Medical Practitioners and Their Families as Patients

METHODS

A retrospective case-note review was undertaken by the author of her own private practice in an inner suburban setting in the city of Adelaide, Australia, of all medical practitioners and their immediate families presenting for assessment and therapy over 15 years from 1984 to 1998.

RESULTS

Case-note review revealed 45 doctors (referred as the primary patient), 21 partners, and 11 offspring. Twenty-six (58%) of the doctors and 52 (68%) of the entire sample were female. When either partner or offspring was the person of first referral, the doctor in the family was included in therapy, either for history and support or more usually for active therapy. Marital and/or family therapy was the prime mode of treatment in a substantial number of cases.

Nineteen (42%) of the doctors were GPs and 21 (47%) were specialists, with five trainees from a range of specialist training programmes (Table 1). For comparison, of the 5271 resident registered medical practitioners in South Australia on 17 April 2000, 1828 (35%) were specialists and 56% were GPs.

Of the doctors referred, 16 (36%) had their own GP, and only eight family members (26%) had their own GP; most were referred by the doctor in the family (Table 1). Twenty (43%) of the 45 doctors were self-referred, with six referred by other psychiatrists (usually for marital therapy) and six by other specialists. Three doctors described the medical person referring them as a friend but not their treating doctor.

The diagnosis of the presenting person at referral (Table 2) was very variable, as may be expected in a community group referred to a practitioner who has general psychiatric, perinatal, infant, family and marital therapy training. The majority had a primary diagnosis of depression, of varying severity with a tendency to adjustment disorder with depressed mood. Given that the psychiatrist was the point of first assessment for the majority of doctors and families, there has been no prior screening and assessment by other practitioners.

With such a range of diagnoses, it is not surprising that the mode of psychotherapy chosen (Table 2) was also variable, the majority being offered marital/family or psychodynamic therapy. There was wide variation in numbers of attendances. Doctors were seen, on average, 12 times (range: 1–54; five were seen once only). Families were seen, on average, 19 times (range: 1–83; two were seen once only).

Because the numbers for each group were small, there are no medication figures for doctors’ families. Antidepressants were prescribed for 16 of the doctors, a rate of 35%. Measures of compliance were taken from self-reports, not known necessarily for accuracy. The doctors reported high rates of compliance and a substantial acceptance of side-effects of medication (Table 3).

Outcome was assessed subjectively by the therapist on a five-point scale. Overall, outcome was noted as ‘excellent’ or ‘reasonable’ for 67% (30 of the 45 doctors) (Table 4). It was more difficult to quantify change in doctor's families so figures are not included.

DISCUSSION

A retrospective case-note review of one's own practice has obvious limitations, including personal bias, subjectivity of memory, and the lack of more objective data for parameters such as compliance and improvement. Another limitation of the present study is the inclusion of partners and siblings as family members, rather than narrowing the definition of subjects to doctors only.

The data, nevertheless, show evidence of patterns of referral and treatment of doctors and their families in a private psychiatric practice setting, rarely explored in the literature. Extensive searches have only located one study in a different country (USA) and a different style (psychoanalytic) of practice. 19

A previous study has found that 42% of doctors had GPs, 20 a slightly higher but nevertheless comparable number to those doctors (35%) and their families (26%) in the present study. It may be relevant to note the self-referral to a psychiatrist, minimizing the possibility of others knowing of the personal difficulties.

The doctors in this group present as compliant and motivated, with the majority tending to continue treatment until agreed termination rather than dropping out. In this context, self-referral would seem to be a significant factor because the doctors are generally well-motivated for treatment rather than reluctantly complying with someone else's suggested treatment plan.

Some of the findings of this review are therefore at striking odds with the published literature, which almost universally finds doctors to be more at risk of development of stress, drug and alcohol abuse and suicide, and more ‘difficult’ to treat. 9 ,21 Not only are they more compliant than a comparison group seen in the same practice (Sved Williams AE: unpublished data, 1998), they rarely presented with alcohol problems, medication non-compliance or suicidal behaviours. There were no suicides in either the doctor or family groups throughout the period of treatment. The most likely explanation for the good outcomes of the doctor group is that the group identified in the present study is different than those generally studied as ‘impaired physicians’. Two explanations at least can be found for this difference, the first that much literature emanates from statutory bodies or similar groups who work with doctors who have indeed been unable to seek help before their practice has been forcibly prevented by such bodies. Alternately, doctors may be changing their patterns of help-seeking behaviour by heeding the literature that exhorts better self-care 22 ,23 and early intervention. The stigma of psychiatric treatment has lessened during the last 30 years, perhaps aiding this process. It is clear that doctors can learn from the literature regarding the care of their physical health: Carpenter et al. have shown that British doctors have low mortality compared to the general population for age-related deaths from causes that may be smoking or diet related (e.g. lung cancer, cardiovascular disease and diabetes). 24 Perhaps the corner is turning in regard to psychological care?

Doctors present with a wide range of psychiatric diagnoses, frequently affective illnesses, but also psychotic illnesses, marital problems and adjustment disorders. Doctors appear, as a group, to accept treatments offered and are apparently at least as compliant with medication as a comparison group (Sved Williams AE: unpublished data from same practice, 1998).

Case-note review shows that doctors present with a wide range of issues and presenting problems. Marital problems are frequent, as are anxieties about off-spring, but no more than in the general population. Many came with anxieties and concerns about parenting issues, not surprising in a perinatal and infant psychiatry practice. While some doctors did discuss work stressors, these themes were not universal and more often related to pressures from peers rather than from patients. Work hours, administrative changes, practice costs (financial and time) were significant topics. Partners’ complaints about working hours were more frequent when the partner came from a field of work entirely unrelated to health. When partners came from a health background, time pressures were more often viewed as a shared difficulty to be controlled rather than a cause of blame between the partners. In general, themes are consistent with those identified through the literature. 25 When the doctor-patient was female and her partner was non-medical, the relationships were in general relatively power-balanced, whereas more often when the doctor-patient was male, control by that person was more apparent.

Other specialists have commented on the change in the treating practitioner over time when treating colleagues. 26 ,27 When first commencing private psychiatric practice, colleague referrals tended to present a daunting challenge. Doctors were viewed as special patients. The expectations that one's peers would be knowledgeable, along with their reputation as ‘difficult’, heightened the anxieties of treating them. With increased experience, they are now viewed as separate but not ‘special’. Treating one's colleagues as ordinary folk with similar problems to others is likely to be beneficial; the best guidance for all patients will be evidence-based practice combined with personal skill development and empathic care.

The one exception made for this group is to prioritize their entry into the practice, based on the knowledge that doctors find it difficult to seek the patient role. 9 Expediting treatment when they do seek help has seemed appropriate wherever possible. Macnaughton, in commenting on Crisci 27 in an emotively titled paper ‘The ultimate curse: the doctor as patient’, has commented that from an ethical point of view this is not appropriate for several reasons, including missing vital steps. 28 She states ‘… the “special” patient may miss out on routine investigations which are usually carried out by juniors [author's emphasis] before they see the consultant’. In the current series, self-referred patients are invited to identify a GP who can ensure that such steps are taken. Most are willing to do this. If not, the author undertakes the role of ensuring that physical illness is identified and managed.

Macnaughton suggests that treating friends may be too emotional and the author agrees with this. In some cases, for example when the referred person is a psychiatrist or psychiatric trainee, the practitioner is likely to know many other psychiatrists in Adelaide and, having made a personal choice to see the author, these issues are discussed immediately and decisions made about the appropriateness of ongoing treatment. No close friends have been seen in the case series identified.

Macnaughton also comments on the infringement of a major principle of ethical decision-making, in that if some patients are ‘special’ and are prioritized, clearly others are ‘less special’. This is an appropriate observation. In Australia, average waiting times for private psychiatric practice vary from State to State and within regions, and decisions about mode of practice are left to the individual practitioner. Given that the author also prioritizes antenatal patients (where self-evidently the situation presents other time considerations) and perinatal patients with infant problems (because these are considered prime situations for early or preventive interventions), the prioritization is consistent with choices about sub-specializing within a specialist practice. Nevertheless, such prioritization may be viewed by others as inappropriate.

In conclusion, doctors and their families in this private psychiatric setting present as a relatively self-motivated compliant group, who are keen to take up treatment offered and who generally fare well with such treatment. It is likely that the gradual destigmatization of psychiatry, the greater training of medical students in psychiatry, a general awareness of the benefits of early intervention, and more successful treatment modes such as improved antidepressants and shorter-term treatments all combine to produce a picture of doctors as patients rarely discussed or seen in the world's literature.