Physician, do not heal thyself

Israeli doctors who treat and prescribe medications for themselves are at risk and may fail to serve as a role model for their patients.

By JUDY SIEGEL-ITZKOVICH
Smoking Doctor Cartoon 311 (photo credit: (Laurie McAdam for The Modesto Bee/MCT))
Smoking Doctor Cartoon 311
(photo credit: (Laurie McAdam for The Modesto Bee/MCT))
About 20 years ago, the deputy head of cardiology at an Israeli hospital invited me for an interview about the latest developments in his field. Entering his office, I detected the odor of stale tobacco smoke.
“Could it be that you, a leading cardiologist, smoke?” I asked in disbelief. He blanched and pulled open the top drawer of his desk, revealing dozens of packets and dirty ashtrays.
“Please,” he entreated. “Don’t write about it in the paper.”
The heart specialist is no longer with us, and in general there are many fewer doctors today who light up than there used to be. But one can still see some MDs huddling outdoors with a cigarette during breaks in medical conference sessions who don’t practice what they should be preaching to their patients.
Physicians get sick, suffer from chronic physical and mental illnesses and eventually die, like their patients do. But too many tell themselves: “It won’t happen to me.” As a result, most of them – according to a prominent family medicine specialist – don’t have a general practitioner or family physician, even though all of them are members of a health fund under the universal National Health Insurance Law.
“Most doctors don’t have their own doctor,” asserts Dr. Amnon Lahad, head of family medicine at at the Hebrew University- Hadassah Medical School and at Clalit Health Services’ Jerusalem district.
“Instead, when they get sick they treat themselves, or, if it’s more serious, they consult with a colleague in a hospital or clinic corridor. Usually, neither of them has the time to sit down together for a consultation. The doctor who is a patient tends to find it difficult to fit an appointment into his [or her] schedule,” says Lahad, who has studied the issue.
The issue of medical care for physicians was most recently raised in Harefuah, the Hebrew-language journal of the Israel Medical Association. “Who will doctor the doctor? Recommendations for doctors on a healthy way of life” was written by Safra Children’s Hospital sports medicine expert Dr. Gal Dubnov-Raz; metabolism and nutrition Prof. Elliot Berry of Hadassah’s Braun School for Public Health and Community Medicine; Hadassah Optimal sports medicine director Dr. Naama Constantini; and Dr. Ofer Shemer of Tel Aviv University’s Sackler Medical Faculty.
“Observing a healthy lifestyle is mandatory for the whole population – the healthy and the sick, young and old, doctors and patients. We are liable to think that we [doctors] are protected from those same diseases and conditions that [we see in] our patients all the time. Doctors,” they write, “tend to go to work when they are ill and to ignore mild symptoms through avoidance and the belief that their medical knowhow will protect them.”
But doctors are exposed to dangers connected with their profession, the authors continue. These include sedentary habits from using the elevator and a computer for hours on end, weight problems due to poor eating habits, hypertension, depression and addiction to tobacco, alcohol and even hard drugs.
Physicians also have the tools to transmit health messages to their patients, the medical journal article writers continue.
“A doctor can serve as a personal example in his behavior and way of life, give positive examples from his personal experience in improving nutrition or increasing physical activity, encourage the patient and supply the mental fortitude he needs to improve his habits.
“The doctor can also create in his clinic an atmosphere of health promotion with leaflets, pictures and posters and even integrate the clinic team in existing groups of exercise, programs to improve lifestyles, healthy cooking workshops and so on.”
While there is little data on the health of Israeli doctors, other countries do more research. There are numerous published studies in the US on the subject. Journal articles show that a third to a half of physicians polled admit to being overweight.
The Australian Medical Association (AMA) has devoted considerable attention to the study of doctors’ health. Just last April, the AMA issued a “Position Statement on the Health and Wellbeing of Doctors and Medical Students.”
“Research shows that doctors with healthy personal lifestyle habits are more likely to impart healthy behaviors to their patients,” it stated. “As a profession, it is important that doctors look after their own health and the health of their colleagues.
Many doctors can become so focused on their practices and the health of their patients that they neglect their own health and wellbeing. It is difficult for doctors to properly look after their patients if they are not staying healthy and well themselves. Junior doctors may experience pressures and stress throughout their training due to long hours and irregular shifts. Experienced doctors confront barriers to their own good health throughout their careers.
“The AMA recommends that all doctors should have their own general practitioner rather than attempting to diagnose and treat themselves. Doctors and medical students should make better life choices to maintain their good health. They should take regular leave, enjoy good nutrition, undertake regular exercise and pursue a balanced lifestyle between work, family and leisure. They should also keep on eye on the health of their fellow doctors. Doctors have legal and ethical responsibilities to respond to when they become aware of a colleague who is having health problems.”
Israel’s Health Ministry has not issued such a clear statement, nor do the Harefuah authors mention in their survey whether the Israel Medical Association has.
The Lancet medical journal in Britain looked some years ago at the possible link between poor doctor health and poor patient care via an objective review written by experts from University of Calgary in Canada. It showed that doctors’ stress, fatigue, burnout, depression or general psychological distress are common and negatively affect healthcare systems and patient care. The researchers proposed that “because wellness may not only benefit the individual doctor but also be vital to the delivery of quality health care, physician wellness should be included as an indicator of health-system quality.
Ultimately,” they continued, “individual doctors will personally benefit from taking better care of themselves. Such efforts would probably lead to increased job satisfaction and overall wellbeing... The organizations employing doctors will benefit by having more productive and efficient healthcare providers in conjunction with reduced absenteeism, job turnover, and recruitment and retention issues. And perhaps the patients themselves will benefit by receiving better quality of care.”
While they could not quote comprehensive surveys of Israeli doctors, they mention that Clalit Health Services issued a study of its medical staffers showing they were just as likely as the general population to undergo screening tests for breast or colon cancer or high blood cholesterol.
However, they were less likely to test their blood pressure and had a significantly lower smoking rate than the public at large. Like ordinary Israelis, many of the doctors polled complained that lack of time, motivation and facilities made it difficult for them to exercise. The authors conclude by urging doctors to take the stairs rather than the elevator, substitute vegetables and fruits for junk food and make other steps to improve their health.
Lahad says that a year ago, the Israel National Council for Community Health recommended a system to improve physicians’ health, giving most stress to their psychological health. But it is a rare physician who is willing to pour his heart out to a staff psychologist or psychiatrist about his emotional or mental problems – either out of embarrassment or fear that it could, if known to management, lead to dismissal.
“It’s a profession with heavy pressure, long hours and lots of burnout. Nobody knows how many doctors here suffer from depression, as there are no surveys, but we all have anecdotal evidence.”
Lahad continues: “It is too easy for a doctor to self-treat. We are free to write our own prescriptions and go for any tests we wish. There are those who go for an excessive number of tests, while others undergo too few; it seems as if younger physicians tend to go for more tests than older ones. I have a health fund doctor who gives me prescriptions. For renewing prescriptions, to save time I write them out myself, but not the first time,” says the Clalit family physician.
Doctors who take measures to promote their own good health “are better health educators of their patients. If they exercise, studies have shown, they tend more to recommend exercise to their patients. If they don’t get a flu shot or if they smoke, they are less likely to talk to patients about smoking cessation or vaccination, so their patients’ health can suffer,” Lahad says.
Dr. Karen Djemal, medical director of TEREM’s Family Care Clinic in Jerusalem and a veteran family physician who recently received an Outstanding Physician award from the Israel Association of Medicine and Law in Israel, says that “in general, doctors aren’t good at taking care of themselves. They have an irrational belief that people who take care of the health of others somehow have immunity from serious disease.”
The very fit Djemal tries to practice what she preaches to her patients and medical staff. She jogs in the early morning in the Katamon neighborhood before going to work and is thrilled when seeing some of her patients doing the same.
“I believe in exercising, eating right and avoiding tobacco. I try to establish role models and habits. For our clinic staff, getting flu shots, mammographies, colonoscopies and other screening tests is encouraged.
Even at Rosh Hashana toasts, we serve cut vegetables, whole wheat crackers and white cheese rather than burekas, cakes and sweetened soft drinks.”
She worries about her staff, not only because she cares but also out of self interest – getting flu shots means they will not have to take off sick.
Asked to comment, Health Ministry associate director-general Dr. Boaz Lev surprisingly failed to advocate an activist approach to the issue. Although he is a jogger who hits the pavement even in 40- degree Celsius heat at a Dead Sea hotel’s medical conference, he said he saw no need for a framework to check and monitor physicians’ health.
“A physician is like everyone else. He is aware of the need for good health, usually more than others. Some have a personal physician, while others don’t. I am not aware whether there is more depression and drinking among doctors than patients. We haven’t checked. We do encourage doctors to get flu shots, but we don’t force medical checks or treatments on anyone. Physicians,” he said, “are no different from others. I don’t see a need for a health-promotion program among them. If I had public money to spent, I would do health promotion for people who don’t have accessibility to it rather than for physicians,” Lev stated.
Djemal suggested that doctors’ employers – hospitals or health funds – should offer a free, once-a-year physical exam, as individuals rather than organized and not with any repercussions on their service.
Lahad says that all doctors should be required to register with a health fund personal physician so they will be less likely to treat themselves.
“I don’t know if there should be mandatory annual checkups, but there must at least be independent counselling for psychological problems. A doctor who suffers from stress or other problems that affect his work needs to be able to talk to a professional who would observe total confidentiality.”
As Israel currently suffers from a serious and growing shortage of physicians, one would think it worthwhile for the ministry to consider a program that would promote better health in those we do have.