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MANAGING THE SICK DOCTOR
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Experimental work in rats showed that fish oils reduce cyclosporin-induced nephrotoxicity and diminish renal thromboxane A2 synthesis.8,9 These exciting developments raise hopes of therapeutic applications. However, Schectman and colleagueslO have sounded a cautionary note. They found that a fish oil concentrate (’Omega-500’, Omegacaps, Missouri) 15 g a day for 3 months followed by 6 g a day for a further 3 months did not sustain the initial reductions in plasma triglyceride concentration. The efficacy of the higher dose also became less pronounced after the first month of therapy. This observation has focused attention on the relative paucity of long-term clinical studies on the efficacy and safety of fish oils. The findings are reminiscent of an earlier study by another group’1 on the effect of two cans of mackerel a day for 2 weeks followed by three cans a week for 8 months, but they do not accord with other data consistent with persistent effects of dietary supplementation with fish oil concentrates on serum lipids4,12 (when these studies were started, purified fish oil was not available in capsules, so double-blind studies have not been carried out). Further clinical studies should now be undertaken to defme the therapeutic role of dietary supplementation with fish oil, a measure that potentially has many valuable indications but, so far, very little proof of clinically useful effects.
MANAGING THE SICK DOCTOR DOCTORS are more likely to have mental illness, and to abuse alcohol and drugs, than are the general population and members of other professions;13 occupational stress may be an important causal factor.14 However, discussion of these conditions has tended to overshadow other disorders that may impair the performance of medical practitioners and affect patient care. The difficulties surrounding early detection of serious illness in doctors were reviewed at a workshop organised by the Faculty of Occupational Medicine of the Royal College of Physicians in June. In Britain, virtually all of the sick doctor referrals to the Health Committee of the General Medical Council since 1980,15 or to the National Counselling Service (including self referrals) since its inception in 1985,16 have been for mental illness or alcohol or drug abuse. Although the prevalence of these conditions and the extent to which they and other disorders affect the work of doctors in the UK is
unknown, undoubtedly these two organisations see only one aspect of a wide range of illnesses. The National Counselling 8.
Elzinga L, Kelley VE, Houghton DC, Bennett WM. Modification of experimental nephrotoxicity with fish oil as the vehicle for cyclosporine. Transplantation 1987;
43: 271-74. 9. Rogers TS, Elzinga L, Bennett WM, Kelly VE. Selective enhancement of thromboxane in macrophages and kidneys in cyclosporine-induced nephrotoxicity. Transplantation 1988; 45: 153-56. 10. Schectman G, Kaul S, Cherayil GD, Lee M, Kissebah A. Can the hypotriglyceridemic effect of fish oil concentrate be sustained?. Ann Intern Med 1989; 110: 346-52. 11. Singer P, Berger I, Luck K, Taube C, Naumann E, Godicke W. Long-term effect of mackerel diet on blood pressure, serum lipids and thromboxane formation in patients with mild essential hypertension. Atherosclerosis 1986; 62: 259-65. 12. Saynor R, Verel D, Gillott T. The long-term effect of dietary supplementation with fish lipid concentrate on serum lipids, bleeding time, platelets and angina. Atherosclerosis 1984; 50: 3-10. 13. Pilowski L, O’Sullivan G. Mental illness in doctors. Br Med J 1989; 298: 269-70. 14. Payne R, Firth-Cozens J, eds. Stress in health professionals. Chichester: Wiley, 1987. 15. Smith R. Profile of the GMC. Dealing with sickness and incompetence: success and failure. Br Med J 1989; 298: 1695-98. 16. Rawnsley K. Sick doctors: measures adopted in Britian and North America to deal with the problem. J R Soc Med 1988; 81: 435-36.
Service should act as an early point of contact, being totally devoid of the disciplinary aspects of the General Medical Council, but because confidentiality is central to its functioning an evaluation of its effectiveness is not possible. Why is the recognition of ill health in doctors often delayed? Many doctors do not register with a general practitioner, or may be reluctant to seek advice, relying instead on self diagnosis and treatment. Doctors often have difficulty in regarding themselves as patients and in acknowledging diagnoses such as depression, which they might see as reflecting on their professional ability to cope. They may be poor at accepting treatment and terminate it prematurely. The spouses of sick doctors with conditions such as alcoholism are understandably reluctant to seek help, especially if they do not know where to turn for confidential advice. Close colleagues, who are often best placed to notice early impairment, and local professional committees to whom the sick doctor may be referred, may find it difficult to make objective judgments about fitness to practise and vacillate until a crisis occurs. The treating doctor may defer adequate supervision of a colleague, or be reluctant to intervene if the unfit doctor-patient decides to continue practising against advice. As in other occupations, the most difficult conditions to evaluate are the mental and psychological states at the borderline of normality. Cultural attitudes and eccentricity may mask underlying psychiatric illness. The early loss of insight into failing performance at work in certain neurological diseases is not to be confused with the psychological denial of the problem drinker. Detailed individual assessment, including psychometric tests, may be essential before a decision can be made about fitness for work in persons who might otherwise be passed as normal. Medical audit, which has been accepted by the profession,17 might occasionally reveal deficiences in the quantity and quality of work carried out by individual doctors with impaired health. Breakdowns in relationships with colleagues and complaints or litigation by patients may also be manifestations of underlying ill health in a practitioner. Misconduct or incompetence due to illness must be distinguished from other causes because management of the sick doctor’s health should not be confused with disciplinary procedures. The Royal College of Physicians and the Faculty of Occupational Medicine have now issued guidelines about medical aspects of fitness to work;18 some occupations such as pilots, drivers of heavy goods vehicles, and divers have specific health requirements laid down at entry to the job and on regular medical review thereafter. The different professional groups dealing with sick doctors would do well to devise guidelines for the detection and subsequent management of impairment due to ill health, including more effective communication with health service managers. The introduction of occupational health services in the National Health Service, with a small but growing number of consultants posts, could greatly assist hospital doctors to implement such guidelines; the specialist physicians should also advise about preventive measures to reduce stress and fatigue. There is no such service for general practitioners.19 Access to a comprehensive and skilled occupational health service for all doctors is long overdue. 17. Medical audit London: Royal College of Physicians of London. 1989. 18. Edwards FC, McCallum RI, Taylor PJ. Fitness for work: the medical aspects. A Joint report of the Royal College of Physicians and the Faculty of Occupational
Medicine. Oxford: Oxford University Press, 1988. 19. Richards C. The health of doctors. London:
King’s Hospital Fund,
1989.
Experimental work in rats showed that fish oils reduce cyclosporin-induced nephrotoxicity and diminish renal thromboxane A2 synthesis.8,9 These exciting developments raise hopes of therapeutic applications. However, Schectman and colleagueslO have sounded a cautionary note. They found that a fish oil concentrate (’Omega-500’, Omegacaps, Missouri) 15 g a day for 3 months followed by 6 g a day for a further 3 months did not sustain the initial reductions in plasma triglyceride concentration. The efficacy of the higher dose also became less pronounced after the first month of therapy. This observation has focused attention on the relative paucity of long-term clinical studies on the efficacy and safety of fish oils. The findings are reminiscent of an earlier study by another group’1 on the effect of two cans of mackerel a day for 2 weeks followed by three cans a week for 8 months, but they do not accord with other data consistent with persistent effects of dietary supplementation with fish oil concentrates on serum lipids4,12 (when these studies were started, purified fish oil was not available in capsules, so double-blind studies have not been carried out). Further clinical studies should now be undertaken to defme the therapeutic role of dietary supplementation with fish oil, a measure that potentially has many valuable indications but, so far, very little proof of clinically useful effects.
MANAGING THE SICK DOCTOR DOCTORS are more likely to have mental illness, and to abuse alcohol and drugs, than are the general population and members of other professions;13 occupational stress may be an important causal factor.14 However, discussion of these conditions has tended to overshadow other disorders that may impair the performance of medical practitioners and affect patient care. The difficulties surrounding early detection of serious illness in doctors were reviewed at a workshop organised by the Faculty of Occupational Medicine of the Royal College of Physicians in June. In Britain, virtually all of the sick doctor referrals to the Health Committee of the General Medical Council since 1980,15 or to the National Counselling Service (including self referrals) since its inception in 1985,16 have been for mental illness or alcohol or drug abuse. Although the prevalence of these conditions and the extent to which they and other disorders affect the work of doctors in the UK is
unknown, undoubtedly these two organisations see only one aspect of a wide range of illnesses. The National Counselling 8.
Elzinga L, Kelley VE, Houghton DC, Bennett WM. Modification of experimental nephrotoxicity with fish oil as the vehicle for cyclosporine. Transplantation 1987;
43: 271-74. 9. Rogers TS, Elzinga L, Bennett WM, Kelly VE. Selective enhancement of thromboxane in macrophages and kidneys in cyclosporine-induced nephrotoxicity. Transplantation 1988; 45: 153-56. 10. Schectman G, Kaul S, Cherayil GD, Lee M, Kissebah A. Can the hypotriglyceridemic effect of fish oil concentrate be sustained?. Ann Intern Med 1989; 110: 346-52. 11. Singer P, Berger I, Luck K, Taube C, Naumann E, Godicke W. Long-term effect of mackerel diet on blood pressure, serum lipids and thromboxane formation in patients with mild essential hypertension. Atherosclerosis 1986; 62: 259-65. 12. Saynor R, Verel D, Gillott T. The long-term effect of dietary supplementation with fish lipid concentrate on serum lipids, bleeding time, platelets and angina. Atherosclerosis 1984; 50: 3-10. 13. Pilowski L, O’Sullivan G. Mental illness in doctors. Br Med J 1989; 298: 269-70. 14. Payne R, Firth-Cozens J, eds. Stress in health professionals. Chichester: Wiley, 1987. 15. Smith R. Profile of the GMC. Dealing with sickness and incompetence: success and failure. Br Med J 1989; 298: 1695-98. 16. Rawnsley K. Sick doctors: measures adopted in Britian and North America to deal with the problem. J R Soc Med 1988; 81: 435-36.
Service should act as an early point of contact, being totally devoid of the disciplinary aspects of the General Medical Council, but because confidentiality is central to its functioning an evaluation of its effectiveness is not possible. Why is the recognition of ill health in doctors often delayed? Many doctors do not register with a general practitioner, or may be reluctant to seek advice, relying instead on self diagnosis and treatment. Doctors often have difficulty in regarding themselves as patients and in acknowledging diagnoses such as depression, which they might see as reflecting on their professional ability to cope. They may be poor at accepting treatment and terminate it prematurely. The spouses of sick doctors with conditions such as alcoholism are understandably reluctant to seek help, especially if they do not know where to turn for confidential advice. Close colleagues, who are often best placed to notice early impairment, and local professional committees to whom the sick doctor may be referred, may find it difficult to make objective judgments about fitness to practise and vacillate until a crisis occurs. The treating doctor may defer adequate supervision of a colleague, or be reluctant to intervene if the unfit doctor-patient decides to continue practising against advice. As in other occupations, the most difficult conditions to evaluate are the mental and psychological states at the borderline of normality. Cultural attitudes and eccentricity may mask underlying psychiatric illness. The early loss of insight into failing performance at work in certain neurological diseases is not to be confused with the psychological denial of the problem drinker. Detailed individual assessment, including psychometric tests, may be essential before a decision can be made about fitness for work in persons who might otherwise be passed as normal. Medical audit, which has been accepted by the profession,17 might occasionally reveal deficiences in the quantity and quality of work carried out by individual doctors with impaired health. Breakdowns in relationships with colleagues and complaints or litigation by patients may also be manifestations of underlying ill health in a practitioner. Misconduct or incompetence due to illness must be distinguished from other causes because management of the sick doctor’s health should not be confused with disciplinary procedures. The Royal College of Physicians and the Faculty of Occupational Medicine have now issued guidelines about medical aspects of fitness to work;18 some occupations such as pilots, drivers of heavy goods vehicles, and divers have specific health requirements laid down at entry to the job and on regular medical review thereafter. The different professional groups dealing with sick doctors would do well to devise guidelines for the detection and subsequent management of impairment due to ill health, including more effective communication with health service managers. The introduction of occupational health services in the National Health Service, with a small but growing number of consultants posts, could greatly assist hospital doctors to implement such guidelines; the specialist physicians should also advise about preventive measures to reduce stress and fatigue. There is no such service for general practitioners.19 Access to a comprehensive and skilled occupational health service for all doctors is long overdue. 17. Medical audit London: Royal College of Physicians of London. 1989. 18. Edwards FC, McCallum RI, Taylor PJ. Fitness for work: the medical aspects. A Joint report of the Royal College of Physicians and the Faculty of Occupational
Medicine. Oxford: Oxford University Press, 1988. 19. Richards C. The health of doctors. London:
King’s Hospital Fund,
1989.