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From the Touro University College of Osteopathic Medicine in Vallejo, Calif (Drs McNerney and Blackwell) and the American Osteopathic Association (AOA) Division of Applied Research (Dr Andes).

Address correspondence to Steven Andes, PhD, CPA, AOA Division of Applied Research, 142 E Ontario St, Chicago, IL 60611-2864. E-mail: sandes{at}osteopathic.org

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.

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 Johansson² 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 coauthors³ 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 coauthors¹ 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 studies⁴ 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:

We have learned that role modeling has a very powerful effect on others. We physicians can, and do, play a significant part in teaching our patients healthy lifestyle behaviors. A physically fit physician sets expectations for patients. Can we not expect, then, the role modeling effect to be positive?

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:

[Osteopathic physicians] need to remember the osteopathic medical tenet that health requires wellness of the body, the mind and the spirit. And DOs need to remind themselves that osteopathic principles apply to them as well as their patients.

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 Martin⁹ 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":

1. Bringing the same sense of commitment [DOs] have to serving patients to serving [themselves].
   
2. Striving to keep the AOA and our state societies and specialty colleges fiscally fit organizations.
   
3. Ensuring our nation's [healthcare] delivery system is healthy. We must reform the dangerously flawed system currently in place if we truly want our nation to be fit.¹⁰
   

	Methods

Top Methods Results Comment Conclusions References

 
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.

	Results

Top Methods Results Comment Conclusions References

 
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.

Respondent Characteristics
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.

Lifestyle Choices
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 (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 (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 (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 (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 (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 (²=5.559, P<.018). This weight correlation was especially true for DOs younger than 40 years (25%), compared with older DOs (63%) (²=22.470, P<.001).

Risky Behaviors
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 use¹³—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.

View larger version (21K): [in this window] [in a new window]   Figure. Percentages of osteopathic physicians who reported engaging in various health-related behaviors in a survey of osteopathic physicians developed by the American Osteopathic Association (AOA) Committee on Physician Health and distributed to attendees at the July 2001 AOA House of Delegates Annual Business Meeting in Chicago, Ill (N=299). *Regular exercise was defined as 30 minutes of physical activity three or more times per week. Regular alcohol consumption was defined as "more than 2 ounces of spirits, 8 ounces of wine, or 24 ounces of beer in a single day, more than once a week." All survey participants were asked if they had their cholesterol level and blood pressure checked in the past year. Participants younger than 50 years were asked if they had received a physical examination in the past 3 years. All other survey questions regarding physical examinations and basic medical screening were age-dependent. Men older than 50 years were asked if they had a colonoscopy at age 50, while women in this age group were asked if they had received a bone density test (dual-energy x-ray absorptiometry or DXA) in the past 3 years.

Demographic and practice characteristics, including age, sex, and practice location and type, showed no significant relationship with either tobacco use or alcohol consumption.

Physical Examinations and Medical Screenings
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 (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 (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.

Patterns of Health Behaviors
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:

• Lifestyle—taking an annual vacation, which was analyzed independently as its own factor, scheduling daily personal time, and exercising regularly (ie, physical activity for 30 minutes or more at least three times a week)
  
• Risky behavior—no tobacco use and low alcohol consumption
  
• Physical examination and medical screening—physical examination within the previous 3 years (if younger than 50 years) and tests of blood cholesterol levels and blood pressure within the previous year
  

Various personal characteristics of survey participants, such as age, sex, and practice type, that affected each of these factors are as follows:

• Lifestyle—Considering all the demographic and practice variables together indicated that DOs were most likely to take an annual vacation if any of the following characteristics applied to them: they did not work in patient care; they practiced in a group setting; or they were unmarried. The importance of practicing in a group for taking annual vacations applied especially to DOs who worked in patient care.
  In addition, four characteristics of participants had substantial effects on the remaining characteristics in this factor: practice type, practice location, retired status, and physician age. A multivariate analysis, which was used to analyze these four characteristics simultaneously, presented a more complete picture of which DOs were most likely to achieve a healthy lifestyle of daily personal time and regular exercise. They were DOs practicing in a suburban area, retired DOs, and DOs between the ages of 60 and 65 years. Osteopathic physicians who retire before age 65 years are most likely to exercise regularly and schedule daily personal time. Unexpectedly, DOs older than 65 years and younger than 40 years scored lower on this lifestyle factor than did DOs of other age groups. These findings suggest that neither age nor retired status alone lead to the healthy lifestyle behaviors of personal time and exercise.
  
• Risky behavior—Results of our survey suggested that women were less inclined to use tobacco and consume alcohol, though this finding just missed the level of statistical significance (P=.051). The same patterns hold for the risky behavior factor as they do for the individual variables within that factor. A multivariate analysis did not reveal any indirect patterns between these behaviors and any other demographic or practice variables in the survey. Thus, it appears that smoking and drinking are very much individual choices by DOs, rather than behaviors that are strongly influenced by other characteristics under investigation in this survey.
  
• Physical examination and medical screening—The percentage of DOs who had their blood cholesterol and blood pressure tested in the previous year did not differ according to any of the analyzed demographic variables. However, when all the demographic variables were used to predict this factor, three characteristics of participants were found to be the most important: physician age, practice type, and practice location. Further statistical analysis indicated that DOs were most likely to receive regular physical examinations and medical screenings if they were younger, practiced in a group setting, and worked in either a suburban or rural area.
  

	Comment

Top Methods Results Comment Conclusions References

 
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.

	Conclusions

Top Methods Results Comment Conclusions References

 
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 Osler¹⁶ 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.

	Footnotes

 
At the time of the survey, Dr McNerney was chairman of the AOA Committee on Physician Health. Currently, Dr McNerney is a member of the AOA Bureau of Osteopathic Education, chairman of the AOA Program and Trainee Review Council, and vice chairman of the AOA Bureau on International Osteopathic Medical Education and Affairs.

Submitted January 8, 2003; revision received December 29, 2006; accepted January 18, 2007.

	References

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10. Ajluni PB. AOA president's inaugural speech page. American Osteopathic Association Web site. Available at: http://www.osteopathic.org/index.cfm/pdf/index.cfm?PageID=aoa_yrfitforlife. Accessed December 12, 2007.

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14. Dierker L, Lloyd-Richardson E, Stolar M, Flay B, Tiffany S, Collins L, et al. The proximal association between smoking and alcohol use among first year college students. Drug Alcohol Depend.2006; 81: 1-9. Epub July 11, 2005.[Medline]

15. American Osteopathic Association. Master file: Database on osteopathic physicians [database online]. Chicago, Ill: American Osteopathic Association; 2001.

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17. Töyry S, Räsänen K, Kujala S, Aärimaa M, Juntunen J, Kalimo R, et al. Self-reported health, illness, and self-care among Finnish physicians: a national survey. Arch Fam Med. 2000;9:1079-1085. Available at: http://archfami.amaassn.org/cgi/content/full/9/10/1079. Accessed September 26, 2007.

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