MJA
MJA InSight
MJA Careers
Medical profession

Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors

Louise M Nash, Michele G Daly, Patrick J Kelly, Elizabeth H van Ekert, Garry Walter, Merrilyn Walton, Simon M Willcock and Chris C Tennant
Med J Aust 2010; 193 (3): 161-166.
Abstract

Objective: To identify factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors.

Design, setting and participants: Cross-sectional postal survey of 2999 doctors (including all major specialty groups, trainees and general practitioners) insured with an Australian medical insurance company. The potential for psychiatric morbidity was measured by the General Health Questionnaire (GHQ), and the potential for hazardous alcohol use by the Alcohol Use Disorders Identification Test (AUDIT). The survey was conducted in 2007.

Main outcome measures: Demographic, work-related and personality factors associated with a GHQ score > 4 and an AUDIT score ≥ 8.

Results: Factors significantly associated with psychiatric morbidity in doctors were: having a current medicolegal matter, not taking a holiday in the previous year, working long hours, type of specialty, and having personality traits of neuroticism and introversion. Factors significantly associated with potentially hazardous alcohol use were being male, being Australian-trained, being between 40 and 49 years of age, having personality traits of neuroticism and extroversion, failing to meet Continuing Medical Education requirements, and being a solo practitioner.

Conclusions: The mental health of medical practitioners is crucial to the quality of care their patients receive. Doctors should reflect on their hours of work and need for holidays. Involvement with medicolegal processes, such as lawsuits, complaints and inquiries, is a stressful part of medical practice today. Doctors need to be educated about these processes and understand how the experience may affect their health, work and loved ones.

Doctors with high levels of psychiatric morbidity or hazardous alcohol use may provide a lesser standard of care than doctors without these problems.1 Factors associated with psychiatric illness in doctors include stressors within and outside of work, personality type (particularly neuroticism) and family history of mental illness.2-5 Specific factors reported in the literature include working long hours,6,7 being young, working night duty, being divorced,8 having high stressful life-event scores,9 and having experienced medicolegal matters.7,10-19 Factors that have been associated with hazardous levels of alcohol consumption in doctors include having high stress and anxiety levels,20 being male, being a surgeon,21,22 and having experienced a medicolegal matter.19

In 2007, a questionnaire was administered to all major groups of specialist doctors insured with UNITED Medical Protection (before it merged with another company to become Avant Mutual Group Limited). The questionnaire examined work-related factors, including medicolegal matters, demographic factors and personality factors.

We have previously analysed the responses from the questionnaire to examine the factors associated with Australian doctors experiencing a medicolegal matter.23 This study investigates whether factors reported in the literature and other factors — including not taking a holiday in the previous year, being Australian-trained, attending a peer review, meeting continuing medical education (CME) requirements, and having a current medicolegal matter — are associated with psychiatric morbidity and hazardous alcohol use for this broad range of Australian doctors. Results from a similar questionnaire administered only to GPs have been published previously.19

This is a collaborative research project between the University of Sydney and Avant.

Methods

A questionnaire was mailed to all specialists (obstetricians, gynaecologists, physicians, surgeons, anaesthetists, psychiatrists, pathologists, radiologists, paediatricians, and accident and emergency specialists), registrars and specialists in training, and a sample of GP non-proceduralists who had been insured with UNITED. GP proceduralists were not included as they had participated the previous year in a similar GP study.19 Surveys were returned by reply-paid mail. Four weeks later, a reminder letter and repeat questionnaire were sent to non-respondents.

The questionnaire elicited demographic and practice details — age, sex, specialty, hours worked per week, country of medical degree, teaching role, attendance at peer review, fulfilment of CME requirements, holiday in previous 12 months — and measures of personality, psychiatric morbidity and alcohol use. The questionnaire also asked if the doctor had ever experienced any of the following medicolegal matters: a claim for compensation for damages, complaint to a health care complaints body, medical registration board inquiry, disciplinary hearing, Medicare Australia/Health Insurance Commission (HIC) inquiry, hospital dispute, hospital investigation, pharmaceutical services inquiry, complaint before an anti-discrimination board, coronial inquiry, criminal charge, or patient complaint direct to the doctor.

Personality was measured using the Eysenck Personality Questionnaire (EPQ) — Revised Short Scale version.24 The EPQ is a valid and reliable self-report questionnaire that measures three major dimensions of personality: extroversion (a low score representing introversion); neuroticism (measuring emotional stability or sensitivity); and “psychoticism” (measuring tough mindedness and, at the extreme, lack of empathy, but not actual psychotic features).

Psychiatric morbidity was assessed using the General Health Questionnaire-28 (GHQ),25 a sensitive and well validated screening tool to detect common non-psychotic psychiatric morbidity by considering symptoms over the previous 2 weeks. It has four subscales: somatic symptoms; anxiety and insomnia; social dysfunction; and depression. Case identification for risk of psychiatric morbidity was based on a combined score > 4, using binary scoring for each question (with the two least symptomatic answers scoring 0 and the two most symptomatic answers scoring 1).

Alcohol use was assessed using the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT),26 a sensitive 10-item questionnaire to detect hazardous and harmful drinking. Subjects scoring a total of 8 or more were classified as potentially hazardous drinkers (AUDIT case identification).

Our study compared respondents with non-respondents by age, sex, specialty and experience of medicolegal matters.

Ethics approval

Our study was approved by the human research ethics committees of Northern Sydney Central Coast Area Health and the University of Sydney, and the board of Avant. Anonymity and confidentiality were protected at all times.

Statistical analysis

Data were analysed using SAS software, version 9.1 (SAS Institute Inc, Cary, NC, USA). Univariate analyses were conducted using Pearson’s χ2 tests. Multivariate logistic regression models were fitted to outcome measures of both GHQ case identification for psychiatric morbidity and AUDIT case identification for potentially hazardous drinking. Variables were included if their univariate P value was less than 0.3. The fit of the model was checked using the Hosmer–Lemeshow goodness-of-fit test.27

Results
Characteristics of respondents

Of 8500 doctors invited to participate in the study, 140 declined, and surveys were sent to the remaining 8360. Of these, 2999 (36%) responded.

The mean number of hours worked per week was 44.8 (SD, 15.1), with male doctors averaging 48.0 hours (SD, 14.2) and female doctors averaging 37.1 hours (SD, 14.3). The mean number of weeks worked per year was 46.0 (SD, 6.0). Thirteen per cent of the cohort had not taken a holiday in the previous 12 months. About two-thirds of respondents (1902/2942 [65%]) had experienced medicolegal matters, with 426 (14%) having a current matter.

We have previously reported the demographic and practice details, and the type, frequency and factors associated with medicolegal matters for this study,23 including a detailed comparison of respondents with non-respondents. There were only minor differences between the two groups.

Potential for psychiatric morbidity

GHQ case identification for psychiatric morbidity for the total cohort was 28% (31% for women, 26% for men). The results of the univariate and multivariate logistic regression analyses for psychiatric morbidity found by GHQ case identification are shown in Box 1. All variables were included in the multivariate analysis except teaching role (for which the P value was > 0.3 in the univariate analysis).

In the multivariate analysis, significant demographic and work-related variables associated with increased potential for psychiatric morbidity were: having a current medicolegal matter (odds ratio [OR], 1.96 [95% CI, 1.52–2.54]); not having had a holiday in the previous year (OR, 1.92 [95% CI, 1.47–2.50]); and working long hours per week (OR, 1.65 [95% CI, 1.20–2.26] for ≥ 60 hours compared with < 40 hours). Specialty was also statistically significant (P = 0.03) (Box 1). Doctors 60 years of age or older had a lower likelihood of psychiatric morbidity than doctors under 40 years of age (OR, 0.58 [95% CI, 0.39–0.84]). Solo practitioners had a lower risk of psychiatric morbidity than non-solo practitioners (OR, 0.78 [95% CI, 0.61–0.99]). The personality trait of neuroticism (defined as having a neuroticism score greater than the median) was the highest risk factor for psychiatric morbidity (OR, 4.65 [95% CI, 3.82–5.65]). Introversion was also a statistically significant risk factor for psychiatric morbidity (P = 0.04).

Potential for hazardous alcohol use

AUDIT case identification for potential for hazardous alcohol use for the total cohort was 15% (8% for women, 17% for men). The results of the univariate and multivariate logistic regression analyses for potentially hazardous alcohol use are shown in Box 2.

Demographic and work-related variables in the multivariate analyses associated with increased risk of potentially hazardous drinking were: being male (OR, 2.55 [95% CI, 1.83–3.55]); being aged 40–49 years compared with under 40 years (OR, 1.86 [95% CI, 1.22–2.83]); not having met CME requirements (OR, 1.72 [95% CI, 1.04–2.87]); and being a solo practitioner rather than a non-solo practitioner (OR, 1.33 [95% CI, 1.01–1.75]). Neuroticism (OR, 2.20 [95% CI, 1.74–2.78]), extroversion (OR, 1.62 [95% CI, 1.28–2.04]) and psychoticism (OR, 1.27 [95% CI, 1.01–1.60]) were all associated with potential for hazardous alcohol use. Doctors were at less risk of hazardous alcohol use if they trained overseas rather than in Australia (OR, 0.56 [95% CI, 0.39–0.81); worked more than 60 hours a week compared with less than 40 hours a week (OR, 0.67 [95% CI, 0.45–0.99]) and had not taken a holiday in more than a year (OR, 0.63 [95% CI, 0.43–0.93]).

Discussion

Our investigation found that the personality trait of neuroticism carried the highest risk for psychiatric morbidity. Of work-related factors, having a current medicolegal matter was the factor most associated with psychiatric morbidity, followed by not taking a holiday in the previous year and working long hours.

For potentially hazardous alcohol use, demographic and personality factors were more significant than work-related factors. The greatest risk factors for hazardous alcohol use were being male, having an Australian medical degree, and having personality traits of neuroticism and extroversion. Two work-related factors were also associated: being a solo practitioner, and not meeting CME requirements. There was no significant association between having a current medicolegal matter and potentially hazardous alcohol use (P = 0.09).

Interestingly, doctors who worked long hours and had not taken a holiday in the previous year were more likely to have psychiatric morbidity but less likely to drink alcohol hazardously, perhaps because they had less opportunity to do so due to their work demands.

Our findings that long working hours and the work-related stressor of a medicolegal matter were associated with psychiatric morbidity in doctors are consistent with the findings of other studies.6,8-12,16-18 Our finding that older doctors had a lower risk of psychiatric morbidity is consistent with a recent Australian study.28

The proportion of clinicians with a GHQ case identification (28%) was close to that observed in the GP study (27%).19 The level of psychiatric morbidity was higher among study participants than in a South Australian general population study, where case identification was 19.5%.29

The reported prevalence of potentially hazardous alcohol use in our study (15%) was higher than that in the GP study (12%)19 and similar to that found in a general Canadian population (14%).30 The female case identification of 8% in our study was the same as that of the Australian national survey of alcohol use in Australian women.31

Our study showed that potentially hazardous alcohol use occurs more in male than female doctors, as reported in other studies.20,21 However, no specific speciality group was identified as being significantly more associated with hazardous alcohol use. This contrasts with a German study that found surgeons to be more likely to drink hazardously.21

Considering personality variables, the results of our study are consistent with the GP study19 and an English study5 in finding that neuroticism and introversion are associated with psychiatric morbidity. The association of neuroticism, extroversion and psychoticism with potentially hazardous alcohol use is similar to the findings of the GP study.19

A medicolegal matter should be regarded as a predictable work-related stressor for which doctors need to be prepared, considering that two-thirds of our sample had experienced a matter at some time and 14% had a current matter. Just as they would advise their own patients, doctors should actively manage stressful life events using positive coping strategies. These strategies include stress reduction techniques, regular exercise, good sleep and diet, as well as working fewer hours a week, being well informed about the legal process, seeking advice from one’s own doctor to ameliorate distress and anxiety, and avoiding negative coping strategies like excessive alcohol consumption and self-medication.

The strength of our study was its large sample size, representing 5% of the entire Australian medical workforce and around 10% of the non-GP specialist groups (ranging from 9% for physicians to 14% for obstetricians and gynaecologists.32 Although the response rate to our survey (36%) was relatively low, the idea that a high response rate is necessary has been challenged (as discussed in our previous study).23

The mental health of medical practitioners is crucial to good patient care. Unlike personality traits, the work-related and lifestyle factors associated with psychiatric morbidity and hazardous alcohol use are more easily addressed. Doctors should reflect on their hours of work and need for holidays. Involvement with medicolegal processes, such as lawsuits, complaints and inquiries, are a stressful part of medical practice today. Doctors need to be educated about medicolegal processes and understand how the experience may affect their health, their work and their loved ones.

1 Univariate and multivariate* analysis of factors associated with psychiatric morbidity (GHQ score > 4)

Variable

No.

GHQ score > 4 (%)

P

 AOR (95% CI) 

P


Medical specialty

0.008

0.03

General practitioner

589

177 (30)

1.00

Obstetrician/gynaecologist

177

43 (24)

0.72 (0.44–1.17)

Surgeon

359

89 (25)

0.74 (0.49–1.10)

Anaesthetist

350

83 (24)

0.71 (0.49–1.02)

Psychiatrist

230

64 (28)

1.09 (0.71–1.67)

Pathologist

86

18 (21)

0.41 (0.21–0.81)

Radiologist

106

32 (30)

1.06 (0.62–1.81)

Physician

478

138 (29)

0.96 (0.68–1.36)

Accident and emergency specialist

60

15 (25)

0.81 (0.40–1.66)

Paediatrician

140

40 (29)

0.91 (0.56–1.48)

In training§

252

91 (36)

1.05 (0.69–1.59)

Other

126

22 (17)

0.43 (0.25–0.76)

Sex

0.006

0.99

Female

868

269 (31)

1.00

Male

2085

543 (26)

1.00 (0.78–1.28)

Age group (years)

< 0.001

0.001

< 40 

482

148 (31)

1.00

40–49

872

271 (31)

1.10 (0.81–1.50)

50–59 

917

281 (31)

0.89 (0.65–1.23)

≥ 60

682

112 (16)

0.58 (0.39–0.84)

Country in which medical degree obtained

0.82

Australia

2470

682 (28)

Overseas

476

129 (27)

Solo practice

0.006

0.04

No

2044

592 (29)

1.00

Yes

899

216 (24)

0.78 (0.61–0.99)

Marital status

0.05

0.29

Single

231

70 (30)

1.00

Partnered

2511

668 (27)

1.17 (0.83–1.65)

Divorced/separated

154

56 (36)

1.31 (0.78–2.19)

Widowed

38

11 (29)

2.34 (0.95–5.77)

Hours worked per week

0.007

0.02

< 40 

823

194 (24)

1.00

40–49

753

209 (28)

1.23 (0.93–1.62)

50–59

747

210 (28)

1.41 (1.05–1.89)

≥ 60

596

190 (32)

1.65 (1.20–2.26)

Peer review in previous 12 months

0.1

0.65

No

875

257 (29)

1.00

Yes

2056

543 (26)

0.95 (0.75–1.19)

CME requirements

0.27

0.32

Not met

112

36 (32)

1.29 (0.78–2.11)

Met or not applicable

2785

764 (27)

1.00

Teaching role

0.35

No

1008

267 (26)

Yes

1907

536 (28)

Holiday in previous 12 months

< 0.001

< 0.001

No

388

161 (41)

1.92 (1.47–2.50)

Yes

2526

643 (25)

1.00

Current medicolegal matter

< 0.001

< 0.001

No

2478

638 (26)

1.00

Yes

421

163 (39)

1.96 (1.52–2.54)

Psychoticism

0.08

0.80

≤ Median

1776

508 (29)

1.00

> Median

1090

279 (26)

0.97 (0.80–1.19)

Extroversion

< 0.001

0.04

≤ Median

1594

500 (31)

1.00

> Median

1238

280 (23)

0.81 (0.67–0.99)

Neuroticism

< 0.001

< 0.001

≤ Median

1714

252 (15)

1.00

> Median

1154

542 (47)

4.65 (3.82–5.65)


GHQ = General Health Questionnaire–28. AOR = adjusted odds ratio. * Hosmer–Lemeshow goodness-of-fit test, P = 0.37. † Univariate analysis. ‡ Multivariate analysis. § Specialist in training, hospital registrar, GP registrar. ¶ This variable was not included in the multivariate analysis (P value > 0.3 in the univariate analysis).
CME = Continuing Medical Education.

2 Univariate and multivariate* analysis of factors associated with hazardous alcohol use (AUDIT score ≥ 8)

Variable

No.

AUDIT score ≥ 8 (%)

P

AOR (95% CI)

P


Medical specialty

0.25

0.54

General practitioner

590

73 (12)

1.00

Obstetrician/gynaecologist

179

27 (15)

0.96 (0.54–1.70)

Surgeon

357

67 (19)

0.92 (0.58–1.46)

Anaesthetist

351

63 (18)

1.10 (0.72–1.69)

Psychiatrist

231

35 (15)

0.89 (0.53–1.49)

Pathologist

89

11 (12)

0.95 (0.46–1.99)

Radiologist

107

16 (15)

0.74 (0.37–1.48)

Physician

480

65 (14)

0.81 (0.53–1.24)

Accident and emergency specialist

63

10 (16)

0.93 (0.41–2.13)

Paediatrician

142

16 (11)

0.85 (0.45–1.59)

In training§

254

33 (13)

1.73 (1.00–2.99)

Other

128

22 (17)

1.28 (0.72–2.27)

Sex

< 0.001

< 0.001

Female

873

72 (8)

1.00

Male

2098

366 (17)

2.55 (1.83–3.55)

Age group (years)

< 0.001

0.01

< 40 

485

46 (9)

1.00

40–49

874

145 (17)

1.86 (1.22–2.83)

50–59 

924

157 (17)

1.78 (1.15–2.76)

≥ 60

688

90 (13)

1.35 (0.84–2.19)

Country in which medical degree obtained

< 0.001

< 0.001

Australia

2484

394 (16)

1.00 

Overseas

480

44 (9)

0.56 (0.39–0.81)

Solo practice

0.004

0.04

No

2058

278 (14)

1.00

Yes

903

159 (18)

1.33 (1.01–1.75)

Marital status

0.011

0.08

Single

231

21 (9)

1.00

Partnered

2529

386 (15)

1.60 (0.96–2.67)

Divorced/separated

154

29 (19)

2.12 (1.08–4.17)

Widowed

38

2 (5)

0.57 (0.12–2.71)

Hours worked per week

< 0.001

0.01

< 40 

819

94 (11)

1.00

40–49

762

120 (16)

1.13 (0.81–1.58)

50–59

756

142 (19)

1.15 (0.82–1.62)

≥ 60

599

74 (12)

0.67 (0.45–0.99)

Peer review in previous 12 months

0.17

0.91

No

882

118 (13)

1.00

Yes

2066

317 (15)

1.02 (0.77–1.35)

CME requirements

0.001

0.04

Not met

113

29 (26)

1.72 (1.04–2.87)

Met or not applicable

2806

401 (14)

1.00

Teaching role

0.35

No

1014

141 (14)

Yes

1922

292 (15)

Holiday in previous 12 months

0.01

0.02

No

388

41 (11)

0.63 (0.43–0.93)

Yes

2545

389 (15)

1.00

Current medicolegal matter

< 0.001

0.09

No

2500

344 (14)

1.00

Yes

421

86 (20)

1.30 (0.96–1.75)

Psychoticism

0.004

0.04

≤ Median

1781

238 (13)

1.00

> Median

1089

188 (17)

1.27 (1.01–1.60)

Extroversion

0.007

< 0.001

≤ Median

1592

212 (13)

1.00

> Median

1245

211 (17)

1.62 (1.28–2.04)

Neuroticism

< 0.001

< 0.001

≤ Median

1719

205 (12)

1.00

> Median

1155

226 (20)

2.20 (1.74–2.78)


AUDIT = Alcohol Use Disorders Identification Test. AOR = adjusted odds ratio. * Hosmer–Lemeshow goodness-of-fit test, P = 0.32. † Univariate analysis. ‡ Multivariate analysis. § Specialist in training, hospital registrar, GP registrar.
CME = Continuing Medical Education. * Hosmer–Lemeshow goodness-of-fit test, P = 0.32.  This variable was not included in the multivariate analysis (P value > 0.3 in the univariate analysis.)

Received 
4 Sep 2009
accepted 
16 Mar 2010
Louise M Nash, MB BS(Hons), BA, FRANZCP, Psychiatrist1,2
Michele G Daly, BSc(Hons), MSc, Research Fellow3
Patrick J Kelly, BMath(Hons), PhD, Senior Lecturer in Biostatistics4
Elizabeth H van Ekert, BADipEd, MMedHum, Risk Manager5
Garry Walter, MB BS, PhD, FRANZCP, Professor of Child and Adolescent Psychiatry,2 and Area Clinical Director6
Merrilyn Walton, BA, MSW, PhD, Professor of Medical Education7
Simon M Willcock, MB BS, PhD, FRACGP, Professor of General Practice3
Chris C Tennant, MD, MPH, FRANZCP, Emeritus Professor of Psychiatry7
1 New South Wales Institute of Psychiatry, Sydney, NSW.
2 Discipline of Psychological Medicine, University of Sydney, Sydney, NSW.
3 Academic General Practice Unit, Hornsby Ku-ring-gai Hospital, University of Sydney, Sydney, NSW.
4 School of Public Health, University of Sydney, Sydney, NSW.
5 MDA National, Sydney, NSW.
6 Child and Adolescent Mental Health Services, Northern Sydney Central Coast Health, Sydney, NSW.
7 University of Sydney, Sydney, NSW.
Acknowledgements: 

Our study was funded by a Northern Sydney Health research grant, the McGeorge Bequest (through the University of Sydney) and Avant Mutual Group Limited. The New South Wales Institute of Psychiatry provided a part-time research fellowship to Louise Nash from January to August 2008.

Competing Interests: 

Avant provided funding for a part-time research officer (Michele Daly) and mail-out of the questionnaire, as well as inhouse support for sample selection and comparison. Simon Willcock is an elected board member of Avant. Elizabeth van Ekert is a former employee of Avant.

Reference Text: 
Firth-Cozens J, Cording H, Ginsburg R. Can we select health professionals who provide safer care? Qual Saf Health Care 2003; 12 (1 Suppl): i16-i20.
Reference Order: 
1
PubMed ID: 
14645743
Reference Text: 
Willcock SM, Daly MG, Tennant C, Allard BJ. Burnout and psychiatric morbidity in new medical graduates. Med J Aust 2004; 181: 357-360.
Reference Order: 
2
PubMed ID: 
15462649
Reference Text: 
Johnson W. Predisposition to emotional distress and psychiatric illness amongst doctors: the role of unconscious and experiential factors. Br J Med Psychol 1991; 64: 317-329.
Reference Order: 
3
PubMed ID: 
1786225
Reference Text: 
Tyssen R, Vaglum P. Mental health problems among young doctors: an updated review of prospective studies. Harv Rev Psychiatry 2002; 10: 154-165.
Reference Order: 
4
PubMed ID: 
12023930
Reference Text: 
Newbury-Birch D, Kamli F. Psychological stress, anxiety, depression, job satisfaction, and personality characteristics in preregistration house officers. Postgrad Med J 2001; 77: 109-111.
Reference Order: 
5
PubMed ID: 
11161078
Reference Text: 
Bruce CT, Sanger MM, Thomas PS, et al. Factors affecting female or male consultant stress in an Australian teaching hospital [letter]. Med J Aust 2003; 179: 174-175.
Reference Order: 
6
PubMed ID: 
12885292
Reference Text: 
Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137.
Reference Order: 
7
PubMed ID: 
9734508
Reference Text: 
Hayasaka Y, Nakamura K, Yamamoto M, Sasaki S. Work environment and mental health status assessed by the general health questionnaire in female Japanese doctors. Ind Health 2007; 45: 781-786.
Reference Order: 
8
PubMed ID: 
18212473
Reference Text: 
Clarke D, Singh R. Life events, stress appraisals, and hospital doctors’ mental health. N Z Med J 2004; 117: U1121.
Reference Order: 
9
PubMed ID: 
15505660
Reference Text: 
Martin C, Wilson J, Fiebelman N, et al. Physicians’ psychological reactions to malpractice litigation. South Med J 1991; 84: 1300-1304.
Reference Order: 
10
PubMed ID: 
1948211
Reference Text: 
Cook R, Neff C. Attitudes of physicians in northern Ontario to medical malpractice litigation. Can Fam Physician 1994; 40: 689-698.
Reference Order: 
11
PubMed ID: 
8199521
Reference Text: 
Mello MM, Studdert DM, Desroches CM, et al. Caring for patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff (Millwood) 2004; 23: 42-53.
Reference Order: 
12
PubMed ID: 
Reference Text: 
Goldberg R, Kuhn G, Andrew L, Thomas H. Coping with medical mistakes and errors in judgment. Ann Emerg Med 2002; 39: 287-292.
Reference Order: 
13
PubMed ID: 
11867981
Reference Text: 
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007; 33: 467-476.
Reference Order: 
14
PubMed ID: 
17724943
Reference Text: 
Zuger A. Dissatisfaction with medical practice. N Engl J Med 2004: 350; 69-75.
Reference Order: 
15
PubMed ID: 
Reference Text: 
Charles S, Pyskoty M, Nelson A. Physicians on trial — self reported reactions to malpractice trials. West J Med 1988; 148: 358-360.
Reference Order: 
16
PubMed ID: 
3363970
Reference Text: 
Newman MC. Emotional impact of mistakes on family physicians. Arch Fam Med 1996; 5: 71-75.
Reference Order: 
17
PubMed ID: 
8601210
Reference Text: 
Cunningham W. The immediate and long-term impact on New Zealand doctors who receive patient complaints. N Z Med J 2004; 117: 972.
Reference Order: 
18
PubMed ID: 
Reference Text: 
Nash L, Daly M, Johnson M, et al. Psychological morbidity in Australian doctors who have and have not experienced a medico-legal matter: a cross sectional survey. Aust N Z J Psychiatry 2007; 41: 917-925.
Reference Order: 
19
PubMed ID: 
17924245
Reference Text: 
Newbury-Birch DR, Walshaw D, Farhad K. Drink and drugs: from medical students to doctors. Drug Alcohol Depend 2001; 64: 265-270.
Reference Order: 
20
PubMed ID: 
11672941
Reference Text: 
Rosta J. Hazardous alcohol use among hospital doctors in Germany. Alcohol Alcohol 2008; 43: 198-203.
Reference Order: 
21
PubMed ID: 
18208862
Reference Text: 
Rosta J, Aasland O. Female surgeons’ alcohol use: a study of a national study of Norwegian doctors. Alcohol Alcohol 2005; 40: 436-440.
Reference Order: 
22
PubMed ID: 
16043434
Reference Text: 
Nash L, Kelly P, Daly M, et al. Australian doctors’ involvement in medicolegal matters: a cross-sectional self-report study. Med J Aust 2009; 191: 436-440.
Reference Order: 
23
PubMed ID: 
19835537
Reference Text: 
Eysenck HJ, Eysenck SBG. Manual of the Eysenck Personality Scales (EPS Adult). London: Hodder and Stoughton, 1991.
Reference Order: 
24
PubMed ID: 
Reference Text: 
Goldberg DP. Manual of the General Health Questionnaire. Windsor: National Foundation for Educational Research, 1978.
Reference Order: 
25
PubMed ID: 
Reference Text: 
Saunders J, Aasland OG, Babor TF, et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcoholic consumption — II. Addiction 1993; 88: 791-804.
Reference Order: 
26
PubMed ID: 
8329970
Reference Text: 
Hosmer DW, Lemeshow S. Applied logistic regression. New York: Wiley, 1989.
Reference Order: 
27
PubMed ID: 
Reference Text: 
Peisah C, Latif E, Wilhelm K, Williams B. Secrets to psychological success: why older doctors have lower psychological distress and burnout than younger doctors. Aging Ment Health 2009; 13: 300-307.
Reference Order: 
28
PubMed ID: 
19347697
Reference Text: 
Taylor A, Dal Grande E, Parsons J. Mental health status of South Australians: October 1997. Adelaide: Government of South Australia, 1997. http://www.health.sa.gov.au/pros/portals/0/Mental-Health-Status-Oct-97-Report-6.pdf (accessed Feb 2010).
Reference Order: 
29
PubMed ID: 
Reference Text: 
Ivis FJ, Adlaf EM, Rehm J. Incorporating the AUDIT into a general population telephone survey: a methodological experiment. Drug Alcohol Depend 2000; 60: 97-104.
Reference Order: 
30
PubMed ID: 
10821994
Reference Text: 
Fleming J. The epidemiology of alcohol use in Australian women: findings from a national survey of women’s drinking. Addiction 1996; 91: 1325-1334.
Reference Order: 
31
PubMed ID: 
8854368
Reference Text: 
Australian Institute of Health and Welfare. Medical labour force 2005. Canberra: AIHW, 2008. (AIHW Cat. No. HWL 41; National Health Labour Force Series No. 40.) http://www.aihw.gov.au/publications/hwl/mlf05/mlf05.pdf (accessed Jun 2010).
Reference Order: 
32
PubMed ID: