We review here what the two of us learned from the stories about sick doctors that we collected a decade ago [1]. These narratives illuminate the dilemma of impaired physicians-or wounded healers, as they have been called-that our profession must examine before others do it for us.

Being seriously ill or disabled gives doctors a foretaste of retirement and the leisure for reveries that their duties have taken from them; it makes them contemplate even their own death. The stories of sick doctors force emotion back into medicine, and when sick doctors themselves learn the comfort that comes from attention and devotion, empathy cannot lag far behind. Practitioners of alternative medicine already know this, their popularity growing in part because they delight their patients with time and attention.

More than most people, sick doctors deny that they are sick. They may worry privately about their health, but the unconscious pact with the Creator that many physicians have made-we will take care of the sick and You will guarantee us good health-makes it hard for them to realize that they, too, are mortal. The hypochondriasis of medical school contributes to easy denial, because when physicians fear one disease after another and find them all phantom, they come to believe in their own invulnerability. Only unrelenting pain, great weight loss, or catastrophic bleeding confirmed by the evidence of radiography or endoscopy awaken them to the reality that they have become patients.

Trained detachment has been praised since Osler's time. "Don't get too involved," older doctors still advise. Their younger colleagues then rehearse equanimity and soon lose their emotions. Professional detachment spreads from office to home, turning into a kind of alexithymia so that many physicians no longer recognize when or if they have any emotion at all. Denial is further fostered by the silence of fellow physicians. In a hospital, the "No Visitors" sign on a doctor-patient's sickroom door may be put up not so much to spare him or her from too many guests as to permit colleagues still vertical to pass by without guilt.

When the delayed realization of illness dawns, long-practiced detachment leads to distance and isolation. Sick doctors often deny foreboding and boast of their composure as if emotion were shameful, because that is how we physicians want our patients to behave. We praise the noncomplainer who does not flinch at liver biopsy and the postoperative patient who jokes rather than moans.

There are other reasons why sick doctors try to be good patients who do what they are told without complaint. One may be that sick doctors hope to return to an active professional life. Admitting a need for emotional comfort might embarrass their attending physicians, which could make for uncomfortable professional relations later on.

When a doctor is sick, especially in a hospital, he or she undergoes a role reversal. Strangely, the doctor is the patient, and the familiar aspects of the hospital are unrecognizable from a stretcher. Loss of control is hardest of all for sick doctors, so used are they to the obedience of others: Sick radiologists try to read their own films, and the bed-bound physician strains to scan the bedside monitor. Sick doctors are lonely patients, isolated but on watch, vigilant against error. Caught in the double bind of wanting to be a good patient yet worrying about what can go wrong, most sick doctors watch their colleagues as closely as they fear their colleagues are watching them. It is not easy to be a doctor and a patient all at once.

The narratives of doctors who have heart attacks or angina show how exquisitely sensitive sick doctors have become to the reality of their own symptoms, even though they have been trained-even paid-to attend mainly to the findings of computed tomography or endoscopy. They learn the truth of what Elaine Scarry [2] has written: "To have pain is to be certain: to hear about pain is to be in doubt."

Nor is it easy to be a doctor taking care of another doctor, for physicians often give doctor-patients credit for knowing more than they really do. They spare their doctor-patients the rituals that other patients must endure. Leaving out the rectal examination is bad enough, but even worse are the occasions when attending physicians are too delicate to inquire about personal problems. This causes doctor-patients to undergo many tests "for completeness" when a little conversation about life and stress might have brought out important issues and eliminated any need for diagnostic studies. If doctors have a personal physician at all, they are likely to have chosen a coeval, which lessens the likelihood of objectivity from the very start. As physicians age, they may be startled to realize that their doctor has grown older, also: A 75-year-old physician might find that he or she is getting care from another 75-year-old physician who is nearing retirement and practicing part-time.

Guilt worsens the plight of the doctor who falls sick. Traditionally, physicians have been such workaholics that they are anxious to continue regardless of risk to their patients. Because they often define themselves by their work, physicians work harder than ever to justify themselves when things are not going right. Some sick doctors claim that they work to meet expenses, but it seems more likely that an exaggerated sense of duty is responsible: Sick doctors often brag about how long they continued to practice despite growing disability. Yet praising seriously ill doctors for dragging themselves to the hospital to make rounds overlooks the harm that impaired physicians may do their patients.

Any patient's response to illness depends upon nature, character, and "premorbid" personality, upon age and accomplishment. Ten years ago, religion brought very little comfort to most doctor-patients, but that may be changing as spiritual matters gain more attention. Old people can grasp the horizon at last, and they fear death far less than the young. It is a prolonged and painful dying that worries us all.

The accounts of sick doctors raise doubts about some popular ethical concerns, such as autonomy, parentalism (formerly called "paternalism"), and truth-telling. Autonomy finds little favor with sick doctors, who are mostly relieved when another physician takes over their case. Sick doctors, in our experience at least, did not want too much detail; they trusted their physicians to be loyal to them. We doctors may represent a special kind of patient because we identify with each other, but medical practice has meant being loyal to our patients' interests at all times, even under managed care. A judicious parentalism may be in order: Many sick doctors have written about the peace of mind that comes when they no longer had to face one decision after another. After all, most sick patients have clouded judgment, as physicians used to know.

Although truth-telling has turned into a prime medical ethic, more important than empathy or kindness, hard truths are sometimes unwelcome to sick doctors, who yearn for compassion and kindness, faith and hope. Doctors should not begin to lie again to their patients-physicians or laity-but should understand how much hope, consolation, and optimism can help.

Doctors will continue to get sick and other doctors will treat them, and sick doctors, thanks to their medical training, will have unique problems and unique perplexities. What can be done to prepare for such problems? Of the many ideas that come to mind, a regular "checkup," like those doctors urge on their patients, seems foremost.

Early in their first year of medical school, students should undergo a physical and mental evaluation to emphasize that such ritual surveillance is the duty of those of us who care for others. To make that examination a preliminary requirement for acceptance to medical school risks excluding many who might prove to be very good doctors. Drug and alcohol addiction head the list of potential problems that these checkups could detect-followed by failing mental vigor in aging physicians-but even physical and mental changes as mild as "burnout" can detract from the care of patients. The mental impairment of younger physicians with other chronic conditions also deserves more attention than it has received. In the urge to protect our colleagues, few have seriously discussed what kind of surveillance is in order for all physicians.

We think it prudent for physicians to undergo repeated surveys at regular intervals: right after graduation, at the time of board certification, and every 5 years thereafter during an active career. Such surveillance should include an evaluation of emotional and mental status along with a complete general examination.

Physicians must learn to accept the duty of dealing with impaired colleagues and bringing them to attention if necessary, just as they have learned the importance of hard work and fairness in the care of their patients. In addition, we each have a duty to be examined ourselves, even when we feel well or deny that we are sick.

Sick doctors learn new lessons when we lose control over our bodies and our lives. We learn how grateful patients are for physicians who are with them in their troubles. Immigrants to the nation of patients, sick doctors are grateful for minor details, for the kindness of strangers turned friends and caretakers. We become aware of the lack of privacy in the hospital, of the side effects of the drugs that help, and of how wonderful it is that in their new fervor for quality improvement, medical personnel now strive to be kind as well as efficient.

The powerlessness and loneliness of patienthood remind sick doctors of what in health we may have given up: close relationships with our family and friends, time for contemplation, many of the joys of living. In return, we have been blessed with the chance to help others and to earn the spiritual arrogance that comes from doing good.

Most important, sick doctors learn the hard way that a doctor without patients is no doctor at all.

Dr. Mandell: 1 Indian Spring Lane, Norwich, CT 06360.