Abstract



Introduction

Studies have shown that doctors treat themselves rather than seek professional help when they are sick.^1–3 In the UK, Chamber found that nine out of 10 doctors who took antibiotics had prescribed these for themselves, and half of those who were taking antidepressant drugs had self-medicated.¹ A recent study in Australia found that 90% and 25% of doctors believed that it was acceptable to self-treat for acute and chronic illnesses, respectively. Although it is appropriate to perform self-care for self-limiting illnesses, there is a potential for losing objectivity and mismanaging themselves in more serious and chronic diseases. This may contribute to the increasing work stress, and sometimes even suicide among doctors.⁴

Guidelines have been drawn up to assist doctors to seek appropriate treatment during their sickness.⁵ However, they are largely not being followed.⁶ There are many possible reasons why doctors behave in this manner, which include difficulty to adopt a sick role, embarrassment, lack of confidentiality, awareness of increased workload for colleagues and organizational barriers.⁷ Existing studies focus mainly on the quantitative outcomes,^1,2,8 which may not accurately capture the underlying reasons and attitudes of doctors treating themselves. Therefore, this study aimed to determine qualitatively the range of help-seeking behavior among a group of primary care doctors, and to explore in depth the reasons for their behavior.


Materials and methods

This study used focus group discussions (FGDs) to answer the research question. Focus groups are a form of group interview that capitalizes on communication among research participants in order to generate data.⁹ It is among the most widely used research tools to examine people’s experiences of disease and of health services.¹⁰ A focus group takes advantage of the interaction among small homogenous groups of people, preferably approximately 6–8 people and they are asked to reflect on and discuss a series of questions posed by the moderator. This qualitative research method was chosen because it can provide in-depth information about the attitudes and behaviors of doctors during illness.

This study was carried out at the Department of Primary Care Medicine, University of Malaya, which runs a primary care clinic in a teaching government hospital. This department, consisting of lecturers, postgraduate trainees and medical officers (total 32), provides outpatient services in an urban setting. There are approximately 300 patient attendances per day. All doctors in the clinic were invited to participate in this study. A semistructured interview guide was created based on literature reviews and discussions between the researchers. It was piloted and revised before the study proper. Ethics approval was obtained from the hospital Medical Ethics Committee and written consent was taken from each participant. All FGDs were conducted by the two researchers, NCJ and NSH, who were both teaching in the department where the participants were working. One of the researchers facilitated the focus group discussion while the other took detailed notes (verbal and non-verbal). These sessions were audiotaped, transcribed in full and checked independently by the researchers. Each FGD session lasted approximately 1½ hours. The researchers made a conscious effort to treat information provided by the participants with sensitivity and confidentiality throughout.

Both researchers analyzed the transcripts and field notes independently to identify emerging themes. These themes were then categorized and coded using the NUD*IST N6 data management software. Throughout the research, these categories were revised and recoded to accommodate new themes until ‘saturation’ was reached. Themes that were identified from the earlier groups were presented to the later groups for discussion. Any differences in opinions regarding the analysis were discussed, and consensus was reached between the two researchers.


Results

Out of 32 doctors in the department, 22 doctors (5 lecturers, 12 postgraduate trainees and 5 medical officers) were interviewed in five focus groups according to their positions in the clinic. Their particulars are summarized in Table 1.

What is the doctors’ help-seeking behavior?

Generally, most participants treated themselves for acute self-limiting illnesses such as upper respiratory tract infection, diarrhoea, urinary tract infection, musculoskeletal pain and epigastric pain. However, most participants would seek help from a gynecologist for antenatal care and specialists for management of their chronic illnesses.

The practice of self-treatment varied among the participants, but most participants would not hesitate to treat themselves when they were ill. They would try to avoid seeing a doctor as far as possible.

‘I usually try to ignore the symptoms to start with, when it doesn”t get better, I’ll resort to what I have in my drawer, samples, and only if it’s really bad, I’ll say can you check my blood count for me.’ (A, female lecturer)

When asked what they would do if they had URTI, most would perform self-care. Some would prescribe for themselves to relieve symptoms, while others would take antibiotics. A few would use home remedies and alternative medicine. This reflects great similarities between the doctors’ help-seeking behavior and that of the general population.

When it comes to chronic illnesses, the majority would seek professional advice. However, who and when they would consult varied among the participants. For antenatal care among the female participants, some would avoid seeing obstetricians from the same practice, and would rather consult a private obstetrician. Others did not mind seeing someone familiar, but would treat themselves for minor symptoms and monitor their own blood pressure and urine glucose. There were two doctors who have chronic diseases (asthma and diabetes mellitus) in the study. Both sought professional help initially, but later defaulted follow-up and decided to monitor and treat themselves. One would self-prescribe while the other did not take any form of treatment despite knowing that medication was necessary.


Why do doctors treat themselves?

Medical knowledge and skill

Some participants believed that, being doctors, they had the knowledge and skills to diagnose and treat themselves. They felt that the doctors they consulted would have given them the same advice and treatment. These participants would only see a doctor if they needed medical certificates (MC). Some would seek help only if their illness did not respond with the initial self-treatment and they believed that they would be able to judge the severity and progress of their illness.

‘Because of our own background, you would probably be able to tell what is rather not serious, what is actually quite simple, and if I only need symptomatic treatment, I probably just treat myself.’ (I, male lecturer)

‘If something like asthma or dyspepsia, you know that you can give time and you can try self treatment first.’ (J, female medical officer)

Lack of health care support for doctors

Some participants had difficulty finding a suitable doctor when they were sick. This was because most of them did not have a regular doctor, and tended to seek help from whoever was available at the clinic. Some felt that they would cause inconvenience to their colleagues, and felt ‘guilty’ about seeking treatment for minor illnesses. Moreover, some doctors whom they consulted were reluctant to see them for minor illnesses. They were also concern about confidentiality.

‘I would rather not treat myself, but I find that I am pushed to treating myself mainly because it is not that easy to get to see somebody, and that not many are willing to see you for what they consider as simple problems.’ (K, female postgraduate trainee)

‘I think there is always a dilemma. If you got something that you think is more serious, and you sit on it for a while thinking am I really stupid, or am I going to bother someone. I suppose there is a danger if you go on treating yourself a bit too long, and you don”t want to bother a colleague, you know.’ (M, female lecturer)

Work commitment

Convenience and lack of time were cited as common reasons for self-treatment among the participants. Easy access to medical services and drugs also made self-treatment ‘appealing’ to the doctors. The underlying common factor was the pressure to recover quickly and continue with their duties without interruption.

A final year postgraduate doctor, who suffered from diabetes mellitus, admitted that…

‘patients are getting better treatment compared to myself… Maybe after a certain period of time, I will see a doctor. Not at this time, there is so much pressure and tension. Don’t want to waste time now.’ (C, male postgraduate trainee)

‘It will be more convenient because we work in a medical practice. There is more hassle trying to register yourself, and taking time off to see a doctor… also travelling.’ (I, male lecturer)

Difficulty in assuming sick role

The reluctance of assuming the patient’s role was another reason why the participants would self-treat, rather than seek help.

‘We doctors always take it for granted that we can manage it, that’s when it really happens, we are always the worst patients.’ One participant commenting on her husband who is a doctor. (J, female medical officer)

A participant who suffered from dengue fever commented…

‘I hate the feeling of like I should know these things, but still not knowing when to recognize it. Not knowing when you should stop and let someone else takes over.’ (A, female lecturer)

Are the doctors aware of the problems with self-treatment?
Most participants recognized the problems with self-treatment. They understood the difficulty in assessing their own illnesses and managing themselves objectively. Some cautioned the possibility of neglecting their illness until it became serious.

‘I think we shouldn’t have treated ourselves differently from other people… I think if we don’t do that, we are basically neglecting ourselves.’ (F, female medical officer)

‘Because so far there is no problem, so that’s why it feels OK. But, sometimes, one wonders when it will get out of hand… because sometimes if you keep on treating yourself, you don’t know when to put a stop to it.’ (G female postgraduate trainee)

As a result, they either over-treat or under-treat themselves. Some did not comply with their medications and follow-up appointments.

When asked why she under-treated herself, one participant replied, ‘Basically I don’t like to take medications.’ (N, female postgraduate trainee.) When asked about compliance with medications, ‘I think, especially for antibiotics, I never finish the whole course.’ (J, female medical officer.) Some felt that ‘…we are not answerable to anybody. If I don’t finish it, nobody is going to ask me.’ (O, male postgraduate trainee.)


Discussion

The help-seeking behavior of the primary care doctors in this study was similar to those in other studies.^1–3 They performed self-care for acute problems, and sought treatment only if they felt that the disease did not respond to the initial self-treatment. Although most of the participants did not suffer from any chronic or psychiatric problems, they would seek professional help if the needs arise. However, two of the participants with chronic illnesses pointed out that they tend to delay treatment and did not comply with treatment despite being fully aware of the consequences. Chambers reported similar findings in a group of general practitioners in UK.¹¹ He found that the GPs were significantly more likely to treat themselves, while they would recommend other doctors to consult their own GPs if sick. This finding highlighted the discrepancy between what doctors advocate and their actual practice when they fall sick. While this help-seeking behavior is common among the normal population, it is disturbing when doctors do not seek help for more serious diseases. This may potentially lead to poor health which has a significant effect on their patient care, personal and family life.

Reasons for practicing self-treatment

Most participants cited their ability to diagnose and manage common illnesses as the reason for self-treatment when they were ill. They felt that this would be part of self-care and they were confident in their ability to decide when they should consult a doctor. While it is appropriate for doctors who have the necessary medical knowledge and skills to provide self-care for common self-limiting illnesses, their abilities to judge when to seek treatment for atypical symptoms and to be compliant with medications and regular monitoring in chronic illnesses are questionable. The decision to seek help not only depends on their medical knowledge and ability to recognize severe symptoms, other factors such as organizational barrier, personal and socio-cultural beliefs also play an important role in their decision-making. Doctors should be made aware that their professional ability to manage medical illnesses does not imply that they are suited to manage their own sickness. In fact, it may be counter-productive and cause unnecessary delay in diagnosis and treatment.

Attitudes of colleagues also influenced the willingness of doctors to seek help in this study. Some participants felt that the doctors they consulted treated them as colleagues rather than as patients, and they would not want to disturb their doctors for simple problems. McKevitt et al. found in their study that the doctors complained that they were not given information about their illness or were not appropriately counselled when they consulted their doctors.¹² These attitudes and practices highlighted the deficiencies in the medical profession. This is partly contributed by the inappropriate expectation commonly shared among medical doctors that their sick counterparts should be able to treat themselves during illness.¹³ This explains the uncompassionate attitudes toward sick colleagues, and hence inadequate or inappropriate medical care.¹⁴ This would put the sick doctor at a disadvantage, causing further neglect and perpetuating the practice of self-treatment.

There were suggestions in the focus group discussions that the doctors were reluctant to assume the patient’s role when they were sick. This is probably because they experienced role ambiguity which constrained their ability to behave like ‘typical’ patients. The reversal of role disempowers them and they have to follow their doctors’ instructions. They might become ‘difficult patients’ because they possess specialized medical knowledge and might be in a position to challenge their treating doctors.¹⁴ Furthermore, playing the sick role implies increased workload for their colleagues, and it might also be perceived as a sign of ‘weakness’ in the medical culture. They might feel embarrassed, and there was a potential loss of privacy.¹⁵ All these factors explain the difficulties doctors face when they are sick.

The easy access to drugs and availability of drug samples from the pharmaceutical industries also contributed to self-treatment among doctors.⁸ This might result in doctors using inappropriate drugs for their illness and there was a potential for abuse.^16,17 This is especially true for drug use in chronic medical and psychiatric illnesses, which require regular monitoring and dose adjustment. Two participants in this study, who suffered from asthma and diabetes mellitus, self-prescribed. However, due to lack of monitoring by their doctor, they were non-compliant with their medications and were using inappropriate drugs. Although they were aware of the implications, they cited reasons such as busy work schedule, examination pressure and dislike of medications as reasons.

Problems with self-treatment

Most participants in this study were aware of the problems with self-treatment. The issues of losing objectivity in assessing and managing themselves, lack of monitoring by an independent doctor, and non-compliance were mentioned. Although it is considered appropriate to practice self-care for self-limiting illnesses, the decisions by doctors to seek help for prolonged illness or chronic medical conditions require careful assessment. Some doctors in this study delayed in seeking help due to personal reasons such as dislike for medications and ‘pressure’ at work. This raises important questions of how well-prepared (or ill-prepared) doctors are in handling their own illnesses, as well as how the medical system and society at large should view and address this issue. Medical schools should encourage appropriate help-seeking behavior among medical students and teach them coping strategies during sickness. Government health authorities, medical organizations, hospitals and clinic administrators should seriously look into providing comprehensive and accessible health care services for doctors. The working environment should not only stress the reduction of sick-days among health workers, it should also place equal emphasis on appropriate illness behavior when someone falls sick. Guidelines should be developed to assist doctors and administrators in how to handle sick colleagues and it should include ways of overcoming barriers highlighted in this study.


Limitations

The doctors who participated in this study were working in the same setting as the researchers. Some of them were family medicine trainees who might be ‘pressurised’ to say the ‘right’ thing to the researchers, who were their supervisors. Similarly, the senior lecturers might face the same pressure in the presence of their junior colleagues. Realizing this, the researchers made a conscious effort to group the participants according to their positions in the department (i.e., medical officers, postgraduate trainees, and lecturers). The data and feedback from the participants revealed that the doctors did not experience much ‘pressure’ during the discussion. Instead, they felt that the focus group allowed them to voice their personal opinions on this neglected issue and they had learned from other participants, ways to cope with sickness.

In conclusion, the help-seeking behavior of primary care doctors during illness was similar to the general population. However, it was disturbing to find that there was a tendency to manage their own illnesses despite knowing that they should seek professional advice. The main reasons cited for self-treatment include work commitment, lack of support services, difficulty in assuming the sick role and their ability to manage themselves. These findings concur with other international studies and it highlights the urgent need to put in place a support system for doctors who need medical help.


Implications for GPs

This study highlighted the help-seeking behavior of a group of primary care doctors and explored the reasons of their behavior. Although it is generally safe to self-treat for self-limiting illnesses, there is a general tendency to apply the same practice to more serious symptoms and illnesses. This may result in inappropriate self-treatment and unnecessary delay in seeking help, hence affecting both the doctors’ health and their ability to care for their patients. We should seriously look into the reasons cited in this study (work commitment, lack of support from colleagues and the health system, difficulty in assuming the sick role, perceived ability to self-treat) and look for solutions and take preventive measures deemed appropriate for our practices.


Acknowledgments

We would like to thank Dr Sylvia Ann McCarthy for her invaluable comments and editing. This research was funded by the University of Malaya F-Vote Research Fund.


References

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Table 1 Socio-demographic background of participants in the FGD

Variables	Frequency (%)
	n  = 22
Mean age (years)	36.1 (30–52)
Sex	Male
6 (27.3)
Female	16 (72.3)
Race	Malay
7 (31.8)
Chinese	6 (27.3)
Indian	5 (22.7)
Others	4 (18.2)
Marital status	Single
5 (22.7)
Married	17 (77.3)
Years of practice (years)	10.6 (3–25)
Position	Medical officer
5 (22.7)
Postgraduate trainee	12 (54.5)
Lecturer	5 (22.7)
Do you have a family doctor?	Yes
4 (18.2)
No	18 (81.8)

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