October 2006: Richard Hetzel visits the UK & Germany - DHASs in Europe

Dr Richard Hetzel is an Adelaide GP with a special interest in doctors' health. He  serves on the executive of the SA Doctors' Health Advisory Service and is a member of the Australasian Doctors' Health Interest Group. He was a key figure behind the setting up of a working party in SA in late 2006 (involving the AMA, the DHAS, the Post Graduate Medical Council and Divisions of General Practice) to consider establishing a Doctors' Health Clinic. He reports on his visit in October 2006 to doctors’ health organisations in Germany, Holland and the UK.

There was considerable interest in hearing about doctors' health work in Australia and about our upcoming international conference in Sydney in October this year. http://www.doctorshealthsydney2007.org

In Berlin, I met three physicians centrally involved in doctors’ health in Germany. Dr Kunstmann is responsible for providing doctors’ health support on behalf of the German Medical Association, Dr Buhren co-ordinates the care of addicted doctors for the German Medical Board and Dr Beelman runs a program in Hamburg for doctors with drug and alcohol addiction.











(L to R) Drs Kunstmann, Buhren, Beelman & Hetzel

After meeting this group, I attended the European Panel for Addiction in the Medical Profession. Papers ranged from a survey of German psychiatrists’ health and illness behaviour to the performance of a doctors’ health clinic in Barcelona, Spain.

In Holland, I learnt about a successful on-line doctors' health program, run by Dr Arno van Rooijen, which results in three hundred follow-up referrals annually.  In England I met Dr Chris Williams and his Doctors Support Line team. mailto:http://www.doctorssupportline.org/ Their phone counselling service is well used, but, following the public reaction to Dr Shipman, they face many new issues regarding the support of impaired doctors.  Dr Mike Peters and Ben Arrowsmith run the Doctors for Doctors programme for the BMA. http://www.bma.org.uk/ap.nsf/content/Hubhealthandwellbeing. 

They are very busy providing courses for doctors in various parts of the UK. It is expected that they will organise an international doctors’ health conference in London in 2008.













(L to R) Drs Hetzel, Peters & Arrowsmith
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August 2005: Visit by Dr Mamta Gautam, MD, FRCPC, MOT
Dr Narelle Shadbolt, Dr Mamta Gautam & Dr Simon Wilcock

In August 2005, DHAS NSW invited Dr Mamta Gautam to visit our organisation and others Australian DHASs. Dr Gautam is a psychiatrist in Ottawa, where she is a leader in the field of doctors' health. As her practice consists entirely of doctors, she has a wealth of experience in dealing with doctors' mental health problems.

Dr Gautam conducted a lively and interactive session at the DHAS NSW Annual General Meeting. She left us with important insights for ourselves and for the doctors whom we see as patients.

Doctor-patients are different, but not that different
Doctors are different from other patients in many ways, but they are patients just the same. The usual dynamic of a consultation is that the doctor is "healthy, wise and trained" and that the patient is "sick, naïve and untrained." This is clearly not the case in the doctor-doctor consultation.

Why we treating doctors find it difficult to treat colleagues
As treating doctors in this situation, we may be prevented from doing our best by "our level of training, our stage of life and our unresolved conflicts". Dr Gautam pointed out that we don't have any training for this situation and might therefore feel insecure. We might identify too closely with the patient, who may resemble us in many ways. We might have unresolved conflicts about our own need to control the consultation, together with an exaggerated sense of responsibility, complicated by self-doubt about our own ability and knowledge.

As treating doctors, we should be alert to our own feelings of counter-transference, such as "idolising the doctor-patient and feeling inferior", "judging the doctor-patient and wanting to compete" or "identifying with the doctor-patient and wanting to be their friend." In the doctor-doctor consultation, we naturally tend to set looser boundaries in an effort to please or to not insult the doctor-patient; in this way doctor-patients might end up with substandard care. Dr Gautam emphasised that we should treat our doctor-patients as we do all other patients. But, additionally, we need to be aware of the typical personality traits of doctors which may come into play in these situations - the doctor-patient's need for control, their perfectionism - they want to get better immediately and they may deny or trivialise symptoms - and doctors' general tendency to be 'people pleasers', reluctant to complain.

Sick doctors very often delay presenting until they are in crisis, resulting in an urgency around the consultation. Doctor-patients will often have built up strong defences, especially around mental health issues and might lack insight. According to Dr Gautam, they often feel "alone, isolated and ashamed".

Confidentiality: its crucial importance and its limits
One of the most important concerns is confidentiality. As the treating doctor, it's crucially important to discuss this, and to be able guarantee confidentiality at all times - even if you meet the doctor socially or in your professional work. There are, however, exceptions to confidentiality, such as suicidal ideation; the existence of such exceptional circumstances should be mentioned at the outset. The treating doctor should take responsibility for the medical management, whilst acknowledging the knowledge, opinions and training of the doctor-patient.

Occasionally the risk to the doctor-patient's safety (or to someone else's) might necessitate more drastic steps such as referral to the Medical Board or certification under the Mental Health Act. . We must recognise that these are our professional responsibilities and that we will not be helping an impaired doctor by failing in these respects.

Treating doctors need care, too
In order to provide the best care for all our patients, including our doctor-patients, we must care for ourselves. We must be aware of the possibility of 'burnout', resulting in emotional exhaustion, depersonalisation and reduced personal accomplishment. This is a well-recognised phenomenon in the helping professions. Make sure that you make time for yourself, taking the same advice that you give your patients every day - healthy eating, exercise, sleep and relaxation. Have your own family doctor. We all know that this is wise advice, but we often question how we can incorporate this into our busy daily practice. According to Dr Gautam, 'don't just say you'll try, just do it.'