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When doctors are patients: a narrative study of help-seeking behaviour among addicted physicians
  1. Jonatan Wistrand
  1. Correspondence to Dr Jonatan Wistrand, Department of Medical History Lund, Faculty of Medicine, Lund University, Inga Maries gata 32 plan 2, Malmö 20502, Sweden; jonatan.wistrand{at}med.lu.se

Abstract

In recent decades studies based on questionnaires and interviews have concluded that when doctors become ill they face significant barriers to seeking help. Several reasons have been proposed, primarily the notion that doctors' work environment predisposes them to an inappropriate help-seeking behaviour. In this article, the idea of the ill physician as a paradox in a medical drama is examined. Through a text-interpretive and comparative approach to historical illness narratives written by doctors suffering from one specific diagnosis, namely opioid addiction, the complex set of considerations guiding their behaviour as patients are to some extent revealed. The article concludes that, in the identity transition necessary to become a patient, doctors are held back by their professional status and that every step to assist them needs to take shape based on an awareness of the underlying principles of the medical drama. Written illness narratives by doctors, such as those highlighted in this article, might serve as a tool to increase such awareness.

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Background

‘A physician who treats himself has a fool for a patient’.1 This is probably one of the most famous aphorisms from the Canadian physician Sir William Osler (1849–1919). And perhaps Dr Osler had a point. In recent decades, several studies have observed how doctors, as they become ill, experience unique and significant barriers to seeking external help.2 ,3 Articles based on questionnaires and in-depth interviews have concluded that physicians self-medicate to a higher degree, are at a higher risk of burnout, are more prone to committing suicide and, to a greater extent than other groups of comparable socioeconomic status, risk addiction to prescription drugs.4–6 A work environment characterised by high levels of psychological demands, excessive workload and a poor sense of control over the tasks at hand, have been proposed as the primary explanatory factors.5 But other possible reasons for the inappropriate health-seeking behaviour and diagnostic delay noted among doctors should also be taken into consideration.7 One such particularly interesting aspect is the idea that the sick doctor constitutes a dramaturgical paradox.i A notion that doctors make anomalous patients since ‘they do not conform to expected ideas about what a patient is in relation to the doctor, and how a patient behaves’.9

This article wishes to highlight the opportunities of using literary accounts of personal illness as a method of increasing understanding of how patienthood is experienced among physicians. By applying a text-interpretative approach to autobiographical illness narratives by doctors, the complex set of considerations guiding their help-seeking behaviour might be better understood. Since literary testimonies are less bound to fit a certain template, they might shed light on partly different aspects than studies based on questionnaires and interviews. In that sense, analysing literary testimonies might complement the knowledge provided by traditional sociological research on the events unfolding when doctors become patients.

Subsequently, one specific illness narrative will be presented, that is, the semi-fictional short story Morphine (1927),10 written by the physician Mikhail Bulgakov (1891–1940). In a particularly illustrative way this story portrays a young doctor's own experience of prescription opioid misuse.ii Following the analysis of Morphine, Bulgakov's testimony will be compared with two autobiographical narratives by doctors addicted to morphine: God's medicine (morphine addiction) by Dr RHK, published in the anthology When doctors are patients (1952),12 and Sista sprutan (English The last shot) by Knut Alm, from the Norwegian anthology Når legen blir syk (English When doctors get sick) (1988).13 iii

The decision to limit analysis to narratives about opioid misuse needs justification. First, morphine addiction is a stigmatised diagnosis particularly difficult to combine with the view of the doctor as a trustworthy and qualified medical actor. Drug misuse and doctoring are incommensurable activities and sooner or later the addicted doctor's professional practice will be impossible to maintain unless external help is gained and the doctor approaches the role of the patient. Second, morphinism among medical professionals has a long and well-documented history, making it possible to localise several biographical accounts from different decades of the 20th century, enabling a comparative historical approach to the health-seeking behaviour of the addicted doctor.

Talcott Parsons, the Hippocratic Corpus and the medical drama

The sociologist Arthur Frank writes that ‘being a patient, [is] a performance that involves meeting certain expectations’.15 The same is, of course, true for doctors. In fact the codes of conduct expected by a trustworthy doctor were spelt out as early as antiquity. According to The Physician, appearing in the Hippocratic Corpus from 400 B.C. a doctor should be ‘prudent’, ‘kind’ and avoid ‘uncontrolled laughter’. Furthermore, in this oeuvre, it is also expressed that a doctor's dignityrequires that he should look healthy […] for the common crowd consider those who are not of this excellent condition to be unable to take care of others.16

In the 1950s, the American sociologist Talcott Parsons formulated a theoretical model according to which interaction between doctors and patients was based on a silently agreed division of roles. Equally with Hippocrates, Talcott Parsons also embraced the notion that, in the medical encounter, a distance between the characteristics of doctor and patient was an essential feature. As caregivers and recipients of care had been positioned in two separate roles, confidence and predictability were created for the course of events taking place according to a predetermined scenario.iv According to Parsons, the division of roles in healthcare are not equal, but rather hierarchical wherethe two polar aspects are the role of physician, as the highest grade of publicly certified expert in health care, and the role of sick person.17

This notion by Parsons of doctor and patient as two compatible, but immiscible, role players in a medical drama is a helpful way of understanding the impaired physician’s plight. When applied to the illness narratives analysed in this article, it becomes evident that part of the difficulties experienced by doctors as they get ill are due to an inability to switch roles. As we shall see, leaving the accustomed professional identity and accepting the role of the patient proves difficult for the addicted doctors; instead a role conflict appears which somehow has to be managed.

Opioid misuse among physicians—a brief summary

Over the past 150 years, a significant number of doctors have succumbed to morphine addiction. True, opium has been used for much longer as a subcomponent of various medical decoctions. But it was not until the German chemist Friedrich Sertürner in the early 1800s managed to extract morphine from the opium poppy that opium was made available for predictable use in a clinical context.11 Following the introduction of the hypodermic syringe around 1850, the medical profession was, for the first time, in possession of an effective analgesic method. The morphine syringe was quickly incorporated into the physician’s basic equipment and control over prescription rights in the second half of the nineteenth century strengthened the medical practitioners' own professionalism.18 But the new miracle drug also turned out to bring risks. Towards the end of the nineteenth century, it became increasingly apparent that a problem of addiction had taken root in the medical profession. In 1883, the American doctor JB Mattisson raised a warning flag in the journal Medical Record by stating thataddiction, hypodermically, is likely to prevail largely in medical circles, inasmuch as the very nature of this method requires a more or less intimate knowledge of morphia and the hypodermic syringe, which the average layman does not possess.19

In 1909, the British physician Oscar Jennings estimated that nine out of ten morphinists were doctors and a fifth of all deaths among doctors were related to morphine addiction.20 The prevalence of opioid addiction was partly due to the fact that morphine was used as treatment against another common drug problem at that time: cocainism. But more important was probably the easy access doctors' had to morphine, in combination with a rooted practice among medical men to experiment with new drugs on themselves for scientific purposes. The ‘auto-medical case story’ was, at the turn of the century, a scientific publication form of significant rank.

Today, drug misuse among medical professionals is still a substantial problem. Statistics differ and the number of unreported cases is likely to be substantial. A survey from the 1990s estimates a prevalence of drug misuse at least three times higher among physicians than among the general population.5 The motives presented by doctors in contemporary studies highlight drug misuse as a way to manage a work situation marked by severe stress, high performance requirements and few natural rests. Opioid use—through prescription or directly from the clinic’s medical supplies—is described in these studies as a way to soldier on when faced with exhaustion.5

Morphine—Mikhail Bulgakov

In December 1927, the short story titled Morphine was published in a Soviet magazine. The author was a doctor, Mikhail Bulgakov, born and raised in Kiev but who was working as a writer in Moscow since the early 1920s. Morphine was a short story essentially based on the author’s own experience of opioid addiction. As a newly graduated doctor, Bulgakov had fallen victim to drug misuse similar to that described in Morphine. The events had taken place in the autumn of 1916 when Bulgakov was stationed at a remote provincial dispensary located in the rural region of Smolensk. There he worked as the sole physician under miserable conditions, subject to both his own lack of medical experience and to the dispensary's deplorable standard. In her biography of Bulgakov, Ellendea Proffer describes the situation as follows:With only the help of a medical assistant […], and sometimes a nurse, the doctor was required to perform all necessary operations whether he had experience or not – and Bulgakov did not.21

Drug misuse became a refuge for the young doctor. Unlike his fictitious character, Bulgakov eventually managed to overcome his addiction. But the experience left him deeply marked. In Morphine, 10 years later, Bulgakov formulated a detailed illness narrative moving freely across the borders between medical case-reporting and literary drama.

The point of departure for Bulgakov's short story is a letter written by the country doctor Dr Polyakov addressed to a former fellow student and colleague: Dr Bomgard. In his letter Dr Polyakov describes how he suffers from a life-threatening disease and is in need of immediate assistance. The nature of the disease is not revealed and Dr Bomgard has to speculate:“Seriously ill … something unpleasant …” ‘What could that mean? Syphilis? Yes, no doubt about it, syphilis. He's appalled, he's concealing it, and he's afraid’” (p.87).10

But before Dr Bomgard departs to help him out, Dr Polyakov shoots himself in the chest. At the moment of death he leaves a paper tome to Dr Bomgard. ‘“The notebook's for you …” Polyakov muttered hoarsely and even more faintly’ (p.90).

It proves to be a series of diary entries in which the period from the first morphine injection to his suicide a year later had been carefully recorded. These diary entries—with Dr Polyakov's reasoning about his addiction—form the short story's actual plot.

On the night of 15 February 1917, Dr Polyakov experiences a sudden abdominal pain, which refuses to fade until the laboratory assistant—Anna Kirillovna—gives him a shot of morphine. In his notebook, Dr Polyakov writes enthusiastically:I must give due praise to the man who first extracted morphine from poppyheads. […] It would be a good thing if a doctor were able to test many more drugs on himself (p.93).

The procedure is repeated the following night, after which Dr Polyakov is captivated. In detail he portrays the pleasant dreams, the cognitive capacity, the overwhelming taste for work and the immediate disappearance of the pain. There is not much doubt that what he describes is first-person testimony, since Bulgakov himself must have experienced the excitement of intoxication, described with such clarity. Later, as Dr Polyakov becomes an addict, Bulgakov depicts with similar accuracy the increased irritability, impulsivity, the visual and auditory hallucinations and the uncontrollable urge for a new injection through this fictional character.

The laboratory assistant at Dr Polyakov's clinic recognises early on that her doctor is misusing drugs. She is the only one who has the keys to the medication room and is able to prepare morphine from crystalline form to injectable solution. However, Anna Kirillovna is too bound to the decision hierarchy of the clinic to be able to prevent Dr Polyakov's decline. For even though he has now become a morphine addict, Dr Polyakov still retains the determining authority following naturally with his professional title.‘Please, Anna Kirillovna, give me the keys to the dispensary’.She whispered: ‘No, I won't’.‘Kindly give me the keys to the dispensary. I'm speaking as a doctor’.In the twilight I saw her expression change. She turned very white, her eyes seemed to sink into her head and they darkened (p.95).

After 9 months, Dr Polyakov is admitted to a psychiatric clinic in Moscow for treatment. But as the abstinence intensifies, he pleads with the physician treating him for permission to return to his medical practice. A word of caution is the only reprimand in a dialogue apparently taking place between colleagues rather than between a doctor and his patient.‘Doctor Polyakov!’ His voice rang out behind me. I turned round, my hand on the doorknob. ‘Listen,’ he said, ‘think it over. […] So far I have at least been able to deal with you as a doctor. But later you will be in a state of total mental collapse’ (pp.100–101).

Despite weight loss, weakness and infected abscesses on his upper arms, Dr Polyakov continues to devote himself to his clinical duties. But finally, on realising that he lacks both the ability to run the clinic and the strength to escape from his addiction, Dr Polyakov writes the letter to Dr Bomgard with which the story begins and then shoots himself.

Bulgakov's testimony in a broadened perspective

Several of the aspects that Mikhail Bulgakov raises in Morphine are also illustrated in contemporary studies about doctors' health-seeking behaviour when faced with their own illness. These include the self-medication, the stigma and colleagues' inability to approach a fellow physician who is ill. But Bulgakov’s short story also pinpoints one of the most central aspects of the dilemma: the difficulty of reconciling the two roles—doctor and patient—in one and the same person. The quandary becomes particularly evident in the portrayal of Dr Polyakov's visit to the treatment clinic in Moscow where he, strictly speaking, never becomes a patient, but continues to be treated as a colleague. The head of the clinic in Moscow is not even capable of the most natural course of action—to report Dr Polyakov’s drug addiction to his employers.‘I beg you, professor,’ I said dully, ‘not to tell them anything … I'd be struck off with ignominy for being an addict … Surely you wouldn't do that to me?’‘Oh, very well then, go’, he shouted irritably. ‘I won't say anything’ (p.101).

According to Talcott Parsons, the division of roles in healthcare is so institutionalised and the dramaturgy between patient and doctor so rooted that any possibility of diverging from the predetermined setting is ruled out. Still, in Bulgakov’s short story it becomes evident that situations might appear when this interaction is not entirely free of friction. With a patient whose primary claim is being a colleague, the attending physician has difficulties in following the implicit script. In an article from late 1990s, social anthropologists Christopher McKevitt and Myfanwy Morgan describe what happens.According to Parsons, when doctors diagnose and treat disease they are using their professional knowledge and authority to legitimize illness in others. […] Yet doctors’ power to identify illness and to create patients seems diminished when members of the profession are themselves unwell.22

What Bulgakov illustrates is how Dr Polyakov deviates from the patient's expected behaviour, clinging to his professional status as a doctor. In the difficult transition from doctor to patient, he receives no assistance from colleagues and co-workers. Instead he is left without guidance of how to act in the medical drama. But Bulgakov’s account is, after all, not the only one of its kind. In order to capture both common traits and substantial differences the short story Morphine will now be compared with two autobiographical illness narratives by addicted doctors from the second half of the twentieth century. We first turn to the pseudonym Dr RHK and his testimony God's medicine (morphine addiction) from 1952.

During an arduous night shift at an emergency department in the 1940s, a young surgeon skilfully delivers an injection of morphine. Although a routine procedure, this injection is still different. For the first time, the young doctor injects morphine into his own blood. In the anthology When doctors are patients (1952) the surgeon Dr RHK describes that particular moment in the emergency department.It is impossible to explain the moral lapse of the moment […]. In my conscious mind, I was aware of all of the implications of the act, but they just didn't count. I was filled with the thought of relief obtainable, such as I had witnessed it when I gave the preoperative medication to the patient (pp.129–130).12

In Bulgakov’s short story, an unmanageable job situation and the pretence of physical pain leads Dr Polyakov into his misuse. The similarity with Dr RHK’s depiction is striking: ‘I could not stand this overwork, this lack of sleep, the ulcer pains another minute’ (p.130). Another similarity with Bulgakov’s narrative is the formal prose that Dr RHK uses when the adverse reactions of various preparations and concentrations are reported in detail. As for example in the following sequence:The respiratory effect was not noticeable as concerns rate and depth. In fact, I have never been conscious of any respiratory action of morphine, other than the marked shortness and irregularity of respiration associated with toxic doses of the drug (p.136).

The ‘auto-medical case story’ from the late 1800s was still, by the middle of the twentieth century, prevailing and at least for Dr RHK it seems to have functioned as a way to legitimise his misuse to himself. His medical descriptions become a strategy to distance himself from the misuser and, like Dr Polyakov, adhere to his accustomed doctor's perspective.

Also when Bulgakov’s short story is set against more contemporary testimonies by drug-addicted doctors, there are similarities. But in such a comparison important differences emerge as well. In the Norwegian anthology, Når legen blir syk (English When the doctor gets sick) from 1988, a general practitioner, under the pseudonym Knut Alm, accounts for a period of morphine addiction a few years earlier. As for Bulgakov and Dr RHK an impossible workload is what leads to the misuse. But unlike these earlier narratives, the testimony of the Norwegian doctor is more about the private person and the patient Knut Alm than about himself as a doctor. The perceived stigma is the major theme of the text.Most difficult was the sensation of shame, of having betrayed. I experienced tremendous feelings of guilt towards both colleagues and family. That taint I might never be able to erase (p.134).13 v

Another important difference between Knut Alm's and Mikhail Bulgakov’s testimonies is the support the Norwegian doctor receives from his manager and associates. As a colleague becomes suspicious and decides to confront Knut Alm, his addiction is uncovered. Psychiatric care follows and the addicted doctor's right to prescribe narcotic drugs is withdrawn. But he is also assisted in catching up professionally and, after 6 months of treatment, to return to his former workplace. The contrast to Bulgakov’s Morphine is obvious where drug misuse and doctoring are allowed to coexist even when the addiction is public knowledge. It is tempting to interpret the more appropriate manner of handling the situation in the 1980s as compared with the 1920s as a consequence of changes in the professional identity of doctors. As doctoring gradually has changed into more of a job than a vocation, its professional identity has simultaneously become more flexible and less dominating.23 As a consequence, Parsons model has also become more applicable to the addicted physician. The shift from doctor to patient is still significant, but as the medical scrubs at the end of the day are possible to put aside, the doctor's coat is no longer impenetrable for colleagues registering signs of illness. Another possible reason for the differences observed over time is that medical practice today is better monitored, by internal routines as well as by external authorities, than it was a few decades ago. Hence nowadays, dysfunctional doctors are more likely to be revealed at an earlier stage where the damage caused and the stigma evolved is less extensive.

Conclusion

This article has sought to contribute to the understanding of the ill doctor's perceived dilemma. The testimonies of Mikhail Bulgakov, Dr RHK and Knut Alm are first and foremost individual testimonies, merely intended to catch the author's own unique experience. Still, these three narratives can also serve as illustrating examples, depicting both different courses of events and important overlapping experiences. One such common theme is role conflict, or role confusion, a description of the ill doctors as individuals lacking both willingness and ability to conform to the expected medical drama. By applying Talcott Parsons's theoretical model for codes of conduct in the clinical setting, to the situation when doctors are sick, it becomes apparent that for the identity transition necessary to become a patient, doctors are held back by their accustomed professional status. Furthermore, the step from doctor to patient seems particularly difficult as it has to take place in the medical setting where the same individual is used to act as a doctor. In the afterword to the anthology When doctors get sick (1987)—a compilation of 50 illness narratives written by doctors—the editors Harvey Mandell and Howard Spiro describe this particularly strange experience: to be simultaneously at home and in uncharted territory.When doctors get sick, the setting does not change, but they are suddenly on the other side of the doctor's desk. In the hospital the doctor lies on the bed, no longer standing beside it. The view has changed – and he is no longer in control.24

The illness narratives of Mikhail Bulgakov, Dr RHK and Knut Alm illustrate how this role confusion applies to the help-seeking physician and to the doctor who is in charge of the medical encounter. The treating doctor has to find a way to handle an individual who is at the same time patient and colleague. The balance is difficult, since putting the collegial mentality aside requires active effort and still the patient neither can nor should be entirely denied his or her professional identity. When the doctor gets ill a certain tension appears, as the biomedical perspective of disease has to be amalgamated with the personal perspective of illness. This tension might not be unique for doctor-patients, but is likely to be more accentuated due to the fact that doctors, more than most other patients, are accustomed to think of disease mainly in objective terms. In that sense, social anthropologists Christopher McKevitt and Myfawny Morgan make a good point when they note that ‘[d]octors who are patients appear to represent a challenge both to the individual's own professional identity and the biomedical paradigm’.9 As the sick doctor tries to adapt to his or her new position in the medical drama, the treating physician plays a critical role.

Addicted doctors are, in a sense, the anomaly of the sick doctor taken to its extreme. In their testimonies they describe the conflict between the two different roles—doctor and patient—and the lingering stigma surrounding misuse as a diagnostic field. From a sociological perspective it could be argued that their addiction is actually dual. These doctors have become dependent on a chemical substance and have proved incapable of managing their prescription right. This probably contributes to the shame and guilt described by doctors with drug problems; in addition to misuse of drugs, it is also a misuse of the confidence provided by patients, colleagues and society at large.

Even though making the transition from doctor to patient might prove difficult, sooner or later every doctor will have to confront the crucial question ‘How do I handle my own ailments?’ Disease eventually afflicts everyone, doctors are not exempted. In that sense, the description of the sick doctor as a paradox is in itself a paradox. Illness narratives by physicians, such as those brought to light in this article, illustrate how every step in assisting a doctor as he or she becomes ill needs to take shape based on an awareness of the underlying principles of the medical drama.

Acknowledgments

The author thanks Dr Herman Holm, Kristofer Hansson and Katarina Bernhardsson for valuable comments on the manuscript.

References

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Footnotes

  • Funding This research project received grant from ‘Greta och Johan Kocks stiftelse’.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i The notion of the sick doctor as a paradox was described already 90 years ago in The Magic Mountain (1924) by Thomas Mann. In this novel Dr Behrens’s fitness to practice his profession is questioned due to his own tuberculosis. Thomas Mann writes: ‘The ailing physician remains a paradox to the average mind, a questionable phenomenon. […] He cannot face disease in clear-eyed hostility to her; he is a prejudiced party, his position is equivocal’.8

  • ii Mikhail Bulgakov's short story Morphine has been subject to several earlier text interpretations, for example, by Victoria Tischler.11

  • iii In its epistemology this article is grounded on a Ricoeurian understanding of life and identity where ‘fiction, in particular narrative fiction, is an irreducible dimension of “self-understanding”’.14

  • iv Much has changed since Parsons’s model was first presented. The behavioural rules of medicine, as well as of society at large, are different today than in the 1950s. In recent decades, several scholars of medical sociology have further elaborated Parsons’ model. Still, as a principle idea, Parsons’s notion of medical practice as a drama remains a useful metaphor to understand some of the difficulties experienced by doctors as they have to adjust to and physically embody the identity of the patient.

  • v Translation to English by Jonatan Wistrand.

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