How physicians professional socialisation and social technologies may affect colleagues in substance use disorders

Abstract

Often, discussions of physicians’ substance use (both licit and illicit) are framed in quantitative terms. The present article provides a complimentary qualitative and posthumanist perspective on substance use challenges illuminated through in-depth interviews with substance use disorder (SUD) recovered physicians’ about their experiences with substance use and SUD within their work culture. SUD recovered physicians’ experiences include descriptions of fears about being revealed as a substance user, self-medicating to enhance performances during operation or morning conferences and the like. The article draws attention to the role of physician work culture in the development and management of physicians own substance use and SUD. It reports results from my Danish study analysing how professional socialisation and social technologies affect physicians disclosure of their own SUD and their help seeking at work. The work-related aspects that in some cases affect the development of substance use and SUD include hierarchical pressure, emotional strain from critical patient cases and work-related competition. In the analysis a disciplinary paradox concerning the social technologies intended to normalise and standardise physicians’ conduct and ensure the quality of treatment. Ironically, the social technologies seemed to have an unintended consequence: to conserve and maintain SUD rather than facilitating treatment and recovery. For instance, I show how the fear of social sanctions in the form of a loss of certification and prescription rights keeps physicians in SUD from seeking external treatment. Rather than producing normalisation as intended, the social technologies in some cases seem to have an adverse effect of strengthening deviance.

Keywords:

• Medical socialisation
• physicians’ self-prescription
• substance use disorder
• functional use
• disciplinary paradox and social technologies

1. Introduction

Physicians in substance use disorders (SUD), including both prescription drugs and illegal drugs, resemble other groups of people suffering from SUD in most respects, but in contrast to others, physicians have prescription rights and access to prescription drugs (Winick 1961). Physicians fulfil a special and very powerful role as health experts and they can self-prescribe and self-treat their conditions (Rosvold et al. 1998; Cicala 2003; Wallace et al. 2009). Accordingly, physicians were found to be more likely than other members of the general public to have prescription drug use disorders (Merlo et al. 2013). Additionally, physicians carry the responsibility for patients’ health. From time to time physicians are called upon to deal with issues of life and death that entail considerable emotional strain (Wallace et al. 2009). Clearly, this work condition is also present for firefighters, nurses, rescue team members and other professionals. Nevertheless, one of the unique aspects of physicians’ work conditions is their ability to prescribe medications and historically it has affected their SUD (Nimb 1975). Nevertheless, given physicians’ role as key gatekeepers to identifying and treating SUD in general, it is of societal interest to analyse possible interrelations between their professional socialisation and their view of and management of SUD among physician colleagues. This analysis can contribute to an understanding of how substance use and SUD are perceived and dealt with in physicians work culture.

Like other people with SUD, physicians deny the existence of the disorder for very long periods of time (Cicala 2003; Wallace et al. 2009). Research has shown that physicians tend to postpone treatment until their addictions have become very serious (Brooke et al. 1991) and that extended periods of addiction without treatment or therapeutic care may cause physicians to commit suicide. In Denmark, Nimb conducted a (20-year follow-up) study of 108 physicians registered for drug use by the Danish Health and Medicines Authority. The restudy revealed that only 40% of the physicians had survived, which is half the survival rate of comparable drug use disordered Danes. Additionally, at least 25% of the deceased had committed suicide (Nimb 1975). These findings were reconfirmed in two later studies (S⊘rensen et al. 1989; Hansen et al. 2002). A recent American survey found that 78% of the surgeons reporting a medical error in the previous three months had an alcohol use disorder (Oreskovich et al. 2012). Clearly, SUD among physicians can be a serious problem both for physician welfare and potentially also for patient safety.

Our recent quantitative Danish studies of physicians’ substance use show that 19% of physicians in Denmark have unhealthy alcohol use and 3% have unhealthy drug (licit and illicit) use (S⊘rensen et al. 2015). Among physicians with unhealthy substance use, 78% report their consumption to be unproblematic, indicating a low degree of problem recognition (S⊘rensen et al. 2015). Moreover, we have shown that unhealthy alcohol use is associated with psychosocial factors: both burnout and alexithymia (Pedersen et al. 2016).

Much research has aimed to establish the prevalence of substance use problems among physicians in various countries. Very few studies have explored either the users’ own perspectives on their substance use and SUD or the socio-cultural and neurobiological aspects related to it. I have only identified a handful of qualitative studies concerning physicians’ substance use disorders. In the following section, I examine these studies to compose a backdrop for my own analysis of SUD-recovered physicians’ perspectives on their substance use disorders, work conditions and colleagues’ reactions.

2. Analytical perspectives on physician socialisation and substance use disorders

In 1961, Winick studied social and personality correlates of addiction and interviewed 98 physician opiate users. Comparing physicians and street addicts, he identified the following characteristics specific to physicians: a) physicians have access to clean ‘drugs’ and therefore rarely have a pusher, and b) they tend to initiate their drug using career about a decade later than other substance users and they rarely identify with the larger ‘SUD population’.

Winick identified a range of causes affecting the development of SUD, including an excessive workload, a desire for performance enhancement, a physical ailment, self-concept (they believed that their drug use was under control), marital problems, levels of aspiration, insomnia, age or fatigue (Winick 1961).

Equally, the more recent studies also identify a multiplicity of factors affecting the development of SUD and some tend to focus on issues of self-prescription (Rosenthal 1994b; Noreik and Asgard 1999; Cummings et al. 2011). Of these, the most developed is Rosenthal’s interview study of physicians with problems (60 British and 30 Swedish physicians). Rosenthal contends that particularly Swedish physicians react late when colleagues suffer from SUD because they view problems with, for example, alcohol as a private issue a tendency confirmed in our quantitative survey from 2014 (S⊘rensen et al. 2016). Additionally, the work culture implies a strong collegiality, and an avoidance of criticism and conflicts that makes some physicians reluctant to deal with SUD, sometimes at the expense of patient safety (Rosenthal 1994b; Farber et al. 2005).

No doubt a great complexity of aspects affect the development of SUD. However, given the limited scope of the present article, I choose to focus narrowly on the potential implications of work cultural factors and neurobiological aspects.

Among the few qualitative Danish and international studies of physicians’ SUD, there are none analysing how professional socialisation and formal sanctions affect physicians in substance use disorders within their work settings. Therefore, the aim of this paper is to explore how specific socio-cultural and neurobiological factors operate within a Danish physician work culture and how they may influence both physicians’ substance use, development of SUD and their management of these.

2.i. How do physicians act when in substance use disorder?

A recent trend in anthropological studies of substance use disorders is to focus not solely on social and cultural aspects of substance use disorders but rather to see these phenomena also partly through the lens of neurobiological perspectives, as a ‘compulsive seeking’ or craving for, for example, pleasure (Raikhel and Garriott 2013).

I am inspired by Weinberg (2013), who’s post humanist approach to substance use is inspired by e.g. Mol’s (2002): “The body multiple” and is concerned to provide;

‘analytic resources with which to describe and explain the composition of selves, bodies, enhancements and afflictions in particular places and at particular times, incarnate and in all their specificity’ (Weinberg 2013, 8).

Furthermore, he describes how a sense of self-estrangement and loss of self-control concerning substance use may occur:

‘A sense of estrangement or loss of self-control over one’s bodily articulations pertaining to drug use emerges when, (1) these articulations are perceived to chronically interfere with others from which one derives a greater sense of felicity or self-esteem and, (2) one’s perceived capacity to discontinue these bodily articulations is somehow compromised as when, for example, people feel they cannot sleep without sedatives, relax without alcohol […], or find confidence without cocaine’ (Weinberg 2013; 7).

These processes of self-estrangement and loss of self-control clearly form part of SUD-recovered physicians’ stories, as I will show in my analysis. Clearly, substance use and SUD are highly interrelated and hard to distinguish, however Weinberg highlights the situatedness of substance use and the sense of control loss. The sense of self-control, self-identification and affliction are made on the basis of subtle, holistic and dynamic regard for the details of bodily articulations of the user, their personalities, drug, set and setting. This post-humanist approach thereby contrasts the conventional addiction science with generic diagnostic criteria and binary oppositions between self-control as and enslavement to drugs. My participants have been diagnosed with reference to generic dysfunctional biological mechanisms. Nevertheless, my analysis will show, how the intensification of their substance use is highly related to the above described complex interrelations between, personality, drug use patterns, set and setting and altogether these interweave into senses of loss of self-identification and self-control.

The following analysis mirrors the above described conditions and is centred around SUD recovered physicians’ reflections on their own substance use and their senses of loss of self-control and self-identification and how these conditions were managed and perceived within the physician work culture.

Weinberg argues that substance use is a setting-specific form of bodily articulation. More specifically, in the case of physicians, this may include a loss of the skilled execution of medical tasks, the clinical gaze and the persona of the physician. Weinberg (2013) argues that a sense of loss of self-identification is informed by a dyadic relationship between the user, the drug and the wider and more diverse constellations of practical and relational contexts one lives within. I will show how medical socialisation plays a key role in the constitution and maintenance of the physician work culture (see Section 2.ii) and how this particular setting may partly affect physicians’ substance use and SUD development in culturally specific ways.

I shall utilise Jöhncke’s (2004) concept of ‘social technologies’ to analyse the formal aspects of the physician work culture (Jöhncke et al. 2004). Social technologies are implemented in social relations and incorporate the institutional intention to shape social relations between people, society as a whole and the welfare of the population. This implies that the conduct, health and moral conditions of particular participants or target groups are the target of attention and intervention (Jöhncke et al. 2004).

The social technologies form part of the medical socialisation. Furthermore, the concept of ‘social technologies’ allows a focus on the interrelations between societal structures (including statutory provisions and ethical codes of conduct) and physicians’ behaviours when suffering from SUD. Using this concept, I hope to highlight how discrepancies come about in the inter-relationship between notions of medical rationality is implemented through ethical codes and the conduct of physicians in SUD.

2.ii. Physicians’ socialisation into a professional culture

Additionally, my position is inspired by the perspectives of researchers such as Good (1994), Hahn (1985) and Armstrong (2006), who have examined how professional physicians are socialised to act in culturally specific ways. They represent different perspectives on the professional socialisation that is accomplished through: social technologies such as education, hierarchical control, legislation, ethical codes of conduct, social sanctions and treatment initiatives. The processes involved in becoming and working as a physician are shaped within specific work cultures that influence physicians’ conduct. Presently, the Danish medical profession is safeguarded by statutory provisions and ethical guidelines (Sundhedsstyrelsen 2013). In the Western Hemisphere, such guidelines date back to the 19th century, and, along with standardisation, helped create a sense of professional identity and collegiality among physicians (Armstrong 2006). Such ethical standards and provisions play a key role in structuring, formalising and influencing the norms and values of the profession. The medical socialisation shapes an ideal that physicians can personify in their work lives.

However, a multiplicity of physician identities exist; they are constantly adjusting in response to changing notions of the medical profession and of medicine in society. Nevertheless, a number of general characteristics may be identified. For instance, medical schools value high performers and the medical education and work cultures appreciate individual specialised competences, control, responsibility, competitiveness, energy and ‘surplus’, that is, being role models to colleagues and patients (Hahn 1985; Good 1994; Ris⊘r 1998). In a Foucauldian vocabulary the professional ‘physician ideal’ is expressed in the ‘medical gaze’, an objectivation, denoting the depersonalisation of the medical object (Foucault 1989). Ideally, the ‘medical gaze’ is a lens focussed at patients’ bodies as objects of diagnostics and to some extend protecting physicians against the emotional identification with emotional strains attending human suffering such as patients’ pain and anxiety. Good elaborated on this concept of ‘medical gaze’ and noted that in his perception:

‘Medical knowledge is not only a medium of perception, a ‘gaze,’ as one might take from Foucault. It is a medium of experience, a mode of engagement with the world. It is a dialogical medium, one of encounter, interpretation, conflict, and at times transformation’ (Good 1994; 86).

In line with Good (1994), I will use the term ‘medical gaze’ as a metaphor for physician socialisation. Physicians meet particular challenges when they become patients, as shown by Jones (2005) and Hahn (1985). They observed how physicians are socialised to view their own both physical and mental illnesses as signs of weakness that may threaten their perception of being in control/being professional. Hahn (1985) identified a number of shared characteristics among physicians who were ill, including self-diagnostics and self-re-examination. As a result of some sense of omnipotence, many physicians tend to downplay symptoms and disease and avoid seeking treatment and showing any signs of weaknesses to colleagues (Hahn 1985; Nielsen 2001; Jones 2005).

Throughout this article, my analytical perspective incorporates aspects of the presented perspectives on medical socialisation knit together with the analytical concepts of social technologies and senses of loss of self-control and loss of self-identification which as shown by (Hahn 1985; Nielsen 2001; Jones 2005) is a challenge to all kinds of diseased physicians and also to SUD affected physicians. The concept of social technologies is applied to show how specific elements of the professional culture may affect a sense of loss of self-control and self-identification, trigger SUD among physicians and how it influences the management of such disorders.

3. The data and the methods

The Danish population comprises 5.6 million people, of whom around 26,000 are physicians. Due to the sensitivity and taboo of SUD among physicians it was very difficult to get in touch with SUD-recovered physicians and as shown, qualitative studies of this group were rare internationally. Contact data on physicians treated for SUD are highly confidential. Therefore, we depended on self-selected participants, whom we recruited among SUD recovered physicians through a flyer, that encouraged them to participate in interviews. I conducted 12 interviews with SUD-recovered physicians and reached saturation already by 9 interviews.

The flyer was distributed by nine Danish treatment institutions (the ones who treat physicians) and to the Danish Medical Association’s Network of Colleagues. Moreover, an advertisement was in a large Danish Newspaper, Politiken, and in the Journal of the Danish Medical Association, Ugeskrift for Læger. Participants were recruited between May 2013 and July 2014. All, but one participant, were included in the study. The excluded physician was still in SUD and was encouraged to enter treatment. I considered that interviewing physicians who were still in SUD would potentially raise ethical issues e.g. dilemmas concerning confidentiality of interview data contrasting the researchers civil obligations to report a potentially patient threatening physician. Before the interviews the author spoke to the participants on the phone and screened their SUD status. Thus, all included physicians had resolved their SUD through some kind of treatment before the interviews.

The research was initiated by a pilot study comprising interviews with the leaders of three treatment institutions that occasionally treat Danish physicians. On that basis, an open interview guide for SUD-recovered physicians was designed (Kvale, Brinkmann 2009, Bernard 2011). My interview guide covered substance use and SUD experiences, broadly focussing on issues such as family relations, psychosocial aspects, work culture and colleagues, SUD management and treatment. All interviews lasted from 1½-2 hours and were recorded, transcribed verbatim and coded in QSR NVivo.

Characteristics of participants

The participants included four women aged 30-47 years and eight men aged 43-64 years. Six of the participants were chief physicians (a highly specialised physician in a managing position) at the time of their interview or had been chief physicians during the course of their SUD. Three were young physicians not yet specialised and three were general practitioners. Six participants had alcohol problems; two of these had a poly-substance use including alcohol and prescription drugs. One person had a cocaine use disorder in combination with occasional prescription drug and cannabis use. Five participants had prescription drug use disorders. The prescription drugs used were cough syrup (i.e. Pectyl), opioids (i.e. morphine, ketobemidone, oxycodone, codeine, tramadol hydrochloride), benzodiazepines (i.e. diazepam), and finally, beta blockers. Those suffering from alcohol-related problems described a daily consumption of up to two bottles of wine or half a bottle of vodka, and up to approximately 25 years with an alcohol use disorder before initiating treatment. One person explained that s/he consumed up to 14 codeine tablets a day and another person consumed 40-50 tablets of various benzodiazepines and morphines on a single day when his/her consumption was at a maximum. The medicine and drug use disordered had been in SUD between 1 year and up to around 25 years.

Data collection was performed in accordance with the ethical guidelines of the Danish Council for Independent Research and the project was approved by the Danish Data Protection Agency (case no. 2013-41-1996). The qualitative interviews were held in accordance with the highest ethical standards (informed consent, anonymity, respect for individual participants' unwillingness to discuss certain topics, etc.). All stored data were anonymised.

Analysis

I chose an abductive approach to the analysis (Tavory and Timmermans 2014) and conducted it in three steps. Firstly, a content analysis focussed at particular themes and perspectives that arose from these interviews was made and I intended to illustrate both general aspects of the data and the variability or the multiplicity of perspectives that my data embraced. My analytical process was structured and restructured within numerous iterations during, which I made a second step, a thematic reading of the data and a third step, a theoretical reading of the data using the above mentioned theories and the analysis was directed at cultural contradictions and social conflicts in work culture. Data were triangulated with anthropological and sociological studies and theories to ensure the validity of my findings (Spradley 2006).

4.i. Analysis – functional use, senses of loss of both self-control and self-identification

Keeping in mind the fundamental stepping stones of the medical profession described above, I analyse physicians’ descriptions of work-related cultural constraints affecting the management SUD in work settings. Additionally, the complex interrelations between, substance user, drug, set and settings are mirrored in the analysis along with the development of senses of loss of self-control and self-identification in Weinbergs (2013) terms. Dave describes himself as a real physician, a clinician who is treating life and death. He explains how his job and his alcohol use disorder are interrelated:

´I am a real physician, I am treating life and death, and I am really happy to be a clinician.

I: What is the worst thing about your job?

Dave: Well, my job can be really stressful and challenging at times. You face [patients’] outcomes, particularly in my specialty [working with chronic diseases]. […] I have been following very sick patients for 20-25 years now. I know their families; I know their children and their parents. On the one hand, these chronic patients and their outcomes demand a strong commitment; this may be distressing and you may take them home in your thoughts at times. On the other hand, [it may be distressing] to work within this system today with demands to increase our productivity with 2-3% yearly while at the same time rationalising to save money. I hate what this brings in terms of administrative tasks. […] It may be that these unspecified tasks [and job stress] are related to my former alcohol addiction. […] I found many reasons for drinking in my job.’ (Quote 1)

Dave indicates that job distress relating both to patients’ outcomes and to unspecified and time-consuming administrative tasks, along with rationalisation demands, affected his development of an alcohol use disorder. His alcohol use increased and developed into a disorder alongside increasing hierarchical pressure when he became a chief physician. Despite their professional socialisation, several of the interviewed physicians describe that it is highly challenging for them to handle emotional strain at work. They describe how “the set”, emotional involvement in patient cases is particularly challenging when identification is at play, for instance, if the patient is a child at the age of their own children, or in cases of long-term involvement as mentioned by Dave. A general practitioner, Anthony explains how sad he could become after the death of a patient:

‘I remember that one of ‘my patients’ died after a long-term cancer disease and I got really sad about that. […] Often, if you are sad, you think: Did we do enough? Could we have done more to help? Could something have been differently?’ (Quote 2)

He would consider and reconsider if he made the right treatment choices etc. Today he shares doubts and feelings of insufficiency with colleagues which is a relief to him. I will now show how some physicians cope with emotional challenges by using substances to regain the sense of self-control of their emotions.

In other situations emotional strain also originates from hierarchical pressures and from an urge to perform well and stay in complete control of life-threatening situations – even though patients may die after a perfect operation or there may simply be no perfect solution to the problem at hand. Nevertheless, some physicians strive to live up to an ideal of staying in control of emotional strain in professional situations. A chief surgeon, Tim speaks about internal competition among colleagues and how it makes physicians conceal emotional strains (e.g. fear or nervousness) in professional situations from their colleagues gaze. He says:

‘[…] No one [no surgeon] will admit that they are afraid of an operation […] It is the ‘Tarzan syndrome’: no-one will admit it. We [physicians pretend] we can do anything. […] [You] cannot have a shaking hand, and you need to know exactly what you want to do, that is the way forward. We [physicians] tend to convince others [colleagues and patients] of this. It [our decisions] could have been no different. But clearly, [when you are about to commence an operation], emotional strain comes into play: Am I capable of this? Can I make it?’]. (Quote 3)

The emotional strain on physicians is in part related to the competitiveness of the work environment; physicians need to give the impression of being in control and of performing well in order to progress in their careers and defend their positions (See also Marsh 2014). Tim describes how he experienced an increased emotional pressure every time a row of colleagues came in to watch some of his most specialised operations. Accordingly, physicians – particularly at higher hierarchical levels – are under pressure to perform well. Chief physicians also carry the responsibility for the operations they and their colleagues perform in case of medical errors and deaths. In the physician work culture there may be an expectation of complete control when diagnosing and treating or operating on patients, even though many aspects of the clinical process are based on estimates and inherently associated with some uncertainty (Good 1994; Jones 2005). The ‘Tarzan syndrome’ is an emic slang term among physicians for the ambition to achieve and a pretence of complete control and calmness despite the existential dilemmas and inner doubts or even anxiety concerning the consequences of a negative result of the patient treatment and for the physician’s career.

Tim honestly describes some cultural strains derived from an intense work situation, for instance the moral dilemma associated with treating patients who are about to die, but also the emotional strains found within a hierarchical and highly competitive work field:

‘[The patient is about to die] he is a young farther. It [this life] has to be saved. If you save him then you do not know if he has suffered a brain injury. Are we working on a cabbage or what? What are we supposed to do? […] Sometimes it is a great strain; it can give you a rapid heartbeat. Anyway […] you know how to settle this. You can take beta-blockers combined with benzodiazepines, and I did so for many years during my career. Not so much in the first years, when I mainly assisted and was relatively free of responsibility; at that time, it wasn’t necessary. But later on, when the professors’ and chief surgeons’ eyes followed you from the other side every time you operated. Then it was like an examination every day [then I needed to take some medicine on a daily basis]. Especially, if it was a tough chief surgeon, who would be yelling if you made mistakes; then I would need to take something.’ (Quote 4)

The moral dilemma concerns the emotional aspects of working at the edge of patients’ life and death. Empathy and care for the patient put an emotional strain on Tim in emergency situations. He considers: ‘Will the patient survive? How do we estimate his chances? Has he already suffered a brain injury from the many severe stokes? Technically, it may be possible to operate, but can I do it without failing? And do I think treatment is the right decision in the circumstances?’

Tim explains how such work-related pressures made him initiate his substance use as a kind of ‘functional use’, with the purpose of achieving particular conditions such as relaxation, performance enhancement or the like (Boys et al. 2001; Lende et al. 2007). Tim felt challenged for instance when met by existential dilemmas at work, and consumed medicine in order to overcome emotional strain and to enhance his work performance. To some extent, he succeeded as he became among the best in his field, but later he lost his sense of self-identification and self-control due to the above described interrelations between the user, drug, set, setting (work cultural aspects) and specific bodily articulations. The situated drug use is illustrated as Tim explains that in the first years of his career, he would only take prescription medicine when he had to speak in front of 30 experienced physicians.

‘I quickly discovered that I had to take a tablet half an hour before the morning conference. I always did so but it was only 5-6-7 times a month.’ (Quote 5)

Tim explains that appearing to be nervous or insecure might harm your position as you would not, for example, be given authority or allocated operations if you did not appear to be confident. Accordingly, physicians should not reveal emotional strain. Interestingly, several of the participants confirm a trend towards increasing functional substance use alongside growing hierarchical pressure (see quote 4).

A desire to stay in control and/or to relax despite their demanding jobs, patient cases, work-related distress or an urge to enhance performance contributes to the intensification of some physicians’ substance use in terms of frequency and amount and may end up pushing them towards senses of loss of self-identification and self-control. Alcohol is the preferred substance among physicians (S⊘rensen et al. 2015). Nevertheless, some physicians also make use of their profession-specific opportunity to self-prescribe and self-treat. I investigate this further in the next section.

4.ii. Self-treatment and loss of both self-identification and self-control

My participants clearly attempt to self-diagnose and self-medicate. Tim has never been diagnosed by other professionals for any mental issues. As shown Tim sometimes felt nervous even fearful and chose to reveal these emotions from the colleagues and patients through self-treatment of the unwanted emotions in order to achieve performance enhancement and feeling in control. Tim has preferred self-treatment with tranquillisers to enhance his performance at work rather than seeking help from others. During his career, his functional self-medication got out of hand; he lost sense of self-identification and self-control concerning substance use. In retrospect, Tim regrets coping with emotional strain through self-medication, he explains.

‘I think it is a high price I have paid after twenty years [referring to the cognitive problems and the SUD he gradually developed].’ (Quote 6)

Tim’s intense use of tranquillisers has caused cognitive problems for him. Which he thinks is a high price. Bill and others describe similar cognitive problems:

‘[…] It annoyed me that my leisure time with my children could become a blur, not that I was moping about, but I could not really remember […] separate the days from each other. I was somehow anaesthetised most of the hours I spent at home.’(Quote 7)

Bill, for example, had a codeine use disorder. Bill finds that the worst consequence for him in his SUD; was that he could not remember clearly his children growing up. Additionally, he describes his life as lonely, running in parallel alongside his family. Due to his codeine use disorder, he would feel irritated and get angry easily due to withdrawal symptoms. When he took his codeines, he became tired and would rather lie on the sofa than spend time with his family or visit friends.

In the above-mentioned cases, the original substance use was intended as a functional use but not intended as a SUD. The SUD was not a conscious choice of lifestyle, but a situated ‘loss of self-control’ informed by the professional socialisation and the work culture and the sets of the particular situations at work and the social technologies of the field. Weinberg (2013) would describe it as a number of patterns of seemingly harmful and intransigent bodily articulation leading to lack of self-identification with the substance use. In my perception another crucial point is that, depending on the eye of the beholder, substance use may be interpreted A) in the user’s perspective, as functional use, for example, performance enhancement at work, or as recreational use in leisure time, allowing the physician to relax away from work, or B) in the perspective of health authorities, as a threat to patient safety and as a SUD already from a very early stage.

Weinberg’s conception of loss of self-identification is illustrated by René, who expresses how the SUD collides with the way he wants to be perceived:

‘The SUD collides completely with the way I want to be seen as a competent and responsible physician.’ (Quote 8)

Similar issues are found in the other interviews. Physicians tend to contrast their lives − their good, interesting, prestigious and well-paid jobs with the prototypical image of a person with a SUD: the poor alcoholic on the bench with bad teeth and a horrible life – and after comparing, physicians say, ‘Well, that is not me’.

The above analysis shows a flipside of the norms and values of the physician work culture. The interviewed physicians explain that they thought of their substance use as a functional use and describe a gradual loss of the sense of self-identification and self-control. Some participants mentioned that they had thought of it as an ‘over use of alcohol’ but not as a SUD per se. This perception changed during the treatment processes.

In the health sector various social technologies (Jöhncke et al. 2004) are intended to safeguard the quality of treatment by directing and redirecting physicians’ conduct. One of these social technologies is the hierarchical organisation of the work environment, which implies both a reward and a control function (Good 1994). Within medicine, control and perfection are highly valued, and their opposites: control loss, lack of self-identification, failure and imperfection may mark the difference between life and death for patients and/or the difference between a good and a bad reputation for the individual physician or the profession.

However, according to my participants, emotional strains are a taboo too in many medical subfields. This means that although some physicians may be afraid of failing or causing a patient’s death or disability and of damaging their own reputation as a competent, entrusted physician, or of harming the profession. These emotions are hardly debated among colleagues.

As shown, aspects of the physician work culture may drive some physicians towards a functional use of medicine or other substances. Ironically, functional use (and the quest for perfection) may lead to a SUD diagnosis that clash completely with the norms and values of the medical profession.

4.iii. Fear of formal sanctions and substance use disorders

Social technologies shape physicians’ conduct in part through sanctions related to the law and the ethical code of conduct for physicians. In cases involving threats to the competences of physicians, that is, transgressions of the ethical codes of conduct, the Danish Health and Medicines Authority has a range of formal sanctions relating to physician SUD.

Physicians with SUD potentially face the following sanctions in Denmark: A) they can lose their ’certification’, that is, their right to serve as physicians. Before this occurs, the physician is forced into surveillance and treatment by health authorities, which demand that urine tests for all types of substances be performed twice weekly; or B) if the physician’s SUD concerns prescription drugs, his/her right to prescribe drugs can be reduced or revoked completely. However, prescription rights and certifications can be regained after a year during which the physician demonstrates long-term “cleanness” through clean urine tests given at an out-patient addiction treatment centre (Hansen et al. 2002). These formal sanctions are similar to those in other Western countries (Rosenthal 1994a; Holtman 2007) and form a key aspect in the physician work culture in terms of the management of SUD. Participants fear these sanctions; in particular, they fear losing their job and reputation. Bonnie explains:

‘In the beginning, I thought [being a physician was] an enormous advantage because I could easily get it [morphine]. However, it was a great failure of my education and physician responsibility. […] You just do not self-medicate and you do not get into substance use disorders. […] This was not exactly how I saw myself as a physician […] I was very much in conflict with my role as a physician, I thought.

I: What did that mean to you when you were in it?

Bonnie: It is double-edged. I was afraid of losing my right to be a physician. […] But I thought it was convenient - I had access to it [morphine] […] But how could I get back to work, and how could I get out of this [SUD]?’ (Quote 9)

She says self-medication and SUD was a great failure of her education and physician responsibility. She adds that when health inspectors noticed her considerable substance use, she needed to change her behaviour to avoid losing her certification. But she simply did not know how to break out of her SUD. She also indicates that there is a great discrepancy between her self-identification and her SUD, which supports Weinberg’s point about lack of self-identification. Bill explains:

‘… it was rather dramatic, I was almost busted in the pharmacy, right. Then I thought: ’Oh no! If I get caught doing this - many things will fall apart, in terms of career and family and in all kinds of ways,’ and I was rather frightened by this outlook.’ (Quote 10)

So fear of sanctions and personal losses in terms of family and career made him quit his SUD.

Bill has not told anyone about his SUD as he still fears ruining his career as a chief surgeon. Bill’s fear of stigmatisation and loss of certification made him avoid formal treatment. Instead, he managed to overcome his SUD through self-treatment.

Another participant feared being imprisoned if his/her SUD was discovered. Some participants prefer outpatient treatment to 24-hour treatment, as it enables them to appear normal and work while in treatment and as colleagues do not need to know about it.

Clearly, physicians fear both the social sanctions and the related stigma. These fears, in combination with the above-described distress management among physicians make them self-diagnose and self-treat through their SUD. More than half of the physicians with alcohol problems had self-prescribed disulphiram several times during their alcohol use disorder in an attempt to regain control, but without success. Ben explains how he initiated disulphiram self-treatment four-five times. However, without proper psychological treatment, he and the other participants experienced that the disulphiram treatment did not work for them, even though it may work for some persons.

According to the literature, self-treatment and self-sacrifice are normal within the physician work culture (Hahn 1985; Nielsen 2001). Clearly, the taboos and stigmas are part of the reason why physicians attempt to self-treat SUD. When physicians self-prescribe and self-treat, they feel they have a chance of avoiding the stigma associated with their disorder (see also (S⊘rensen, Andersen Unpublished)). Accordingly, it is tempting for physicians to self-treat because they may potentially avoid revealing their SUD. From my interviews it appears that especially ex-alcohol use disordered physicians stay out of formal treatment institutions for a very long period of time. Periods of self-treatment may make the disorders invisible to their colleagues and may in some cases work or just temporarily stop or limit the effects of the SUD and cause physicians to avoid treatment institutions for a long time.

Clearly, fear of formal sanctions such as job loss make physicians taboo their own SUD to such an extent that it becomes very difficult for them to seek help within the treatment system. Paradoxically, the fear of formal sanctions may contribute indirectly to tabooing SUD and thereby keep physicians in SUD rather than seeking external treatment. Despite physicians’ self-treatment attempts, without professional treatment provided by specialists in the field, there is an increased risk of untreated long-term disorders, which can have a negative impact on the physicians’ health and in some cases, on patient safety (Wallace et al. 2009).

4.iv. Managing colleagues with substance use disorders

From my interviews it is clear that in a range of physician workplaces, colleagues tend to view substance use of any kind as a highly private matter. Several of the chief physicians explained that they had known chief physician colleagues with alcohol problems, but they had considered this a purely private problem that legitimated non-intrusion. Therefore, a trend towards covering for colleagues exists (Rosenthal 1994b; S⊘rensen et al. 2016).

The tendency towards covering up problem colleagues rather than encouraging them to enter treatment is rooted partly within the collegiality of physicians and partly within a general tendency to consider any substance use or SUD as a private problem that colleagues do not deal with. According to Brian:

‘As a group we are reluctant to deal with [SUD] within the health services, especially among physicians, because we are very shy in relation to our work and our personal identity. […] I was an administrative chief physician […]. In that situation, it is [transgressive] to admit it [having an alcohol use disorder]. […] I preferred not to have a note on my back, among my tasks, saying: I drink. Therefore, we [physicians] tend to cover for each other in the physician world.

[…] we had numerous highly placed chief physicians and professors with a very visible alcohol problem that was not dealt with. […] Instead, we made fun of each other in the nooks saying: ‘Who should we ask today?’ No, he is too drunk. That is what we say in the physician world, right.’ (Quote 11)

The SUD taboo is present at an institutional level among leading physicians at physician workplaces. SUD are tabooed generally in society and, apparently, with particular strength within the physician work culture (S⊘rensen et al. 2016). SUD and loss of self-control and self-identification clash with the norms and values of the medical profession and therefore they are sanctioned, viewed as out of place and tabooed (Douglas 1996). The SUD taboo relates both to various social technologies and to other aspects of the physician work culture, including what Jones (2005) described as a marginalisation of diseases with psychosocial components within medicine. The SUD taboo, mentioned by my participants, carries a double bind as SUD belongs to the periphery of medicine; additionally the values of the profession may contribute to marginalisation of the problem. This marginalisation works both directly, through the lack of priority given to SUD as a field of the discipline, and through the sanctioning of SUD; and indirectly, as colleagues’ SUD are tabooed and the problem is perceived as private (S⊘rensen et al. 2016). Accordingly, physicians with these disorders taboo their own problems and self-treat to avoid both colleagues’ stigmatisation and formal sanctions.

My analysis of the physician work culture illustrates how both informal and formal mechanisms affect the work culture and specifically, physicians in SUD. The paradox of the social technologies is that they are intended to safeguard the competence of physicians and the quality of treatment, but simultaneously, they contribute to the proliferation of fear and taboos concerning SUD. Due to fear and taboos of social technologies, some physicians in SUD continue serving for decades without external treatment and formal help at the expense of their own health and potentially, the safety of their patients.

5. Medical socialisation, self-medication and social technologies

The present article is narrowly focussed on experiences of SUD, described by SUD-recovered physicians’ and additionally on their view of the implications of the physician work culture. This means that the study is limited in the sense that it does not direct much attention to the implications of family relations affecting substance use disorders. I leave the analysis of private and personal factors affecting SUD to others (see, for example, (Merlo et al. 2013)). There may be a selection bias among the self-selected participants; they may represent a particular kind of physician, who is interested in sharing his/her experiences in order to help colleagues. SUD-recovered physicians with frequent withdrawals may not be represented. Nevertheless, SUD have multiple expressions and as shown in my analysis, the physician work culture in some cases plays a role in the development of SUD.

From my analytical position, with a focus on users’ perspectives on SUD management at the workplace, a flip side of the ideal of normalising physicians’ conduct is revealed. I show how the social technologies intended to discipline physicians for their conduct partly foster aspects of deviance in terms of SUD and make individuals stay in SUD due to fears of social downfall and stigmatisation.

I have shown that the professional ideal fosters tendencies to self-diagnose, self-treat and self-re-examine among physicians in SUD. This is confirmed by our quantitative study among 4,000 Danish physicians, 78% physicians with a risky use of substances find it irrelevant to seek help (S⊘rensen et al. 2015). Moreover, self-medication is in some cases a coping strategy among physicians struggling to regain control of various kinds of distress. SUD is not a consequence of a lifestyle choice but rather related to a setting specific form of loss of self-control implying any number of different patterns of interrelations between the user, drug, set and setting mirrored in seemingly harmful and intransigent bodily articulation, which leads to lack of self-identification with ones own behaviour as stated by Weinberg (2013). As shown, substance related sense of loss of self-identification and self-control may occur if physicians fail to live out the disciplinary socialisation and live up to the professional ideals. Additional fears of being revealed as unprofessional due to SUD and the risk of losing certification appear to keep physicians in SUD rather than encourage to seeking help.

Ideally, physicians strive to exclude ‘illegitimate emotions’ such as doubts and nervousness in many work-related situations, but in reality, this does not always seem possible. The emotional challenges of the physician job are also presented by (Domenighetti et al. 1991; Wallace et al. 2009), who show that physician work culture is emotionally charged with situations that are associated with suffering, fear, failure and death, which often culminate in difficult interactions with patients and families who are in crisis due to illness. In my analysis, also emotional dimensions of competition are highlighted and illustrated by the physicians’ functional use for relaxation in their leisure time or to escape emotions that threaten their career progression because they are unacceptable at work. I have shown that such stressful and emotionally challenging work conditions may affect a substance use and make it develop into a sense of loss of both self-control and self-identification.

Previous studies of physicians in the patient role focus on a ‘physician ethos of invulnerability to illness’, which is established through factors including personal disposition and medical knowledge (Fox et al. 2009). Equally, a review (Wallace et al. 2009) describes how physicians are rewarded for self-sacrifice and how the values of the profession may unintentionally lead to the assumption that the best doctors are those with few needs, those who make no mistakes and those who are never ill. It has been observed in international research (Brooke et al. 1991; Cicala 2003; Jones 2009) that physicians receive treatment late in the course of distress, especially in cases of mental health problems and SUD because it is considered embarrassing to seek help in these cases and physicians worry about lack of confidentiality (Ro et al. 2007).

As demonstrated by (Palm 2003) and others, there is a widespread perception in society and among physicians that SUD are moral problems, problems of the ‘will’, as if they were a question of ‘pulling oneself together’ along with ‘real diagnoses’ (Palm 2003; Jones 2005). The professional socialisation including the ‘clinical gaze’ but also the moral perspective cause SUD to be viewed as private problems and lead to stigmatisation within a medical culture that values control, strength and responsibility. In this perspective, colleagues may find it hard to intervene and it is legitimate to be private about this issue (S⊘rensen et al. 2016). Additionally, physicians in SUD tend to taboo their disorders due to fear of stigma and social sanctions such as the loss of their prescription rights and their certificate.

In line with (Rosenthal 1994b; Farber et al. 2005), my interviews indicate that physicians tend to cover for colleagues in SUD. In some cases, then, it seems that collegiality works at the expense of patient safety in relation to SUD. Clearly, it becomes highly problematic because such problems will grow at the expense of the physicians concerned, their colleagues and the safety of their patients. In other words, by covering up this problem, the profession is maintaining the SUD taboo and contributing to tendencies such as self-treatment and self-prescription rather than external help-seeking and solutions. Despite offers from the Danish Medical Association; an anonymous telephone help line and other kinds of anonymous peer support. Similar offers are found internationally e.g. (Wile and Jenkins 2013). Ill physicians’ tendencies towards self-treatment and avoidance of help-seeking appeared to be a profession-specific issue that was also found by (Hahn 1985; Brooke et al. 1991; Good 1994; Rosvold et al. 1998; Nielsen 2001).

As mentioned in the introduction, physicians in SUD share many characteristics with other people in SUD. I have now shown how work-related conditions and social sanctions seem to affect the ways in which physicians in SUD act, the substances they use, their ways of consuming these substances and how they manage their SUD. Additionally, the work related conditions and social sanctions also form part of the reason why physicians can and do work while in SUD, sometimes for long periods of time, before seeking external treatment and why some of them may end their life by committing suicide (Nimb 1975; S⊘rensen et al. 1989; Hansen et al. 2002; Ringgaard and Kragh 2013). In contrast to the numerous quantitative studies of physicians’ SUD. My study contributed to a more thorough understanding of the users’ experiences with and perspectives on SUD. My research facilitates an understanding of the interrelations between substance use, work culture, set and the impact it may have on SUD development and SUD management within the physician work culture.

6. Conclusion

I have identified a disciplinary paradox in the physician work culture, as the social technologies intended to normalise and standardise physicians’ conduct and assure the quality of physicians’ work, seem to have an unintended consequence: to conserve and maintain SUD rather than facilitate treatment and change. In other words, the social technologies of the physician work culture have the adverse consequence of producing and maintaining deviance in stark contrast to the intended quality assurance and normalisation.

As shown physicians in SUD often have a problem of self-identification with their substance use behaviour, it is not a self-willed lifestyle choice. Situated constellations of hierarchical pressure and other emotional strains within medicine may contribute to the development of functional self-medication, which, as time passes, may lead to what is presently diagnosed as: SUD. Health authorities intend to regulate and avoid SUD by means of social technologies such as legislation, hierarchical control, treatment and education as well as specific social sanctions affecting physicians with SUD. The fundamental intention of the social technologies is to allow the affected physicians to regain self-identification and self-control and return to work, whenever possible.

Nevertheless, fearful taboos threaten physicians with SUD. From our study it is clear that these fears relate to losing certification and prescription rights, because such losses may potentially lead to social downfall. Such fears make physicians hide their SUD for decades without seeking external treatment, and self-diagnosing and self-treatment appear to be prevalent. These fears keep physicians in SUD from seeking external help and treatment until they get a “wake up call”, either because they get seriously ill or because their relatives or employers give them an ultimatum: enter treatment or you will be fired or divorced or the like.

In the future, taboos and fears of the social sanctions must be countered through a more sophisticated communication of the sanctions, emphasising that all physicians know that such sanctions are often temporary and always followed by treatment and help directed towards job re-entry.

We need to recognise that physicians and other health professionals dealing with prescription drugs have a work-related risk of developing prescription drug use disorders. The physicians in SUD need help and attention from others, especially colleagues, to regain control and return to work. Unfortunately, physician colleagues tend to cover for each other rather than intervening in SUD. Physician colleagues tend to perceive SUD as a private issue and therefore mainly as a non-intervention field, despite the potentially serious consequences for both the impaired physicians and their patients. Physicians’ special access to substances and their work conditions do in some cases affect both the development of SUD and their management of them. Although other professions also experience SUD, physicians are special due to their role as gatekeepers to our health services and their significance as role models for patients. This gives them a key position in the general improvement and management of SUD. Nevertheless, the good news is that with external treatment it is, indeed, possible to recover and to regain prescription rights, certifications and to be reintegrated at work, especially in cases of early identification of SUD. As shown in the analysis Weinbergs definition of substance use developing into a setting specific form of loss of self-control implying any number of different patterns of interrelations between the user/physician, drug, set and setting/work culture mirrored in seemingly harmful and intransigent bodily articulation, which leads to lack of self-identification with ones own behaviour is highly relevant. In the future more research in these terms is needed to get a deeper understanding of these problems among physicians both local and comparative international studies. Such studies would contribute to a solid base for improvement of the possibilities for early interventions for the benefit of both physicians and their patients.

Disclosure statement

No potential conflict of interest was reported by the authors.