Background
While we have recently documented the relatively good health and personal health practices of Canadian physicians collectively, no one has considered data on the physical and mental health or personal health practices of physicians in BC. 

Such an investigation is worthwhile because physicians’ personal health habits strongly and consistently affect patients’ health habits.[1]

Methods
Described previously in more detail,[2] a national study was conducted from November 2007 to May 2008 using a random sample of 3213 Canadian physicians. 

The protocol was piloted and then approved by the UBC Be­havioural Research Ethics Board. The questionnaire included questions about physician demographic characteristics, general health, and health practices. 

Many of the questions about health habits were taken verbatim from the Canadian Community Health Survey (www.statcan.gc.ca/cgi-bin/imdb/p2SV.pl?Function=getSurvey&SDDS=3226&lang=en&db=imdb&adm=8&dis=2 [13]), the National Study on the Work and Health of Nurses (www.statcan.gc.ca/cgi-bin/imdb/p2SV.pl?Function=getSurvey&SDDS=5080&lang=en&db=imdb&adm=8&dis=2 [14]), and the CDC’s Behavioral Risk Factor Surveillance System (www.cdc.gov/BRfss/questionnaires/english.htm [15]).

We sent the questionnaire and cover letter to 8100 randomly selected physicians, excluding residents and retired physicians. Mailings began in November 2007, with follow-ups to nonresponders in December 2007 and January 2008.

Responses were ac­cepted until April 2008, and a fourth mailing went to BC physicians in order to boost response rates. Res­ponses were eventually received from 582 BC physicians and 2631 physicians from other provinces, for a response rate of 41%.3

We weighted data for nonresponse using the raking ratio method to match physicians’ demographic characteristics known to the Canadian Medical Association: province by type of phy­sician (family/general versus other specialist) and sex by age group (20–39, 40–49, 50–59, 60–69, 70+). 

The analysis was run in SAS and R3 environments using weighted data. The analysis was run using unweighted data as well, and we did not find significant differences, suggesting the absence of a nonresponder bias.

Results
As shown in Table 1 [16], BC physicians were slightly more likely to be male, middle-aged, and born outside of Canada than were other Canadian physicians. 

They were more likely to be family physicians and to practise in community hospitals and in settings that were urban/suburban rather than inner city. 

They were also more likely to practise in a private office/clinic, freestanding clinic, or nursing home, and less likely to practise in academe. 

Their primary professional income sources were more likely to be fee-for-service or service contracts, and BC physicians were less likely to be salaried or capitated. 

Table 2 [17] demonstrates that BC phy­sicians’ physical and mental health and their disability status were extremely similar to those of all Canadian physicians, though they were slightly more likely to have disability insurance.

BC physicians and all Canadian physicians had similar BMI readings, with a BMI of 25 or less reported by 57% of physicians in BC and 55% of physicians in other provinces.
 
Regard­ing personal health habits (Table 3 [18]), BC physicians resembled all Canadian physicians in their use of tobacco, alcohol, and supplementary calcium and other vitamins/minerals. 

Some dif­ferences in health habits were found, including BC physicians’ fruit and vegetable intake (Table 4 [19]), which was less than that of all Canadian physicians. 

While BC physicians exercised considerably more than other Canadian physicians, 42% of them did not meet Centers for Disease Control and Prevention (CDC) physical activity guidelines;[4] this is true for 39% of BC physicians who trained in Canada, 19% of BC physicians who trained in the US, and 52% of those trained in another country (P=.02; data not shown). 

BC physicians’ personal screening practices were generally similar to all Canadian physicians’ (Table 5 [20]), although BC female physicians were somewhat more likely to have had a Pap smear in the past year than were all Canadian female physicians (55% vs 47%, P = .05), and BC male physicians were somewhat less likely (P = .05, data not shown) to have had a testicular exam by a clinician. 

BC physicians who have been trained in a Canadian medical school are more likely to have had a Pap test in the last year than those trained in the US or another country (56% vs 44%, or 44%, data not shown); for all Canadian women physicians, those trained in Canada (48%) and the US (49%) were more likely than those trained elsewhere to have had a Pap test (39%). 

BC physicians’ personal and professional attitudes were also very similar to those of all Canadian physicians, as was their knowledge of available mental and physical health re­sources (Table 6 [21]).

While BC and other Canadian physicians have generally similar levels of professional burnout, other Canadian physicians say they are less likely to ever feel cynical, and more frequently feel exhilarated by their work than BC physicians do (Table 7 [22]).

Conclusions
Most personal and professional characteristics of BC physicians are positive and are similar to those of other Canadian physicians. However, there are some differences and some areas worth targeting for health promotion. 

Although the demographics and work environments of BC physicians differed from other Canadian physicians in only a few ways, these differences may be significant. 

For instance, the fact that BC physicians were less likely to practise in inner city settings or in academe, plus the fact that BC has a higher percentage of physicians born outside Canada, suggests that there may be insufficient medical faculty to train physicians to meet the future health care workforce needs of the province. 

While policymakers should expect to see this situation improved by the expansion of UBC’s Faculty of Medicine, this should be monitored.

BC physicians’ physical and mental health and their disability status were extremely similar to those of all Canadian physicians, though BC phy­sicians were slightly more likely to have disability insurance. 

Nonsalaried physicians working in BC are eligible to apply for disability insurance under an agreement between the BCMA and the Ministry of Health Services,[5] while physicians in other provinces must self-fund 100% of their disabi­lity insurance (oral communication with Sandie Braid, director, Insurance Department, BCMA, 1 February 2010). 

Given this situation, it is somewhat surprising that the differential rate of disability insurance is not larger.

BC physicians’ average fruit and vegetable intake was less than that of Canadian physicians overall (P<.0001), and 42% do not meet CDC physical activity guidelines. 

However, BC physicians’ exercise habits are still considerably better than those of other Canadian physicians: BC physicians averaged 207 minutes per week of exercise, meeting the Canadian Task Force on Preventive Health Care’s[6] recommended requirement of 30-plus minutes most days of the week. 

This echoes trends in the BC general population, the most active of all the provinces: 55% of British Columbians over age 20 are moderately physically active.[7]

This finding suggests that a number of factors may encourage physical activity in BC, including the natural and built environment, the provincial culture, and the types of people who choose to live in BC. 

If such factors were identified for physicians (and others), they could be promoted to further increase physical activity here and elsewhere in Canada among physi­cians and their patients. 

Importantly, physicians could then serve as even better role models for the general population: physicians who have healthy personal habits are more likely to counsel their patients on related prevention issues,[1] and those who disclose their own healthy habits (including exercise and diet) are perceived as more believable and motivating than others.[8]

Population obesity rates are also significantly lower in BC than other provinces.[9] While BC physicians trend toward lower BMI readings when compared with other Canadian phy­sicians, the difference is not statistically significant. 

This reinforces the importance of targeting physicians for health promotion interventions, especially for physical activity, and fruit and vegetable consumption.

BC physicians’ cigarette and alcohol consumption habits were similar to those of other Canadian physicians. As in the US (where about 4% of physicians smoke cigarettes),[10,11] only 3.3% of Canadian physicians smoke, compared with 18% of Canadian women and 15% of Canadian men in the general population.[12] 

Most (75% of female physicians and 83% of male physicians) consume alcohol at least monthly, almost identical to the 77% of Canadian women and 82% of Can­adian men who report drinking alcohol in the past year.[13]

But (as reported among US female physicians),[10] both BC and other Canadian physicians were much less likely to report heavy drinking (5 or more drinks on one occasion once a month or more often in the past 12 months)  than was the general population: 3.4% of BC female physicians (vs 3.7% of Canadian female physicians and 9.6% of Canadian women) and 9.2% of BC male physicians (vs 11% of Canadian male physicians and 24% of Canadian men).[13] 

The majority of BC physicians report never binge drinking (80% for females, 66% for males).

Regarding professional burnout, BC physicians report similar levels reported by other Canadian physicians. 

On the positive side, BC physicians more strongly endorsed indicators of value congruence, such as sharing health system values and feeling that personal career goals are supported, than did other Canadian physicians. 

However, BC physicians were also more likely to feel strained by work and cynical about their contribution, and were less exhilarated by their work. 

Overall, these results indicate that when comparing the work experience of BC physicians with their counterparts across Canada, the similarities are more striking than the differences. 

However, there are a few indicators that BC physicians are both more idealistic (specifically their strong­er endorsement of value congruence), and are experiencing more strain than their counterparts in other provinces.[14] 

The most effective burnout interventions develop qualities of the work environment through organi­zational development, the personal ex­periences of individuals through therapy,[15] and collegial relationships among health care providers.[16]

Our next steps with these data will involve formulating interventions to further improve the health of BC physicians. This will serve both BC doctors and their patients, as there is a strong and consistent relationship between physicians’ personal health choices and the recommendations they make to their patients.[1] 

Interventions should reduce negative provincial disparities (such as lower fruit and vegetable consumption), and promote areas where physician role-modeling may be most influential (such as exercise).

Acknowledgments
Production of this report has been made possible through a financial contribution from the Physician Health Program of BC, the BC Medical Association, the Healthy Heart Society of BC, Health Canada, and by the Canadian Medical Foundation (CMF), a charitable organization dedicated to achieving excellence in health care through medical philanthropy and through the generosity of CMF’s donor, MD Financial. 

We would also like to acknowledge the support of the Canada Research Chair program, Canada Foundation for Innovation, Canadian Medical Association, Michael Smith Foundation for Health Research, and the British Columbia Knowledge Development Fund.

Competing interests
Dr Clarke acknowledges that as the executive director of the Physician Health Program his interests may be affected by the publication of this article.

Dr Frank is a professor and Canada Research Chair in the School of Population and Public Health, and in the Department of Family Practice at the University of British Columbia. Dr Oberg is a research scientist at the Bastyr University Research Institute, Seattle, Washington. Dr Segura is a post-doctoral fellow at the School of Population and Public Health, UBC. Dr Clarke is an occupational medicine physician. Dr Shen is a statistician in the School of Population and Public Health, UBC.