Saturday, January 8th, 2011
The route to assuming the mantle of medical authority is a familiar one: the weeding-out process and survival of pre-medical studies, the plodding discipline of medical school, and the special expertise of post-graduate medical education all prepare the budding doctor to be adept at making diagnoses and rendering treatments. In the metamorphosis to medical professionalism, doctors may gradually come to view patients as a drag on treatment adherence; their individual wants and peculiarities are seen as psychological obstacles to optimal treatment outcomes. So, there are separate worlds of doctors and of patients.
But what happens when those worlds intersectâ€”when the doctor is a patient? It is well known that physicians frequently have difficulty accepting the patient role for themselves and following recommendations and guidelines for care they recommend to their patients. Yet, arguably, public safety may be at issue when physicians donâ€™t seek appropriate medical care or fail to follow through on prescribed treatment. This is particularly true for treatment of disorders related to mood and cognitionâ€”depression, drug addiction, alcoholism, and dementia.
These maladies affect physicians to at least the same degree as the general population; indeed, a recent study found that the chances of dying by suicide are about 70 percent higher for male physicians than for men in the general population, and between 250 percent and 400 percent higher for female physicians than other women (T. Hampton, JAMA, 2005, 394:1189â€“1191). Untreated depression in physicians is such a serious concern that American Foundation for Suicide Prevention issued a consensus statement in 2003 stressing the need to change professional attitudes and institutional policies to encourage physicians to seek help when needed.
Barriers to treatment
Why do physicians resist medical treatment, especially for mental and substance use conditions? To understand this, we must look at a number of special issues for doctors in addressing their own health care needs:
- Personal views toward seeking medical or mental health care;
- The stance of other doctors toward them as patients and professionals;
- The laws governing reporting impaired physicians to the state;
- The attitudes of systems in which doctors practice; and
- Medical insurance and payment matters.
Attitudes toward seeking care. Doctors strive to avoid shame and appearing weak to their patients and medical colleagues, an attitude that is reinforced by their medical training and acculturation. In addition, doctors are aware of medical uncertainty in predicting the outcomes of a given medical condition, and this awareness may contribute to delaying establishing a diagnosis for themselves. Also, they are used to being in charge of diagnosis and recommending and evaluating courses of treatment. So, when doctors are ill, they want to maintain control of the medical decision-making process.
Perhaps the biggest obstacle for physicians who need professional help has to do with trust, which is crucial to all healthy physician-patient relationships. Trust is based on the expectation that the treating doctor will remain engaged as the physician-patient’s advocate in the ongoing work of diagnosing illness, making recommendations for appropriate care, and negotiating and implementing effective treatment strategies. Too many doctors seem to rule out this kind of physician-patient relationship for themselves because of the additional complexity that colleagues treating colleagues introduce into the relationship.
Attitudes of physician colleagues. Like most patients, physicians ask the question, “What would you do, doctor, if you were in my shoes?” But unlike non-physician patients, they are concerned that their treating doctors will treat them deferentially or abandon them as patients if they share their weaknesses, self-doubts, or secrets with a colleague.
Reporting requirements. Doctors may avoid seeking medical or psychiatric care because of legal obligations for physicians and health care professionals to report impaired doctors to the state. Because of the need to protect patients and the public, physicians and other health care personnel in Minnesota are required by law to report professional colleagues to their respective licensing boards if they suspect impairment or unprofessional conduct with patients.
Attitudes of health systems. The culture of the health care system in which a physician practices may create a barrier to seeking treatment for mental or substance abuse problems. Increasingly, physicians are employees of large clinic corporations, and as such, they fear being viewed as disposable when perceived by the corporation as unproductive or a liability to the clinic’s reputation.
Medical insurance and payment matters. Health insurance plans that limit physicians” access to treating physicians may pose barriers to getting treatment. For example, physicians whose access to medical care is restricted to physicians in their medical facility or insurance plan may be reluctant to seek in-house treatment for mental health conditions. In addition, they are rightly concerned about issues of privacy and confidentiality, as they know that medical and claims data may be passed on rather easily to other parties.
Steps to obtaining treatment
What steps can physicians take to improve access to needed medical services for themselves or their colleagues?
Seek and accept help from colleagues. Oftentimes help or an intervention is prompted by patient complaints about a physician’s inattention or inappropriate behavior. Thankfully, colleagues and clinic administrators are becoming more comfortable encouraging their medical colleagues to get help from other doctors and professionals, while saving face with clinic personnel and patients. Usually a doctorâ€™s work colleagues are the first to celebrate and praise the physician for getting help and to offer support, whatever the illness or malady.
Most organizations assist their physician and health care colleagues in obtaining help with alcohol and drug problems. As these beneficial efforts are expanded, it is vital that the clinic physician or health care professional be allowed to and encouraged to seek professional help outside of the clinic provider network. This means extending work-based health care coverage to cover the costs of out-of-network care so that physicians and other health care personnel need not be treated by the same doctors with whom they work each day.
Diversion program for impaired physicians. Doctors who get appropriate medical attention for psychiatric, substance abuse, neurological, or medical conditions related to physical or cognitive impairments can set up a plan of evaluation, care, and monitoring with the Minnesota Health Professionals Services Program (HPSP). Physicians or other health care professionals eligible for and accepted by the HPSP diversion program can usually remain in practice when they adhere to their negotiated plan of care with HPSP. More information about HPSP and the Minnesota Board of Medical Practice may be found at www.hpsp.state.mn.us and www.bmp.state.mn.us.
Treating physicians who file quarterly reports to HPSP must attest to the physician-patient’s compliance to a plan of care monitored by the HPSP staff. Thus, HPSP diversion provides a pathway to treatment for impaired physicians, but HPSP monitoring introduces a level of scrutiny that can detract from open disclosure and partnership in the doctor-patient relationship.
The treatment relationship
A healthy doctor-patient relationship requires the treating physician and the physician-patient to consider their comfort levels about the quality of their communication and to share their views about the following aspects of therapy:
- Why and how the patient is here at this time;
- Outside shared relationships and potential conflicts of interest or triangulated relationships, if any;
- Issues concerning data and communication privacy and privilege;
- How the diagnostic examination and test results will be interpreted and shared with the patient and others;
- The rationale for all tests and examinations;
- The expected frequency and duration of appointments;
- Negotiations with the patient concerning care plan and progress; and
- The doctor’s treatment planning recommendations.
If either the treating physician or patient is uncomfortable during this process, this discomfort should be discussed, understood, and resolved in short duration. If this is not possible, the doctor should recommend referral of the patient to another physician.
The physician-patient. Although doctors often experience anxiety when switching their role from the treating authority to the recipient of medical care, it is not true that doctors make poor patients because they know too much. Like most patients, doctors greatly appreciate frankness and honesty from their treating physicians.
Physician-patients should view their tendency to self-prescribe and their failure to adhere to a plan of care with their doctor’s advice as an occupational hazard. They should inform their treating physicians when they have disagreements or doubts about receiving “formal” medical care or when they disagree with the care recommendations.
The treating physician. The treating doctor needs to be fully aware of the physician-patient’s attitudes toward being ill and being treated for illness. To set the proper tone and structure for the physician-patient relationship, the doctor should treat the patient in the usual clinical setting. Treating doctors must maintain their professional boundaries with their patients who are professionals. In this regard, the general rule is, “Why would I consider treating this patient differently than any other?” A warning signal is the thought (whether expressed or not), “I don’t do this with other patients, but for you, because you are a doctor, I will.”
Treating doctors may feel angry with their professional patients. They may not understand this anger. It may be born of anxiety for the fate of the patient, identification with the patient, or a feeling that the patient has behaved stupidly or brought on his troubles; or it may come from the doctor-patient’s nonadherence to treatment recommendations.
Changing attitudes, policies
Increasing media attention to and public dialogue about health issues such as depression and other mental health issues, alcoholism, and chemical abuse highlight the need for physicians to seek treatment for these conditions. Physicians often are more reluctant than their patients to seek treatment for any condition that may be associated with impairment or social stigma, for reasons related to both professional and personal circumstances and characteristics.
The American Medical Association has recommended that professional attitudes and institutional policies be changed so that physicians with health problems can more easily seek and find appropriate medical care. This entails a clear understanding between treating physicians and their patients about special aspects of the doctor-professional relationship; clarity of legal requirements concerning reporting impairment; and access to physicians and mental health professionals outside of the doctor’s clinic.
Lee H. Beecher, M.D., is a clinical associate professor in the Department of Psychiatry at the University of Minnesota, immediate past president of the Minnesota Physician-Patient Alliance (MPPA), and a psychiatrist in private practice in St. Louis Park.
The author references Michael H. Gendel’s article “Treatment Adherence in Physicians” (Primary Psychiatry, Vol. 12, No. 6, June 2005, pp. 48-54) in preparing this article.