Methods

Study design

This study was designed to provide a systematic, qualitative perspective on GPs experiences of “significant illness”, their interaction with healthcare providers and the influence this has on practice. Approval was granted by the Swindon NHS Research Ethics Committee.

Participants

A maximum-variation sampling strategy was used to capture a broad range of perspectives and experiences. GPs in two primary care trusts were contacted and asked if they had “xperienced significant illness”. This phrase was designed to include psychiatric, physical, acute and chronic, but not minor, illnesses. Seventeen GPs (10 male and seven female) agreed to participate in interviews (median age 46 years). Whereas 17 is a relatively large sample size for in-depth qualitative research, (interpretative phenomenological analysis advocates including up to 10 participants), we felt that including all 17 respondents would permit a novel understanding of the diverse experiences of illness in GPs as well as an in-depth analysis.6 Participants included locums, partners, retired GPs and individuals who were on maternity or sick leave. Significant illnesses reported by participants were categorised as five chronic medical, four mental health, three malignancies, three trauma, one surgical and one undiagnosed.

Collection and analysis of data

Semistructured interviews were undertaken either at the participants’ own homes or their surgery. Interviews were guided by a schedule, which was designed to elicit the experience of being a patient, the way that being a patient had affected practice, and participants’ reflections on their own experiences of treating other doctors. The interview schedule covered three broad areas. Initially, the participants were invited to articulate their lived experience of being a patient (eg, “Can you tell me about when you were a patient?”). Second, participants considered whether being a patient had affected their practice, and if so, how this had been manifested (eg, “Has your experience of being a patient changed the way in which you practice as a GP in any way?”). Finally, they discussed their experience of treating other doctors and how this had impacted on their own practice (eg, “Has this experience affected the way that you consult or think fellow GPs should consult, if another doctor presents?”). The interviews were audiotaped, transcribed verbatim and anonymised.

Interpretative phenomenological analysis6 was used to generate both a descriptive and interpretative account of GPs’ experiences and to provide an overview of their experiences. Analysis was primarily undertaken by the research co-ordinator (FEF) coding each transcript into themes. As similar themes from each transcript were grouped and examined, overarching categories were identified. Reliability was assessed in three ways. An exemplar transcript was coded independently by an experienced qualitative researcher (KJR) and no significant inconsistencies were found. The emerging findings were reviewed by the research team and consensus was reached about the structure of the categories. Participants were provided with a synopsis of findings to ensure that the interpretation accurately reflected their experiences. No participants disagreed with the analysis, suggesting that agreement was achieved.

Results

The BMA guidance Ethical responsibilities in treating doctors who are patients5 was reviewed individually by three members of the research team (FEF, KJR and GJT). Each researcher identified several key points that they believed summarised the 250-word document. These were reviewed, amalgamated and consensus was reached. The following was produced:

Doctor patients must:

• Be treated as individuals and not just as healthcare professionals

• Have access to services with the same level of confidentiality

• Be aware that they are now the patient.

Our own data were then reviewed for evidence about each of these areas. These are presented below.

Doctor–patients must be treated as individuals and not just as healthcare professionals

The BMA guidance indicates that both the medical status and individual needs of unwell doctors should be taken into account. Many of our participants echoed this sentiment but their accounts reveal how challenging this can be:

“I think if you’re a patient then you often want to be treated as a patient… there’s an element of almost ignoring the fact they’re a doctor, but at the same time I can’t do that because they are a doctor and you’ve got to take that into account” (GP012)

Ambiguity among GPs about the status of doctor–patients is illustrated by the notion that they are the “same but different” to non-medical patients:

“The doctors I have seen… I … didn’t change anything but was aware that actually there is a difference… every patient’s different anyway” (GP004)

It was recognised that doctor–patients who consult their GP had the same

“hopes, fears and expectations” (GP001)

as their non-medical counterparts, but the level of medical knowledge held by doctor–patients meant that they were different to non-medical patients. Furthermore, the shared language between medical professionals sometimes contributed to a misplaced sense of mutual understanding. This uncertainty about how far doctors who are unwell resemble or differ from non-medical patients can create an unsupportive environment, in which the needs of the doctor–patient are not met:

“some of them will pitch it at you as a fellow doctor, but not as a patient. Often when you’re actually needing it as a patient… and that can… be quite sort of brutal” (GP008)

By contrast other GPs felt incensed when their medical expertise was overlooked by colleagues who treated them:

“(consultant) saying to his deputy over my head, ‘we are going to have to do something, something major here’, or some euphemism which I completely knew what they were talking about. ‘Don’t talk over my head!’ … as if I didn’t understand… and as if I didn’t know the implications” (GP001)

The BMA guidance recommends that doctor–patients are given the same level of examination as other patients and that the doctor providing care should “avoid relying solely on doctor–patients to give them information about their condition” (BMA, 2008). Our data reveal examples of deviation from this guidance. Some GPs described how doctors contacted them by phone requesting a prescription or a referral without wishing to see the treating doctor face-to-face for a consultation, and without a desire to seek the treating doctor’s opinion. In these situations, the doctor–patients provided all the information and often made their own diagnosis before consulting the GP. Decision-making with doctor–patients who were perceived to have higher medical status was particularly difficult for younger GPs.

“it is hard if somebody’s had 35 years of making medical decisions, even if it is in another specialty, they’re very hard… to argue with… you obviously try and get along and reach an agreement obviously, but umm that agreement is generally in favour of their decision rather than yours… they might accept your opinion but usually, more often than not, they’re basically asking for a referral… a referral that’s come from general practice.” (GP015)

In the UK National Health Service (NHS), GPs are gatekeepers. In order to access other health services, patients need to be assessed by their GP who will then refer them for further treatment as appropriate. As we have noted above, our participants suggest that some doctor–patients attempt to circumnavigate the system by diagnosing themselves, asking for a referral over the telephone with no desire to seek the opinion of the “treating” doctor. Indeed,the fragility of achieving the balance of shared illness management and the anxiety that consultations can cause for both the doctor providing and seeking care were clearly articulated by our participants. Some considerations for achieving this equilibrium were articulated, in particular the importance of avoiding assumptions. One participant identified that experience of treating doctor–patients is crucial to develop this insight:

“It’s down to experience… I think the more you look after… other health professionals the more you realise that you should never make any assumptions” (GP003)

Another GP stressed that making assumptions about the doctor–patients’ level of knowledge could compromise their safety:

“I think there’s quite a danger… you assume they know things that they might not know” (GP012)

Negotiating shared care involved an equilibrium that was described by one participant in this study as

“forging a middle way… between taking things for granted and… yet allowing them to be vulnerable” (GP006)

Recognising and responding to individuality seemed to be key in achieving the balance between treating doctor–patients as individuals and not just as healthcare professionals:

“he just responded to what I was saying and there was a recognition from him… completely of me as an individual, and my individuality meant that actually I had some medical knowledge” (GP004)

Positive examples of this were evident in the data:

“my own GP… has been utterly and wonderfully, fantastically supportive and… has completely got it right between treating me as a friend and patient and colleague, so she’s completely got the right combination” (GP006)

Doctor–patients must have access to services with same level of confidentiality

Our interpretation of the term “access to services” is the ease or difficulty with which doctor–patients are able to access healthcare. Our findings reveal differences between the experience of access to services in primary and secondary care. Most of the GPs in this study felt they had good access to primary care services and some reflected upon their perception of special treatment. Indeed, notions of professional courtesy (the giving or receiving of an extra level of care in recognition of one’s, or one’s patient’s professional status), were evident in the accounts of participants both from the perspective of doctors receiving care…

“certainly with my GP I think he’s always very available. I think he’d always be very available for anyone, but I think being a colleague it probably meant he went the extra mile now and again… there was probably a little bit of… preferential treatment.” (GP012)

…as well as those providing care:

“Whenever I see patients who are related to the profession I always do my little bit extra. And I’ve seen fellow GPs, retired GPs in our waiting room and he’s sitting there with all the rest. Had I have gone out and seen him I’d have dragged him off into a side room just to give him a little bit of privacy” (GP007)

This reflects efforts by some GPs to deliver healthcare for colleagues with an enhanced level of privacy, challenging the BMA assertion that the “same level” of confidentiality should be provided.

Difficulty in accessing secondary care was more common. Sometimes this related to the organisational problems of taking time off work:

“having to go back in and out for outpatient appointments and various investigations and things has been really difficult to be able to get time to do that” (GP011)

When participants experienced long waits for treatment or found that resources to meet their needs were unavailable, they sometimes responded by asserting their medical status:

“I had to really pull rank in order to get my bed that day which I found a bit sad because nobody was saying ‘he’s a doctor, you do something about it’” (GP007)

Whereas the BMA document states that doctor–patients are entitled to “the same high standard of treatment and respect as other patients”, some participants believed that they had rights to preferential treatment because of their medical qualification. They emphasised their professional rather than their health status:

“I think again that’s what makes you cross because then when you do need to go and have a hospital appointment or whatever, you kind of expect your colleagues to be there for you because they know that you don’t go sick.” (GP011)

By contrast, other participants felt that medical colleagues in secondary care had increased the accessibility of their services. This was sometimes attributed to mutual understanding about the pressures of working within medicine. Some interpreted the extra effort made by colleagues as an attempt to maintain the efficiency of medical services:

“they (clinic) were fantastic about seeing me at sort of quarter to eight in the morning, before they had taken their coats off so that I could get back for morning surgery without anyone knowing I had been anywhere… not as preferential treatment just so that I could keep my end of the NHS going, so that it wasn’t disadvantaging patients in any way by… turning up late … that’s really appreciated” (GP001)

Issues of confidentiality that are highlighted by the BMA guidance were less evident in our findings, although this may be a reflection of the language used by participants. Our findings identified references to trust and safety, within which notions of confidentiality were implicit:

“I am aware that it is very difficult for doctors or nurses or… colleagues generally to find a safe place to verbalise their concerns” (GP006)

“doctors need to have a doctor whom they trust” (GP014)

Only one GP directed concerns about confidentiality at the broader healthcare system:

“I would be uncomfortable saying… any of my intimate things at my own GP’s in lots of ways. I wouldn’t actually trust the confidentiality and the robustness of the… professionalism, the sensitivity, the caring-ness of… the NHS… that I’ve experienced and worked in” (GP004)

Confidentiality was therefore not an issue that was directly referred to by participants. Of prime concern was the ease (or otherwise) of accessing care and the expectation that colleagues would offer “professional courtesy”, or preferential treatment to fellow members of the profession. In contrast, the focus of the BMA document emphasises the need for confidentiality when treating doctor–patients, with weight given to the possibility that concerns about confidentiality may act as deterrents to doctors seeking help.

Doctor–patients must be the patient in the partnership

The guidance asserts that doctors who are unwell should “assist in the development of a productive doctor–patient relationship”, by “bearing in mind that they have become the patient in the partnership”. The doctor–patient should therefore accept the authority of the doctor who is providing care. However, acceptance of the patient role was, for some of our participants, tempered by an acknowledgement of their own status:

“I’m seeing her as an equal, but an equal who happens to need her care for now” (GP014)

Status was often linked with age or experience. The participants who had more recently completed their training articulated greater anxiety about treating senior colleagues. By contrast, the more experienced GPs often felt more comfortable in this role but were sometimes aware of how nervous the younger doctors were of them as patients:

“it’s something which, in the early stages of my career I’d have been very anxious about umm but no longer so; I mean I feel quite comfortable and confident in that… it’s lack of experience and… sort of gravitas that comes with having been around a bit longer…” (GP009)

Doctor–patients who are receiving care are often ambiguous about the definition of being a patient. For example, one GP reflected on his perception of patient-mode—acknowledging the variety of ways that this can manifest:

“I think… you know I can sort of switch into patient mode, not that there is a thing that defines a patient mode” (GP003)

Our data reveal examples of participants who accept the patient role and, conversely, some who do not. For many GPs the process of accepting the role of patient challenged their sense that they should be able to cope with illness. In addition, their busy workload and difficulty in obtaining cover often contributed to their reluctance to become a patient:

“I was busy, and I didn’t want to be a patient and I didn’t want to make a fuss” (GP001)

“Well I’d arranged two weeks out of the surgery and locums in, all the usual sort of stuff that you have to do in order to cover your work load, and in general practice that’s not that easy.” (GP007)

“We know how busy it is, we know how pressurised it is, you know how much extra work you’ve got to do if someone’s off sick, and so I think generally you try not to go off sick unless you’re absolutely at death’s door as a doctor”. (GP011)

Even when participants were clear that they needed to seek help, the busyness of their schedule and the weight of their workload acted as a barrier to them seeking treatment. This was an issue that was raised frequently by our participants:

“and I knew I needed to get some help and I thought… and I was just so busy. I mean that’s the other thing; you know when you work in general practice it’s… it’s so full on. It’s difficult to find time for health care [………] I mean to make an appointment to go and see your GP is invariably in office time, you know your surgery and getting a locum in my case, I’d probably pay for a locum to take off time to have a colonoscopy is difficult.[…] I couldn’t find where I was going to find the time. So I guess it’s easier to neglect your own health isn’t it?” (GP016)

Some GPs embraced the patient role by handing over their care completely:

“the importance to me of being a patient during that time and not being a doctor; I just kind of sort of wiped out the fact that I was a doctor during that time and just let other people look after me, and that was my way of dealing with it” (GP009)

Notions about what constitutes a “good” patient were often linked to accepting the system of health care and avoiding the temptation to circumvent the organisational structure. For some GPs acceptance was the most effective route to accessing health care:

“To some extent I think I adopted quite a passive role as a patient… I ask questions but kind of accept and know how the system works and go along with it” (GP003)

For others it required a concerted effort to “be good”; something that further highlights how GPs sometimes try to circumvent the referral system, an issue that we raised earlier in this article.

“I felt a bit guilty about going straight to the hospital the day before although I phoned my GP and asked them to set it up, in fact the hospital didn’t seem to realise that and were slightly odd about having just turned up, and I… anyway so in order to be a good girl, I went and had an appointment with my GP that next day” (GP006)

Discussion

The BMA document reveals inherent contradictions by acknowledging the medical expertise of doctor–patients, while simultaneously implying that they should be treated in the same way as non-medical patients. The data we have presented demonstrate that although it is fair to expect doctor–patients to bear in mind that when they are ill, they should regard their role as “the patient in the partnership”,5 they feel it is impossible to be treated in the same way as non-medical patients. At the very least, the fact that doctor–patients have medical knowledge needs to be explicitly recognised by treating doctors who should consider tailoring their communication strategies appropriately. Our data highlight the complexities of approaching consultations with doctor–patients, who were viewed by GPs in this study as both the same as, but different to, non-medical patients. From the perspective of the GP who is unwell, this ambiguity can manifest in an unsatisfactory or inappropriate approach to medical care.

In particular, we suggest that there is a need to raise treating doctors’ awareness of the need to avoid making assumptions about a doctor–patient’s knowledge or insight into their condition. The participants in our study highlighted that the most successful strategy for developing and maintaining productive relationships with doctor–patients was through acknowledgment of the patient’s individuality. This will, of course, bear reference to the patient’s medical status but should also account for their unique hopes, fears and expectations. Negotiating this balance is a skill that many develop over time.

The BMA document advocates that accepting the role of the patient may assist in a more productive relationship between the doctors giving and receiving care. However, the current study reveals an unwillingness to become a patient often as a result of work-related pressures and this is likely to be increased by the perceived pressure to appear healthy.2 Most GPs in this study equated “being a patient” or “patient-mode” with relinquishing their control, which translated as following and accepting the system of health care, rather than being at its helm. However, their experiences often rendered them unwilling to accept this role, leading to examples of pulling rank or bypassing the system. The guidance implicitly suggests that boundaries are important and that doctor–patients should hand over some power to the treating doctor. However, the implication that the doctor providing care should take control is not always supported by examples in the current data. More experienced GPs found it difficult to hand over control, whereas many of the younger, less experienced GPs were unwilling to take charge of consultations with senior colleagues. We suggest that guidance about how to be a doctor to a doctor and how to be a patient should be a feature of medical training. This would afford trainees the opportunity to consider the issues that might arise and learn strategies to offset anxiety. We recognise that adding more to the already full curriculum is not a straightforward task, but suggest that this is nevertheless an important issue that warrants consideration. Although each doctor is likely to treat only a few fellow professionals in their career, all doctors are themselves likely to experience illness at some point in their careers. Raising awareness of the complexities of both treating and being a doctor–patient will therefore ensure that there is clear guidance as to how to act in a professional manner when faced with this situation. A further effect of including this in the curriculum will be the open acknowledgement that doctors do become ill; something that is raised in the BMA document: “there is a cultural expectation within medicine that doctors do not expect themselves or their colleagues to be sick”. Addressing this inaccurate perception would go some way towards addressing the dilemmas our participants have raised. More experienced GPs could use continuing professional development to reflect upon their understanding of being a patient and how best to accept this role.

Reports about access to health care were mixed. References to professional courtesy (eg, the unwritten expectation that fellow professionals will “go an extra mile” or “do a little bit extra” for patients who are “related to the profession”) suggest that there is an expectation within the profession that their treatment will always be positively affected as a consequence of their medical status. However, our findings also demonstrate that this expectation is not always met, and that GPs “pull rank” when their anticipation of preferential treatment is not met. Ensuring that BMA guidelines stating that doctor–patients should have the same standard of treatment as non-medical patients are met, while being aware that there is an expectation that professional courtesy may result in care over and above that offered to/received by non-medical patients, creates an ethical tension. This was exemplified by GP007 who mentioned feeling uncomfortable when noticing that a retired colleague was in the waiting room “sitting there with all the rest”. Perhaps a more realistic wording of the BMA assertion would be that doctor–patients should have “at least as high” standards of treatment and respect as all other patients”.

Whereas confidentiality is a key aspect of the BMA guidance, it featured less strongly in the findings of our study. However, the participants did articulate awareness about trust and safety, within which notions of confidentiality were implicit. Whereas the BMA advocates that doctors receive the “same level” of confidentiality as other patients, our data identified examples of enhanced privacy for doctor–patients. The expectation was evident that doctors should be given a private or “side” room both for consultations in primary care and treatment in secondary care.

Conclusion

This study supports ethical guidance that acknowledging individuality is central to the process of treating doctor–patients. Accepting the role of patient is less easy and may be particularly challenging for more experienced GPs, or for doctors whose expectations of professional courtesy are not met. Acknowledging the anxiety of less experienced GPs has important implications for medical training, and future research could explore the perspectives of this group in greater depth. Guidelines about being a doctor to a doctor–patient and how to be a patient should be an ingrained feature of medical training and continuing professional development. Future research should focus upon how to integrate these ideas into medical education.