hypoglycaemia unawareness. Now, after 45 years of living with diabetes, I have total unawareness of nocturnal hypoglycaemia, and limited ability to recognise daytime episodes. Regrettably, like most diabetics, I deny that I am hypoglycaemic, even when it is obvious to all around me, and I may become obstreperous when asked to consume carbohydrate! The reason for this denial response is obscure, but may relate to the strict warning given to all newly-diagnosed diabetics (and indelibly etched on their consiousness) to avoid sugar — a message that floats to the surface during hypoglycaemic confusion. The reason for the violent, uncooperative behaviour is equally obscure, but may simply represent release of the underlying personality from inhibition by the superego, much as occurs with alcohol intoxication. When acutely drunk, some people become aggressively antisocial, while others become quiet and morose. International Diabetes Federation meeting in New Delhi, 1976 The author (left) enjoys himself with colleague Brian Hirschfeld and elephant. My wife has rescued me from countless episodes of nocturnal hypoglycaemia, and has saved my life on several occasions. Fortunately, I have rarely become violent when hypoglycaemic, and have learned — admittedly slowly — that when my wife says “You’re hypo!” (a) she is always correct, and (b) it is easier to eat the jelly beans than to argue! Certainly, the frequency of daytime and nocturnal hypoglycaemia can be reduced by using newer long-acting insulin analogues such as insulin glargine or insulin detemir, and can be virtually abolished using a continuous subcutaneous insulin infusion (CSII) — but at a price! Insulin glargine, not yet available under the Pharmaceutical Benefits Scheme, costs $800–$1200 a year. CSII costs about $2500 a year for the consumables alone, but the Federal Government, in its May 2004 Budget, promised to subsidise these costs to the value of $20 per month from September 2004. I have tried CSII on three separate occasions and, while my glycaemic control was undoubtedly better, the inconvenience, high cost, and risk of skin infections were unacceptable. A basal-bolus insulin regimen using Novorapid three times a day via an Innovo pen injector suits me well, and the Innovo memory feature is of great assistance on the occasions when I can’t remember if and when I gave the last dose. Insulin glargine at bedtime allows me much smoother glycaemic control than isophane insulin. Of course, not all diabetics feel as positively as I do; many fear injections, fingerpricks, blindness and gangrene (but, interestingly, not heart attacks!). My view is that injections using 31-gauge needles really don’t hurt, that fingerpricks are a small price to pay for good health, and that long-term complications should be preventable without sacrificing an enjoyable lifestyle. However, diabetes is a constant companion, and one is reminded that one is diabetic every hour of every day. The ability to cope with that certainty goes a long way towards being able to live successfully with diabetes.

Alan E Stocks AM, FRCPE, FRACP

Mood disorders. Recognition and treatment. Peter R Joyce, Philip B Mitchell (editors). Sydney: UNSW Press, 2004 (xvi + 508 pp). ISBN 0 86840 447 0. This is a big book about a big topic. Anyone concerned with observing — or improving — the human condition must be informed about mood disorders. The book covers both depression, which is the most common disorder, and the various levels of mania, where depression usually presents intermittently. Medical practitioners, in particular, need to be up-to-date in their knowledge of mood disorders in order to improve and save lives. The editors begin wisely. Instead of starting their book with its subjects stretched out anatomised on dissecting room tables, they begin with descriptions of being depressed or being manic written by people who have experienced these conditions. Any reader who has escaped these painful and destructive disorders should read the descriptions carefully and reflect upon them. This book, of more than 500 pages, containing 40 essays by clinicians, covers everything from brain imaging and electroconvulsive therapy to psychotherapy. It is an encyclopaedia, worthy of its subject, and I used it like an encyclopaedia. I put it on my shelves and took it down when I wanted to expand my knowledge in a particular area, or to examine whether or not I was up-to-date on a topic. Professor Mulder’s contribution on the duration and natural course of depression is particularly important (it is often subdued but only occasionally totally vanquished). The book was both illuminating and helpful. Importantly, it is also very thoroughly referenced so that one can pursue a topic further if one wishes. I would like to make one personal observation. To my mind depression is, in some respects, like pain. All pains have a lot in common, but there are many different causes of pain and many different kinds of pain. In most cases the cause determines the management (eg, the pain of acute appendicitis is better dealt with by appendicectomy than by referral to a pain unit). So it is with depression, but some contributors (eg, in “Psychological therapies for depression”) could lead one to believe that there are some invariant aspects of depression which require psychotherapy of some complexity. Sometimes this is true and sometimes not. Many patients make a full recovery with appropriate medication, some commonsense support, and information and advice of the kind that we would give to patients with diabetes mellitus. Who should buy this book? Certainly all psychiatrists, but there are many other practitioners who have to deal with this common and lethal spectrum of disorders. For many it will not be their primary text, but it will be a very good resource when difficulties arise. John H T EllardPsychiatrist, Sydney, NSW

John H T Ellard

Med J Aust 2004; 181 (7 Suppl).