Principal findings
It was found that a majority of physicians self-treated when last ill and did so with prescription medication. Most physicians did not believe they needed a personal physician to provide health care. For those who sought care from another physician, the specialty of the physician consulted was the most important factor in their decision of whom to consult. Only 14% consulted a FM/GP. These were more likely to be younger doctors and holders of medical degrees from non-Hong Kong universities. Self-prescribing doctors were more likely to be Hong Kong-educated, engaged in general practice and non-members of the HKCFP.
Strengths and weaknesses
Study population
This is the first study to include all physicians listed on the medical register of a population. Previously, participants have been randomly sampled physicians or subgroups of physicians, such as particular specialties e.g. family physicians [4] or neurologists [16], or those under a certain age [17]. This is also the first study on doctors' illness behaviour in Asia.
The response rate was 44% which was in the low range when compared with studies by Pullen (44%, N = 1125)[3], Wachtel (67%, N = 306)[5], and Toyry (74%, N = 3313)[17]. In the context of Hong Kong based surveys of medical doctors, in which Leung and colleagues [18] concluded that the response rate is low (less than 20%) even when cash incentives are offered to respondents, this survey demonstrated a significantly higher response rate. Nonetheless, a low response rate undoubtedly limits the interpretation of the data.
When determining how representative our sample population was in relation to the general physician population, it was very noteworthy that there was no database of basic physician demographics to which we could compare our sample. As the Hong Kong Department of Health Manpower Survey [15] was the only information available, it was used as the basis for comparison, despite being a voluntary survey itself, with a 53% (N = 5276) response rate. Unknown response and selection biases also make it impossible to determine if this was a representative sample.
Rationale for the wording "last illness"
The choice of wording used, asking respondents to recall when they were "last ill", was deliberately set in order to tap individuals' subjective perception of being ill. By leaving it undefined we had hoped to include as wide an interpretation as possible which would encourage respondent consideration of mental and emotional conditions when answering the question.
Using broad, undifferentiated wording does prevent us from specifically assessing the "correctness" of the respondent's management decision. Even among doctors who sought medical attention the last time they were ill, we are unable to judge whether this was an "appropriate" consultation. We can only observe that the patient's perceived illness was such that they felt they needed to see a doctor. Similarly, for physicians who chose to self-medicate when they were last ill, their perception of being ill did not warrant seeing a doctor yet a majority considered themselves ill enough to take prescription medication.
Though not knowing the specifics and circumstances of the illness limits our judgement of the action, our data still enable us to determine that the practice of self-prescribing medication is common and that one-third of all respondents considered their last illness significant enough to seek medical attention.
The timing of the last illness was not specified with the aim of prompting respondents to recall an actual event. This allowed for information to be obtained from a different perspective than surveys which asked hypothetical questions or provided case scenarios in which the respondents would anticipate their actions in a given situation. However, the limitation is that answers would be dependent on respondent memory and truthfulness.
Comparison with international findings and implications
Self-management
From the number of physicians who admitted to taking self-obtained prescription medication for their last illness in this survey, it would appear that a good proportion of these had "illness" that for lay people would require a visit to the doctor.
Doctors, however, clearly are a different population from the general public but they still get ill and perception of what constitutes "being ill" varies widely from individual to individual, as in lay people. Being trained doctors, with the knowledge and having the resources to take care of themselves, physicians can and do self-diagnose and self-treat when "ill" to a greater extent [17, 19] with wide ranging opinions as to where the threshold for seeking help is. An Australian survey found that many physicians were prepared to treat themselves for serious illnesses [3]. Another showed that most doctors believed it was acceptable to self-treat for minor illness but were split over the self-management of chronic disease [2]. It has been shown for some chronic illnesses, self-management by patients, in collaboration with their doctor, can improve health outcomes [20] so there may be justification for physicians with chronic diseases to do the same.
Statements from the General Medical Council and Australian Medical Association [21, 22] have also noted that it "makes sense to treat minor ailments" and emergencies. However, the main theme reiterated by medical associations and colleges is the concern about compromising clinical judgement and objectivity when the physician is treating himself. This has resulted in the recommendation discouraging physicians from self-treating in most circumstances [21, 23, 24].
The Medical Council of Hong Kong does not specifically address this issue although it implies a similar viewpoint as it stated with reference to issuing sick leave certificates, "...a doctor cannot be his own patient..." [25]. The Hong Kong Medical Association Ethics Committee indicated that there was, "...no government regulation nor any specific guidance in the Professional Code and Conduct, on the treatment of one's own/family members' illnesses although doctors should be cautioned against doing so..." in a written personal communication.
Despite the well-meaning aim of promoting prudent self-care practices among physicians and protecting patients, these ethical guidelines are not necessarily followed [26]. On the other hand, the effectiveness of the more forceful option of governmental legislation (against self-prescribing) on physician impairment is uncertain with a paucity of research noted in this area [27]. This issue of physician self-prescribing is summed up in a telling comment from Rosvold and Tyssen [28], "self-prescribing is not to be viewed simply as a cause of physicians' impairment, but more of a symptom of poor health-care for physicians".
Even among those who had ever seen a doctor before, the majority indicated that the most important reason for choosing the doctor that they did was physician specialty. Of those who sought consultation for their last illness, only 14% chose to consult a FM/GP which suggested that there was a degree of self-diagnosis and self-referral occurring. Having an initial assessment by an objective primary care physician, preferably one's own, did not appear to be common practice. However, it must be recognized that in the Hong Kong setting, primary care medicine is also practised by community based specialists in the sense that these physicians may provide general outpatient care as well as specialist outpatient care. In this study, it was not possible to determine whether the specialty certification status of the doctor consulted matched his/her predominant area of practice.
Personal physician
One of the pillars of recognized good health care for any individual is having a designated primary care physician to provide and coordinate care and is recommended in policy or position statements of respected medical associations [22, 23]. It has been shown that there is an association between doctors who have a family physician and compliance with preventive health behaviour [29, 30] and that these doctors are three times more likely to visit a physician for health maintenance than those without a family physician [31]. "Doctors themselves are concerned about the current level of illness within the profession and securing appropriate personal health care might be regarded as essential" [1].
Despite this, only 30% of respondents felt they needed a personal physician. This compares unfavourably with surveys of physicians in various other countries. In an Australian survey, 42% had a GP although less than a third actually consulted their GP for health problems [3]. In Rhode Island, USA two-thirds of physicians indicated that they had a primary care physician [5] and in New Zealand, 71% claimed to have one [6]. This discrepancy may be due in part to the Hong Kong health care system in which a solid primary care infrastructure is still lacking, when compared to these more established systems. As well, our survey did not measure the numbers of respondents who actually had a personal physician, only their perceived need for one so this 30% may, in fact, be an overestimation.
Being female and having membership in the HKCFP were found to be related to the generally more healthy practices of consulting another doctor when ill and believing in having a personal physician. Female doctors in Australia have also been shown to be more amenable to seeing another physician for medical care and were more likely to discuss problems with their doctor [3]. Presumably members of the HKCFP would have a greater interest, and vested interest, in promoting and propagating the concept of quality primary care. Many may have pursued further training, and thus have gained a better understanding of the principles of family medicine, including the health benefits of having a personal primary care physician.
