Authors: Alex Wessely, Clare Gerada
Publication date: 12 Nov 2013
Doctors are frequently affected by mental health problems, but they often present late for treatment. Alex Wessely and Clare Gerada set out an anthropological approach to why doctors make bad patients
Doctors have high rates of mental health problems, including anxiety, depression, addiction, and increased suicide rates. The rate of suicide is particularly raised among female doctors, who are two and a half times more likely than other women to kill themselves.Despite this level of morbidity, doctors make bad patients and present late for treatment, often following a crisis at work or after a drink driving offence.
Reasons doctors don’t seek help
The reasons for doctors’ failure to seek appropriate and timely help are multifactorial. They are in part a result of structural barriers, such as being unable to seek help during working hours, and because of frequent moves that make it difficult to register with a general practitioner or to continue care with a mental health team. They also have problems accessing confidential help, among other professional concerns, including fear of affecting career progression and stigma about disclosing they have mental illness.
Psychological barriers to disclosure hinge on the belief that doctors do not become ill, or that the patient is the “one with the disease.” Personality factors are also important: the personality traits that are positive features in doctors as carers can predispose them to becoming unwell and not seeking help. For example, and adapted from work by psychiatrist Gwen Adshead, doctors are:
- Perfectionists (“I must do this right, mistakes are intolerable”)
- Narcissists (“I am the greatest”)
- Compulsives (“I must do this, and I can’t give up till I finish”)
- Denigrators of vulnerability (“People who need help are failures. If I need help, I am a failure”)
- Martyrs (“I care for my patients more than myself, and my needs are secondary to those I treat”)
All of these are important barriers to obtaining care. But they may be consequences of a far more important and entrenched primary cause, in that the way in which doctors are trained makes them reluctant to seek help.
The medical self
The nature of doctors’ training results in a deep rooted sense of being special and the institutionalisation of their professional identity, with the creation of a medical self that emphasises and embodies the personality characteristics listed above. This allows doctors to do their job effectively, when they have to deal with stressful and long hours, and provides the veneer of invincibility to live and work in such close proximity with sickness.
These characteristics, however, also distort doctors’ ability to seek help and adopt the role of patient. For example, when accompanying a relative or friend to hospital doctors often find it hard to relinquish their professional role and be the concerned lay “other.” Abandoning their medical self is challenging, even in the short term. This dissonance might also explain why doctors are able to sacrifice their personal, social, financial, and often spiritual lives at work, remaining there long beyond what would be considered safe for themselves or their patients.
Even before starting medical school aspiring doctors have an embryonic sense of their medical self. They are in a relatively unique position in relation to their vocational calling, and they are committed to their chosen careers at a much earlier stage in their education. To gain entry to medical school, young people have to participate in years of community service alongside being grade A students in almost every aspect of their lives. Simon Sinclair, a doctor who studied anthropology and researched the behaviour of medical students, called this “anticipatory socialization.”
When at university, friends are whittled down to fellow medical students, and, as medical students progress to become doctors, their lives become absorbed by medicine. Most waking hours are spent within the bounded space of the hospital, both physically and mentally. Even their private lives become subsumed by the institution as the hospital effectively replaces family and home. Students learn a new scientific language and a new way of seeing—the medical gaze. They also gain a new uniform and a new name, “Dr,” which becomes their label wherever they go.
This institutionalisation during medical school transforms the individual into the finished product of a doctor. The individual emerges into working life with particular shared characteristics and skills that allow them to wield legitimate authority within society. Medical graduates become embedded into a profession that implicitly or explicitly sees itself as special. This is reinforced by society’s view of doctors, and the classic archetype of the “elevated healer.”
This process of passing through medical school, and then through further training, creates a person with tremendous power that is authorised and elaborated through how he or she speaks, acts, writes, and interacts. This is reinforced every day at work, in interactions with colleagues and with patients, even through the simple act of introducing oneself as “doctor.”
All encompassing role
When qualified, responsibilities permeate all aspects of doctors’ lives in a similar way to a religious vocation, and members of the profession are constantly compelled to define themselves by their work. Doctors cannot leave their working identity at the hospital or consulting room door at the end of the day. They are expected to inhabit their professional role at all times and in all places, and are often called upon to offer help by friends or family or in “Good Samaritan” roles.
The individual and the doctor become indistinguishable from each other. Importantly, being a doctor is set in contrast with not being a patient, a dichotomy firmly established throughout medical training and experience. In subtle ways, this training makes doctors feel vulnerable to impairment, perhaps partly explaining why doctors often do not register with a general practitioner.
When a doctor does become a patient, consultations are difficult to negotiate, especially where mental health is concerned. This scenario is more challenging because the clinician whom the doctor sees would previously have been viewed as a colleague and will now be acting within the framework from which the doctor seeking treatment has been ejected.
At a collective level, the medical community holds to a notion that doctors should not be ill. Either consciously or unconsciously, just asking for help is translated in their colleagues’ eyes as a display of weakness. Doctors who become patients believe they are letting down the profession, not least because, when a colleague becomes ill, it is up to those who remain to pick up the slack.
When impairment is identified, colleagues often express shock and surprise as to its true extent. They perform retrospective trawls, usually as part of a significant event analysis. They look for clues of impairment that should have been obvious, such as needle track marks, pinpoint pupils, persistent lateness, or behavioural change. The impairment is masked, however, because it is part of an unspoken agreement not to scrutinise colleagues in the way that patients are scrutinised, because this would risk blurring the distinction between doctors and patients.
Doctors who become patients often try to regain control of their medical self during consultations by talking shop to reassert their medical self. There is not just a personal unwillingness for doctors to see themselves as unwell; there is also a professional stigma attached to it.
Max Henderson, an academic psychiatrist from King’s College London, led a team of psychiatrists, psychologists, sociologists, and occupational physicians in a qualitative study of doctors who had been away from work for at least six months, at least in part owing to a health reason.
They found that the perception of stigma was reinforced by the regulatory constraints placed on doctors who were out of work for health reasons. Doctors described how being away from work made them feel isolated and sad. Many experienced negative reactions from their family, and some deliberately concealed their problems.
Self stigmatisation was central to the participants’ accounts. Several described themselves as failures and appeared to have internalised the negative views of others. They had lost all sense of self worth and meaning.
Doctors also described a lack of support from colleagues and feared a negative response when returning to work. In addition, although there is less stigma around mental health among the general public, the medical profession is lagging behind in this respect.
Good outcomes for doctors who become patients
When doctors relinquish their medical self and become patients, the outcomes are good in terms of reduced distress and impairment and global improvement (see box). This could be linked to the characteristics that constitute a good doctor in the first place, such as perfectionism and drive. After doctors have accepted they are patients, and fully inhabited the role of the patient, these tools can be called upon to help them recover.
Practitioner health programme
The practitioner health programme (PHP) is a confidential, London based health service for doctors and dentists. On average, it has 5.5 new presentations each week, most of which are doctors. Practitioners presenting to the service have considerable, often severe, mental health problems, similar to a cohort presenting to mental health services in the NHS.
Follow-up data show that health practitioners treated at PHP recover at a faster rate than patients who are not doctors or dentists. There are now follow-up data on practitioner patients extending to five years. These show that there are improvements in mental health, social functions, and numbers returning to work or training, as well as a reduction in the involvement of the regulator. These improvements persist over time and are regardless of sex, diagnostic category, or age of patient.
Among alcohol dependent patients, nearly 80% remain abstinent at three years, with 90% of opiate addicts remaining abstinent. Nearly 80% of practitioner-patients remain or return to work after contact with the service.
This anthropological approach to the factors that affect doctors when they become patients is by no means true for all doctors, and many doctors successfully negotiate their professional and private lives. It may, however, help explain why some get into difficulty.
Competing interests: We have read and understood the BMJ Group policy of declaration of interests and declare: CG is medical director of the practitioner health programme; AW: None declared.
- Brooks S, Gerada C, Chalder T. Review of literature on the mental health of doctors: are specialist services needed? J Mental Health 2011;I:1-11.
- Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 2004;161:2295-302.
- Strang J, Wilks M, Wells B, Marshall J. Missed problems and missed opportunities for addicted doctors. BMJ 1998;316:405-6.
- Klitzman R. When doctors become patients. Oxford University Press, 2008.
- Adshead G. Disruption and disorder: personality dysfunction in doctors. Presentation to European Association Physician Health Barcelona. Dec 2010.www.eaph.eu/eaph.nsf/AttachmentsByTitle/barcelona_disruptive/$FILE/Disruptive+and+distressed+doctors+-+Relevance+of+personality+disorder.pdf.
- Sinclair S. Making doctors. An institutional apprenticeship. Berg Publishers, 1997.
- Henderson M, Brooks SK, del Busso L, Chalder T, Harvey SB, Hotopf M, et al. Shame! Self-stigmatisation as an obstacle to sick doctors returning to work: a qualitative study. BMJ Open 2012;2:e001776. http://bmjopen.bmj.com/content/2/5/e001776.full.
- Brooks S, Gerada C, Chalder T. Doctors and dentists with mental ill health and addictions: outcomes of treatment from the Practitioner Health Programme. J Mental Health 2013;22:237-45.
- Practitioner Health Programme. Three year report. 2012. www.php.nhs.uk.
Alex Wessely independent researcher London
Clare Gerada medical director, practitioner health programme Riverside Medical Centre, St George Wharf, Wandsworth Road, London