Working together to ensure health care access for doctors

Physicians share a collective responsibility to support their peers in the help‐seeking process

Suggesting that a doctor should “go to a doctor” sounds simple. However, the reality can be very different.1 This article considers the complexity that underpins this concept.

The 2013 Beyondblue survey2 documented the health of doctors, with a focus on mental health issues and the impact of the work environment. Internationally, mental health issues (burnout, stress and suicidal thoughts) and workplace bullying have been the focus of many recent studies.2,3,4 While the Beyondblue study is over 5 years old, the findings of a recent survey of doctors in Metro South Health in Brisbane resonated strongly with the previous study.5 Despite this focus on mental health, the physical health issues that doctors experience are similar to those in the general community.6 In the Metro South Health survey, over 20% of doctors reported having a chronic illness.5

Ensuring health access for doctors is also important for the delivery of quality, safe health care.7 A 2009 seminal article turned the spotlight on physician health, positioning this as a “missing quality indicator”.8 Since then, the Quadruple Aim of quality care was defined in 2014, adding clinician wellness to the Triple Aim approach to optimising health system performance.9 The need to support physician wellness within the workplace is paramount and there is currently a strong focus on identifying workplace interventions that foster a positive work culture of wellness.7

If individual physicians are to effectively address their personal health needs, they should have a general practitioner. Maximising doctors' health has benefits for the individual physician, their patients and their health care team. Many articles in the doctors' health literature confirm the importance of having a GP.1,2 Educators in medical school and clinical training echo these words. The Medical Board of Australia includes this advice in its Code of Conduct.10

Yet doctors often experience significant barriers to their health care access. These barriers exist at individual, provider and systemic levels.1 Despite the acknowledgement of these barriers, there is a paucity of research exploring this topic.1,11 The Beyondblue study noted that nearly 60% of doctors thought that being a patient caused embarrassment for the doctor.2 Shame and stigma complicate health care access, especially for mental health issues.12 Quantitative research reporting how many doctors have a GP rarely delves more deeply to understand how often a doctor seeks care and for what health issues. Qualitative research usually focuses on the very sick doctor or the impaired doctor,12 limiting generalisability to the wider medical community wishing to seek care.13

The navigation of the help‐seeking process by the doctor patient is often presented as the responsibility of that doctor patient alone. However, this perspective should be contested. The help‐seeking process includes determining who to see, when to go to the doctor, what health issues should be taken to the doctor, and how to engage within the therapeutic relationship. Each of these steps can be problematic. Simply encouraging a doctor to seek care by saying “You should see a doctor about that, doctor!” may do little to enable help seeking. Exploring each of these steps offers some useful insights to support the process.

Firstly, there is the decision of whom to see. The treating doctor needs to be independent, accessible, and trusted to provide high quality, compassionate care. Sometimes there are specific concerns such as gender concordance and cultural issues to be considered. Navigating sensitive health issues requiring an intimate examination or questions about mental health can also factor into the choice of GP. For rural doctors, finding a GP who is independent and accessible can be particularly challenging. These issues are faced by the general community seeking care as well. It is common for members of the community to ask their close friends and family for advice on whom to see. For doctors, this conversation can be difficult.11

Determining when to go is another hurdle. Most studies show that doctors “do not have time” to see their GP13 — many doctors find it difficult to prioritise their health, yet they find time to attend to other less important matters.

Building a strong therapeutic relationship enables both the treating doctor and the doctor patient to better navigate the complexity of the interaction between them.13 The relationship may seem less important when attending for a routine procedure, such as an immunisation, but discussing the investigations required for a more serious health issue can be more challenging. Strengthening the relationship over a number of consultations provides both the treating doctor and the doctor patient with the opportunity to be more comfortable with their respective roles. Issues such as cost of care, self‐care and reviewing results need to be carefully considered within the boundaries of the therapeutic relationship. Confidence in this relationship helps to reduce concern about when to make that next appointment.

All patients struggle to know what health issues they should present to their GP. Many patients are reluctant to present with a trivial issue for fear of wasting a GP's time. Doctors often trivialise their illness and may delay seeking care.11 Having a trusted relationship with a GP can reduce this hesitation.

Finally, deciding how to be a patient may challenge our professional identity if it is founded on the stereotypical image that a doctor is either a patient (sick) or a doctor (well). The doctor patient is a health literate patient and the treating doctor needs to engage the doctor patient in a therapeutic relationship that is patient‐centred, appropriately incorporating the health literacy of the doctor patient to maximise their health and wellbeing.13,14

While the individual doctor has responsibilities for their personal health care access, many barriers can be reduced through a collective response from the medical profession. Doctors have an important role in enabling their colleagues to access care by reducing the systemic, provider, and even the individual barriers.

The profession has a role in addressing the systemic problems, both structural and cultural. Structural issues include rostered hours and appropriate cover for leave. Cultural issues include the stigma and shame. The profession's attitudes towards doctors with mental health issues are concerning; for example, the Beyondblue survey reported that over 40% of doctors believed that doctors with a history of mental health problems were considered less competent by their peers.2 Doctors can help manage these concerns through strong advocacy, as individuals and as a collective voice.

It is not enough to abrogate our responsibilities to the collective voice alone. Doctors need to reflect on their personal attitudes to these issues, such as participating in the banter of tearooms by failing to counter negative comments made about colleagues who take time off work or about those who have mental health problems. We are all role models for our peers. Such banter and bravado can be damaging. Knowing that our peers talk this way reduces our capacity to take time off or seek support for our mental health issues.

It is also our professional responsibility as individuals to overtly enable the help seeking of our colleagues. By noticing how structural issues might be affecting our colleague's help seeking, we can provide appropriate support. Many doctors advise a colleague (especially a junior colleague) to seek help. It is rarely useful to simply state: “You should see a doctor about that”. While this may provide the functional purpose of ticking the box of “support”, without compassionate and practical support to navigate the who, when, what and how of health access, this statement rings hollow.

We share a collective responsibility to support our colleagues when they return to work. Do we ask how they are? Do we hesitate for fear of encroaching on their privacy? Do we simply say “welcome back”? Do we stay silent? While doctors are very capable of reaching out to patients, words can fail us when reaching out to colleagues with health issues, especially with mental health issues.

Finally, all doctors will find themselves in the role of treating doctor with a doctor patient to care for. While doctors' health education focuses on strategies to support wellbeing, training to be the doctors' doctor has been limited. It is a professional responsibility for doctors to acquire the skills to be a doctor for a doctor. These skills need to be incorporated within the medical school curriculum and embedded within specialist training, including that of GPs. Understanding how to deliver care to doctor patients opens the opportunity to reflect on what we expect as a doctor patient.

Reflecting on the complexity of help seeking for a physician (who, when, what, how) highlights our personal and collective responsibilities to support our peers in this process. These responsibilities extend well beyond our individual responsibility to have our own GP. Now is the time for this important conversation.