Twenty seven general practitioners participated (22 in one of five groups; five in individual interviews). Six participants were part time occupational physicians and six were recently appointed principals. Twenty one were men and six were women. The table shows their numbers of years since registration and practice location.
Health of the profession
Participants were reluctant to declare themselves ill but readily shared anxieties about the health of the profession:
We are seeing . . . increasing illness in doctors and that's quite scary. It used to be 50 year olds with MIs . . . also seen recently is a number of younger doctors in their 30s with various stress related illnesses.
Several said that self employment made it difficult for general practitioners to look after their own health.
Attitudes to acknowledging personal illness
General practitioners talked about the pressure to appear physically well. One said, “Nobody wants to go and see a doctor who is sick,” reflecting the perception that patients believed a doctor's health reflected his or her medical competence. This attitude affected their approach to screening.
We have a number of doctors in my practice and the number of cholesterol checks is very unimpressive. They make sure that their patients have their cholesterol checked . . . but will they go to their doctor and be screened themselves? They might . . . take it themselves, but it won't go into their chart.
Many agreed that they were poor at looking after themselves. Almost all reported working through, and expecting colleagues to work through, illnesses that they would not have expected patients to work through.
I broke my leg . . . and went into the surgery . . . because I couldn't get a locum at short notice.
Unless you're unable to get out of bed you'll crawl in and work.
Acknowledging psychological illness was extremely difficult. General practitioners regarded psychiatric illness in themselves as a weakness. Paradoxically, they reassured patients that “it's just another illness.” Concerns about confidentiality emerged as another factor affecting their use of psychiatric services.
Doctors feel they shouldn't be sick . . . you don't want to go and see your local psychiatrist in case one of your patients is sitting beside you.
Embarrassment was also a barrier to consulting other general practitioners and specialists about illness in themselves or their families.
Responses to personal illness
Comments indicated a perception of “us/doctors” and “them/patients,” with a reluctance to accept treatment and an underlying assumption that the roles of patient and doctor were incompatible: “We think we're superhuman and that we don't get ill, or if we do, we can cope with it.”
Professional culture appeared to discourage discussion of personal health with colleagues. When asked about discussing personal health, one responded, “You keep quiet about it.” This generated laughter in the group, which was confirmed with participants to mean a shared experience of embarrassment.
Some reported that in medical school and hospital “illness was not really tolerated and you were expected to do the job.” Recently appointed principals reported that self care was not taught adequately at either undergraduate or postgraduate level. One general practitioner illustrated the process of self diagnosis.
Take a change in bowel habit and colonic carcinoma . . . if you are a GP . . . at what point do you declare yourself as having a change in bowel habit? Do you under-react or over-react? . . . we don't know how to apply the protocols we work with every day to ourselves.
Several reported that their medical knowledge made them prone to swing between panic and denial when they experienced symptoms: “One minute you think it's just a headache, next minute you're sure it's a brain tumour.” Similar stresses were described regarding illness in their family.
Influences of general practice organisation on support
A sense of obligation to partners emerged in an interchange in one of the focus groups.
You don't stay off work because you're not going to earn money, you continue to work because of your partners.
Your partners are working twice as hard to carry you.
This view was supported in an indepth interview and in another focus group:
A terrible sense of duty of letting your partners down if you don't go in.
The real quandary arises when that person decides to come back. You might not think they are ready . . . but they are feeling guilty because the locums can't cover everything.
Fragile partnerships seemed to influence general practitioners' reluctance to acknowledge and manage personal illness appropriately. Several reported knowledge of difficult relationships between partners: partners are not necessarily friends.
They maybe try to cover each other equally at work . . . but they don't . . . socialise together. . . . They work in the surgery and that's it.
Most agreed that they did not take an active interest in their partners' health and played down evidence of colleagues being unwell. The reasons given illuminate difficulties experienced when doctoring doctors:
You didn't want to be made wrong . . . to be told “I wouldn't do that, that is stupid” . . . You are not sure whether they want you to interfere.
Some did not want their colleagues to comment on their health, but others wanted and needed muted cries for help to be acted on.
He made a few statements to his partners that he really couldn't cope but it wasn't really taken very seriously because he didn't make it very serious. He was registered with the practice and it went on for quite a while till he just cracked.
Informal shadow contract
We used a synthesis of the elements described above to construct an informal shadow contract (box). The terms in the contract were not stated explicitly but were communicated through anecdotes and black humour. At times participants questioned their compliance with this contract, recognising its destructiveness. Some identified themselves as its cocreators but felt helpless to change it. The contract was subsequently presented to four additional small groups of general practitioners, who confirmed that it agreed with their experience.
Informal shadow contract
I undertake to protect my partners from the consequences of my being ill. These include having to cover for me and paying locums. I will protect my partners by working through any illness up to the point where I am unable to walk. If I have to take time off, I will return at the earliest possible opportunity. I expect my partners to do the same and reserve the right to make them feel uncomfortable if they violate this contract.
In order to keep to the contract I will act on the assumption that all my partners are healthy enough to work at all times. This may mean that from time to time it is appropriate to ignore evidence of their physical and mental distress and to disregard threats to their wellbeing. I will also expect my partners not to remind me of my own distress when I am working while sick.