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105Editorial S W I S S M E D W K LY 2 0 0 7 ;1 3 7 : 1 05 1 0 6 w w w . s mw . ch

Self-treatment and self-medicationby Swiss primary care physicians:

a cause for concern?Matthias Schwenkglenks

Why should a carpenter not make his ownfurniture? At first glance, the idea of physicianslooking after their own health appears natural.

At second glance, however, questions arise. If weconsider severe, chronic and mental conditions,

where do we set the limits to self-treatment? Doesself-treatment and self-medication have a measur-able impact, positive or negative, on a physicians

well-being? Do physicians differ from the generalpopulation, or from comparable subgroups in thepopulation, in terms of their subjective or objec-tive health status, use of health care resources, oruse of screening and preventive services? If the an-swer to any of these questions is yes, what causalmechanisms are active in the background? Is there

a need for corrective action, and if so, what formmight this take? Physicians are far from forming anegligible fraction of the entire population, and sothis set of topics is clearly relevant from the per-spective of occupational medicine and publichealth. Taking the public health argument further,

we may even need to enquire whether impairedhealth among physicians may have a negative im-pact on the quality of the health services providedto the population as a whole.

However, before these questions can be appro-priately addressed a sound, empirically-based de-

scription of the underlying facts is indispensable.To date, no such data has been available forSwitzerland. In the present issue of SMW this gapis partly filled by Schneider and colleagues, whoreport findings from a mailed survey on medicalcare and pharmaceutical drug use among Swiss pri-mary care physicians. With its focus on self-treat-ment, self-medication and potential over-medica-tion, the article raises a number of questions.

The findings that physician self-treatment andself-medication are very frequent, and that manyphysicians avoid seeking the help of other physi-cians when health problems arise, are in line withexpectations and reports from several countries[14]. They can hardly be questioned. However,the authors conclusion regarding increased use ofmedication among Swiss physicians appears onlypartly meaningful, and the connotation of in-creased use of problematic drugs such as anal-

gesics and tranquillisers I find a matter for concern.Data from the Swiss Health Survey representativeof the Swiss population aged 15 or over (with noupper limit), were used as the comparator whenthese points were established. Would it not havebeen more appropriate to compare the physiciansample with a subpopulation showing a moreclosely matched age distribution and perhaps alsomore closely matched levels of education and job-related stress? Considering that the drug cate-gories compared were not entirely equivalent andthat some of the differences in observed use ofmedication were rather moderate, any relevantconclusions should be drawn with great caution,even though similar findings have been published

for France and Norway [5, 6].As the authors report, the use of analgesics,

benzodiazepines and antidepressants was more,not less, frequent among those physicians whosought help from other physicians, which contra-dicts the notion of overuse induced by self-med-ication. (Why was consultation of other health careproviders not used as a potential predictor in themultivariate regression analysis of medication use?

And, as an aside, how would the regression resultshave looked if clearly non-significant predictorshad been eliminated?)

A link between the observed level of drug con-sumption and psychological distress in an evermore complex health system environment is es-tablished, but the regression results do not showincreased use of analgesics, tranquillisers or anti-depressants in physicians with lower work-relatedsatisfaction or higher perceived stress (althoughthere is a relatively clear association betweenmedication use and lower self-perceived mentalhealth). Those with higher perceived stress andlower self-perceived mental health were less, notmore, likely to use self-medication.

Some of the reported regression-based find-ings can even be interpreted as confirmation ofrational behaviour: many female physicians saw agynaecologist; older physicians were more likelyto visit any health professional; physicians livingalone were more likely to see a mental healthspecialist, etc.

ECPM Research, University of Basel, Basel, Switzerland

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Self-treatment and self-medication by Swiss primary care physicians: a cause for concern? 106

The descriptive data presented by the authorsare highly important and make clear that the situ-ation in Switzerland is roughly similar to what weknow from other Western countries. Further stud-ies would be needed to confirm negative effectsfrom physician self-treatment and self-medica-tion. While the authors fully acknowledge this lackof evidence, a negative picture of self-medication

nevertheless emerges, partly based on common-sense or normative arguments.

In consequence, should we, or should we not,now be concerned about Swiss physicians lookingafter their own health? As a non-physician perhaps

viewing the matter at some remove, my position isthat we should not be concerned about physiciansself-treating trivial conditions. This may indeedbe highly cost-effective from the viewpoint ofhealth economics. On the other hand, we must ofcourse be concerned where more serious condi-tions are involved. Some of the commonsense and

normative arguments put forward by Schneiderand colleagues are judicious, e.g. that lack of dis-tance may be a substantial barrier to effective self-treatment and that there are clear (but not easilydefinable) limits where severe illness and mentalhealth problems are involved. It is consistent withthese arguments that studies from other countrieshave found inappropriate self-referral behaviour[1], different perceptions (partly depending on thephysicians speciality) of acceptable limits to self-treatment [3], and barriers to rational health be-haviour due to physicians high expectations con-

cerning their own effectiveness (partly acquiredduring training) and culture-specific perceptionsand connotations of the physicians role [79]. Thenotion that work-related stress has increased inrecent decades is commonplace but neverthelesstrue, for physicians as well as other professionals.

Within the medical profession, primary care

physicians may be most affected by situations ofeffort-reward imbalance.

In the light of these arguments we shouldinterpret the points brought out by Schneider andcolleagues as important questions which are ad-mittedly difficult to answer empirically. Long-term prospective cohort or case-cohort designsmeasuring attitudes and resource use patterns as

well as health outcomes would perhaps be a suit-able means of addressing the impact of self-treat-ment. However, apart from the financial andadministrative effort involved, the participantsbehaviour may be influenced by the study situa-tion. Moreover, the results may only be valid for asingle generation of physicians and not for futuregenerations with different attitudes. At the otherend of the spectrum, retrospective study designs

would require much less time and effort but wouldbe likely to suffer from limited data availability,recall bias and related problems. Given these dif-

ficulties, creative approaches are required. Wouldit be thinkable to base careful, tentative correctiveaction on current knowledge and commonsensearguments, and to accompany it by appropriate,controlled evaluation studies? It might be easier tomeasure the impact of intervention than to mea-sure the impact of physician self-treatment andself-medication considered in isolation.

Correspondence:Matthias Schwenkglenks, PhD MPHECPM Researchc/o ECPM Executive OfficeUniversity HospitalCH-4031 Basel

E-Mail: m.schwenkglenks@unibas.ch

References

1 Chambers R, Belcher J. Self-reported health care over the past

10 years: a survey of general practitioners. Br J Gen Pract. 1992;42(357):1536.

2 Christie JD, Rosen IM, Bellini LM, Inglesby TV, Lindsay J, AlperA, et al. Prescription drug use and self-prescription among resi-dent physicians. JAMA 1998;280(14):12535.

3 Davidson SK, Schattner PL. Doctors health-seeking behaviour:a questionnaire survey. Med J Aust 2003;179(6):3025.

4 Hem E, Stokke G, Tyssen R, Gronvold NT, Vaglum P, EkebergO. Self-prescribing among young Norwegian doctors: a nine-

year follow-up study of a nationwide sample. BMC Med. 2005;3:16.

5 Verger P, Aulagnier M, Protopopescu C, Villani P, Gourrheux JC,Bouvenot G, et al. Hypnotic and tranquillizer use among generalpractitioners in south-eastern France and its relation to occupa-tional characteristics and prescribing habits. Fundam Clin Phar-macol. 2004;18(3):37985.

6 Rosvold EO, Vaglum P, Moum T. Use of minor tranquilizers

among Norwegian physicians. A nation-wide comparative study.Soc Sci Med. 1998;46(45):58190.

7 Rogers T. Barriers to the doctor as patient role. A cultural con-struct. Aust Fam Physician. 1998;27(11):100913.

8 Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T.Challenge of culture, conscience, and contract to general practi-tioners care of their own health: qualitative study. BMJ. 2001;323(7315):72831.

9 Rockenbauch K, Meister U, Schmutzer G, Alfermann D. Alumniof medical sciences and their life satisfaction. Gesundheitswesen.2006;68(3):17684.

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