Dr Kerryn Phelps, AMA President, to The Australian Orthopaedic Assocation, 'The Business of Orthopaedics' Conference

Those guys write and comment on the business of everything on a daily basis in an authoritative way. I am but a hardworking GP.

Then I saw the speech topic I had been given - 'HEALTH BREAKDOWN - The Risk To Your Greatest Asset' - and I knew an MBA was not a prerequisite to be a speaker at this forum.

A medical degree, loads of personal experience, and a generous serve of common sense will get me through this assignment.

The best doctors are healthy doctors.

I think Paul and Terry will agree with me that all the business advice in the world is no good to you if you're not around and fully fit to run your business - to properly look after your patients.

As a doctor it is equally important to look after your own health as it is to provide the best care for your patients.

A sick or unhealthy doctor is not a good advertisement for a medical practice.

Doctors' health - physical, mental and attitudinal - is an issue that is gaining a higher profile within the profession and within the broader community.

Before I go into some of the clinical health detail, let me say at this point that 'self-esteem' is an important part of a doctor's overall health profile.

While doctors have enjoyed a respected place in the community, more and more these days we see doctors being blamed for any real or perceived woes in the health system.

This is wrong and must stop.

Doctors by their very nature - and their years of study - are dedicated to caring for and improving the health of their fellow human beings.

But others in the community see doctors as an easy target when they want to shift blame for their own mistakes.

Politicians do it. We've all heard the 'greedy doctors' mantra.

ACCC Commissioners do it. Often. According to them, doctors working together on rosters to provide around-the-clock medical care is anti-competitive. What rot.

The health funds do it. Yes, the holier-than-thou taxpayer-funded health insurance industry says it's the doctors' fault when private health premiums rise and rise and rise.

They even had the gall to attack the AMAQ the other day over sponsorship for a 'no gaps' campaign.

It's the height of hypocrisy for the health funds to play the 'class divide' card. After all, they are the masterminds of the definitive system of 'haves' and 'have-nots' - with a government subsidy to boot!

What I'm saying is that the blame game is not good for doctors.

We are in the business of practising medicine and caring for patients.

We are not there to wear a target on our chests to take the flak for other people's mistakes and poor judgement. It's just not healthy.

Back to the clinical side of things.

While doctors' health is a concern for all doctors, most of the published studies, to date, have been based on GPs.

We all know that stresses and pressures affect all the specialties - perhaps none more so than anaesthetics - but the general trends apply to all doctors.

Last November, the AMA Queensland hosted the 2nd National Doctors' Health Conference.

Out of that conference came a report - 'Towards Better Healthcare For Doctors' by Doctor John Buchanan.

Both the conference proceedings and the Buchanan report echo the findings of a report that also came out late last year.

In September 2001, the Departments of General Practice of The University Of Melbourne and Monash University prepared a report on GP Wellbeing for the Commonwealth Department of Health and Aged Care.

As these reports are among the most current and authoritative studies of this kind in Australia, I will draw on them extensively in my comments today.

The Departmental report defined GP wellbeing - a euphemism for doctors' health - in the following way:

Wellbeing has been defined in this project as the presence of physical, mental and social health.

It can be considered a continuum.

At one end of this continuum are satisfied GPs; next come those with poor morale and who are dissatisfied with general practice as it currently exists, even though they may be 'coping' with their work; then come the GPs who are significantly stressed and at high risk of burnout; and finally, there are those who are 'impaired and in need of professional treatment.

Impairment can be defined as being ill; the main forms of doctor impairment are psychiatric illnesses and substance abuse.

While impairment might be less a common condition than dissatisfaction or stress, it is of considerable importance given the degree of morbidity and mortality associated with it.

The wellbeing of GPs is a major concern for the individual doctor, the profession, funders and consumers alike.

Reduced wellbeing may lead to health problems for GPs, difficulties in coping with work, and a reduction in quality of care to patients.

This same report identified the major sources of stress in General Practice as:

Excessive workload/stress - exacerbated when GPs feel they are working harder for no extra benefit.

Paperwork - rather than do the 'red tape' paperwork during consulting time, doctors tend to do it at night or take it home, putting pressure on family life and personal relationships.

After Hours Work - being on call is a potential stressor. Programs like Practice Incentive Payments (PIP) actually encourage after hours work which, over time, has a negative effect on the health and wellbeing of the doctor.

Work family Interface - unsatisfactory resolution of the conflicting needs of work and family contributes to stress levels.

Remuneration - GPs are feeling powerless to increase their incomes to offset greater administration, staff costs and other overheads. Low morale results because the workload increases, but remuneration stays the same or suffers a net decrease.

Lack of a structured career pathway - onset of depression through the feeling of being stuck in a 'rut'.

Patient expectations - consumerism has led to a lowering of respect for doctors within the community.

Uncertainty/ Making Mistakes and Litigation - again, consumer expectations are fuelling greater fears of litigation. Many GPs do not fully understand their legal rights and responsibilities.

Violence and GP safety - a survey of rural GPs catalogued verbal insults, threats, physical assaults, sexual abuse, property damage and harassment, with 20 per cent of respondents being physically attacked.

GP Registrars - reported main stressors as job versus family conflict, pressures of preparing for College examination and patients' in realistic expectations.

The AMA's Safe Hours campaign is one of several initiatives we have been running to ease the pressure on junior doctors.

Add all those together and you have a pretty potent recipe for potential disaster.

Throw in concerns about medical indemnity insurance and the unnecessary intervention of the ACCC and it is obvious that a doctor's health is under attack from many different sources.

But what about the doctor as patient?

The GP Wellbeing Report found that GPs tend to disregard the health advice that they would give their patients.

Relatively few Australian GPs have their own GP and the majority diagnose and treat their own illnesses.

Studies show that they are likely to receive inferior care when they are ill. One study found that 26 per cent of surveyed doctors suffered a condition that warranted a medical consultation, but reported feeling inhibited about consulting a GP. This was truer for female GPs.

The medical community, unfortunately, has a professional culture of working through illness and undertaking self-treatment as the norm.

Self-treatment includes prescribing medication. A large proportion of Australian GPs admit to self-prescribing sleeping tablets and a small but notable group had self-prescribed opiates.

When it comes to physical health, Australian GPs are generally in better shape than the general population. Dr Peter Larkins will speak in detail on this subject a little later.

Meanwhile, authorities have suggested that the medical culture tends to view ill health, particularly psychological or addictive behaviour, as a weakness.

We've got to turn that attitude around.

Research indicates that GPs are prone to psychological conditions, including depression and substance addiction. This can be extended to all doctors.

Psychological ill-health among GPs has attracted attention - as it would across the whole profession - because of its perceived ability to impair a patient's quality health care.

The definition of 'impaired doctor' includes emotional problems, physical impairment, ageing problems, sexual misconduct and severe stress.

Areas of concern in assessing the factors that may affect the mental health of doctors include:

Personality characteristics - while an American study found that people entering medicine are more vulnerable than the general population to mental health problems, this has not been the case in Australia.

Emotional Disorders - consistent with overseas studies, emotional problems, particularly depressive symptoms, are prevalent among Australian GPs. There is considerable overseas evidence that GPs are more likely to commit suicide, with depression, alcoholism and drug abuse key factors. There has been no recent Australian research to make valid comparisons.

Alcohol abuse - again, no reliable Australian research to compare with overseas studies.

Drug Dependency - research indicates that GPs are an 'at risk' group for substance abuse. In Australia, it is thought that impairment due to drugs may be more serious than impairment due to alcohol.

Social Impairment - marital distress is common and it remains unclear whether it is more or less common in GPs than among other groups in the population.

Looking at the psychological problems confronting doctors' health, research suggests that one of the main factors contributing to impairment is inadequate coping skills.

Ineffective coping skills are particularly hazardous when working in an environment with a high level of demands - an environment in which doctors work, for example.

Many of you may be feeling depressed hearing all this negative data on doctors' health.

Relax. The data refers to a minority of doctors and the good news is that doctors and doctors' groups like the AMA are aware of the problems and are seeking to put in place programs and information to help our colleagues through difficult times.

In fact, in a matter of weeks the AMA will have doctors' health advice on its website. Look it up.

While the doctor whose health is under pressure should seek help from other doctors, there is also a set of rules that should be followed by doctors who treat other doctors.

The Sunshine Coast Division of General Practice has modified the British Medical Association's guidelines for GPs when treating doctor-patients for local use. They read like this:

It is recommended that the GP should:

Recognise their doctor-patient's need for support and information as an individual rather than as a health care professional.

Acknowledge and discuss any potential boundary issues early in the development of the doctor-patient relationship. This is especially important where doctors know one another or practise in rural/remote situations.

Not prescribe for colleagues who are not their patients in anything other than exceptional circumstances and to resist treating or giving advice to their doctor-patients outside of a formal consultation.

Examine their doctor-patients as thoroughly, and in the same circumstances as they would other patients. They should make appropriate follow-up consultations and not rely on the doctor-patient to oversee their own treatment.

Involve the doctor-patient in the decision making process with regard to their treatment with the right to a second opinion in the case of disagreement about diagnosis or management.

Ensure the same level of confidentiality towards their doctor-patients as to any other patients. In some cases, it may be appropriate to file their doctor/patient charts in a separate area.

Objectively assess their doctor-patient's ability to work in their usual professional role. It is misplaced loyalty to put the interest of a colleague above the safety of their patients. Other issues, such as the impact of sleep deprivation on a doctor's health and ability to practise safely must also be objectively assessed.

When the doctor-patient has a lack of insight, and fails either to agree to health assessment or to abide by the results of such an assessment, the attending GP may need to seek advice from other appropriate authorities.

If the doctor-patient will not comply with professional advice, and if their behaviour poses a risk to their own patients, the attending GP must consider their professional responsibility to contact the appropriate authorities. The examining GP may conceivably have a legal liability if they take no steps to prevent a doctor, who is medically unfit, from practising.

And some advice for the doctor as patient….

All doctors should have their own GP. It is not advisable for a doctor to assume responsibility for the diagnosis and management of his or her own health problems or those of their immediate family, except in the most unusual circumstances.

Doctors have an ethical duty to ensure that their own health problems are effectively managed.

This may all sound like pretty heavy stuff…and so it should.

The important message I want you to take away from me today is that you have to be able to look after yourselves if you are to have any credibility or confidence in looking after your patients and fulfilling the trust they have placed in you.

It is common sense. It is good business sense. Look after your health and you're in a better position to look after your business - the business of being a good doctor to your patients. Look after yourselves.

Thank you.