Intended for healthcare professionals

Rapid response to:


Why doctors don’t take sick leave

BMJ 2015; 351 doi: (Published 09 December 2015) Cite this as: BMJ 2015;351:h6719

Rapid Response:

Why are so many doctors leaving the profession: is the answer one, seven or forty-two?

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?

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.

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.

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.
2. Oxtoby K. 2015b. Why doctors need to resist “presenteeism” BMJ 2015;351:h6720 doi:10.1136/bmj.h6720.
3. Davies M. 2015. Medicolegal aspects of working while unwell BMJ Careers.
4. Centre for Workforce Intelligence 2014. In-depth review of the general practitioner workforce: final report.
5. Campbell D. 2015.
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.
7. Silverthorne S. 2010.
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

Competing interests: No competing interests

18 December 2015
Daniele Carrieri
research fellow
P. Foxall, M. Jackson, K. Mattick, P. Dieppe, on behalf of the participants of “Care Under Pressure” symposium
Egenis, University of Exeter