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Self-reported Health, Illness, and Self-care Among Finnish Physicians
A National Survey
Saara Töyry, MD;
Kimmo Räsänen, MD, PhD;
Santero Kujala, MD;
Markku Äärimaa, MD, PhD;
Juhani Juntunen, MD, PhD;
Raija Kalimo, PhD;
Riitta Luhtala;
Pentti Mäkelä, MSc;
Kati Myllymäki, MD;
Markku Seuri, MD, PhD;
Kaj Husman, MD, PhD, MSc
Arch Fam Med. 2000;9:1079-1085.
ABSTRACT
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Background Physicians' health problems have been discussed mainly in relation to substance abuse and psychiatric disorders. In this study, the prevalence of common chronic diseases and their treatment were determined.
Objective To find differences in self-reported health status, amount of sick leave, and the use of health services among physicians according to sex and specialty. Data were also compared with those of the total employed population.
Design and Setting Cross-sectional postal questionnaire survey in Finland.
Participants and Methods A random sample of licensed physicians younger than 66 years (n = 4477) was randomly selected from the register of the Finnish Medical Association. A total of 3313 physicians (74%) responded.
Main Outcome Measures Perceived health, prevalence of diseases, self-treatment of diseases, amount of sick leave, and medical consultations.
Results Female physicians assessed their health as being better than other female employees and had used health services and had been on sick leave more often than their male colleagues. Male physicians assessed their health as being equal to that of other men. Both female and male physicians had fewer sick leave than other employees. However, physicians—especially men—reported many common chronic illnesses as often or more often than other employees. Physicians had consulted other medical professionals less often than other employees, and they primarily self-treated their illnesses. Of the specialties, psychiatrists had used health services and had been on sick leave more often than other physicians.
Conclusion This study indicates that the usual form of care of physicians' diseases is self-treatment and "working through" illnesses.
INTRODUCTION
PHYSICIANS' HEALTH problems have been discussed mainly in relation to substance abuse and psychiatric disorders rather than in terms of physical diseases.1-10 The way physicians' personal health habits affect clinical practice has also been of interest.11-14 It has been shown that physicians with good personal health habits or a desire to improve their own health are more likely to counsel or screen patients regarding prevention. Having a personal history of a particular disease may also affect clinical practice, but its effect is not great.14
Studies from several countries have shown that the overall mortality of physicians is lower than that of the general population.15-17 Physicians have a low rate of sick leave,18-20 and this low rate could be assumed to mean low morbidity.21 Physicians' use of formal health services is low, and self-treatment is common.18-20,22-24 The need for health services for physicians has already been recognized. Guidelines on the medical care of physicians have been established both for self-treatment and for physicians treating other physicians.24-25 However, the guidelines are not being followed.24
The objective of this study was to obtain information on the self-reported health status, amount of sick leave, and use of health services among Finnish physicians by sex and specialty. Physicians' data were also compared with those of the total employed population.
PARTICIPANTS AND METHODS
PARTICIPANTS AND METHODS
In October 1997, a postal questionnaire was sent to 1 in every 3 licensed physicians (n = 4477) randomly selected from the register of the Finnish Medical Association. This register covers all licensed physicians in Finland. The criteria for inclusion were (1) permanent residence in Finland, (2) age younger than 66 years , and (3) not retired. To ensure anonymity, the Finnish Medical Association sent the questionnaires, which were then returned directly to the Finnish Institute of Occupational Health. After 1 reminder, a total of 3313 physicians (74%) responded (Table 1). This sample was representative of Finnish physicians according to age, sex, specialty, and employment location.26-27 In 1997, 58% of Finnish physicians were specialists, and specialist licenses were granted in 32 specialties after 6 years of postgraduate training and in 60 specialties after 8 years of training (former subspecialties). General practice is the largest specialty in Finland and general practitioners primarily work in health centers. Only about 7% of Finnish physicians earn their living solely as private practitioners, but about one third of physicians operate a part-time private practice in addition to working in a hospital or health center. Most private practitioners work in group practices.
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Table 1. Characteristics of Physicians
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Most questions concerning health status and the use of health services were exactly the same as those used in national studies of the Finnish adult population.28-29 For the comparison, unemployed and retired persons were excluded from the data of the national studies. Perceived health was asked as a structured question about whether a person assessed his or her health to be "good," "fairly good," "average," "rather poor," or "poor."28 The prevalences of diseases were asked by using mainly the same list of diseases as in previous national health studies, and each person was asked whether he or she had experienced any of the diseases during the past 12 months. Furthermore, the physicians were asked if they had treated themselves or had been treated by another physician. Sick leaves and medical consultations during the last year were also asked about with the same questions as in the national health studies, and the respondents were asked how many days of sick leave they had taken and how many times they had consulted a physician during the past 12 months. Sickness absence was measured as the cumulative incidence and the length of absence only for those who had been on sick leave. This measure is supposed to be more useful for medical purposes than if the total population is included.30 The question about laboratory tests during the preceding 5 years was not included in the national health studies, but it was used for comparisons between male and female physicians and between specialties.
STATISTICAL ANALYSIS
Dichotomous variables were tested with the Mantel-Haenszel test when age-standardized rates between male and female physicians and age- and sex-standardized rates between specialties for each specialty (with >20 respondents) with other physicians were compared. The z test for proportions was used for comparisons between physicians and the employed general population. Continuous variables were analyzed using an analysis of variance, and the z test for means was used to compare physicians with the general population. The data were analyzed with the SAS program (version 6.11; SAS Institute Inc, Cary, NC). Since many statistical comparisons were made, statistical significance was considered at P<.01.
RESULTS
PERCEIVED HEALTH
After adjustment for age, no significant difference in the assessment of subjective health was found between male and female physicians or between male physicians and other male employees (Table 2). Female physicians assessed their health to be good or fairly good more often than other female employees. Among physicians, as among the population in general, younger persons assessed their health as good or fairly good more often than older persons did.
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Table 2. Physicians and Employed General Population Who Assessed Health as Good or Fairly Good*
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When one specialty was compared with other specialties, child psychiatrists (61.1%; P = .007) and psychiatrists (61.0%; P = .001) least often assessed their health as good or fairly good while internists (88.6%; P = .001) most often evaluated their health as good or fairly good.
PREVALENCE OF SELF-REPORTED DISEASES
Among physicians, men reported hypertension more often than women while women reported thyroid dysfunction and neurologic conditions more often than men (Table 3).
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Table 3. Self-reported Diseases of Physicians and Employed General Population During the Past 12 Months*
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When physicians were compared with the total employed population, both male and female physicians reported mental disorder, chronic eczema, disease of the digestive system, and back complaints more often than other employees of the same sex, and male physicians also reported asthma more often than other male employees. Furthermore, male physicians reported hypertension, heart disease, diabetes, chronic bronchitis, chronic pyelonephritis, and rheumatic arthritis as often as other men. Male physicians reported all comparable diseases as often as other male employees. Female physicians reported heart disease, diabetes, asthma, chronic pyelonephritis, and rheumatic arthritis as often as other female employees but reported hypertension and chronic bronchitis less often. Thyroid dysfunction, neurologic conditions, obstetric disorders, and arthrosis were not comparable with the general population because the prevalences of these conditions were not determined in the national population studies.
When specialties were compared, only pulmonologists (80.0%; P = .003) reported at least 1 chronic disease during the past 12 months more often than other physicians.
SELF-TREATMENT OF DISEASES
Diseases that were more often self-treated were hypertension, diabetes (men), mental disorders, asthma, chronic bronchitis, chronic pyelonephritis, chronic eczema, diseases of the digestive system, back complaints, and arthrosis (Table 4). Male physicians self-treated diseases of the digestive system and back complaints more often than female physicians, but both men and women self-treated these diseases at a high rate (80%-84% vs 72%-74%).
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Table 4. Self-treatment as Only Care of Physicians' Self-Reported Diseases*
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SICKNESS ABSENCE
Fewer male than female physicians had been on sick leave during the past 12 months (Table 5). However, for those who had been on sick leave, there was no difference in the number of sick leave days between male and female physicians (Table 6). Younger physicians took sick leave more often than older physicians, but when older physicians took sick leave, it was more likely to be longer.
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Table 5. Physicians and Employed General Population on Sick Leave During the Past 12 Months*
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Table 6. Sick Leave Days of Physicians and Employed General Population During the Past 12 Months*
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Fewer physicians had been on sick leave during the last year compared with other employees of the same sex (Table 5). When only those who had been on sick leave were included, however, no significant difference was found in number of sick leave days between physicians and other employees (Table 6).
When specialties were compared, anesthetists (56.7%; P = .001) and psychiatrists (56.0%; P = .001) had been on sick leave during the last year the most often and obstetricians-gynecologists (21.2%; P = .001) the least often. For the duration of sick leave, however, there were no significant differences between the specialist groups. Full-time private practitioners took sick leave less often than other physicians (20.0% vs 39.6%; P = .001), but when they took sick leave, the length of absence was significantly longer (36 vs 11 days; P<.001).
For both sexes, acute infections (respiratory and gastrointestinal tract) made up more than half of the diagnoses (65.1% for men, 68.9% for women), followed by musculoskeletal diseases (mostly back complaints) for male physicians and obstetrical or gynecological conditions for female physicians (Table 7). Older physicians' sick leaves were due to cardiovascular diseases, back complaints, and other musculoskeletal diseases more often than those of younger physicians. Reasons for sick leave did not vary significantly between male and female physicians.
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Table 7. Reasons for Sick Leave of Physicians*
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MEDICAL CONSULTATIONS
Fewer male than female physicians had consulted a physician during the last year (Table 8). When physicians were compared with the total employed population, both male and female physicians had consulted a physician during the last year less often than other employees of the same sex.
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Table 8. Physicians and Employed General Population Who Consulted a Physician at Least Once During the Past 12 Months*
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Child psychiatrists (84.2%; P = .006) and psychiatrists (71.8%; P = .001) most often had consulted a physician when comparing the specialties.
LABORATORY TESTS
Fewer male than female physicians (62.3% vs 74.3%; P = .001) had laboratory tests taken during the preceding 5 years. Psychiatrists (82.4%; P = .005) had laboratory tests taken the most often and surgeons (44.6%; P = .001) the least often.
COMMENT
Socioeconomic status has been shown to be a critical determinant of morbidity, and rates of sick leave have also paralleled socioeconomic differences in morbidity and mortality.21, 31 Also in our study, physicians were on sick leave much less often than other employees, and female physicians also assessed their health as good or fairly good more often than other female employees. However, physicians reported several common chronic illnesses as often or even more often than other employees, and male physicians assessed their health as equal to that of other male employees.
Self-treatment as the only care of diseases was typical for physicians. Diseases that were more often treated by another physician rather than by self-treatment were heart disease, thyroid dysfunction, neurologic conditions, rheumatic arthritis, and obstetric conditions. According to another study, as illness severity increased, physician patients indicated less desire to make decisions about the care of their own illnesses.32
Two thirds of mental disorders being self-treated is a problem for the profession. Self-treatment in the form of self-medication is common. Most (61%-76%) of the physicians had reported self-prescribing medications.19, 23-24 One major concern is self-treatment with opiates and benzodiazepines—a practice that can increase the risk of drug abuse or dependence.3-4,10
Female physicians used health services (medical consultations and laboratory tests) more than their male colleagues did. Among the general population, the trend was the same. Female physicians also took sick leave more often, although the mean duration of absence for those who had been on sick leave was the same for both sexes. However, female physicians perceived their health as no worse than the male physicians did. In Finland, among the population in general, women's health is considered to be better than men's.27 In the United States, female physicians have also reported having generally good health habits, and their health behavior has even been considered a useful standard for other women in the United States.33
When the different specialties were compared, the health practices of psychiatrists were most significant. Psychiatrists assessed their health as worse and took sick leave more often than other physicians, although the mean duration of their sick leave was the same as for all specialties. Psychiatrists also had medical consultations and laboratory tests taken more often than other physicians. The question arises as to whether psychiatrists' attitude toward their own health differs because of the nature of their work or whether their health is actually worse. When self-reporting of at least 1 chronic disease during the past 12 months was examined, the psychiatrists did not differ from the other physicians. However, other studies have shown more burnout and depression and higher rates of substance use among psychiatrists than among other specialties.6, 10, 34
When the health of physicians is compared with that of the general population, there are some limitations. The assessment of perceived health may be influenced by profession and therefore may differ from that of the general population. We must also be critical when comparing the rates of illnesses between physicians and the employed general population. In the national health studies, the illnesses had to be treated or diagnosed by a physician, and, among the general population, this criterion means treatment or diagnosis by another person; but among physicians it can also mean treatment or diagnosis of their own disorders. This difference can raise the prevalence of some diseases for physicians in comparison with other employees, if it is assumed that other employees had not consulted a physician for some illness (eg, mental disorder) and a physician could report the illness without seeing another physician and even self-treat the illness. For the conditions that physicians reported more often than other employees, for example, mental disorders and back complaints, the criteria are not exact. Physicians are also assumed to be reluctant to acknowledge their own illnesses.20 Primary care services are, however, accessible to all Finns regardless of their financial status and occupational health care also covers the majority of employees; therefore, accessibility to care is the same for physicians and other employees. It is understandable that physicians had medical consultations less often than other employees did. There are some minor disorders that most physicians can easily treat themselves (eg, acute infections and minor musculoskeletal problems). However, it is difficult to set a limit on what is acceptable and when the bounds of safety are exceeded.
Sickness absence is used as an integrated measure of physical, psychological, and social functioning in studies of working populations.21 Among physicians, going to work does not necessarily indicate unimpaired functioning. There are also cultural and organizational factors that affect the decision not to take sick leave, for example, the awareness that an absence will lead to an increased workload on colleagues.20 The criteria for staying away from work due to an illness also seem to vary depending on age, sex, employment position, and specialty. In particular, male physicians older than 44 years and private practitioners seldom took sick leave. The question arises of whether older male physicians and private practitioners still follow the tradition of continuing to work regardless of being ill. However, when they did report an absence, it was significantly more likely to be long.
Some of the difference in the habit of taking sick leave between private practitioners and other physicians can also be explained by the Finnish sickness insurance system. Everyone who is a permanent resident in Finland has insurance for sick leave. Sick leave insurance is handled by the Social Insurance Institution, a body subordinate to Parliament. People are paid a daily sickness allowance as compensation for loss of earnings. However, working people must be on sick leave a total of 10 days before insurance compensation begins. For employees, employers provide coverage from the first day, and there is no loss of income. Self-employed persons must, however, wait the 10 days before receiving compensation. This 10-day waiting period may raise the threshold for taking sick leave among private practitioners.
Longer periods of absence are shown to be better indicators of ill health compared with shorter periods.21 In our study, we did not inquire about the length of individual sick leaves. However, when the total length of absence during the past 12 months was examined for those who had been on sick leave, there was no significant difference for the number of sickness absence days between the employed general population and physicians. This finding indicates that the difference in health between the total employed population and physicians is not high in Finland, but health behavior does differ. The threshold for taking sick leave is higher for physicians. The health status of Finnish people is comparable to that in other European countries27; therefore, our study may also reflect the behavior of physicians elsewhere.
Physicians' disclosure of healthy personal behavior has been shown to improve both their credibility and their ability to motivate patients.35 Most physicians perceive the need to visit a physician more often than they actually report doing so for health maintenance reasons.36 In the realm of prevention, physicians' tendency to treat their own illnesses and work while ill does not set a good example for their patients.
AUTHOR INFORMATION
Accepted for publication May 12, 2000.
This study was funded by the Finnish Work Environment Fund.
We thank Satu Helakorpi, MSc, from the National Public Health Institute, Helsinki, Finland, for analyzing the control population data from the Health Behaviour Among Finnish Adult population, Spring 1997 study.28
Corresponding author: Saara Töyry, MD, Research and Development Centre for Occupational Health Services, Finnish Institute of Occupational Health, PO Box 93, 70701 Kuopio, Finland (e-mail: Saara.Toyry{at}occuphealth.fi).
From the Finnish Institute of Occupational Health, Research and Development Centre for Occupational Health Services, Kuopio, Finland (Drs Töyry, Räsänen, and Husman and Mr Mäkelä); Finnish Medical Association, Helsinki, Finland (Drs Kujala, Äärimaa, and Myllymäki and Ms Luhtala); LEL Employment Pension Fund, Helsinki (Dr Juntunen); Finnish Institute of Occupational Health, Department of Psychology, Helsinki (Dr Kalimo); and Kuopio Regional Institute of Occupational Health, Kuopio (Dr Seuri).
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