The experience of the Comprehensive Care of the Sick Physicians Programme (PAIME) of the Spanish General Council (CGCOM)

Mingote-Adan, José Carlos; Garrote-Díaz, Juan Manuel; Romero-Agüit, Serafín
doi:10.1016/j.medcle.2019.02.012
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prevention and management of psychosocial risks to community health and safety is a strategic and fundamental issue in modern democratic states that affects not only physicians&#44; but also other professionals&#44; such as professional drivers&#44; teachers&#44; public authorities and politicians&#46; The mental health of professionals in jobs that require a high level of reliability must be assessed given that the life and safety of the population depend on them&#46; Furthermore&#44; the conditions in which they develop their occupational activity must be considered to ensure they are more suited to the optimal practice of their professional activity and to prevent possible risks to users&#44; which may hinder their important social duty and harm their personal health as well as the health of those to whom they are attending&#46; Prevention of psychosocial risks demands suitable control of medical information between the professionals responsible&#44; supervisory authorities&#44; and the institutions in which they work&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In his Epitaph&#44; an Athenian physician from the 2nd century B&#46;C&#46; makes this address&#58; &#8220;These are the eternal duties of a physician&#58; First&#44; cure his mind and give assistance to himself before assisting anyone else&#46;&#8221;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Comprehensive Care of the Sick Physician Programme &#40;<span class="elsevierStyleItalic">Programa de Atenci&#243;n Integral al M&#233;dico Enfermo</span>&#44; or PAIME&#41; is the efficient institutional answer that enables the fulfilment of a twofold objective&#58; on the one hand&#44; ensure that the sick physician is attended to in an appropriate manner&#44; and on the other hand&#44; guarantee the protection and safety of both users and the health professionals attending to them&#44; ensuring the physician is found to be in optimal conditions to exercise his or her professional duty&#46; This is a pioneering programme in Europe&#44; created in 1998 at the Medical Association of Barcelona&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> which has consolidated precedents in other developed countries&#44; such as the United States&#44; Canada and Australia &#40;1&#41;&#46; PAIME is a programme focused on treating and aiding the recovery of sick physicians suffering from psychological problems and&#47;or addictive behaviours to alcohol and&#47;or other drugs&#44; including psychotropic medications&#44; which may interfere with their professional practice&#44; therefore assuring their return to the medical practice in optimal conditions to allow for greater patient safety&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The philosophy of PAIME is against persecution and it is not punitive &#40;except in cases in which a clear risk of malpractice is detected&#41;&#46; It encourages patients to voluntarily access the programme&#39;s services and it promotes their rehabilitation in a climate of strict confidentiality with highly specialised care teams&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In fact&#44; in light of the general &#8220;law of silence&#8221; that Dowling described in 1955<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> to refer to the usual lack of shared responsibility of physicians with regard to sick and incompetent colleagues&#44; the American Medical Association led a series of conferences and programmes&#44; such as the event held in San Francisco in 1975&#44; on &#8220;The incapacitated physician&#58; a challenge to the profession&#8221;&#44; with the aim of implementing suitable interventions to aid them efficiently&#46; These included the creation of a special medical figure&#44; the &#8220;confronting physician&#8221; with competencies to &#8220;guide the sick physician to suitable treatment&#44; protect his&#47;her professional and economic interests&#44; take care of his&#47;her rehabilitation and occupational reorientation if necessary&#44; and offer him&#47;her personal and social support at all times&#46;&#8221; Later&#44; employee assistance programmes were developed worldwide to improve health and to enable physicians to undertake their work suitably&#44; such as those organised by the American Medical Association<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a> &#40;1986&#41;&#46; The role of physician does not provide protection against illness&#46; The factors that lead physicians to suicide are linked to access to and dependence on drugs&#44; the stress derived from the profession and conflicts on a personal and social level&#46; Other authors&#44; such as Cruz and Cols state&#44; &#8220;The detection and treatment of mental disorders in medical professionals is difficult&#46; Physicians can be quite tolerant of the emotional changes in their colleagues&#44; with a strong resistance to intervene in problems considered personal&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> This situation has been described by the American Medical Association since 1973&#44; when it denounced the apathy&#44; ignorance and lack of general responsibility of physicians regarding the deteriorated and incompetent physician&#44; meaning treatment interventions usually arrive too late in the course of events&#44; even following the suicide of the physician&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">PAIME provides a response to the Medical Code of Deontology of the OMC&#44; a fundamental reference framework in the physician&#8211;patient relationship&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Purpose and objectives of PAIME</span><p id="par0035" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Provide healthcare&#44; assistance and psychosocial support to the physician who so requires it in order to favour his&#47;her recovery and rehabilitation at the first stage of intervention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Propose and guide towards the most appropriate treatment plan on an individual basis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Prevent undesired situations that may occur suddenly as a consequence of the mental disorders or behaviour the physician is suffering from&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Preserve the quality of professional acts and the service offered to citizens&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Therefore&#44; clinical assistance with the following characteristics is offered to any physicians with mental health problems and&#47;or addictive behaviours&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Criteria of</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Confidentiality</span></span>&#58; In addition to general standards related to data protection&#44; the opportunity for the health professional to have a suitable environment for his&#47;her mental healthcare is considered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Criteria of</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Voluntariness</span></span>&#58; Assessments are not for the purpose of experts and voluntary inclusion in the programme is essential&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Criteria of</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Seriousness</span></span>&#58; Psychosis&#44; personality disorders and major depressive disorders&#44; or disorders related to addictive substances&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Criteria of</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Significant Occupational Impact</span></span>&#58; When mental health issues have a negative impact on the work environment&#44; whether it is with regard to colleagues or users of the service&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Criteria of</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Serious Risk</span></span> to the health of the physician or third parties&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Criteria of</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Prevention and Care Quality</span></span>&#58; <span class="elsevierStyleItalic">After exposure to particularly stressing situations</span> in the workplace&#44; side effects of personal&#44; occupational or social conflicts&#44; etc&#46; that may lead to serious chronic disorders&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">PAIME activities</span><p id="par0095" class="elsevierStylePara elsevierViewall">Its activities are developed via scheduled consultations with physicians &#40;mainly psychiatrists&#41; and therapists appointed to the PAIME programme and the care task is focused on patients sent from the different derived organisations and those that personally request assistance&#46; This task includes specialised care via&#58; exploratory interviews&#44; diagnostic evaluation&#44; psychotherapeutic intervention&#44; psychopharmacological treatment and control&#44; and the preparation of clinical reports&#46; In addition to this care task&#44; activities are arranged&#44; including&#58; coordination with the Primary Care Team and with all other care devices in the patient&#39;s health area&#44; coordination with the occupational hazard prevention services users of the programme depend on&#44; ordering of hospitalisations and the referring of patients to other specialists and other centres&#44; coordination and participation on mental health prevention and promotion activities in collaboration with different scientific companies and organisations&#44; participation in mental health research projects and especially in the health labour area&#44; and the drawing up of reports&#44; statistics and statements&#44; with the necessary guarantees of confidentiality in all cases&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Methods</span><p id="par0100" class="elsevierStylePara elsevierViewall">A cross-sectional&#44; observational analytical study was designed with all the professionals attended to by the Organizaci&#243;n M&#233;dica Colegial&#39;s &#40;OMC&#41; PAIME in the period comprised between 1 January 1988 and 31 December 2014&#46; The study population &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3668&#41; is comprised of all physicians who suffered a psychological disorder and&#47;or addiction that required medical treatment &#40;outpatient or inpatient&#41; and who were taken on by the programme during this period&#46; The cases recorded in the period 1998&#8211;2010 were grouped in the records consulted&#44; for which reason they have been excluded for some analyses&#46; From the year 2011 the periodic capture of data for the programme began&#44; facilitating its statistical analysis&#46; The assessment was anonymised&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The centralisation and gathering of data from different PAIMEs was performed thanks to the efforts of the OMC through the Foundation for Social Protection&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Sick Physician</span><p id="par0110" class="elsevierStylePara elsevierViewall">The Sick Physician is considered to be a professional with a mental or addictive disorder whose ability to exercise his&#47;her professional duty may be diminished and may harm patients and who had accessed PAIME during the study period&#46; None of the cases detected were excluded&#46; Definitive diagnoses were established following the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders &#40;DSM-IV&#41; of the American Psychiatric Association&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Other variables</span><p id="par0115" class="elsevierStylePara elsevierViewall">Information on gender&#44; age groups&#44; marital status&#44; programme access channel&#44; reasons for request&#44; origin of referral&#44; specialisation and occupational status of all cases was obtained from PAIME records&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The age variable was categorised in ranges &#40;&#8804;30 years&#44; 31&#8211;40 years&#44; 41&#8211;50 years&#44; 51&#8211;60 years&#44; &#8805;61 years&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The marital status variable was categorised as single&#44; married&#44; in a relationship&#44; separated&#44; divorced and widowed&#46; The programme access channel was categorised as spontaneous voluntariness&#44; induced voluntariness&#44; confidential communication and formal complaint&#46; The reason for request was categorised as colleague&#44; superior&#44; family member&#44; occupational risks&#44; psychiatrist&#44; management&#44; own initiative and other&#46; The specialisation variety included the list of 49 specialisations recognised in Spain in Specialised Health Education&#46; The occupational status was categorised as permanent contract&#44; temporary contract&#44; free exercise or mixed &#40;work contract<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>free exercise&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Statistical analysis</span><p id="par0130" class="elsevierStylePara elsevierViewall">Descriptive analyses were based on frequency distribution and they were performed in all sick physician cases observed in the study period&#46; Only the cases with lost data for certain variables were excluded from the frequency analysis of the particular variable&#46; For the Prevalence of the sick physician&#44; the number of cases recorded each year was used and divided by the total number of registered doctors in the same period&#46; <span class="elsevierStyleItalic">p</span> values were calculated using Pearson&#39;s chi-squared test or Fisher&#39;s exact test&#46; All statistical analyses were performed using the software Stata&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="par0135" class="elsevierStylePara elsevierViewall">During the study period&#44; 3668 cases of sick physicians were recorded in Spain&#46; Of these&#44; 2415 cases &#40;66&#37;&#41; correspond to the period 1998&#8211;2010&#44; and they are found in a unique consolidated record that does not allow the study variables to be analysed&#44; for which reason they have been excluded&#46; In the period 2011&#8211;2014&#44; a total of 1253 cases of sick physicians were recorded in Spain&#46; Of these&#44; 53&#37; were men and 47&#37; were women&#46; 36&#37; of cases were concentrated in the 51&#8211;60 years age group&#46; With regard to marital status&#44; married professionals amounted to almost half of cases &#40;45&#37;&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the frequency distribution of the main characteristics of the study population&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Access channels and occupational status of the Sick Physician</span><p id="par0140" class="elsevierStylePara elsevierViewall">In the overall distribution for the period 2011&#8211;2014&#44; 915 cases of sick physicians &#40;73&#37;&#41; saw the individual involved access the programme voluntarily and spontaneously&#44; with this being the most frequently used access channel&#44; followed by that of induced voluntariness with 288 cases &#40;23&#37;&#41;&#46; With regard to the origin of referrals&#44; by order of frequency&#44; 307 cases &#40;24&#46;5&#37;&#41; were due to own initiative&#44; followed by 175 cases &#40;14&#37;&#41; and 166 cases &#40;13&#46;2&#37;&#41; derived from a colleague and a family member respectively&#46; Regarding the occupational status of the sick physician when accessing the programme&#44; six out of every ten cases involved professionals with a permanent contract&#46; Full distributions are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Specialisation</span><p id="par0145" class="elsevierStylePara elsevierViewall">More than 70&#37; of the total number of cases of sick physicians were concentrated in eight specialisations&#44; with family and community medicine the most frequent specialisation with 45&#37; of cases&#44; followed by paediatrics with 6&#46;2&#37;&#44; anaesthesia with 5&#46;2&#37;&#44; psychiatry with 4&#46;5&#37; and internal medicine with 4&#37;&#46; From fifth place in frequency the surgical specialisations appear&#58; gynaecology and obstetrics &#40;3&#46;3&#37;&#41;&#44; orthopaedics and traumatology &#40;2&#46;6&#37;&#41; and general surgery &#40;1&#46;8&#37;&#41;&#46; Only one in every four cases of sick physicians for the period can be found in the remaining 41 specialisations&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Reasons for request and prevalence</span><p id="par0150" class="elsevierStylePara elsevierViewall">In the reasons for request for the period 2011&#8211;2014&#44; almost two thirds of cases &#40;62&#37;&#41; correspond to mental disorders&#44; 18&#37; to alcoholism&#44; 13&#37; to dual pathology&#44; and the remaining percentage to drug-related problems&#46; Distribution by year for the reasons for request is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">The overall and annual prevalence of sick physicians in this same period oscillates between 0&#46;16&#37; in 2011 and 0&#46;13&#37; in 2014 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; with no significant changes in annual prevalence observed during this period &#40;trend <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">With regard to definitive diagnoses in accordance with the classification of DSM-IV&#44; once professionals were assessed and attended to in PAIME&#44; by order of frequency results showed&#58; mood disorders &#40;27&#46;1&#37;&#41;&#44; disorders related to the consumption of alcohol and other substances &#40;23&#46;1&#37;&#41;&#44; adjustment disorders &#40;16&#46;9&#37;&#41;&#44; anxiety disorders &#40;10&#46;5&#37;&#41;&#44; personality disorders &#40;10&#46;1&#37;&#41;&#44; schizophrenia and other psychotic disorders &#40;4&#46;4&#37;&#41;&#44; and unspecified disorders &#40;less than 8&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">With regard to sociodemographic characteristics&#44; the equal distribution between the sexes in the sample stands out&#44; with a similar percentage of men and women applying to attend the programme&#44; in accordance with a clear feminization of the profession in recent years&#44; and the current relative share of male and female practicing doctors&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">With regard to age groups&#44; it is notable that 44&#46;2&#37; of treated cases are aged over 51 years&#44; with a relative decline in demand amongst younger groups&#46; This is fundamentally related to the current demographics of the medical community&#44; but the fact that demand increases gradually with age suggests that it is also possibly an effect of continued exposure to the psychosocial risks of the job&#44; such as the inherent stress in clinical practice and other accumulated stressors &#40;working conditions&#44; salary&#44; etc&#46;&#41;&#44; external violence&#44; psychological harassment and interpersonal conflicts&#46; This fact is surprising&#44; given that most mental disorders begin during adolescence and the early stages of adulthood&#44; which coincides with the period of university studies and medical specialisation&#46; Evidently&#44; doctors&#8217; academic and workplace stresses act as a filter that selects those with better intellectual and psychosocial resources to face the demands of the medical profession&#44; but this is not sufficient reason for them to be protected from the psychosocial risks of the medical profession&#46; A white coat can&#8217;t protect doctors from common stress&#44; nor from the inherent stress of clinical practice &#40;complexity&#44; uncertainty&#44; poor results from treatment&#44; etc&#46;&#41;&#44; and the syndrome of professional burnout&#46; Currently&#44; there is robust quantitative evidence showing that professional burnout is associated with suboptimal patient care&#44; with a double risk of being involved in incidents that affect patients&#8217; safety&#44; and three times more chance of receiving a low level of satisfaction from patients&#44; as well as displaying various mental disorders and illnesses&#44; according to a recent metaanalysis by Panagioti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In terms of the method of access&#44; it is notable that the majority of cases request help voluntarily&#44; whether it be spontaneous or triggered by a colleague or family member&#44; which indicates good dissemination and acceptability of the Programme amongst the medical community&#44; as it is run by some especially skilled and prestigious professionals&#44; who provide comprehensive health care&#44; social care&#44; legal support and consultancy to doctors who need it&#44; with the aim that they will return to work with the proper safeguards for the quality of their care&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">With regard to the specialist area of the doctors assisted&#44; it is notable that 51&#37; of them work in Primary Care and Paediatrics&#44; followed by Anaesthesia &#40;5&#46;2&#37;&#41; and Psychiatry &#40;4&#46;5&#37;&#41;&#44; in greater relative proportion with respect to other medical and surgical specialisms&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In terms of reason for the consultation&#44; it is notable that 62&#37; seek advice due to different mental disorders&#44; followed by problems related to alcohol &#40;18&#37;&#41;&#44; dual pathology &#40;13&#37;&#41; and the rest for problems related to drugs&#44; a profile which is fairly similar to other PAIMES &#40;Comprehensive Healthcare for Physicians&#41; at both the national and international levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">8&#8211;15</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">With regard to final diagnoses&#44; mood disorders predominate &#40;27&#46;1&#37;&#41;&#44; followed by substance use disorders &#40;23&#46;1&#37;&#41;&#44; adaptive disorders &#40;16&#46;9&#37;&#41;&#44; anxiety disorders &#40;10&#46;5&#37;&#41;&#44; personality disorders &#40;10&#46;1&#37;&#41;&#44; schizophrenia and other psychotic disorders &#40;4&#46;4&#37;&#41;&#44; with the rest suffering from a non-specified disorder&#46; Doctors&#44; like all human beings&#44; are as vulnerable to illness as their patients&#44; and as a consequence they suffer from the same health problems as the general population&#44; although if they are not properly prevented and treated they can have negative repercussions on the quality of care they provide to patients&#46; For example&#44; rates of depression and substance use are as frequent as for the general population&#44; although with a greater risk of suicide&#44; according to the review of Myers and Gabbard&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The lifetime prevalence &#40;the proportion of a population that&#44; at some point in their lives&#44; has had a health episode&#44; a risk factor or a specific illness&#41;&#44; of symptoms of self-assessed clinical depression is 12&#46;8&#37; in a prospective study of more than 1300 doctors followed between 1948 and 1964 by Ford et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> which is almost identical to the 12&#37; rate of major depression in men in the USA&#46; The lifetime prevalence of self-identified symptoms of depression in female doctors of 19&#46;5&#37; in the Study on the Health of Women Doctors &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4501&#41; is comparable to that of the general population and professional women&#44; published by Frank and Dingle&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">But because of the internalised social stigma&#44; the fear of status loss&#44; disrepute and of compromising their career&#44; some doctors resist seeking proper professional help and often resort to self-diagnosis and self-prescribe psychotropic medication&#44; or to the suboptimal treatment of their mental disorders with &#8220;informal&#8221; consultation and inadequate monitoring&#44; meaning that their problems worsen&#44; become more serious and are complicated with other illnesses&#46; This is a serious Public Health problem that has affected people with mental illness for centuries&#44; indicating that certain diagnoses cause prejudice towards suffers and the professionals who care for them&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">To resolve this problem&#44; the image of Psychiatry needs to be changed in the media in order to change public opinion&#44; above all because it would encourage realistic expectations of treatment methods and their effectiveness&#46; Because being diagnosed with a mental disorder is not the same as being an &#8220;impaired doctor&#8221;&#46; Most doctors who are being treated for a mental disorder are not professionally impaired&#44; although their working efficiency may be reduced&#46; Likewise&#44; any lack of knowledge or skills that are necessary to practice medicine is not a result of impairment&#44; but is simply incompetency&#46; Impairment is the inability of a graduate to practice medicine with reasonable expertise and safety due to a mental disorder or a physical illness that affects his&#47;her perceptive&#44; cognitive or motor skills&#44; or due to regular or excessive use or abuse of drugs legally defined as controlled substances&#44; alcohol or other substances that impair capacity&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">The growing concern of public opinion and of health professionals with regard to the mental disorders physicians suffer and the negative consequences of these disorders on patient safety has given rise to the gradual emergence of specific programmes &#40;PAIME&#41; and the proposal of a series of directives for their prevention and treatment&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In general&#44; physicians are not aware of the psychosocial risks to which they are exposed as they are inherent to clinical practice&#46; Furthermore&#44; they may lack the resources to address them efficiently&#44; given that neither during their university degree or postgraduate studies do they acquire sufficient training in psychosocial competencies&#44; at least at the same level as scientific and technical competencies&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Spain&#39;s PAIME has proven its efficiency in treating sick physicians and it must be maintained and optimised with precise resources to guarantee optimal care functioning&#46; Difficulties exist in how to approach physicians with a subsidiary pathology from PAIME care&#44; meaning occupational hazard prevention services are essential in aiding the detection&#44; assessment and referral of cases with serious mental disorders&#46; This is in addition to preventing and promoting mental health&#44; although the knowledge of all physicians on the programme&#44; with their ability to inform their sick colleague or request help from their medical association&#44; is proven to be the best channel of access to PAIME at this time&#46;</p></span><span id="sec1040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect5100">Conflicts of interest</span><p id="par9175" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mingote-Adan JC&#44; Garrote-D&#237;az JM&#44; Romero-Ag&#252;it S y PAIME working group&#46; La experiencia del Programa de Atenci&#243;n Integral al M&#233;dico Enfermo &#40;PAIME&#41; de la Organizaci&#243;n M&#233;dica Colegial en Espa&#241;a&#46; Med Clin &#40;Barc&#41;&#46; 2019&#59;152&#58;324&#8211;328&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The components of PAIME working group are&#58; Aliende-Miranda JJ&#44; de la Fuente-Darder B&#44; S&#225;nchez-Fern&#225;ndez M&#44; Mielgo-Casado N&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Distribution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Sex &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1253&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Men &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">589 &#40;47&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Women &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">664 &#40;53&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Age groups &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1183&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804;30 years &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">122 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>31&#8211;40 years &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">240 &#40;20&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>41&#8211;50 years &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">299 &#40;25&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>51&#8211;60 years &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">427 &#40;36&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8805;61 years &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Marital status &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1113&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Single &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">328 &#40;29&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Married &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">500 &#40;45&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Parnerts &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69 &#40;6&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Separated &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Divorced &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">117 &#40;10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Widower &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Program Entry Routes &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1253&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spontaneous Volunteer &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">915 &#40;73&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Induced Volunteer &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">288 &#40;22&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Confidential Communication &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;3&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Formal complaint &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Origin of the derivation &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1253&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Own Initiative &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">307 &#40;24&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Colleague &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">175 &#40;14&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Family &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">166 &#40;13&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Superior &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79 &#40;6&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Occupational hazards &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychiatry &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">448 &#40;35&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Especiality &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1253&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Family and Community Medicine &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">564 &#40;45&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pediatrics &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;6&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anesthesia &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychiatry &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57 &#40;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Internal Medicine &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Gynecology and Obstetrics &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44 &#40;3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Orthopedics and Traumatology &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>General Surgery &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">339 &#40;27&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Working relationship &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1253&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Permanent contract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">738 &#40;58&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Temporary contract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">361 &#40;28&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Free professional practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;7&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Work contract<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>free professional practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Motives of demand&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mental disorders &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">208 &#40;57&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">210 &#40;68&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">103 &#40;58&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">193 &#40;63&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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