Preamble

This position statement focuses on promoting the health and wellbeing of doctors and medical students during their training and professional careers. In order to deliver high-quality health care to their patients and the community, and to experience medicine as a rewarding and satisfying career, doctors need to be well. Research has consistently shown that doctors with healthy personal lifestyle habits are more likely to impart healthy behaviours to their patients.¹

The addition of ‘wellbeing’ to this position statement emphasises promotion of health and contentment, and supports the World Health Organisation definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

There has been a welcome increase in the awareness of doctors’ health issues in recent years and this position statement reflects the medical community’s changing attitude to the promotion of health amongst our colleagues.

Most doctors have an above average health status similar to others in advantaged socio-economic groups. They are less likely than the general population to suffer lifestyle-related illnesses, such as heart and smoking-related disease.^2-3 However, there is evidence that doctors are at greater risk of mental illness and stress-related problems and more susceptible to substance abuse.^4-5 Further, depression and anxiety are common among doctors and their suicide rate is higher than in the general population.⁶ Medical students also experience higher rates of depression and stress.⁷

Some sub-groups of doctors may be at greater risk of poorer health and wellbeing because of their professional circumstances. These include, but are not limited to:

• doctors working in rural and remote areas with inadequate resources and professional support,
• doctors who work excessive hours and/or are unable to access sufficient leave,
• international medical students and graduates and doctors from non-English speaking backgrounds,
• doctors who work shift work, ⁸
• Aboriginal and Torres Strait Islander doctors,
• those exposed to blood-borne diseases and other specific occupational risks, and
• doctors who are the subject of medico-legal process such as lawsuits, complaints and inquiries.⁹

Medicine and stress

While not all stress is negative (and some stress is necessary), there are multiple internal and external stressors in medicine. Internal stressors may come from the personality traits of the individual that chooses to practise medicine. These qualities include dedication, commitment, and a sense of responsibility, competitiveness and altruism. These attributes underpin professional success but can become a source of pressure in a doctor’s or medical student’s working or study life and increase the risk of anxiety and depression. A proportion of doctors and students have obsessional traits, which can predispose them to stress.¹⁰

There are also a large number of external pressures including but not limited to:

• innate professional responsibilities of doctors,
• increased clinical workload due to insufficient staffing and resources in the health system,
• lack of control over work-life balance,
• professional, social and geographical isolation,
• the requirement for ongoing medical education,
• the demands of keeping pace with rapid developments in medical technology and knowledge,
• changes in the administration and regulations in the health system, and
• community expectations.

Encounters with patients and their families, which often involves dealing with suffering and death in emotionally charged clinical situations, can drain the “reserves” of doctors with repercussions on their personal lives. Such experiences are in addition to the pressures experienced outside the workplace such as relationship and financial problems.

Junior doctors experience specific pressures related to their professional stage and development and can be at risk of poor health.¹¹ Compared to most professionals of a similar stage, junior doctors can be expected to work longer hours without adequate recovery time. It can be difficult to balance training and educational commitments with a heavy workload. Unpredictable schedules can prevent junior doctors from committing to regular social activities or meeting family and other commitments. A perceived lack of control over work-life balance has the potential to lead to exhaustion and job burnout.

For senior doctors, dealing with stress can be made more difficult by professional isolation, especially for those in private practice without access to institutional support.¹² The stresses that doctors experience change over time, and for senior doctors these can include the challenges of managing a business, employing staff, juggling commitments to patient care, teaching, administration, professional development, family and caring responsibilities.¹² Older doctors will also have increasing frequencies of chronic disease.

Some stressors such as long hours have been traditionally associated with the medical profession, but there is evidence that some doctors are less willing to accept the personal costs of medical culture. Many junior and senior doctors view their identity and responsibilities to the profession differently from previous generations.¹³

Barriers to own health care

Governments, the public and the medical profession have high expectations that doctors will be competent, compassionate, professional and resilient under stressful circumstances. There is also a strong community expectation that doctors will seek appropriate medical care from another doctor when they are unwell. The reality is that there are significant barriers, real and perceived, that prevent some doctors and students from seeking access to formal healthcare. ¹⁴ These include:

• concerns of lack of confidentiality,
• embarrassment and perceptions of weakness,
• stigma of ill-health in the medical profession,
• perceived impact on career development,
• perceived impact on colleagues and patients,
• expectation that doctors will work while unwell,
• implications of Mandatory Notification, and
• difficulty of access (time, experienced personnel, geographic isolation) to professional treatment.

Barriers to care can result in doctors using inappropriate practices rather than seeking formal healthcare. These include inadequate preventative care, self-diagnosis, self-treatment and delayed presentation to other practitioners. Students and doctors are often reluctant to have a general practitioner for independent medical advice. Similarly, they may not adhere to routine preventative health measures, such as screening tests and vaccinations. Doctors may also be unable to correctly identify the early warning signs of mental illness and burnout.

The reluctance of doctors to consult a general practitioner about their medical problems and ready access to knowledge and medications in the workplace can encourage self-treatment and self-prescribing. Self-treatment can also include informal pathways of care such as ‘corridor’ consultations and self-referring to a specialist. The literature suggests that prescription drugs are used more frequently by doctors than the general public and the practice of self-treatment and self-prescription is common.⁸

Key issues for doctors and medical students

Doctors and their families should have their own general practitioner and manage their own health within the usual professional context of a doctor/patient relationship. This practice should be fostered as a medical student, in order to promote a life-long pattern of seeking professional care. Other than in an emergency or working in an under-serviced area, it is advisable for doctors to avoid treating themselves or their family. If living in an under-serviced area, doctors should be encouraged to investigate other ways to get access to formal health care.  

In these situations, they should also be aware of the emergency phone advice services available to them.

The AMA encourages doctors and medical students to practise good lifestyle behaviours and to seek formal health care when necessary. It is valuable for doctors to find that which energises, restores and nourishes them as a person, whether this is creatively, physically or spiritually, and to make time for this in their lives.

Doctors and medical students must be able to obtain access to confidential medical and other health services so that they are confident that seeking help will not stigmatise them or affect their career progression. There must be clear referral pathways and models of care for those in need of assistance. The profession needs to develop a culture that supports those in difficulty without judgement.

Doctors must know how and when to respond if they are concerned about the health of a colleague. When a doctor has concerns about a colleague’s health, there is a legal and ethical responsibility to take action to minimise the risk to patients and the doctor’s health. Such action should be seen as an act of caring for which the majority of unwell doctors, many of whom have exhausted their personal resources to deal with their problem, are ultimately grateful.

Advice can be sought from local state-based doctors’ health programs and the Medical Board of Australia.   Where a significant risk to patients exists, or the doctor lacks the insight, capacity or willingness to participate, mandatory notification must take place.

The AMA encourages doctors and medical students to:

• take responsibility for their own physical and psychological health,
• establish a continuing therapeutic relationship with a general practitioner,
• ensure they have all relevant evidence-based preventative health,
• ensure all appropriate insurances are in place to support them through illness,
• incorporate regular leave, good nutrition, exercise, leisure, spirituality and family time into a healthy and balanced lifestyle,
• recognise the dangers to others associated with:

(i) a reluctance to admit illness or failing competence, and
(ii) continued or regular self-diagnosis, treatment and prescribing, and

• provide treatment to doctors and medical students with the same skill and professionalism provided to all other patients, with particular emphasis on confidentiality.

To support doctors and medical students, the AMA believes medical schools, hospitals, medical colleges, the Medical Board of Australia as well as State and Federal governments should:

• promote good health and the adoption of a healthy lifestyle throughout their medical training and career,
• address issues which compromise the ability to provide formal medical care,
• ensure access to confidential and high-quality medical and health services,
• establish professional debriefing, support and mentorship,
• identify internal and/or external stress factors contributing to, and recognise the warning signs and behaviour patterns of, poor health,
• promote access to early and expert assistance from professional services and providers,
• incorporate skills such as stress and time management into continuing medical education,
• establish clear referral pathways for doctors and medical students in need of assistance,
• adopt a “no-judgement” culture that supports those in difficulty, so that doctors are confident that seeking help will not affect their career,
• ensure that the training and workplace environment supports doctors’ health, conduct and performance – and therefore helps to promote good patient health and reduce patient risk,
• implement and support safe rostering practices and safe working hours, ¹⁵ and
• provide exemptions from mandatory notification requirements for doctors treating colleagues and medical students.

Sick leave

Employers of doctors must ensure they have access to sick leave that at least meets the standards for public sector employees. Self-employed doctors should ensure they have income protection insurance for accidents or sickness to provide an adequate income to cover their essential financial obligations so financial worries do not compound the effects of ill health.

Research into the health and welfare of doctors and medical students

The AMA will continue to advocate for and support research into the health and welfare of doctors and medical students, with specific attention to such issues as safe working hours and the recognition of vulnerable sub-groups.

There is limited research in Australia on doctors and medical students who are at risk of suicide or who have taken their own lives. Similarly, there are no national information systems on the suicide or attempted suicide of doctors and medical students that could guide systemic improvements to the health and wellbeing of the profession.

The AMA supports:

• the establishment of a research, epidemiological database of doctors and medical students at risk of suicide and completed suicide,
• systematic research on coronial and other reports of completed suicides of doctors and medical students to ensure system failures are identified and rectified, and
• the establishment of a profession-funded national confidential health program to improve and promote the health and wellbeing of the medical profession.

References

1. Oberg EB, Frank E. Physicians' health practices strongly influence patient health practices. J R Coll Physicians 2009; 39(4): 290-1.
2. Carpenter L, Swerdlow A, Fear N. Mortality of doctors in different specialties: findings from a cohort of 20,000 NHS hospital consultants. Occup Environ Med 1997; 54: 388-395.
3. Clode D. The conspiracy of silence: emotional health among doctors. Melbourne: Royal Australian College of General Doctors. 2004.
4. Willcock SM, Daly MG, Tennant CC, Allard BJ. Burnout and psychiatric morbidity in new medical graduates. Med J Aust 2004; 181: 357-360.
5. Schattner P, Davidson S, Serry N. Doctors’ health and wellbeing: taking up the challenge in Australia. Med J Aust 2004; 181: 348-349.
6. Elliot L, Tan J, Norris S. The mental health of doctors –A systematic literature review executive summary. Melbourne: beyondblue: the national depression initiative, 2010. http://www.beyondblue.org.au /index.aspx? link_ id=4.1262&tmp=FileDownload&fid=1947 (accessed December 2010).
7. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Med Educ 2005; 39: 594–604.                         
8. Reid K, Dawson D, Comparing performance on a simulated 12 hour shift rotation in young and older subjects. Occup Environ Med 2001; 58:58-62.                
9. Nash LM, Daly MG, Kelly PJ, van Ekert EH, Walter G, Walton M, Willcock SM, Tennant CC. Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors. Med J Aust 2010; 193 (3): 161-166.
10. Riley GJ. Understanding the stresses and strains of being a doctor. Med J Aust 2004; 181 (7): 350-353.
11. Markwell AL, Wainer Z. The health and wellbeing of junior doctors: insights from a national survey. Med J Aust 2009; 191 (8): 441-444.
12. Dobb G. Stresses change, but do not go away. Australian Medicine 2009; 21 (19): 12.
13. Australian Medical Association. Work-life flexibility survey: report of findings. Canberra: AMA, 2008.   
14. Hillis JM, Perry WRG, Carroll EY, Hibble BA, Davies MJ, Yousef J. Painting the picture: Australasian medical student views on wellbeing teaching and support services. Med J Aust  2010; 192 (4): 188-190
15. Australian Medical Association. National code of practice. Hours of work, shiftwork and rostering for hospital Doctors. Canberra: AMA, 2002.