Physician, do not heal thyself
Israelidoctors who treat and prescribe medications for themselves are atrisk and may fail to serve as a role model for theirpatients.
About20 years ago, the deputy head of cardiology at an Israeli hospitalinvited me for an interview about the latest developments in hisfield. Entering his office, I detected the odor of stale tobaccosmoke.
“Couldit be that you, a leading cardiologist, smoke?” I asked indisbelief. 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.”
Theheart specialist is no longer with us, and in general there aremany fewer doctors today who light up than there used to be. Butone can still see some MDs huddling outdoors with a cigaretteduring breaks in medical conference sessions who don’t practicewhat they should be preaching to their patients.
Physiciansget sick, suffer from chronic physical and mental illnesses andeventually die, like their patients do. But too many tellthemselves: “It won’t happen to me.” As a result, most of them –according to a prominent family medicine specialist – don’t have ageneral practitioner or family physician, even though all of themare members of a health fund under the universal National HealthInsurance Law.
“Mostdoctors don’t have their own doctor,” asserts Dr. Amnon Lahad, headof family medicine at at the Hebrew University- Hadassah MedicalSchool and at Clalit Health Services’ Jerusalemdistrict.
“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 aconsultation. The doctor who is a patient tends to find itdifficult to fit an appointment into his [or her] schedule,” saysLahad, who has studied the issue.
Theissue of medical care for physicians was most recently raised inHarefuah, the Hebrew-language journal of the Israel MedicalAssociation. “Who will doctor the doctor? Recommendations fordoctors on a healthy way of life” was written by Safra Children’sHospital sports medicine expert Dr. Gal Dubnov-Raz; metabolism andnutrition Prof. Elliot Berry of Hadassah’s Braun School for PublicHealth and Community Medicine; Hadassah Optimal sports medicinedirector Dr. Naama Constantini; and Dr. Ofer Shemer of Tel AvivUniversity’s Sackler Medical Faculty.
“Observinga healthy lifestyle is mandatory for the whole population – thehealthy and the sick, young and old, doctors and patients. We areliable to think that we [doctors] are protected from those samediseases and conditions that [we see in] our patients all the time.Doctors,” they write, “tend to go to work when they are ill and toignore mild symptoms through avoidance and the belief that theirmedical knowhow will protect them.”
Butdoctors are exposed to dangers connected with their profession, theauthors continue. These include sedentary habits from using theelevator and a computer for hours on end, weight problems due topoor eating habits, hypertension, depression and addiction totobacco, alcohol and even hard drugs.
Physiciansalso have the tools to transmit health messages to their patients,the medical journal article writers continue.
“Adoctor can serve as a personal example in his behavior and way oflife, give positive examples from his personal experience inimproving nutrition or increasing physical activity, encourage thepatient and supply the mental fortitude he needs to improve hishabits.
“Thedoctor can also create in his clinic an atmosphere of healthpromotion with leaflets, pictures and posters and even integratethe clinic team in existing groups of exercise, programs to improvelifestyles, healthy cooking workshops and so on.”
Whilethere is little data on the health of Israeli doctors, othercountries do more research. There are numerous published studies inthe US on the subject. Journal articles show that a third to a halfof physicians polled admit to being overweight.
TheAustralian Medical Association (AMA) has devoted considerableattention to the study of doctors’ health. Just last April, the AMAissued a “Position Statement on the Health and Wellbeing of Doctorsand Medical Students.”
“Researchshows that doctors with healthy personal lifestyle habits are morelikely to impart healthy behaviors to their patients,” it stated.“As a profession, it is important that doctors look after their ownhealth and the health of their colleagues.
Manydoctors can become so focused on their practices and the health oftheir patients that they neglect their own health and wellbeing. Itis difficult for doctors to properly look after their patients ifthey are not staying healthy and well themselves. Junior doctorsmay experience pressures and stress throughout their training dueto long hours and irregular shifts. Experienced doctors confrontbarriers to their own good health throughout theircareers.
“TheAMA recommends that all doctors should have their own generalpractitioner rather than attempting to diagnose and treatthemselves. Doctors and medical students should make better lifechoices to maintain their good health. They should take regularleave, enjoy good nutrition, undertake regular exercise and pursuea balanced lifestyle between work, family and leisure. They shouldalso keep on eye on the health of their fellow doctors. Doctorshave legal and ethical responsibilities to respond to when theybecome aware of a colleague who is having healthproblems.”
Israel’sHealth Ministry has not issued such a clear statement, nor do theHarefuah authors mention in their survey whether the Israel MedicalAssociation has.
TheLancet medical journal in Britain looked some years ago at thepossible link between poor doctor health and poor patient care viaan objective review written by experts from University of Calgaryin Canada. It showed that doctors’ stress, fatigue, burnout,depression or general psychological distress are common andnegatively affect healthcare systems and patient care. Theresearchers proposed that “because wellness may not only benefitthe individual doctor but also be vital to the delivery of qualityhealth care, physician wellness should be included as an indicatorof health-system quality.
Ultimately,”they continued, “individual doctors will personally benefit fromtaking better care of themselves. Such efforts would probably leadto increased job satisfaction and overall wellbeing... Theorganizations employing doctors will benefit by having moreproductive and efficient healthcare providers in conjunction withreduced absenteeism, job turnover, and recruitment and retentionissues. And perhaps the patients themselves will benefit byreceiving better quality of care.”
Whilethey could not quote comprehensive surveys of Israeli doctors, theymention that Clalit Health Services issued a study of its medicalstaffers showing they were just as likely as the general populationto undergo screening tests for breast or colon cancer or high bloodcholesterol.
However,they were less likely to test their blood pressure and had asignificantly lower smoking rate than the public at large. Likeordinary Israelis, many of the doctors polled complained that lackof time, motivation and facilities made it difficult for them toexercise. The authors conclude by urging doctors to take the stairsrather than the elevator, substitute vegetables and fruits for junkfood and make other steps to improve their health.
Lahadsays that a year ago, the Israel National Council for CommunityHealth recommended a system to improve physicians’ health, givingmost stress to their psychological health. But it is a rarephysician who is willing to pour his heart out to a staffpsychologist or psychiatrist about his emotional or mental problems– either out of embarrassment or fear that it could, if known tomanagement, lead to dismissal.
“It’s aprofession with heavy pressure, long hours and lots of burnout.Nobody knows how many doctors here suffer from depression, as thereare no surveys, but we all have anecdotal evidence.”
Lahadcontinues: “It is too easy for a doctor to self-treat. We are freeto write our own prescriptions and go for any tests we wish. Thereare those who go for an excessive number of tests, while othersundergo too few; it seems as if younger physicians tend to go formore tests than older ones. I have a health fund doctor who givesme prescriptions. For renewing prescriptions, to save time I writethem out myself, but not the first time,” says the Clalit familyphysician.
Doctorswho take measures to promote their own good health “are betterhealth educators of their patients. If they exercise, studies haveshown, they tend more to recommend exercise to their patients. Ifthey don’t get a flu shot or if they smoke, they are less likely totalk to patients about smoking cessation or vaccination, so theirpatients’ health can suffer,” Lahad says.
Dr.Karen Djemal, medical director of TEREM’s Family Care Clinic inJerusalem and a veteran family physician who recently received anOutstanding Physician award from the Israel Association of Medicineand Law in Israel, says that “in general, doctors aren’t good attaking care of themselves. They have an irrational belief thatpeople who take care of the health of others somehow have immunityfrom serious disease.”
Thevery fit Djemal tries to practice what she preaches to her patientsand medical staff. She jogs in the early morning in the Katamonneighborhood before going to work and is thrilled when seeing someof her patients doing the same.
“Ibelieve in exercising, eating right and avoiding tobacco. I try toestablish role models and habits. For our clinic staff, getting flushots, mammographies, colonoscopies and other screening tests isencouraged.
Even atRosh Hashana toasts, we serve cut vegetables, whole wheat crackersand white cheese rather than burekas, cakes and sweetened softdrinks.”
Sheworries about her staff, not only because she cares but also out ofself interest – getting flu shots means they will not have to takeoff sick.
Askedto comment, Health Ministry associate director-general Dr. Boaz Levsurprisingly failed to advocate an activist approach to the issue.Although he is a jogger who hits the pavement even in 40- degreeCelsius heat at a Dead Sea hotel’s medical conference, he said hesaw no need for a framework to check and monitor physicians’health.
“Aphysician is like everyone else. He is aware of the need for goodhealth, usually more than others. Some have a personal physician,while others don’t. I am not aware whether there is more depressionand drinking among doctors than patients. We haven’t checked. We doencourage doctors to get flu shots, but we don’t force medicalchecks or treatments on anyone. Physicians,” he said, “are nodifferent from others. I don’t see a need for a health-promotionprogram among them. If I had public money to spent, I would dohealth promotion for people who don’t have accessibility to itrather than for physicians,” Lev stated.
Djemalsuggested that doctors’ employers – hospitals or health funds –should offer a free, once-a-year physical exam, as individualsrather than organized and not with any repercussions on theirservice.
Lahadsays that all doctors should be required to register with a healthfund personal physician so they will be less likely to treatthemselves.
“Idon’t know if there should be mandatory annual checkups, but theremust at least be independent counselling for psychologicalproblems. A doctor who suffers from stress or other problems thataffect his work needs to be able to talk to a professional whowould observe total confidentiality.”
AsIsrael currently suffers from a serious and growing shortage ofphysicians, one would think it worthwhile for the ministry toconsider a program that would promote better health in those we dohave.
有本事就学学猫科的自养功夫，独立守神，肌肉若一：
