We carried out in-depth interviews on 19 doctors who had been off work for 6 months or more. These doctors had various combinations of physical and psychiatric disorders. The majority, although not all, had had some dealings with the GMC. A number of potential participants declined to participate in the study, with many suggesting that they were concerned about confidentiality and anonymity. This is interesting in itself and shows a distrust of how the findings might be used, despite reassurance about the purpose of the study and how confidentiality would be maintained.
Many of our participants had a mixture of physical and mental health difficulties. The interviews which were semistructured and therefore to some degree led by the interviewee. They tended to focus on the mental health issues, which is why these appear more prominent in the analysis.
Commitment to, and identifying with, the role of a doctor was a common theme that emerged. It is likely that medicine with its long training and long hours of work preferentially attracts individuals likely to make a commitment to their work. The flip-side of such an approach is the relative absence of an alternative structure or purpose if, for whatever reason, an individual is unable to work.
The centrality of this role also seemed to be strengthened by the perception among doctors that they are ‘invincible’, and that ‘illness is only for patients’, alluded to in both Cohen's review for the Royal Medical Benevolent Fund (Cohen D, personal communication) and Harvey's review for the National Clinical Assessment Service.8
It is understandable therefore that for some doctors, the recognition of illness presents a challenge over and above that of just the disorder—it forces an entire reappraisal of their view of the world and their place within it. The accounts given by several doctors convey a sense of great surprise, often only implicitly, that they had suffered a health problem. While these issues have been recognised as factors in delaying or preventing a doctor seeking medical attention,8
they have not previously been considered as reasons for a doctor having difficulty in returning to work.
One of the most striking findings was the negative view the doctors had of themselves since ill health became a part of their identity. This may have been exacerbated by the views and behaviours they perceived from family members and colleagues: many felt unsupported or judged. It is important to note that these feelings are the perceptions of the participants; as no significant others were interviewed, we do not have information about their views. The participants in our study described having experienced negative interactions with their families and colleagues during their illness, as well as seemed to anticipate this as part of any return to work process.22
It has been suggested that doctors stigmatise mental illness more than the public,23
but the self-stigmatisation seemed to extend to physical illness as well. As is common with stigma, the doctors’ accounts are likely, in part, to represent negative internalised self-perceptions and their views about how others perceive them.24
Profound and potentially destructive negative self-images were shared by several participants. While low self-esteem can be part of a depressive disorder, not all doctors had experienced a depressive episode or were currently suffering from depression; a number had made a clinical recovery from their health condition. Our findings went beyond low self-esteem into the realm of self-stigma. Self-stigma describes the phenomenon whereby people adopt and internalise external social stigma and experience loss of self-esteem and self-efficacy.26–28
As a result, they refrain from taking an active role in various areas of life. Many of the doctors we interviewed appeared to have absorbed negative views of themselves. Moreover, at least two doctors described difficulties in dealing with having a disabling physical health problem, only to then have to cope with yet more perceived criticism regarding a mental health problem. It is possible that in absorbing them, doctors perpetuate and reinforce the negative views of others. An alternative suggestion may be that the doctors have internalised the view of themselves as invincible to the extent that they view themselves as failures, and cannot conceive that anyone else might view their illness differently. So rather than absorbing negative views of others, they may in fact be externalising their own negative views. A future study would benefit from assessing the views held by those close to doctors.
We are not aware of a literature describing why doctors may be more prone to self-stigmatise and are therefore restricted to hypothesising. It is possible that it reflects a general tendency to stigmatise—doctors have been shown to stigmatise others with mental health problems.23
It may, in part, be connected to the issue of ‘invincibility’ which is constructed in binary fashion—you are either invincible, or you are completely useless. It may also reflect a more widespread aspect of medical culture where doctors develop a sensitivity to the views of others. Normally, this is the positive views of colleagues and patients that can be quite intoxicating. Doctors may also be predisposed to internalise negative views of others.
Any understanding of the difficulties faced by doctors in returning to work needs to be able to incorporate both the omnipotent ‘doctors are invincible’ view and the negative self-stigmatising views elicited in our study. Although these may seem to be mutually exclusive, an alternative hypothesis would be that the self-stigmatising views are a direct consequence of the unhealthy ‘doctors are invincible’ view. The competitive medical environment reinforces the need for toughness and self-reliance which has become more of a wider cultural phenomenon rather than a trait identified in a few. It is possible that, for some, this has a selective advantage—that is, for some students and trainees, this outlook assists in being able to manage the suffering of the patients and families they are learning to treat. Its success in the short-term means it often remains unchallenged. The incorporation of the ‘illness is for patients’ view however reduces the chances of alternative ‘healthier’ narratives about the interchangeability of the patient and doctor roles being generated. Thus, when a doctor does become ill, they are challenged on a range of levels, dealing not only with the illness but also for some the loss of their self-image as invincible.
A number of doctors though do not have access to strategies which will allow them to come to terms with these issues while maintaining their personal integrity. A greater willingness to accept the possibility that one might at some stage become a patient, together with greater input from trainers and senior colleagues as to how this might be managed, could reduce the sense of shock and bewilderment should illness strike.
As with all stigma, reducing social distance can help change minds.29
It is possible that recent improvements in the quality of NHS occupational health services30
and the services provided to treat sick doctors, such as the Practitioner Health Programme, might mean that more doctors who have had complex difficulties are able to return to active practice more rapidly. The presence of these doctors in the workforce will therefore increase over time, improving the chance that students and trainees will come into contact with such doctors, and this will act as a counter-weight to the notion that ‘doctors are invincible’. But if we are to create an environment which facilitates the return to work of doctors with long-term difficulties, attention must be paid to how the ‘invincible’ culture in medicine is generated. The regulator, which now has responsibility for UK medical undergraduates, the Deaneries and the medical schools must work together to enable students and trainees to recognise their own vulnerabilities and facilitate the generation of strategies should they become ill. Further, aspects of personal and colleague health, especially mental health, should be part of the curriculum for all medical students. Doctors must learn to provide themselves and their colleagues with the same level of excellent care that they provide for their patients.