Abstract
The degree to which osteopathic physicians (DOs) take care of their own health is of interest not only to the osteopathic medical community, but also to physicians' patients. The American Osteopathic Association (AOA) Committee on Physician Health asked attendees at the July 2001 AOA House of Delegates Annual Business Meeting in Chicago, Ill, to complete a one-page survey on their personal health practices. This survey comprised 22 questions on such items as vacation and personal time, exercise habits, weight control, tobacco and alcohol use, and regular physical examinations and medical screening. Two hundred ninety-nine attendees completed the survey during the 15 minutes immediately after the report of the Committee on Physician Health (response rate: ∼75%). The results indicate that DOs are similar to the proverbial patient in terms of personal health practices. Although DOs follow some physicians' orders, they do not follow others. Most DOs take regular vacations and daily personal time, and they get some of their recommended physical examinations and medical screenings. The authors suggest that DOs pay greater attention to their exercise habits, weight control, and signs of substance abuse.
Previous research has suggested that physicians are an important group to study regarding personal health-related beliefs and behaviors.
1 Patients, of course, look to their physicians for health advice and medical care. Gross and coinvestigators
1 found that physicians' own health habits influence the preventive health counseling they provide to their patients. Physicians are also an excellent group to study for healthcare habits because they generally have access to high-quality medical care, as well as higher-than-average education and economic status—eliminating factors that are known barriers in access to healthcare.
Indeed, various studies
2,3 have shown how physician lifestyle and physician health are linked. In a survey of 1040 family practice physicians in Sweden, Sundquist and Johansson
2 found that physicians with high job strain (ie, low control of their work environments and high work demand) exhibited a more than threefold increase in risk of impaired general health, compared with physicians with medium job strain. Among male physicians, low job strain was associated with low risk of impaired health.
2 These findings highlight the need for vigilance on physicians' working conditions.
In a survey of 298 primary care physicians in the United States, Abramson and coauthors
3 found that physicians who regularly exercise are more likely to counsel their patients to exercise––sharing the knowledge that regular physical activity can reduce the incidence and prevalence of many chronic diseases. The authors determined that inadequate time with patients and limited physician knowledge and experience regarding exercise are the most common barriers to effective patient counseling.
3
Gross and coauthors
1 reported that a physician's specialty may influence his or her approach to patient care and personal use of preventive health services. In this analysis, a cohort of 915 physicians was surveyed to determine if they had a regular source of care (RSOC).
1 The results of the analysis showed that 312 (34%) of the surveyed physicians had no RSOC, and 60 physicians (7%) reported treating themselves.
1 When compared with pediatricians and psychiatrists, internists (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.58-6.74), pathologists (OR, 5.46; 95% CI, 2.09-14.29), and surgeons (OR, 2.42; 95% CI, 1.17-5.02) were significantly more likely not to have an RSOC.
1 Earlier studies
4 also demonstrated that physicians with poor personal health practices, such as tobacco or alcohol use and lack of exercise and seat belt use, are less likely to provide counsel to their patients about those health practices.
The osteopathic medical profession has long recognized the importance of physician health. The American Osteopathic Association (AOA) established the Committee on Impaired Physicians in 1987, primarily to aid osteopathic physicians (DOs) in dealing with issues related to chemical and alcohol dependence and mental and personal conflict (Resolution 61 [M/1988]—Statement of Purpose of the AOA Committee on Impaired Physicians). In 1999, the AOA renamed this committee the Committee on Physician Health and expanded its responsibilities to include all aspects of physician health, including personal health practices and lifestyle (Resolution 18 [A/1998]—Change of Name of Committee on Impaired Physicians to Committee on Physician Health). The expansion of the committee's duties was based on the belief that threats to DOs' health include not only behaviors such as tobacco and alcohol use, but also lifestyle issues such as job stress, vacations, and amount of personal time (Resolution 18 [A/1998]—Change of Name of Committee on Impaired Physicians to Committee on Physician Health).
In the early 1990s, John C. Licciardone, DO, MBA, and Robert D. Hagan, DO,
5 analyzed the physical fitness levels of first-year osteopathic medical students, concluding that a “greater emphasis on health promotion in the medical curriculum may help students to adopt more healthy behaviors and, in addition, encourage them to provide preventive medical counseling to their patients.” In the same issue of
JAOA—The Journal of the American Osteopathic Association, then–AOA Editor in Chief Thomas W. Allen, DO,
6 made the following assertion:
The November 1999 issue of
The DO included an article titled “Practice what you preach: DOs need to apply preventive medicine to their own lives,”
7 which emphasized the importance of DOs taking care of their own health. The article quoted Richard B. Tancer, DO,
7 a then-member of the AOA Committee on Physician Health, who noted the following:
That same issue of
The DO also noted the importance of osteopathic medical students tending to their own health.
8
In 2002, Ronald R. Gaber, EdS, and Daniel M. Martin, MA,
9 reviewed the Still-Well osteopathic medical student wellness program at A.T. Still University-Kirksville (Mo) College of Osteopathic Medicine, emphasizing that practicing proper health maintenance is integral to osteopathic medicine and medical education. The article noted that the Still-Well program's theme of “I am my own first patient” emphasizes healthy behaviors and physical exercise for osteopathic medical students and DOs.
9 Gaber and Martin
9 pointed out, “Little is known about students' lifestyle commitment to healthy behaviors. Despite this lack of information, physicians will often be responsible for their patients' attitudes regarding lifestyle and health.”
Most recently, 2007-2008 AOA President Peter B. Ajluni, DO,
10,11 announced that his “presidency [would be] focused...on health and fitness.” The theme for his three-point initiative is “DOs: Fit for Life”:
To evaluate how well DOs protect their own health, the AOA Committee on Physician Health developed a self-administered questionnaire about physicians' personal health behaviors.
12 The committee created this survey instrument with technical assistance from the University of Illinois at Chicago Survey Research Laboratory and School of Public Health. The survey consisted of 22 items, including questions about lifestyle, health-related behaviors, and health-promoting actions. The questionnaire also requested basic demographic data, including information on practice characteristics.
To encourage a high response rate, the questionnaire was distributed to all attendees at the July 2001 AOA House of Delegates Annual Business Meeting in Chicago, Ill, during the report of the Committee on Physician Health. Participants were given approximately 15 minutes to complete the survey after the presentation of the committee's report. The data were coded and analyzed using SPSS statistical software (versions 13.0 and 14.0; SPSS Inc, Chicago, Ill) for both univariate and multivariate analyses.
Two hundred ninety-nine DOs participated in the AOA Committee on Physician Health Survey—approximately three-fourths of the DOs present at the July 2001 AOA House of Delegates Annual Business Meeting. However, because not all participants responded to every survey question, the sample size for many items is less than 299. Sample size also varies for survey items within reported characteristics for the same reason.
The present article first outlines general trends that were observed. Then, important differences in health behaviors are noted according to demographic and practice characteristics. Finally, patterns of health behaviors among survey respondents are analyzed.
Participants represented a cross-section of the osteopathic medical community in terms of age, sex, practice location, medical specialty, and practice characteristics (
Table 1). Forty-eight survey participants (16%) were younger than 40 years, 110 (37%) were between 40 and 49 years, 85 (28%) were between 50 and 59 years, and 54 (18%) were aged 60 years or older. Two hundred forty DOs (80%) were men; 57 (19%) were women.
One hundred four survey participants (35%) practiced in cities, 123 (41%) in suburban areas, 33 (11%) in small towns, and 37 (12%) in rural areas. Two hundred two DOs (68%) reported their medical specialty as primary care. Two hundred twenty-seven participants (76%) worked in patient care, 31 (10%) in teaching or research, 10 (3%) were retired, and 26 (9%) were engaged in other medical activities. Ninety-five DOs (32%) were in solo practice, 137 (46%) practiced medicine in partnerships or groups, and 50 (17%) practiced in other settings.
Although DOs tend to take vacations regularly, they are much less likely to fulfill other dimensions of a healthy lifestyle (Figure). Two hundred sixty-seven survey participants (90%) reported taking annual vacations, but only 147 (50%) scheduled daily personal time. Only 152 participants (51%) exercised regularly, and 166 DOs (56%) were more than 10% over their recommended body weight.
Although practice characteristics and age had some effect on these lifestyle items, we cannot report, based on the survey results, that any specific category of DO consistently leads a healthier lifestyle than any other category of DO (
Table 2). Nevertheless, DOs in teaching and research (24 of 31 [77%]) were significantly less likely than other DOs (239 of 263 [91%]) to take annual vacations (χ
2=5.505,
P<.019). Osteopathic physicians in solo practice (38 of 95 [40%]) were significantly less likely than other DOs (106 of 189 [56%]) to exercise regularly (χ
2=6.144,
P<.013). Similarly, DOs practicing medicine in suburban settings (53 of 123 [43%]) were significantly less likely than other DOs (99 of 174 [57%]) to exercise regularly (χ
2=5.398,
P<.019).
Osteopathic physicians younger than 40 years (39 of 48 [81%]) were significantly less likely than other DOs (227 of 249 [91%]) to take annual vacations (χ
2=4.232,
P<.040), and DOs younger than 50 years (65 of 157 [41%]) were less likely than other DOs (81 of 139 [58%]) to schedule daily personal time (χ
2=8.397,
P<.004) (
Table 2). Osteopathic physicians younger than 50 years (78 of 157 [50%]) were significantly less likely than older DOs (88 of 139 [63%]) to be overweight (χ
2=5.559,
P<.018). This weight correlation was especially true for DOs younger than 40 years (25%), compared with older DOs (63%) (χ
2=22.470,
P<.001).
Only 20 participating DOs (7%) reported using tobacco, and only 57 (19%) reported consuming “more than 2 ounces of spirits, 8 ounces of wine, or 24 ounces of beer in a single day, more than once a week” (
Table 2). Allowing for an average underreporting rate of about 13% for self-reported tobacco use
13—and assuming the same rate of underreporting for alcohol consumption—we estimate that approximately 8% of DOs use tobacco and 21% consume more than the recommended amount of alcohol.
Demographic and practice characteristics, including age, sex, and practice location and type, showed no significant relationship with either tobacco use or alcohol consumption.
Data from AOA Committee on Physician Health Survey indicate that DOs obtain some of the commonly recommended physical examinations and medical screenings (
Table 2). Two hundred forty-four participants (82%) reported having their blood cholesterol levels and blood pressure tested during the previous year. Osteopathic physicians in primary care (172 of 202 [85%]) were significantly more likely than DOs in other specialties (50 of 70 [71%]) to have taken these tests (χ
2=7.549,
P<.006). In addition, DOs older than 40 years (214 of 249 [86%]) were much more likely than DOs younger than 40 years (29 of 48 [60%]) to have their blood cholesterol and blood pressure checked (χ
2=17.628,
P<.001).
In addition, survey results revealed that many DOs have been getting physical examinations regularly. Ninety-nine of 149 survey respondents (66%) younger than 50 years reported that they had a physical examination within the previous 3 years. Among male DOs older than 50 years, 89 of 116 (77%) had an annual prostate examination, and 49 of 115 (43%) had a colonoscopy at age 50. Among the 15 female DOs older than 50 years, 11 had an annual Papanicolaou smear, 11 also had an annual mammogram and breast examination, and 10 had dual-energy x-ray absorptiometry within the previous 3 years.
In contrast to these encouraging findings, the survey revealed that only 43 of 114 (38%) male DOs older than 50 years obtained a colonoscopy at age 50 and had a prostate examination every year thereafter. Likewise, only 6 of 15 female DOs older than 50 years had an annual Papanicolaou smear, an annual mammogram, and dual-energy x-ray absorptiometry within the previous 3 years.
Many health behaviors analyzed in the present study, such as tobacco use and alcohol consumption, have frequently been correlated.
14 Therefore, examining such behaviors together can provide more useful information than examining them separately. Exploratory factor analysis is a statistical method for identifying constellations (ie, sets) of correlated behaviors, called
factors, that occur together.
A single behavior can be its own factor if it correlates with no other behavior. The data derived from the health behavior questions in the AOA Committee on Physician Health Survey were subjected to an exploratory factor analysis using the varimax rotation option of SPSS version 14.0 (SPSS Inc, Chicago, Ill). This analysis uncovered four constellations of correlated behaviors (ie, factors) among the participants in the survey (
Table 3). This is an important finding by itself, because, if DOs lived completely healthy lives, all health behaviors would be correlated, with the resulting expectation that there would be only one factor. In the present study, all factors had at least two related variables:
Various personal characteristics of survey participants, such as age, sex, and practice type, that affected each of these factors are as follows:
Although the findings of the present investigation are important and useful for determining the overall health of DOs and improving patient education, it should be kept in mind that these results are based on the self-reports of a convenience sample––rather than on verified data from a random sample. In addition, members of the AOA House of Delegates tend to be older, are more likely to be male, and more likely to work in patient care and solo practice than the general DO population.
15 For these reasons, the results of this survey cannot be generalized to all DOs. Nevertheless, the surveyed sample is diverse, and members of the AOA House of Delegates are among the “elites” of the osteopathic medical profession. Therefore, these survey participants would probably be more aware of the importance of concepts involved in “good health” than most other DOs. The general findings and policy implications for the results of the AOA Committee on Physician Health Survey raise serious issues for the entire osteopathic medical profession.
In terms of their personal health behaviors, DOs resemble the stereotypical patient. They are healthy overall, and they carry out some physician instructions—but not others. Losing weight and getting more exercise, in particular, are two areas in which DOs need to “walk the talk” and follow the advice they give to patients regarding making consistently healthy lifestyle choices. Controlling weight and getting regular exercise are problems for DOs regardless of age, sex, or practice type. Some DOs also need to address their regular use of tobacco and alcohol.
Osteopathic physicians cannot credibly attribute their shortcomings in personal healthcare to such commonly cited reasons as practicing in a solo setting, working in a rural area, or special gender-related pressures. The results of the AOA Committee on Physician Health Survey indicate that it is possible for DOs of both sexes and those who are in solo practices or practices in rural areas to lead healthy lifestyles.
An often overlooked health risk factor for all physicians is their treatment of themselves. Canadian physician Sir William Osler
16 wrote, “The physician who treats himself has a fool for a patient.” Previous studies have demonstrated that between 42% and 82% of physicians administer healthcare to themselves in some manner.
17 We urge the AOA to conduct additional studies to determine the prevalence of “self-doctoring” throughout the osteopathic medical profession and to examine other aspects of DOs as patients.
Physicians teach patients by example as much as by their words. Physicians who ignore their own health encourage their patients to do likewise. Physicians who convince themselves that they are “too busy” to be healthy forget that almost everyone nowadays faces increased job pressures, extended workdays and workweeks, and greater demands on time. Data from the AOA Committee on Physician Health Survey reveal that DOs need to perform careful self-evaluations of many aspects of their personal health.