1. Preamble

The focus of this position statement is on promoting the health and wellbeing of medical students and medical practitioners during their training and professional careers. Maximising their health and wellbeing will facilitate their enjoyment of medicine and the quality of care provided to patients and the community. The addition of 'wellbeing' to the statement emphasises promotion of health and contentment, rather than purely avoidance of impairment or illness.

Medical practitioners have an above average health status similar to others in advantaged socio-economic groups. Some issues of concern, however, include higher than average rates of suicide,^{1, 2} stress related problems,³ and substance abuse ³. There is also some evidence that doctors have poorer treatment outcomes than the general population with under or over treatment being possible causes ⁴. In addition, some sub-groups of medical practitioners may be at greater risk of poorer health and wellbeing because of their professional circumstances. These include, but are not limited to:

• rural and remote practitioners working in areas with scarce resources;
• some groups in training in hospitals with excessive work hours;
• female practitioners trying to balance competing professional and other obligations;
• overseas trained doctors (OTDs);
• practitioners from a non-English speaking background;
• Aboriginal and Torres Strait Islander practitioners;^{3, 5, 6} and
• those exposed to blood borne diseases and other specific occupational risks.

2. Medicine and Stress

While not all stress is negative and some stress is necessary, there are multiple internal and external stressors in medicine. Internal stressors may come from the very nature of the individual that chooses to practise medicine. These qualities include dedication, commitment, a sense of responsibility, competitiveness, and altruism. These attributes can become a source of pressure in the doctors' working or study life. There are also a large number of external factors that are considerable causes of stress, such as the need for ongoing medical education, rapid developments in medical technology and knowledge, changes and influences of administration in the health system, community expectations, and cultural myths. In addition, the encounters with patients and the complexity of their needs can drain the "reserves" of doctors and have repercussions on their personal lives.

Some stressors such as long hours and the effects on family life are historically part of the profession, but there is evidence that doctors are now more likely to speak up and express distress with aspects of medical culture. Younger doctors are viewing their identity and responsibilities to the profession differently from those of previous generations.

Medicine has many losses, from disappointment with treatment outcomes through to the death of patients. Some argue that burn out occurs from not having the opportunity to grieve the losses of medicine. The cultural expectation within medicine is that neither medical practitioners nor their colleagues will be sick or unable to deal with the challenges placed upon them. There can be fear of admitting illness, or not coping due to the pressure that might put on colleagues, and this can lead to a reluctance to respond to early warning signs.

Key issues in doctors' health and wellbeing include the importance of:

• medical practitioners and their families having their own general practitioner and managing their own health within the usual professional context of a doctor/patient relationship. Other than in an emergency or working in an underserviced area, it is advisable to avoid treating oneself. If living in an underserviced area, then the practitioner should be encouraged to investigate other forms of consultation (eg phone/email).
• encouraging and assisting students and practitioners to 'care for self' in order to experience medicine as a rewarding and satisfying career, and have sufficient energy left for other areas of their life. It is valuable for doctors to find that which nourishes them as a person, whether this is creatively, physically or spiritually, and to make time for this in their lives.
• medical students having access to confidential medical and other health services so that they are confident that seeking help will not damage their career progression. Support and non-judgement of those doctors regarded as impaired to become healthy and support to continue work if that is what they so choose. There should be clear referral pathways for those in need of assistance and the establishment of a 'no blame' culture that supports those in difficulty, without judgement.
• knowing how and when to respond to colleagues whose health a doctor may have concerns about. It is important that a doctor's or colleague's health, conduct or performance does not put patients at risk. If a doctor has concerns about a colleague's health, then there is a responsibility to take action for patient care and the doctor's health. Such action should be seen as an ethical responsibility and an act of caring. Advice can be sought from doctors' health programs and reporting to a disciplinary authority should be a last resort after all other avenues have failed.

3. Medical Practitioners are encouraged to:

3.1 take responsibility for their own physical and psychological health;

3.2 establish a continuing relationship with a general practitioner who they trust;

3.3 be especially sensitive to the problems involved in the transition from colleague to patient, - for oneself and when assuming the role of the treating medical practitioner to colleagues, - and provide treatment in keeping with the accepted rules of the doctor-patient relationship, with particular reference to confidentiality;

3.4 establish a network of peers for debriefing, support and mentorship, and seek out information and support from Colleges, Divisions and other groups that have resources on doctors' health;

3.5 identify any internal and/or external stress factors in their professional life and seek early and expert assistance from professional services and providers;

3.6 recognise there are dangers to others associated with a reluctance to admit illness or failing competence, and continued or regular self-medication and prescribing; and

3.7 incorporate regular leave, good nutrition, exercise, leisure and family time into a healthy lifestyle.

4. Role of the AMA

4.1 The AMA recognises and commends the work done by many organisations in improving doctors' awareness and skills in managing their own health.

4.2 The AMA has always been a conduit for doctors in trouble, and will continue to play a role in connecting doctors with help when needed. The AMA will act in concert with medical schools, teaching hospitals, medical colleges and medical boards, and governments to promote good health for medical students and practitioners emphasising the preventive aspects of health and wellbeing. These bodies should be encouraged to play a key role in encouraging medical practitioners to understand and adopt a healthy lifestyle throughout their medical training and career.

4.3 The AMA will advocate for the addressing of structural issues in the financing and provision of medical services that compromise medical students and practitioners ability to self care and through that has the potential to impact on the quality of care experienced by the community.

4.4 The AMA will advocate for and support research into the health and welfare of medical students, doctors in training, and medical practitioners, with specific attention to such issues as "safe hours", focussing particularly on the wellbeing of recognised vulnerable subgroups of practitioners.

4.5 The AMA, at both Federal and State/Territory levels, in conjunction with State and Territory Medical Boards, Medical Colleges, Divisions of General Practice and other relevant bodies, will continue to pursue practical strategies to support medical practitioners in promoting and maintaining their health and that of their families.

References:

1. Desjardins, Michel Physician Suicide - Can something be done, Canadian Family Physician Vol 43, November 1997.

2. Lawrence, J (1996) Stress and the doctor's health. Australian Family Physician (25), 8: p1249-1256.

3. British Medical Association (1992) Stress and the Medical Profession. Chamelon Press Ltd., London.

4. O'Hagan, J and Richards, J (eds) (19980 In Sickness and in Health: A handbook for medical practitioners and other health professionals, their partners and their families. Doctors' Health Advisory Service. Griffen Press, New Zealand.

5. Pullen, D; Lonie, C; Lyle, D; Cam, D and Doughty, M (1995) Medical care of doctors. Medical Journal of Australia. 162: p 481-484.

6. Hammond, J (1993) Mother, doctor, wife. Canadian Family Physician. 39; p 1591-1596.