This paper will address the ways in which all of us as doctors respond to the impact of illness in patients. The constructs used are psychoanalytic and the experience comes from running a psychological service for doctors for the past seven years. In line with the Nuffield Hospitals Report (1996) it is a service funded by the Regional Postgraduate Medical Dean.

Studies of utilisation of psychiatric services have shown that between 4 and 18% of medical students annually identify themselves as ‘impaired’ (Dickstein et al, 1990). An unknown number of students may be ill but do not seek help – they soldier on through classes and clinics not realising that their sleep disturbance, worry, vague pains, flagging spirits, failing grades or increasing use of alcohol represent symptoms of strain and possible psychiatric disorder. Some suspect or know that they are ill but the stigma of accepting mental illness or seeking professional help is so profound that they suffer silently.

This paper will concentrate on some of the practical contributions that consultant psychiatrists can make in the prevention and treatment of psychiatric impairment in doctors. We will illustrate this with case material from programmes in which there has been a good deal of psychiatrist participation.

This paper will focus primarily on the most recent research studies involving doctors in the UK. We will not discuss the treatment of doctors who are psychiatrically unwell as this is covered in other papers elsewhere in this issue. Before reviewing specific studies, we will consider the measurement of psychiatric disorder, stress and burn-out.

There is a widespread concern that the medical profession is itself sick. This is represented in professional disillusionment and demoralisation, an increasing inclination to consider leaving the profession, and the ill-health of its practitioners in terms of their mental health, marriages and use of drugs and alcohol (British Medical Association, 1992). These trends have been attributed, at least in part, to protracted job stress and dissatisfaction, which may in turn be a major determinant in the quality of health care (Caplan, 1994). Although these issues have been cautiously acknowledged for some time, the concept of ‘burn-out’ has provided an opportunity for more open acceptance and creative debate.

During the research interviews for Isobel Allen's prospective studies of medical careers (Allen, 1994), many young doctors voiced concerns about their working conditions. Although a relationship between doctors' health impairment and their arduous working conditions has only recently been empirically established (Baldwin et al, 1997a), concern about sick doctors, at all stages of their careers, has been growing for many years. There are very few empirical data on sick doctors' help-seeking, but the enlightened self-interest of trusts and health boards may become an important new driving force, because of the more clearly defined responsibilities of National Health Service (NHS) senior staff for the well-being of their colleagues and possible liability for colleagues' impaired clinical practice (General Medical Council, 1995; British Medical Journal, 1997). The anticipated UK shortage of doctors may also act as a stimulus for measures designed to encourage the retention of a healthy medical workforce.

The General Medical Council (GMC) relies upon consultant psychiatrists throughout the UK to assist in carrying out its twin tasks under the health procedures of protecting patients and guiding doctors. One of the reasons for the fitness of a doctor to be seriously impaired is the illness, usually mental illness, of that doctor, and frequently doctors do not realise the extent to which their ability to carry out their work has been affected.

A recent working party report published by the Nuffield Provincial Hospitals Trust (1996) made a series of recommendations for the improvement and better coordination of existing services. This comes at a time when new and expensive counselling services are springing up everywhere, the most ambitious being the British Medical Association's 24-hour counselling service for doctors and their relatives.