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Physicians’ Self-care Practices
Physicians are not very good at caring for themselves and at seeking help for their problems. Many physicians themselves do not have a primary care provider and neglect to have physical examinations. Even when they develop a problem such as depression, very few physicians seek treatment for it. Most physicians continue to work when they are unwell and expect the same from their colleagues. Such attitudes have been reported in trainee doctors as well as with older, established ones. In short, doctors rely on denial and avoidance to cope with their problems.
Doctors may also not seek help out of fear that might be stigmatized as being incompetent, or unable to cope. Or they may be afraid that seeking treatment may cause licensing boards to investigate them, thus placing their medical license and career in jeopardy. They may also feel uncomfortable in the role of a patient.
The culture of the medical profession is an important deterrent to doctors taking care of their emotional and physical problems. Physicians are educated in a system that rewards individual achievement, self-reliance, independent judgment, industry and self-sacrifice. This system can also inculcate the notions that the best doctors have few needs, make no mistakes and are never ill. Physicians are under pressure from colleagues and patients to appear physically well, even when they are sick, because they believe their health is interpreted as an indicator of their medical competence.
Colleagues’ Behavior and Support
Colleagues of unwell or impaired physicians are often not helpful to the affected physician. Often, when a physician is affected by illness or impairment, neither the physician himself nor his colleagues are willing to talk about the illness or impairment - a conspiracy of silence. Even when the impaired physician’s illness or impairment poses a threat to patient safety, and even when the affected physician is at risk of committing suicide, his colleagues may not report or address the problem, because confidentiality between colleagues is valued in the medical profession. Colleagues are more likely to report a substance-abusing physician than one who is emotionally or cognitively impaired.
Healthcare Institutions
Healthcare organizations may not provide even basic resources for physician wellness and self-care, such as adequate rest, recovery and nutrition.
Negative Consequences of Physician Unwellness
Burnt out or ill physicians can leave the healthcare organization or even leave the medical profession prematurely. This represents a significant loss to the organization and the profession. Replacing a physician with a new hire and training a physician are both expensive. When an organization has to employ a new physician to replace one who has left, the estimated cost is US$ 150,000 - 300,000.
Even if physicians do not leave an organization, physician burnout causes them to be less productive and efficient. Manifestations of these include increased absenteeism, ordering unnecessary tests and procedures, reduced practice revenue, less time spent with patients, and early retirement. Suspension of a physician because of mental health problems also is costly to an organization.
Physician fatigue, stress and illness also significantly degrade the quality of medical care provided to patients and lead to medical errors. Even in the absence of overt physical or mental illness, studies have shown that physicians dissatisfied with their jobs have riskier prescribing profiles, less adherent patients, and less satisfied patients (which likely are indicators of lower quality of care).
Residents suffering from burnout or depression reported providing poor quality care - examples of this were failure to fully discuss treatment options or answer patient questions, treatment or medication errors (not due to lack of knowledge or inexperience), and reduced attentiveness or caring behavior towards their patients. Studies also show that medical students and physicians who have a poor personal health profile are less likely than those who are healthy to recommend preventive interventions and a healthy lifestyle to their patients.
Conversely, physician wellness and satisfaction are positively correlated with patients’ adherence to treatment and to satisfaction with care.
Measuring Physician Wellness as a Quality Indicator
Because physicians who are unwell can adversely affect patient outcomes and the healthcare organization’s functioning, physician wellness should routinely be measured as a Quality Indicator that reflects the organization’s health. A standardized questionnaire can be used to measure this. An example is the quality of work competence survey published by Arnetz et al. This survey measures ten items - mental energy, work climate, work tempo. work-related exhaustion, skills development, organizational efficacy, and leadership. A single total (weighted) score can then be calculated.
Interventions to Improve Physician Wellness
Some studies have reported that structured interventions to improve physician wellness can reduce burnout and sick leave. Others have shown significant reductions in medication errors and malpractice claims. More research is needed to study the impact of physician wellness programs on patient outcomes and organizational performance. Of course, individual physicians should also strive to take better care of themselves - ‘Physician heal thyself.’
Reference
Physician wellness: a missing quality indicator.Wallace et al. Lancet 2009;374:1714
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