We conducted a qualitative observational study in which a group of doctors with cancer (doctor-patients-DP) was compared with a group of patients with cancer who were not doctors (non-doctor patients - NDP).

Thematic analysis following Braun and Clarke's five‐stage method was used [11-14]. A research team, composed of the PI (EM) and two research assistants (EL and CD) transcribed into a written form (reported in a file) with the information provided by each patient. The first phase of data analysis was to familiarize with the data by reading the file of each patient repeatedly and assessing factors that shaped the subjects' experiences. In the second phase, a preliminary coding framework was developed by two researchers (EM and CD) using a subset of transcripts, and the remaining transcripts were independently coded by EM. In the third phase, the themes and codes were checked for consistency. Discrepancies were resolved through discussion until a 100% agreement was reached. In the fourth phase, a revision of the themes was carried out, during this phase some themes collapsed into each other, and others themes were divided into separate ones. In the last phase, themes were defined and named and the data within them were analyzed (Fig. 1).

Fig. (1). Open interview.

From July to November 2021, 59 patients were enrolled in the study. Among them, 29 were doctors and 30 were non-doctors. Mean age and gender were 55.9 years ± 9.3 SD (range 38-82 y), M/F ratio 12/17 for DP, and 56.3 years ± 8.9 SD (range 40-83 y), M/F ratio 11/19 for NDP, respectively. As reported in Tables 1 and 2, the socio-demographic and clinical characteristics of the two patient groups including sex, marital status, number and age of children, educational background, job position, faith (religion or personal), stage, site of tumor and anticancer therapies are mostly overlapping. The only difference was related to the educational background; both groups of patients had university degrees, but all doctors also had specialties in addition to the degrees in medicine and surgery. The medical specialties of the doctors were the following: anesthesia, physical therapist, orthopedics, gastroenterology, endocrinology, geriatrics, oncology, general medicine, radiology, hygiene, otolaryngology, cardiology, pediatric, internal medicine, surgery, urology, gynecology. The average number of working years was 20.7 and 18.6 for DP and NDP, respectively.

In both groups, six main themes and ten subthemes were identified relating to a cancer patient’s experience. The main themes were: 1) practical aspects related to diagnosis, 2) diagnosis experience, 3) treatment experience, 4) changes in work, 5) changes in personal/family life and friendships, 6) comfort in faith. The changes in subsequent clinical practice and doctor-patient relationships were identified exclusively for the study group of doctors/patients.

The themes and subthemes explored are reported in Table 3.

Most patients from both study groups immediately carried out the necessary tests to confirm the diagnosis. Only a few patients (1 DP and 3 NDP) postponed diagnostic tests by choice even though clinical symptoms of cancer were present and the suspicion of cancer was strong. Most DPS who wanted to have diagnostic tests done as quickly as possible admitted that being a doctor shortened the time to book and perform the tests needed to confirm their cancer diagnosis, while several NDPS who wanted to have tests right away, found it difficult to book an appointment and be seen within a short period. The only DP who deliberately postponed diagnostic tests reported that although it was clear to him that he needed to seek help, the busyness of his schedule and the weight of the workload acted as a barrier to seeking treatment. For a few of the NDPS, the reasons for postponing diagnostic tests were: the belief that the suspicion of a neoplastic disease was unfounded or not so strong as to have to perform the tests quickly, the fear of having the diagnosis of cancer confirmed, and the need to provide care for other sick family members as well as themselves.

A significant difference was observed between the two study groups in the number of specialists consulted during the diagnosis and treatment. Most of the DPS consulted only one, or at most two, specialists for the diagnosis and treatment. Many of them decided to be treated at their place of work. Having connections within the industry led to receiving a subjectively higher quality of care and facilitated the choice of the oncological team to rely on. The number of physicians consulted by NDP was much higher, with up to three specialists during the diagnostic phase and the same number in the treatment phase. The main reason for this behavior was the confusion derived from the different suggestions received from relatives, friends, and/or colleagues regarding the specialists to be consulted.

Emotional/psychological reactions to the cancer diagnosis were very similar in the two groups, although the reasons behind the specific reactions were very different. Most of the DP and NDP reacted to the cancer diagnosis with an attitude of acceptance and determination to face the diagnostic therapeutic path as quickly as possible. Many doctors felt prepared for their own cancer experience, primarily due to knowing the various steps of the patient's path and understanding their likely prognosis. Professional patients' knowledge enabled them to recognize their diagnosis was not a death sentence. A few described a complete absence of fear. Many NDP who had already experienced cancer within their family, or through friends or colleagues, reported that they never thought they were immune to cancer. They had an idea of what they would have to face in the event of being diagnosed with cancer. Some character aspects, such as optimism and having a positive outlook on life helped these patients to face their diagnosis with determination. A small number of patients from both groups (1DP and 3 NDP) reacted to the cancer diagnosis with a severe state of anxiety that for some of them resulted in real despair. For one doctor who had cared for terminal patients, having background knowledge was not helpful; on the contrary, it led to imagine catastrophic scenarios of metastatic disease and death. For some NDP, anxiety, and desperation were due to the fear of not being able to deal with the treatment and its side effects and the fear of suffering and death.

Two-thirds (20/29) of DP and only one-third (10/30) of NDP did not want to discuss the prognosis in depth with their referring oncologists. Many DPS said they already know their cancer prognosis thanks to their background knowledge, while for some NDP the main reason for not asking detailed questions about the prognosis was the fear of learning that their cancer had a poor prognosis. Most of the NDP asked for information about the stage of the disease and its prognosis from the referring physician but also sought information independently via the Internet or from friends and family.

More than half of the patients in both groups (18/29 Dps and 19/30 NDP) reported that they weren't worried about their privacy. They shared the diagnosis of cancer with family, friends, and colleagues. A subset of doctors shared the diagnosis with their family but only disclosed some information related to the disease, avoiding talking about certain topics such as stage, prognosis, survival, or mortality rate to protect loved ones from excessive worries about their health. As doctors, they knew they were the ones on whom others relied for their well-being and, at times, comfort and consolation, and they found it very difficult to admit that they had to cross over and become a patient. About a third of NDPS and a few doctors with cancer decided not to share their cancer diagnosis with colleagues in the workplace. The fear of demotion or the loss of authority in one's role was one of the main reasons for this decision. Most patients in both groups received support from family, friends, and colleagues. Only a few patients from both groups, 2 DPS, and 3 NDP, reported with disappointment that they did not receive the support, empathy, and understanding expected from some colleagues with whom they had shared the diagnosis.

For many DPS, having a professional background contributed to more active participation in care. Medical knowledge has enabled them to self-manage side effects and adverse events related to treatment both in the hospital and at home. Most of the doctors, despite having the possibility and knowledge to make choices about their treatment, decided to rely totally on the team of specialists chosen. Some doctors (5/29) with limited knowledge (for example, doctors whose cancer was outside of their specialty) preferred to be treated as normal patients and to receive standard information. A very small number of NDPS found that providers were reluctant to discuss the decision-making process in detail, especially regarding the use of different therapies other than the one proposed or complementary and alternative therapies.

Many DPS chose to be treated at their place of work considering an advantage, in their knowledge, and understanding of the said place. They felt it gave them the ability to move within the healthcare system that is already familiar to them. Familiarity with the context helped in the procurement of information and resources and helped to create an overwhelming environment in the hospital. During the diagnostic and therapeutic path, some DPS benefited from modification to the usual hospital practice, with some patients receiving treatment in separate rooms or in a less crowded time slot than other patients. Most of the NDPs were satisfied with the treatment they received in the hospital and the relationship with the health professionals (doctors, nurses, technicians). Few NDP (3/30) and only one DP felt discriminated against because of their illness, reporting that they felt discriminated against mainly by health professionals such as nurses or health assistants rather than by doctors. Rudeness, unkind responses, and long waits for therapies are among the behaviors displayed by the healthcare personnel that have mainly contributed to making patients of both groups feel discriminated against.

Before starting the treatment, many NDPS were afraid of the possibility of side effects, but most of them found that the treatment phase was less overwhelming than expected. Many DPS, thanks to their background knowledge, felt prepared to face the side effects of the treatments. For many patients (mainly women, but not only) of both groups, hair loss due to chemotherapy was one of the most difficult side effects to accept. Some patients of both groups suffered psychological discomfort from cancer and its treatment, including anxiety, depression, and concern for the suffering of others as a result of their disease. One of the late and longer-lasting side effects reported by patients in both groups was mild but persistent cognitive dysfunction, including a lack of mental stamina and problems with concentration and short-term memory.

All patients of both groups had temporarily stopped their work for some months during the diagnostic and treatment phase. No patient had to permanently stop working or lose their job because of the disease, but two DPS and one NDP anticipated their retirement from work by a few years compared to the expected date. Significant emotional difficulties accompanied the return to work for more than a third of doctors, especially those who worked with cancer patients.

A higher number of patients in both groups reported a loss of interest in their jobs. For the DPS, the main reasons for the loss of interest in the job were the need to take care of themselves associated with feelings of disempowerment and loss of professional identity. A handful (5/29) of DPS described finding it difficult to separate the identity of a physician from that of a patient. Some of the DPS acknowledged that they were no longer confident in carrying out their work and were afraid of making mistakes. Very few DPS (2/29) felt unmotivated to continue in their work. Despite everything, DP, after having stopped working for a few months, did not encounter any difficulties in starting to work again.

After the diagnosis of cancer, about a quarter of the DP and very few NDP changed their previous beliefs regarding their professional lives. Some DPS renounced any career advancement for various reasons such as physical difficulties (mainly fatigue), but also because the new position required an excessive mental effort, required more time away from their family, friends, hobbies, or because the new professional role also required moving to another city. A few NDP had to change some job roles due to cancer, but none of them had been demoted.