Muhammad Hanif Shiwani  ( Barnsley General Hospital NHS Foundation Trust, Wakefield, UK. )

Medicine is physically and mentally a demanding profession. Long working hours, night calls, treating serious and critically ill patients, dealing with terminally ill patients and their relatives, maintaining continuous medical education, striving to fulfill personal development plans and aiming to achieve higher goals, are among many of the reasons to make a doctor's life stressful and expose them to personal health problems.

There are many reasons for stress. A doctor can be a victim of bullying at work or professional jealousy.¹ There can be undue interference by influential people for providing ethical medical practice or insecurity and absence of adequate access to justice. Prevalence of absolute lack of facilities for medical defence and protection for the doctors, threat of receiving physical abuse from the families and friends of patients and mobs, besides political, religious and sectarian victimization are some important causes of stress.

 Due to many of these reasons many doctors are unhappy in Pakistan and want to migrate abroad to look for better working conditions.

Many senior doctors continue to work after their retirement age and find it difficult to do so in physically intense specialties and choose non clinical teaching and administrative jobs. Their health very often does not allow them to look after their patients as effectively as they would have done at a younger age. Passion for the profession along with the financial needs are the most likely reasons why doctors continue to work after the age of super- annuation.

There is very limited information documented on chronic illness among physicians. Prevalence rate of physical disabilities of 2.5 % to 4% have been reported.² The prevalence of mental health problems among doctors is higher than among people in equivalent professions. Depression and anxiety have been well recognized among the medical community.³ Reports on surveys of mental health among hospital doctors in the United Kingdom have consistently found levels of depression, anxiety, and psychiatric symptoms to be significantly higher than among the general population. Similarly, general practitioners and surgeons in New Zealand have almost three times higher poor mental health compared to the general population.⁴

Substance abuse among doctors is well known the world over. Alcoholism and illicit drug use among doctors is similar to that in the general population, however there are many reports from Scotland and North America suggesting a higher incidence of alcohol related cirrhosis and suicidal tendencies among the medical professionals.^5,6 Alcoholism, presumably, is not as common in Pakistan as in the West. Doctors are at a higher risk of developing addictions.⁷ Studies have shown that doctors tend to work-through their illness or self-treat,8 which has been well documented.³ Prescribing practice is very poorly controlled in the country and self-prescription is a well known fact. Even the "controlled drugs" can be obtained from a pharmacy/chemist without prescription and in large quantities. Doctors are prone to suffer with abuse of opiates and benzodiazepines due to easy access to these drugs.⁹ Their addiction is often reported by their colleagues or the families.^10,11 These doctors do not always seek help from their colleagues and like many of their patients they struggle to cope with their problems.This is a serious cause of concern.

It is an ethical responsibility and also not advisable for doctors to assume responsibility for the diagnosis and management of their own health problems or those of their immediate family, except in the most unusual circumstances.¹²

Pakistan carries one of the world's highest burdens of chronic hepatitis and mortality due to liver failure and hepatocellular carcinoma. Hepatitis B and C are highly prevalent. According to an estimate approximately ten million people in Pakistan (6% of the population) are living with HCV infection.^13,14 Being a part of the general population, a proportion of doctors might be suffering with, if not, are severely exposed to this kind of transmissible disease. Accidental needle prick injuries in clinical practice are common and remain significantly underreported.¹⁵ A survey in UK has shown a significantly high mortality from cirrhosis in anaesthetists, suggesting an occupational hazard which warrants some investigation.¹⁶ It is not safe for doctors to start working unless they have been adequately immunized against many transmissible diseases specially viral hepatitis.

It is generally believed that working for limited hours, as 48 hours per week, provides sufficient mental and physical rest. This helps in acquiring a clear thinking process at work and performing with sharper reflexes and judgment. This is necessary for arriving at a correct diagnosis and managing the patient efficiently. In Europe, the introduction of European

Working Time Directives (EWTD) encourages doctors to work limited number of hours. This provides them sufficient compulsory period of rest in between their duties and also minimizes the work at unsocial hours. This provides quality time for themselves and families, which is important for doctor's mental and physical well-being. The EWTD is a European law seeking agency to protect the health and safety of workers.¹⁷ Whether the working for limited hours would improve doctor's health and quality of life in developing countries is yet to be explored.

However, there is no doubt that tired, sick and "burnt out" doctors, either physically or mentally, cannot perform safe medical practice. This can result in professional misconduct and inadequate patient care.¹⁸ Doctor's well being and good health is extremely important as only healthy doctors can perform healthy practice and work for better health of the nation. In UK, The Health & Safety at work Act 1974 requires employers to secure the health, safety and welfare of employees at work (including mental health); providing a safe place of work, safe systems of work and information and training.¹⁹

The concept and practice of occupational health in our country hardly exists. As defined by the International Labour Organization (ILO) and World Health Organization (WHO) the "Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and, to summarize, the adaptation of work to man and of each man to his job".²⁰

A good practice of occupational health is safe for the patients and doctors. This is a specialty that needs due recognition and development in the country. Very often doctors themselves are unaware of their poor health or if they are, they do not know whom to contact or if they do, they do not want to be exposed. A well-established department of occupational health with adequate expertise and appropriate confidentiality can provide a significant health care support to the doctors and could be responsible for their well-being.

Doctors' unhappiness is a problem but it's a concern when they become unwell. It is important to recognize the difference.²¹ In Pakistan we do not have any functional national policy or guidelines on doctors working conditions and working hours. Neither is there any data on the incidence and prevalence of health related problems among doctors. There is a need for higher authorities to acknowledge the concerns and obtain a consensus from the professional bodies to provide an environment to facilitate doctors' well being and good health.

It is the prime responsibility of the health care employers, whether a public or private organization, to look after doctors health. The medical associations all over the world represent doctors and work as professional representative bodies and play a vital role in protecting their members. Such organizations in developed countries openly discuss the health related issues of their colleagues and seek the preventive and remedial measures. A greater professional awareness of various aspects of doctors' health related problems is required at all levels. It is the responsibility of PMA to devise necessary measures for safeguarding doctors' rights and improving working conditions. Developing a support group of professionals for helping the sick doctors can be considered.

References

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 2.Gautam M, MacDonald R. Helping Physicians cope with their own chronic illnesses. West J Med 2001; 175: 336-8.
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11. J String, M Wilks, B Wells. Missed problems and missed opportunities for addicted doctors. BMJ 1998; 316:405-6.
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