Why doctors don’t take sick leave
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6719 (Published 09 December 2015) Cite this as: BMJ 2015;351:h6719
All rapid responses
Of the well balanced selection of commentaries Oxtoby scatters in her piece on doctors not taking sick leave, the suggestion of it being seen as “moral failure” by McDonald, a paediatrics registrar, might strike a chord with some trainees. In a recent incident a junior trainee ‘rep’ was invited to meet two senior doctors and a member of the HR team. The issue of filling junior doctor rota gaps due to sickness was addressed - a few days prior to the release of the next six month rota, the rep was informed of the ‘plan’ for 2nd on call duty shifts to be extended. In the same breath, the suggestion was made that junior doctors these days lack a true vocation and might, in some cases, be feigning illness.
The site of moral failure in such an ugly - and I hope isolated - incident should be all too clear. However, I wonder to what degree deeply entrenched and malignant schemas in medical culture related to unconscious defences against our vulnerability are more subtly exploited by those higher up our food chain.
Competing interests: No competing interests
Why are so many doctors leaving the profession: is the answer one, seven or forty-two?
"The answer to the ultimate question of life, the universe and everything is 42." (Adams D, 1978, ‘The Hitch Hikers’ Guide to the Galaxy’)
D. Carrieri,1 P. Foxall,2 M. Jackson,3 K. Mattick,2 P. Dieppe,2 on behalf of the participants of “Care Under Pressure” symposium held at the University of Exeter on the 27th of November 2015
1 Egenis, Centre for the Study of Life Sciences, University of Exeter
2 University of Exeter Medical School, University of Exeter
3 Centre for Medical History, University of Exeter
A recent series of BMJ articles address the issues of doctors’ reluctance to take sick leave, and some of the medicolegal consequences, focusing particularly on the UK.1-3
Whilst stressing the importance for doctors to resist “presenteeism” and to seek adequate professional support when unwell, these articles identify several cultural and institutional barriers to help-seeking, including fear of career repercussion and of letting down colleagues and patients. There is another related and increasingly urgent “symptom” that needs to be added to this grim picture. Certain groups of UK doctors are leaving their profession at an alarming and increasing rate.4 Not only are older doctors taking early retirement, but young, recently qualified doctors are also leaving the country, or the profession, in unprecedented numbers.5 Data on sickness, drug and alcohol dependence, as well as suicides in doctors, suggest that stress and inability to cope are likely to be amongst the major reasons for doctors leaving medicine, and findings from the USA and elsewhere indicate that the problem is not confined to the UK.6
A multi-disciplinary group of academics and medical practitioners met in Exeter recently for a symposium entitled “Care Under Pressure” to brainstorm the problem of stress and burnout in healthcare practitioners, and try to develop a research agenda to help us understand what is going on, with a view to finding solutions. We identified a wide variety of possible causes for this loss of professionals, many of which can be characterised by the title of this article: one, seven or forty-two?
ONE
We tend to blame individuals for their failing to stay healthy, strong and enthusiastic about their job. They lack ‘resilience’ we say, and endeavour to train students and recently qualified doctors to be more resilient so that they can cope with the pressure. Furthermore, we live in a culture that is hugely individualistic and hedonistic, and one in which we always need to find an individual to blame for anything that goes wrong. So if it is not the individual practitioner who has failed because they were not resilient enough, then it must be the senior partner of the practice, or the medical director of the hospital, or the minister of health, or someONE whose fault it is.
We believe that one is NOT the answer. Indeed, we believe that the need to try to blame individuals for any difficulty is one of the major problems. Medical culture remains very ‘macho’ and many doctors find it very difficult to admit to any problem because they think their colleagues will think of it as sign of weakness, or lack of competence, and judge them rather than support them.
SEVEN
Groups of up to 7 individuals can function effectively and supportively.7 Larger groups fragment into smaller factions. In the past many units responsible for the provision of health care worked in effective small groups, which might include a mix of doctors, nurses and allied health professionals who get to know each other well, and can share their problems, talk through difficult clinical, emotional or personal problems, and generally support each other effectively.
After a series of re-organisations of UK services, people do not function in such groups, instead they do shift work, often working alongside relative strangers. Moreover, the increasing prevalence of a punitive audit culture discourages doctors to share their problems with colleagues or even to take sick leave for fear of career repercussions.1
Wellbeing is a relational concept, and the health and wellbeing of individuals depends on good relationships with other people. If working in many parts of the NHS does not allow that any more, then it is likely that this is one of the causes of dissatisfaction, stress, and ultimately failure of medical practitioners.
FORTY-TWO
Douglas Adams’ fictional computer (called “Deep Thought”) took years to compute the answer to life, the universe and everything, and the answer was 42.
So is the computer to blame? Perhaps, in part, yes. Medicine is no longer about the art of interacting with another human; it is about technology and computers. Patients often complain that their doctors spend all their time staring at their computer screens, instead of the patient, and contact time with patients is often dominated by ‘pop-up’ reminders on the screen of what you should be doing for them. Furthermore, the destructive new shifts that doctors are asked to work seem to be designed and administered by computers and not people. And you cannot control computers, they control you. It is well established that lack of control over your working life is a major cause of ill-health and dissatisfaction 8-9 and Deep Thought and its allies seem to have invaded medicine to this effect.
In conclusion, we think the causes are not about individuals (one), but about the lack of supportive working relationships within groups (seven), and the dominance of technology in general, and computers in particular (forty-two), taking away our independence.
The interrelated problems of retention in the profession and of doctors’ burnout are incredibly urgent (the former may be seen as a serious symptom of the latter). As researchers willing to address this problem, we are aware of the time pressure. However, in order to start reversing this downward spiral, we believe that it is fundamental to adopt an open approach – open to the voices and perspectives of as many involved parties as possible (healthcare practitioners, managers, patients etc.); open to learn from positive examples of Trusts/clinical teams who have manged to reduce stress levels; open to learn from other countries, and from other professions which face similar problems (airplane pilots, the army, teachers etc.); open to the richness that different disciplines (history, sociology, education, occupational health, cultural studies, etc.) can bring to understand this problem and to lead to informed suggestions and interventions. The meeting we held in Exeter represents a first step towards the development of this research agenda.
1. Oxtoby K. 2015a. Why doctors don’t take sick leave BMJ 2015;351:h6719 doi:10.1136/bmj.h6719. http://www.bmj.com/content/351/bmj.h6719
2. Oxtoby K. 2015b. Why doctors need to resist “presenteeism” BMJ 2015;351:h6720 doi:10.1136/bmj.h6720. http://careers.bmj.com/careers/advice/Why_doctors_need_to_resist_%E2%80%...
3. Davies M. 2015. Medicolegal aspects of working while unwell BMJ Careers. http://careers.bmj.com/careers/advice/Medicolegal_aspects_of_working_whi...
4. Centre for Workforce Intelligence 2014. In-depth review of the general practitioner workforce: final report. http://www.cfwi.org.uk/publications/in-depth-review-of-the-gp-workforce
5. Campbell D. 2015. http://www.theguardian.com/society/2015/dec/04/almost-half-of-junior-doc....
6. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377-1385. http://archinte.jamanetwork.com/article.aspx?articleid=1351351&resultcli...
7. Silverthorne S. 2010. http://www.cbsnews.com/news/rule-of-7-the-ideal-work-group-size/
8. North FM, Syme SL, Feeney A, Shipley M, Marmot M. Psychosocial work environment and sickness absence among British civil servants: the Whitehall II study. Am J Public Health. 1996 86(3):332-40.
9. Limb, M. 2015. Stress levels of NHS staff are “astonishingly high” and need treating as a public health problem, says King’s Fund. BMJ Careers http://careers.bmj.com/careers/advice/Stress_levels_of_NHS_staff_are_%E2....
Competing interests: No competing interests
It is unclear if Clare Gerada is speaking of her own working day, or that of others doctors that she hears from in her role as medical director of the NHS Practitioner Health Programme, when she is quoted ‘If I was sick now, how would I leave a morning surgery when 25 patients are there to see me and there is nobody to cover?’
Let’s ignore the ageing demographic - with it’s ever increasingly elderly, frail and co-morbid population that brings increased complexity to many consultations - and pretend we still live in 2006/2007, when average consultation times were 11.7 minutes for a GP partner and 12.8 minutes for a salaried GP. So a 25 patient ‘morning surgery’ is going to take a partner 4 hours and 52.5 minutes, or a salaried GP 5 hours 20 minutes (not allowing for unexpected interruptions or any natural breaks). These are both significantly longer than either a consultant’s programmed activity (PA) (4 hours) or a session as defined in the BMA salaried GP model contract (4 hours 10 minutes) – which are good bench marks to the duration you might, reasonably, expect a ‘morning surgery’ to last. Let’s hope that their job plan includes protected, non-patient facing time to review results, letters, sign repeat prescriptions, write referrals, liaise with other professional and all the other jobs that 25 patient contacts generate.
IF doctors are, truly, trying to see 25 patients in a morning (or any) surgery they are setting themselves up to fail, not only themselves but their patients. Though not directly comparable, it is interesting to note that it is a legal safety requirement that the longest an HGV driver is allowed to driver for is 4 hours 30 minutes before they must take a 45 minute break.
BUT I suspect that there are those that inflate the number of contacts for the sake of a good sound bite. This machismo - akin to the Yorkshire man in the Monty Python sketch who brags ‘I had to get up in the morning at ten o'clock at night, half an hour before I went to bed, eat a lump of cold poison, work twenty-nine hours a day down mill, and pay mill owner for permission to come to work, and when we got home, our Dad would kill us, and dance about on our graves singing "Hallelujah."’ It is detrimental to the profession. It makes those of us who are mere mortals feel inadequate. It puts pressure on us to see more patients, in an unsustainable fashion, which in the long run will likely damage both our own and our patient’s health.
So will both those who do actually see 25 patients in a morning surgery, and those who don’t but claim to, PLEASE STOP IT - not only for your own sake, but that of your colleagues and your patients.
Daniel Hughes - a mere mortal
Competing interests: No competing interests
Some years ago I was admitted to the Medical Assessment Unit of the hospital where I worked with a short septic illness. A very bright young doctor who had been our house officer saw me and asked "How did you get roped in, Dr Williams?" Somewhat puzzled I replied, "Roped into what?" "You know, the patient experience thing", he said smiling.
" Umm..., actually, I'm not very well at the moment and that this was not role-play", as I tried to defuse his embarrassment.
I believe it was a learning experience for both of us. For me, that it is OK to be recognised as a patient, and for the young doctor, that yes, doctors do become unwell like anyone else and need care.
I worked with a number of doctors who misdiagnosed their own illnesses, continued to work with serious consequences to themselves.
Competing interests: No competing interests
Perhaps it might be useful to consider the impact of an apparently rigid career system on choices Junior Doctors make regarding sick leave.
As Foundation Doctors we are allowed to take a maximum of 20 days sick leave per year in order to progress to the next grade. There are understandable reasons for this from a training perspective. The rule ensures we all have had enough clinical experience prior to full registration or completion of the Foundation Programme.
However, grouping requirements about sick leave with a list of other educational criteria that have to be met, such as Work Place Based Assessments, makes sick leave become a barrier between the doctor and their career progression.
Another thought would be that for juniors, prolonged sick leave means loss of income. Foundation Year 1 Doctors are only entitled to 1 month of fully paid sick leave. Financially this is just not viable for many.
I learnt my lesson by getting a needle stick injury on a night shift after returning to work too early, following an operation for malignant melanoma. I pressurised myself into minimising numbers of sick leave days in order to try to get full registration on the same date as my colleagues. Common sense prevailed and I have a new flexible view of training outside of the defined timetable given to us - but it took a very painful postoperative night shift to realise this.
Competing interests: No competing interests
It is a valuable start to understand the opinions of practicing physicians and those extending help to doctors who need to take sick leave[1]. Ask any doctor working in the National Health Service today and they will be able to tell you a similar personal story. They are so common that they become trivial.
There is a purpose to telling stories that is important to doctors’ daily clinical practice and to this Feature. They give us the opportunity to develop understanding and find possible ways to a resolution[2]. Without this, familiarity may just breed contempt.
References
[1] Oxtoby K. Why doctors don’t take sick leave BMJ 2015;351:h6719
[2] Calman K. A study of storytelling, humour and learning in medicine Clinical Medicine 2001 vol.1 no.3;227-229
Competing interests: No competing interests
Kathy Oxtoby's analysis of the reasons as to why doctors are reluctant to take sick leave are fine as far as they go. Nobody likes letting colleagues down and many are nervous about adversely affecting their careers. However, I feel there is a deeper, more sociobiological reason for this phenomenon which lies in the nature of the doctor/patient relationship.
This relationship is at its heart one of unequal status. The doctor is accorded a higher status than the sick patient, at least for the duration of the illness, even though in normal life he, and I suspect this applies more to male than to female doctors, may naturally be of lower status than his patient. Doctors 'punch above their weight' in terms of social status because they have access to a body of knowledge of, and have acquired skills in relation to, healthcare, which other people do not have and consider to be valuable. Strip doctors of their knowledge and skills and put them in a cave with others from a broad spectrum of society and they would find their true level, often rather lower than that which they currently enjoy.
It follows, then, that to put a doctor into the subservient role of patient, involving a rapid descent of the greasy pole of status, would cause considerable anxiety to him. Marika Davies has outlined the pitfalls of continuing to work when sick but preservation of one's social status is such a fundamental instinct for most people, including doctors, that they feel compelled to carry on regardless.
Competing interests: No competing interests
Re: Why doctors don’t take sick leave
While I accept the points raised in Oxtoby’s articles, in my view, there should be greater acknowledgement that doctors’ attitudes and behaviours are gradually changing over time. As highlighted, a key concern for most doctors who become ill is the potential impact on their ability to do their job, and for those off sick, when they will be able to return to work. NHS Occupational Health (OH) services can therefore play an important role in the management of doctors’ ill-health.
Earlier studies identified that doctors seldom consulted OH services and only did so when forced by regulatory requirements. In a more recent report looking at OH attendances and management-reported sickness absence in doctors and dentists, it was identified that the population of doctors studied did utilize OH services and that they attended for a wide range of health issues and services. A 3 year trend analysis in the same Health Board re-affirmed these findings and also found that OH management and self-referrals for doctors, absent from work, significantly increased over time.
In my experience as an NHS OH physician, there has been a gradual shift towards acceptance of ill health, the support available, and the responsibility to seek medical care, notably so for those affected by more significant medical conditions resulting in longer term sickness absence. Potential reasons for this could be cultural, generational, increased awareness or prompted by GMC requirements.
Work still needs to be done to improve perceptions of OH, understanding of the expertise and support the specialty has to offer and access to OH services. Specific fears around confidentiality need to be effectively addressed as well as appointment of Consultant OH physicians to manage these often complex consultations. Where high quality, competent OH services exist, doctors are likely to use them. While a case for specific services for this professional group in the UK has been highlighted, in the absence of additional resources and funding in wider parts of the country, the development of existing NHS OH services to effectively manage doctors’ health should be supported.
Drushca Lalloo
Consultant Occupational Physician
Glasgow, Scotland
1. Kathy Oxtoby. Why doctors don’t take sick leave. BMJ 2015;351:h6719 doi: 10.1136/bmj.h6719 (Published 9 December 2015)
2. Kathy Oxtoby. Why doctors need to resist “presenteeism”. BMJ 2015;351:h6720 doi: 10.1136/bmj.h6720 (Published 9 December 2015)
3. Waldron HA. Sickness in the medical profession. Ann Occup Hyg. 1996;40(4):391-6.
4. Lalloo D, Ghafur I, Macdonald EB. Doctor and dentist contacts with an NHS occupational health service. Occup Med (Lond) 2013;63:291–293.
5. Lalloo D, Demou E, Macdonald EB. Trends in NHS doctor and dentist referrals to occupational health- accepted for publication by Occup Med (Lond) December 2015.
Competing interests: No competing interests