Introduction

Top Abstract Introduction Participants and methods Results Discussion References

The health of the medical profession is causing some concern.^1-7 Doctors are reluctant to seek health care through usual mechanisms ^{3 7-10} and find it difficult to adopt the role of patient.⁹ The consequences include self prescription, working through illness, self referral, ^{2 6-13} and late presentations with serious problems.⁸ This inappropriate self care occurs in a profession that reports high levels of stress ^{1 2 12 14} and psychological distress ^{2 15 16} and comparatively high suicide rates.¹⁷

Questionnaire surveys of the extent of distress and illness in doctors have been reported. ^{3 10-16} However, questionnaires may impede analysis of reasons why doctors respond in particular ways to illness in themselves. This study aimed to explore, qualitatively, general practitioners' perceptions of the effects of their profession and training on their attitudes to illness in themselves and colleagues.

	Participants and methods

Top Abstract Introduction Participants and methods Results Discussion References

We sent a letter inviting a purposeful sample of 141 general practitioners representing both sexes, different lengths of experience, and urban and rural locations to attend focus groups on occupational health issues relevant to general practice. We also invited 13 general practitioners who were part time occupational physicians and 18 recently appointed principals. This sample was selected from a list of all general practitioners in Northern Ireland. Our experience of general practitioners' low response rates to invitations to attend focus groups on other subjects suggested we needed to contact a large number of doctors to get a representative sample. Doctors known personally to the research fieldworkers were not invited.

Grounded theory acknowledges that researchers do not approach reality without some preconceived ideas.¹⁸ We used concept mapping to explore preconceptions. From this map, we generated the primary questions for the focus groups. The map was considered provisional, to be modified or discarded in view of emerging findings that were explored by secondary questions. We audiotaped focus groups and interviews with the participants' permission and transcribed the tapes. The groups provided the range and social context and interviews allowed exploration of emerging findings in depth. This represents a synthesis of approaches used in qualitative research.¹⁹ We treated details of participants with sensitivity and confidentiality throughout.

Two researchers independently analysed transcripts and notes of verbal and non-verbal communication using the grounded theory approach. Emerging themes and links were identified and coded. The categories into which the data were placed were modified to accommodate new data until "saturation" was reached.²⁰ Themes emerging from analysis of early groups were presented to later focus groups and interviews to ensure they agreed with their experience.

	Results

Top Abstract Introduction Participants and methods Results Discussion References

Twenty seven general practitioners participated (22 in one of five groups; five in individual interviews). Six participants were part time occupational physicians and six were recently appointed principals. Twenty one were men and six were women. The table shows their numbers of years since registration and practice location.

Health of the profession
Participants were reluctant to declare themselves ill but readily shared anxieties about the health of the profession:

We are seeing . . . increasing illness in doctors and that's quite scary. It used to be 50 year olds with MIs . . . also seen recently is a number of younger doctors in their 30s with various stress related illnesses.

Attitudes to acknowledging personal illness
General practitioners talked about the pressure to appear physically well. One said, "Nobody wants to go and see a doctor who is sick," reflecting the perception that patients believed a doctor's health reflected his or her medical competence. This attitude affected their approach to screening.

We have a number of doctors in my practice and the number of cholesterol checks is very unimpressive. They make sure that their patients have their cholesterol checked . . . but will they go to their doctor and be screened themselves? They might . . . take it themselves, but it won't go into their chart.

I broke my leg . . . and went into the surgery . . . because I couldn't get a locum at short notice.

Unless you're unable to get out of bed you'll crawl in and work.

Doctors feel they shouldn't be sick . . . you don't want to go and see your local psychiatrist in case one of your patients is sitting beside you.

Responses to personal illness
Comments indicated a perception of "us/doctors" and "them/patients," with a reluctance to accept treatment and an underlying assumption that the roles of patient and doctor were incompatible: "We think we're superhuman and that we don't get ill, or if we do, we can cope with it."

Take a change in bowel habit and colonic carcinoma . . . if you are a GP . . . at what point do you declare yourself as having a change in bowel habit? Do you under-react or over-react? . . . we don't know how to apply the protocols we work with every day to ourselves.

Influences of general practice organisation on support
A sense of obligation to partners emerged in an interchange in one of the focus groups.

You don't stay off work because you're not going to earn money, you continue to work because of your partners.

Your partners are working twice as hard to carry you.

It's a conscience thing.

A terrible sense of duty of letting your partners down if you don't go in.

The real quandary arises when that person decides to come back. You might not think they are ready . . . but they are feeling guilty because the locums can't cover everything.

They maybe try to cover each other equally at work . . . but they don't . . . socialise together. . . . They work in the surgery and that's it.

You didn't want to be made wrong . . . to be told "I wouldn't do that, that is stupid" . . . You are not sure whether they want you to interfere.

He made a few statements to his partners that he really couldn't cope but it wasn't really taken very seriously because he didn't make it very serious. He was registered with the practice and it went on for quite a while till he just cracked.

Informal shadow contract
We used a synthesis of the elements described above to construct an informal shadow contract (box). The terms in the contract were not stated explicitly but were communicated through anecdotes and black humour. At times participants questioned their compliance with this contract, recognising its destructiveness. Some identified themselves as its cocreators but felt helpless to change it. The contract was subsequently presented to four additional small groups of general practitioners, who confirmed that it agreed with their experience.

	Discussion

Top Abstract Introduction Participants and methods Results Discussion References

Our findings confirm previous reports that embarrassment and unease with the role of patient influence how doctors approach illness in themselves. ^{3 8-11 21} Within the professional culture and working arrangements of general practice, these influences contribute to the potential for self and mutual neglect as described in the informal shadow contract.

The number of participants was sufficient to confirm saturation in responses.²⁰ The fact that feedback showed that the findings agreed with the experiences of other general practitioners also supports the validity of our results.

Pressure to appear healthy
General practitioners perceive that patients and colleagues link good health in doctors with medical competence. Thus doctors feel compelled to portray a healthy exterior while being aware of their vulnerability. Their concerns about confidentiality were linked to this, particularly in relation to psychological illness.

Managing illness
Training in recognition and management of doctors' own health problems and those of their colleagues has been advocated.²² However, participants were not aware of this having been included in their training.