Preventive, Lifestyle, and Personal Health Behaviors Among ...

Original Article

Preventive, Lifestyle, and Personal Health Behaviors Among Physicians Mohsen Bazargan, Ph.D., Marian Makar, M.D. Shahrzad Bazargan-Hejazi, Ph.D., Chizobam Ani, M.D., Kenneth E. Wolf, M.D. Objective: This study examines personal health behaviors and wellness, health-related lifestyles, and prevention screening practices among licensed physicians. Methods: An anonymous questionnaire was mailed to a random sample of 1,875 physicians practicing in California. Data from 763 returned questionnaires (41%) were analyzed. Results: Our data show that 7% of this sample were clinically depressed, 13% reported using sedatives or tranquilizers, over 53% reported severe to moderate stress, and only 38% described their level of daily stress as slight. About 4% self-reported recent marijuana use. More than 6% screened positive for alcohol abuse and 5% for gambling problems. Thirty-five percent of participants reported “no” or “occasional” exercise. About 27% self-reported “never” or “occasionally” eating breakfast. In addition, 34% reported 6 or fewer hours of sleep daily, while 21% self-reported working more than 60 hours per week. Physicians’ excessive number of work hours (more than 65 hours per week) was associated with lack of exercise, not eating breakfast, and sleeping fewer than 6 hours per night. California physicians report breast, cervical, colorectal, and prostate cancer screening behaviors that exceeded population estimates in California and Healthy People 2010 national goals.

P

hysicians’ personal lifestyles, habits, and health behaviors have been shown to be associated with their prevention-related counseling and screening practices with their patients (1–7). In addition, health behaviors among physicians are an important marker of how the public perceives harmful lifestyle behaviors (8, 9). Physicians with impaired physical and mental health can have a direct impact on patient health care and safety (10). Physician impairment is an emerging field of study and of interest to psychiatrists in academic settings (11). The objective of this study was to assess risky behaviors, including alcohol dependency, gambling disorder, drug abuse, and smoking; adherence to colorectal, breast, cervical, and prostate cancer screening guidelines; healthy lifestyles and behaviors, including exercise, sleep patterns, eating habits, and intake of vitamins and caffeine; and mental health and self-reported stress among licensed California physicians.

Methods

Received March 6, 2008; revised May 20 and August 4, 2008; accepted August 21, 2008. Drs. Bazargan, Makar, Ani, and Wolf are affiliated with Charles Drew University of Medicine and Science in Los Angeles; Dr. Bazargan-Hejazi is affiliated with the Department of Psychiatry at Charles Drew University and UCLA in Los Angeles. Address correspondence to Mohsen Bazargan, Charles Drew University of Medicine & Science, Research Center in Minority Institutions, 1731 East 120th St., Los Angeles, CA 90059; [email protected] (e-mail). Copyright © 2009 Academic Psychiatry

A four-page, 125-item, anonymous questionnaire with a small monetary incentive and prestamped response envelope was mailed to 1,875 randomly selected licensed physicians practicing in California. We obtained a computerized list from the California Medical Board of all licensed physicians in the state. The SPSS software (version 16.0) was used to generate a random sample from the licensing board’s list. The survey instrument was a collection of questions and validated instruments taken from various sources (12–18). In addition to demographic characteristics, the survey instruments included items designed to capture adherence to colorectal, breast, cervical, and prostate cancer screening guidelines, as well as healthy lifestyle behaviors, including exercise, sleeping and eating habits, and intake of vitamins and caffeine. Harmful alcohol drinking was measured using the Alcohol Use Disorders Identification Test (AUDIT). This

Academic Psychiatry, 33:4, July-August 2009

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Conclusion: Additional interventions designed to improve physicians’ lifestyles and personal health behaviors should be encouraged. A focus on creating healthy lifestyles will benefit physicians as much as the general population. Academic Psychiatry 2009; 33:289 –295

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PERSONAL HEALTH BEHAVIORS AMONG PHYSICIANS

10-item assessment tool has been widely used, demonstrating high sensitivity (92%) and specificity (94%) (14 – 16). Participants who score 8 or higher are classified as potentially hazardous drinkers. Gambling behavior was measured by 20 items adopted from the South Oaks Gambling Screen (SOGS) (17). The reliability of this instrument has been documented (18). Response to each item is given a score of 1 if the symptom is present, giving a possible range of 0 to 20. A score of 5 or higher is indicative of “problem gambling.” Depression was measured using the Center for Epidemiologic Studies Depression Scale (CES-D) (12). This scale measures the current level of depressive symptomatology, and its reliability and validity has been tested in the general population (coefficient ␣⫽0.80). Results Sample This study had a response rate of 40.7% (763 out of 1,875 mailed surveys were returned). For a sample size of 763, there is a 95% probability that our survey results are within plus or minus 3.6% (the margin of sampling error) of the actual population distribution for any given question. The prestamped, anonymous questionnaire does not allow an extensive comparison of responders with nonresponders. However, our sample was similar to the California Active Patient-Care Physician population with respect to gender and ethnicity (19). Men formed 75% of the sample participants, which is similar to the ratio of California Active Physicians (76%). Over 69% of the sample identified themselves as Caucasian, 18% Asian, 2.5% African American, and 4% Latino, which also closely resembled the ethnic distribution of California Active Physicians where 66%, 22%, 3%, and 4% are Caucasian, Asian, African American, and Hispanic or Latino, respectively (19). Table 1 summarizes the demographic characteristics of our sample. Lifestyle and Health Habits Lifestyle and health habits reported from our sample are displayed in Table 2. Thirty-four percent of participants reported that they get 6 hours or fewer of sleep per night, and 20.9% stated that they work 60 hours or more per week. Over 35% reported almost no or occasional exercise, while 63% of physicians claimed to engage in moderate (31%) to vigorous exercise (32%) for at least one half-hour three times per week. Over 27% reported that they never (11%) or sometimes (16%) eat breakfast. Fewer 290


than 6% claimed to be vegetarian, and 55% claimed to make a conscious effort to limit the amount of red meat in their diets, whereas 39% reported no restriction on consumption of red meat. More than half of the sample reported taking vitamin supplements/pills daily. Over 49% of our physicians have gambled for money, and close to 5% scored above the threshold for having a gambling problem. In addition, 6% were identified as having an alcohol problem. Over 4% admitted that they have used marijuana or hashish recently, and 13% admitted that they used sedatives or tranquilizers within the previous 12 months. Furthermore, 6% reported smoking tobacco products within the previous 7 days. The study found that over 28% of our sample of physicians had no family doctor, and only 52% had asymptomatic medical check-up visits. Only 7% of participants admitted to no dental examinations within the last 2 years, and almost 87% have had their cholesterol checked in the last 2 years. Of the participant physicians ages 40 and older, 82% reported having an eye examination within the last 2 years. Of women ages 40 and over, 41% had a bone density scan within the past 5 years.

TABLE 1. Demographic Characteristics of Sample (Nⴝ763) Demographic Characteristics Gender Male Female Age (meanⴞSD) ⬍40 years old 40–49 years old 50–64 years old ⱖ65 years old Ethnicity* Caucasian/white Asian/Pacific Islander Latino/Chicano/other Spanish African American/black Middle Eastern Other Marital Status* Married Never married Divorced/separated Living with someone (in marriage-like relationship) Widowed Children* Yes No

n (%) 573 (75.1) 190 (24.9) (53⫾14.6) 149 (19.5) 198 (26.0) 245 (32.1) 171 (22.4) 517 (69.3) 144 (19.3) 29 (3.9) 19 (2.5) 19 (2.5) 18 (2.4) 581 (76.9) 63 (8.3) 55 (7.3) 39 (5.1) 18 (2.4) 593 (78.5) 162 (21.5)

*Not all respondents provided answers in these categories.


BAZARGAN ET AL.

Prevention Behaviors Table 3 reports prevention screening behaviors and compares the cancer screening practices of our physician sample with a statewide sample of adults in California using the California Health Interview Survey (13). Of the participant physicians ages 50 and older, 67% reported being screened for colorectal cancer using sigmoid/ colonoscopy within the last 5 years. Among men ages 50 and older, 86% reported having had prostate cancer screening within the past 2 years. Of women ages 40 and older, 77% had a mammogram within the past 2 years, and 85% of all women physicians surveyed reported having had a pap smear for cervical cancer in the past 2 years. Self-Reported Health Status and Wellness The data show that the vast majority (84%) of the physicians participating in this study reported their health status as excellent (37%) or very good (47%) compared with only 26% of participants completing the California Health Interview Survey (13). However, the percentage of physicians meeting the diagnostic criteria for depressive disorders (7%) was similar to national estimates, at 6.6%

from the National Comorbidity Survey Replication (20). In addition, 53% of the sample reported experiencing severe or moderate levels of stress, and 38% described their level of daily stress as slight. Demographic Characteristics and Lifestyle, Health Habits, and Behaviors Our data show that the age of physicians participating in this study is associated with most variables measuring health-related lifestyles and personal health and prevention screening behaviors. Younger physicians were more likely to report working longer hours and sleeping less. They also were more likely than their older counterparts to admit smoking tobacco products, using illicit drugs, and smoking marijuana, and they were more likely to have screened positive for gambling problems compared with their older counterparts. Additionally, older physicians in our sample were more likely than their younger counterparts to adhere to guidelines for breast, prostate, and colorectal cancer screenings and to eat breakfast, exercise regularly, consume vitamin supplements, have a regular family physician, and have asymptomatic physical

TABLE 2. Health Behaviors, Health Related Lifestyle, and Risky Behaviors (Nⴝ763)* Lifestyle and Health Habits Has family doctor Asymptomatic check-ups Exercise None/occasional Moderate Vigorous Sleep in 24 hours 6 hours or fewer 7–8 hours 9 or more hours Vitamin supplements Regularly Occasionally Rarely/never Work hours per week ⱕ20 21–40 41–60 ⬎60 Coffee intake on average day None ⬍1 cup 1–2 cups 3–4 cups 5 or more cups

n (%)

Lifestyle and Health Habits

546 (71.6) 400 (52.4)

Tea intake on average day None ⬍1 cup 1–2 cups 3–4 cups 5 or more cups Eat breakfast Almost daily Sometimes Rarely or never Type of diet Vegetarian Limit red meat No restriction (red meat) Drug use** Sedatives or tranquilizers Marijuana or hashish Crack or cocaine Amphetamines/other stimulants Alcohol problem (AUDIT)*** Drinking problems Tobacco (cigarettes/cigar) Last 7 days Gambled for money Gambling problem

261 (35.4) 237 (31.1) 240 (32.5) 227 (33.7) 413 (61.4) 33 (4.9) 391 (51.3) 172 (23.0) 185 (24.7) 28 (4.2) 211 (37.1) 282 (42.8) 138 (20.9) 209 (28.0) 116 (15.5) 282 (37.8) 116 (15.5) 24 (3.1)

n (%) 433 (57.9) 160 (21.4) 131 (17.5) 19 (2.5) 5 (0.7) 544 (72.4) 122 (16.2) 85 (11.3) 42 (5.6) 412 (55.2) 293 (39.3) 100 (13.1) 30 (4.0) 5 (0.7) 3 (0.4) 43 (5.7) 46 (6.0) 370 (49.4) 32 (4.3)

*Not all respondents provided answers to all questions; some data missing. **Within last 12 months. ***Alcohol Use Disorders Identification Test (AUDIT) score ⬎7.



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check-up visits. However, younger women physicians were more likely to follow guidelines for cervical cancer screenings than older women physicians. Only five variables measuring health-related lifestyles, personal health behaviors, and prevention screening behaviors showed a significant association with gender. Female physicians were more likely to have asymptomatic check-up visits and less likely to use sedatives than male physicians. Interestingly, although male physicians were more likely to smoke and score positive in gambling problems, they were also more likely to exercise than their female counterparts. African-American and Latino physician participation in this study, although consistent with the physician demographic data of the state (18), was too small to allow for a statistically meaningful comparison among all ethnic groups. However, reducing the ethnic groups to three major categories, including Caucasians (n⫽517), Asians (n⫽144), and all others (African Americans, Latinos, etc., n⫽85), allows us to detect interesting differences. White physicians in our sample were more likely to report exercising and eating breakfast regularly, sleeping more than 6 hours per day, using vitamin supplements, and having asymptomatic check-up visits, compared with Asian and other minority physicians. However, Asian physicians in our sample were least likely to report problems with alcohol.

associations between weekly working hours and personal health behaviors, lifestyle, and adherence to cancer screening recommendations, adjusting for age, gender, and marital status. The force entry method (21) was employed, in that all of the covariates were placed into the regression model in one block. Table 4 summarizes the results of 13 separate logistic regression equations. Working 40 hours or fewer is the referent group for each logistic regression equation. For example, the first equation shows that, controlling for age, gender, and marital status, working hours per week is not significantly associated with colorectal cancer screening behavior [OR⫽1.1 (CI⫽0.6 –2.0); OR⫽1.6 (CI⫽0.7–3.6)]. Table 4 shows that only four of the habits/behaviors (eating breakfast, hours slept in a 24-hour period, exercising regularly, and level of stress) are significantly associated with working hours per week. Controlling for age, gender, and marital status, those who worked more than 65 hours per week were two times less likely to routinely exercise, seven times less likely to sleep more than 6 hours, and four times less likely to eat breakfast than their counterparts who worked 40 hours or less. Additionally, those who worked more than 65 hours per week were 3.3 times more likely and those who worked between 40 and 64 hours were 2.0 times more likely than their counterparts who worked less than 40 hours to describe their daily level of stress as severe. Discussion

Excessive Number of Work Hours and Lifestyle, Prevention, and Health Behaviors Multiple logistic regression analysis was performed to calculate odds ratios and 95% confidence intervals (CI) for

Our data provide evidence that although most of the lifestyle habits, preventive screenings, and health-related behaviors of California physicians are exemplary, others

TABLE 3. Cancer Screening Behaviors of Physician and California Residents Frequency and Percentage* Physician Sample

CHIS Variables Sigmoidoscopy/colonoscopy screening

Prostate screening

Cervical screening (pap smear) Breast cancer screening (mammogram)

Categories

n

%

n

%

p

Never ⬍5 years ⬎5 years Never ⬍2 years ⬎2 years ⬎2 years ⬍2 years ⬎2 years ⬍2 years

7,605 5,487 5,092 1,089 4,028 625 4,669 17,250 7495 13,598

41.8 30.2 28.0 19.0 70.1 10.9 21.3 78.7 35.5 64.5

78 240 40 17 312 32 28 162 27 90

21.8 67.0 11.2 4.5 86.4 8.9 14.7 85.3 23.1 76.9

⬍0.01 ⬍0.01 ⬍0.05 ⬍0.05

CHIS⫽California Health Interview Survey, 2003 (13) *Only insured CHIS data values represented in tables

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BAZARGAN ET AL. TABLE 4. Adjusted Odd Ratios and 95% Confidence Interval (CI) Comparisons Work Hours Per Week1 Dependent variables (lifestyle, habits, and screening behaviors) Sigmoidoscopy or colonoscopy within last 5 years Prostate screening within last 2 years Cervical screening (pap smear within last 2 years) Breast cancer screening (mammography) Exercise (not regularly) Sleep in 24 hours (less than 6 hours) Breakfast (not having regularly) Alcohol problem (AUDIT) Use of sedatives/tranquilizers Smoking habits Level of stress Asymptomatic check-ups Use of vitamin supplements (used regularly)

40–64 hours OR (95% CI)

>65 hours OR (95% CI)

1.6 (0.7–3.6) 2.0 (0.7–6.1) 0.3 (0.2–9.0) 1.2 (0.2–7.2) 1.5 (1.2–3.1)* 3.0 (1.9–4.6)*** 1.9 (1.3–2.9)*** 0.6 (0.3–1.6) 0.9 (0.5–1.9) 3.1 (0.9–9.6) 2.0 (1.4–3.0)*** 0.8 (0.5–1.3) 1.1 (0.6–1.7)

1.1 (0.6–2.0) 1.4 (0.6–3.1) 0.5 (0.2–1.7) 1.5 (0.5–4.2) 1.8 (1.1–2.6)** 7.2 (4.1–12.8)*** 4.0 (2.3–6.9)*** 0.4 (0.2–1.1) 0.9 (0.5–1.5) 2.7 (1.0–7.5) 3.3 (2.0–5.4)*** 0.7 (0.5–1.1) 0.9 (0.6–1.4)

Reference group ⬍40 work hours per week. Each row shows the impact of working hours on the dependent variable, controlling for age, gender, and marital status. For example, working hours per week is significantly associated with self-rated level of daily stress, in that those who worked ⬎65 hours per week and those who worked between 40 and 64 hours were 3.3 and 2.0 times more likely, respectively, to describe their daily level of stress as more severe than were their counterparts who worked ⬍40 hours. OR⫽adjusted odd ratio (controlling for age, gender, and marital status); AUDIT⫽Alcohol Use Disorders Identification Test *p⬍0.05; **p⬍0.01; ***p⬍0.001 1

remain comparable with those of the general population. For example, our data prove that physicians who participated in this study were more likely than the general population, adults with health care coverage, or those with higher education to adhere to recommended guidelines for colorectal, breast, cervical, and prostate cancer screenings. In addition, unlike the general population and even individuals with health care coverage, physicians who participated in this study reported behaviors that exceeded Healthy People 2010 national goals for breast, cervical, and colorectal cancer screenings (22). More than 35% of our sample reported not exercising at all or getting only occasional exercise. This rate is slightly higher than the National United States survey (Behavioral Risk Factor Surveillance System), which showed that 26% of adults reported no moderate or vigorous activity in a usual week (23). One out of three physicians reported having 6 or fewer hours of sleep per night. Moreover, 27% claimed that they never (11%) or sometimes (16%) eat breakfast. Seventy-three percent of physicians—slightly less than the adult U.S. population— eat breakfast regularly. The third National Health and Nutrition Examination Survey (NHANES III) shows that 77% of adults consume breakfast on any given day (24). Over 60% of our sample reported working more than 40 hours per week. One out of five physicians participating in

our study worked more than 60 hours per week. Physicians in our sample reported working on average 10 hours more than the general population surveyed in the California Health Interview Survey (13). Our data document that, controlling for demographic variables, most routine activities (e.g., exercise, eating breakfast, and sleeping) were related to working hours. In addition, excessive work hours (ⱖ65 hours per week) were associated with selfreported daily levels of stress. It is well established that excessive work hours continue to seriously endanger both physicians and their patients (25–29). Although the implementation of restricted work hours from the Accreditation Council for Graduate Medical Education appears to have led to fewer errors among residents in training (30), currently no restrictions are imposed on nontraining physicians’ work hours. Seven percent of this sample was clinically depressed, 13% reported using sedatives or tranquilizers, and over 53% reported severe to moderate stress. Feeling “anxious” or “stressed” is common among physicians (31); yet, negative mood has been shown to impact doctors’ ability to be empathetic with patients (32). A recent study that examines the prevalence of health-promoting and health-risking behaviors among physicians and physicians-in-training reports that 74% of a sample of 963 medical students, residents, or attending physicians reported these feelings



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“more than rarely” (31). Other studies that have investigated the psychological well-being of physicians have suggested that mood disorders and mental health-seeking behavior among medical students, residents, and attending physicians need additional investigation (11, 31, 33–37). Our findings indicate that a vast majority of California physicians’ lifestyles, habits, preventive screenings, and health-related behaviors are exemplary. But desired health behaviors were not observed in a small proportion of physicians. For example, 6% of our sample screened positive for having alcohol and 5% for gambling problems; another 6% and 4% admitted using marijuana and tobacco products, respectively. These percentages translate to 3,500 to 5,000 physicians who are providing care to an estimated more than 1 million patients in California (38). Physicians know best how to live healthfully, but physicians themselves also may fail to abide by the guidelines that they provide for others. The ancient maxim medice, cura te ipsum applies today to numbers that cannot be ignored. Therefore, motivational interventions, such as seminars and workshops, are recommended and should have the direct aim of encouraging physicians to avoid risky behaviors and seek professional help for substance abuse and gambling addictions. Additionally, physicians must have the opportunity to seek confidential mental health treatment so as to maximize their optimal functioning in an effort to prevent impairment (39). Interventions should encourage the use of a primary care physician among all physicians, because 28% of our sample did not have a family doctor. A focus on creating healthy lifestyles will benefit physicians as much as the general population (31, 40, 41). These results are not without limitations. First, this study is based on self-report, where responses regarding socially undesirable behaviors may be understated. Second, the response rate is below 50%; however, this response rate is similar to other studies conducted among physicians (1, 3, 31, 42). Third, although our sample closely reflects the ethnic distribution of California physicians, the number of women and particularly AfricanAmerican and Hispanic/Latino respondents in our sample limits the generalizability of the study. Fourth, these data are cross-sectional and limit our ability to make causal inference among health-related lifestyle, preventive behaviors, and mental health or health-risking behaviors. Finally, further extension of this study should examine the impact of type of practice and specialty on outcome measures. 294


At the time of submission, the authors disclosed no competing interests.

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