Exploring the relationship between physicians’ personal and clinical prevention habits.
As reported by the Centers for Disease Control and Prevention (CDC), noncommunicable diseases (NCDs), such as heart disease, cancer, chronic respiratory disease, and diabetes, are the leading causes of death worldwide and represent an emerging global health threat. Deaths from NCDs now exceed all communicable disease deaths combined. Lifestyle choices are critical for the prevention of these types of diseases. The World Health Organization (WHO) reports that the four leading risk factors for NCDs are tobacco use, unhealthy diet, insufficient physical activity, and the harmful use of alcohol.
Due to their level of education and status, there is no denying that physicians are influential members of society. In fact, all physicians are educators by the very nature of their work. One of their main functions in the doctor-patient relationship is to provide information. Indeed, the majority of people cite their physician as their primary source of information regarding healthy lifestyle decisions and are more likely to adopt a healthy behavior when their physician recommends it (Oberg & Frank, 2009). Accordingly, since physicians are important health role models and advisors who often meet with patients during potentially impressionable times, their own health behaviors may affect their ability to engage their patients in healthy living (Oberg & Frank, 2009). General practitioners, in particular, are viewed as the most trusted source of health information compared to specialists or health coaches.
Dr. Erica Frank has globally led the study and promotion of the relationship between physicians’ personal and clinical prevention habits, publishing over 100 articles on physician health. She has participated in multiple national studies in the United States, Canada, Germany, Colombia, and Israel, and is the Founder/Principal Investigator of the Healthy Doc = Healthy Patient initiative. This research began in 1991 with Dr. Frank conducting “The Women Physicians’ Health Study,” which demonstrated that physicians’ health practices strongly and consistently influence their patient care practices and that (contrary to myth) physicians have extremely healthy personal practices.
There are multiple reasons to examine physician health, not only from a physical perspective but also from a mental perspective. In addition to the benefits for patients, healthy lifestyle practices for doctors may be important to prevent job-related stress and impairment. Heavy workload, high responsibility, constant contact with ill and emotionally burdened people, and increased bureaucratization and administrative duties add to physicians’ work-related stress and may lead to burnout (Voltmer et al., 2013).
However, to truly advance research on what affects physician health, there must be a general understanding and acceptance of the definition of physician wellness. In an attempt to clarify the concept of physician wellness, Brady et al. (2017) proposed the development of a holistic definition of physician wellness that includes mental, physical, social, and spiritual quality of life in both physicians’ work and personal lives. Moreover, they also noted that physician wellness includes the absence of distress and the presence of positive well-being, beyond mere job satisfaction; a perspective on wellness that reflects the WHO model of health (Brady et al., 2017).
Through extensive research, Dr. Frank and her research team were able to establish that physicians’ physical health practices, in particular, are better than the rest of the population. In the “Comparison of Cardiovascular Risk Factors and Outcomes among Practicing Physicians vs the General Population in Ontario, Canada (2019)”, results showed that practicing physicians in Ontario had fewer cardiovascular risk factors, underwent less preventive testing, and were less likely to experience major adverse cardiovascular outcomes than the general population.
Additionally, a 2009 study in Canada determined that more than 90% of physicians reported being in good to excellent health, and only 5% reported that poor physical health made it difficult to handle their workload, more than half the time in the previous month (Lovell et al., 2009). Their personal screening practices were largely compliant with the Canadian Task Force on Preventive Health Care recommendations.
Another study that examined physicians’ personal health behaviors was conducted by Voltmer, Frank, and Spahn in 2013, who took a representative sample of physicians in private practice in Schleswig-Holstein, Germany. They found that physicians reported significantly better physical health compared to the general population. The majority presented with normal weight or overweight, frequency of exercise, and fruit and vegetable consumption which was higher than in the general population. In addition, approximately 70% drank coffee or tea more than once a day, but only 13.2% of females and 21.8% of male physicians were current smokers.
While research has shown that physicians are generally considered in better physical condition than the rest of the population, it has also shown that work-related stress and burnout among physicians exist at higher rates than in other parts of the population. Burnout typically results from chronic stress, with chronic feelings of exhaustion, negative attitudes toward work, and decreased professional efficacy (Melnikow et al., 2022). One theory of burnout, the Job Demands-Resources (JDR) theory, considered two major elements contributing to burnout: 1) high job demands, including workload, role ambiguity, role conflict, role stress, stressful events, and work pressure, combined with 2) limited job resources including social support, autonomy, and skill variety (Melnikow et al., 2022).
Voltmer et al. (2010) investigated the work-related behavior and experience patterns and predictors of mental health of physicians working in medical practice in Germany. In this study, the researchers examined work-related characteristics, perceptions, behavior and experience patterns, and mental health in physicians working in private practice. It was determined that unfavorable working conditions such as long work hours, high workloads, patient expectations, or administrative duties, contribute to physicians’ stress and potential burnout.
These findings on physician mental health are concerning because poor physician wellness increases the risk of negative mental health outcomes and even suicide in physicians, and also compromises the quality, safety, and efficiency of medical care for patients (Brady et al., 2018). Burned-out physicians are more likely to order unnecessary care, commit a medical error, and leave the medical profession early (Fahrenkopf et al. 2008). Patients of burned-out physicians may suffer from an increased risk of mortality and longer post-discharge recovery times (Welp et al., 2014).
As we have recently witnessed, the COVID-19 pandemic has resulted in an overall surge in new cases of depression and anxiety and an exacerbation of existing mental health issues, with a particularly emotional and physical toll on healthcare workers. Limited resources, longer shifts, disruptions to sleep and work-life balance, and occupational hazards associated with exposure to COVID-19 have contributed to physical and mental fatigue, stress and anxiety, and burnout (Melnikow et al., 2022).
Dr. Frank, through her extensive research and with the ATHP, has brought important attention to this topic of physician wellness. In addition to investigating the health of physicians, she also tested how physicians’ health choices impacted the recommendations that they made to their patients. As her research has proven, physicians who practice healthy habits play a key role in helping their patients to adopt healthy lifestyles for the primary prevention of chronic diseases (Oberg & Frank, 2009).
The Healthy Doctor = Healthy Patient relation was investigated through objectively measured clinical preventive experiences. In one such study, eight indicators of quality of health care (screening and vaccination practices) for primary care physicians and their adult patients were assessed in Israel’s largest health maintenance organization. The results showed that for all eight indicators, patients whose physicians were compliant with the preventive practices were more likely to also have undergone these preventive measures than patients with noncompliant physicians. They also found that more similar preventive practices showed somewhat stronger relations. For instance, patients whose physician had received the influenza vaccine were more likely to get vaccinated as well. (Frank et al., 2013). The findings suggest that there is room for improvement in some physicians’ preventive practices (particularly around screening and vaccination) and that improving the health of physicians could improve outcomes for their patients as well.
In the 2009 research paper, “Physicians’ health practices strongly influence patient health practices”, Oberg and Frank note that physicians who were attempting to improve poor habits counseled patients significantly more often than physicians who were not trying to change their own behavior. For prevention and health promotion topics ranging from dietary fat intake, sunscreen use, mammography screening, physical activity, smoking, alcohol use, and others, they discovered strong personal–clinical correlations.
This correlation also holds true for addiction and substance abuse. According to Frank et al. (2008), the drinking behaviors of physicians might influence their attitudes and comfort about counseling those who drink excessively, because there is a strong and consistent relation between physicians’ personal health practices and their counseling practices, including their practices around alcohol.
According to the WHO, the harmful use of alcohol is a causal factor in more than 200 disease and injury conditions. Worldwide, 3 million deaths every year result from harmful use of alcohol, which represents 5.3% of all deaths (WHO 2022). Clinical alcohol screening and brief counseling help to reduce excessive consumption and related harms and are therefore recommended by the US Preventive Services Task Force. Such counseling is among the most effective and cost-effective clinical preventive services. In the US, however, few health providers ask patients about their alcohol use (Frank et al., 2008). While several factors contribute to low counseling rates, many physicians are unaware of guidelines for low-risk drinking and harmful levels of alcohol consumption, and many feel ill-prepared to counsel their patients.
In the paper “Health Care Providers’ Advice to Quit Smoking”, Kruger et al. (2012) used data from the 2000, 2005, and 2010 Cancer Control Supplement of the National Health Interview Survey to examine changes in the number of adults who received smoking cessation advice from their health care providers. The findings showed that the percentage of smokers who received cessation advice was 53.3% in 2000, 58.9% in 2005, and 50.7% in 2010. They also found that receiving cessation advice was strongly related to the desire to stop smoking: smokers advised by physicians to quit were nearly twice as likely as those who did not receive such advice to want to stop smoking. Therefore, to reduce smoking rates, physicians should increase their efforts to advise smokers to quit.
It is quite clear that the role of physicians as role models of healthy behaviors is quite significant, as ‘practicing what we preach’ may be an effective and efficient strategy to increase health promotion activities among patients. To meaningfully reduce the growing rate of chronic illnesses worldwide, a preventative approach to addressing lifestyle choices must be adopted. Physicians should also be provided with the necessary tools they require to avoid burnout as increasing job demands create more stress and anxiety among healthcare workers.
Physicians stand to benefit from interventions that help them adopt healthier lifestyles – this benefit is not only for their personal health but for the health of their entire patient population, which is likely to profit from more efficient and effective health promotion counseling.
Dr. Frank, in founding NextGenU.org, the world’s first portal to free, accredited higher education in health sciences, used now in every country, recognized the need to help primary-care physicians, nurses, and allied health professionals gain a deeper understanding of the adverse effects of lifestyle choices on health, including smoking and alcohol use. Through courses like Lifestyle Medicine, NextGenU.org provides a foundation for theoretical and practical knowledge and skills, as well as an opportunity to plan strategies and practice techniques to encourage positive health behavior changes.
Additionally, the Addiction Training for Health Professionals (ATHP) program is a key partner and sponsor, contributing to the creation of courses, curricula, and training programs for physicians and their teams to prevent and treat substance use disorders. The program’s primary aim is to maximize the number of physicians receiving addiction training and improve health systems through education related to clinical practice, research, policy, and public health.
NextGenU.org is preparing physicians to adequately screen, diagnose and treat patients with substance use disorders through free courses addressing addiction and mental health concerns.
In our next blog, we explore some discoveries and key takeaways from the research on International Health Workers and Addiction. Stay tuned!
Sherry Joseph
Author
References
About Global NCDs. (n.d.). The Centers for Disease Control and Prevention (CDC). Retrieved August 19, 2022, from https://www.cdc.gov/globalhealth/healthprotection/ncd/global-ncd-overview.html
Alcohol. (2022, May 9). World Health Organization. Retrieved August 19, 2022, from https://www.who.int/news-room/fact-sheets/detail/alcohol
Brady, K. J., Trockel, M. T., Khan, C. T., Raj, K. S., Murphy, M. L., Bohman, B., … & Roberts, L. W. (2018). What do we mean by physician wellness? A systematic review of its definition and measurement. Academic Psychiatry, 42(1), 94-108.
Compton, M. T., & Frank, E. (2011). Mental health concerns among Canadian physicians: results from the 2007-2008 Canadian Physician Health Study. Comprehensive psychiatry, 52(5), 542-547.
Dyrbye, L. N., Trockel, M., Frank, E., Olson, K., Linzer, M., Lemaire, J., … & Sinsky, C. A. (2017). Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Annals of Internal Medicine, 166(10), 743-744.
Fahrenkopf, A. M., Sectish, T. C., Barger, L. K., Sharek, P. J., Lewin, D., Chiang, V. W., … & Landrigan, C. P. (2008). Rates of medication errors among depressed and burnt out residents: prospective cohort study. Bmj, 336(7642), 488-491.
Frank, E., Elon, L., Naimi, T., & Brewer, R. (2008). Alcohol consumption and alcohol counselling behaviour among US medical students: cohort study. Bmj, 337.
Frank, E., Dresner, Y., Shani, M., & Vinker, S. (2013). The association between physicians’ and patients’ preventive health practices. Cmaj, 185(8), 649-653.
Frank, E., Oberg, E., Segura, C., Clarke, A., & Shen, H. (2010). The physical and mental health status and health practices of physicians in British Columbia. Anesthesiology (P=. 4), 7, 6.
Frank, E., Segura, C., Shen, H., & Oberg, E. (2010). Predictors of Canadian physicians’ prevention counseling practices. Canadian Journal of Public Health, 101(5), 390-395.
Frank, E., & Segura, C. (2009). Health practices of Canadian physicians. Canadian Family Physician, 55(8), 810-811.
Frank, E., Wirsching, M., & Spahn, C. (2010). Work-related behavior and experience patterns and predictors of mental health in German physicians in medical practice. Fam Med, 42(6), 433-9.
Ko, D. T., Chu, A., Austin, P. C., Johnston, S., Nallamothu, B. K., Roifman, I., … & Frank, E. (2019). Comparison of Cardiovascular Risk Factors and Outcomes Among Practicing Physicians vs the General Population in Ontario, Canada. JAMA network open, 2(11).
Kruger, J., Shaw, L., Kahende, J., & Frank, E. (2012). Peer reviewed: health care providers’ advice to quit smoking, national health interview survey, 2000, 2005, and 2010. Preventing Chronic Disease, 9.
Melnikow, J., Padovani, A., & Miller, M. (2022). Frontline physician burnout during the COVID-19 pandemic: national survey findings. BMC Health Services Research, 22(1).
Oberg, E., & Frank, E. (2009). Physicians’ health practices strongly influence patient health practices. The journal of the Royal College of Physicians of Edinburgh, 39(4), 290.
Sasangohar, F., Jones, S. L., Masud, F. N., Vahidy, F. S., & Kash, B. A. (2020). Provider Burnout and Fatigue During the COVID-19 Pandemic: Lessons Learned From a High-Volume Intensive Care Unit. Anesthesia & Analgesia, 131(1), 106–111.
Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-85.
Voltmer, E., Frank, E., & Spahn, C. (2013). Personal health practices and patient counseling of German physicians in private practice. International Scholarly Research Notices, 2013.
Welp, A., Meier, L. L., & Manser, T. (2015). Emotional exhaustion and workload predict clinician-rated and objective patient safety. Frontiers in psychology, 5, 1573.