Intended for healthcare professionals


Why doctors need to resist “presenteeism”

BMJ 2015; 351 doi: (Published 09 December 2015) Cite this as: BMJ 2015;351:h6720
  1. Kathy Oxtoby, freelance journalist
  1. kathyoxtoby{at}

A culture of avoiding time off when sick may be storing up problems for the future, Kathy Oxtoby hears

Doctors are less likely than other healthcare workers to take days off sick. Official figures show that they take a third as many sick days as other NHS staff and a fifth the number taken by healthcare assistants and ambulance staff.1

The will to be at work even when ill is embedded in medical culture (see box), but the drive to work when unwell affects not only doctors. It also has an impact on doctors’ friends and family and on the patients they treat.

Some doctors avoid taking time off sick simply because they would prefer to be at work, says Cosmo Hallstrom, a consultant psychiatrist who is based in London and works in private practice after 25 years in the NHS. “Doctors are highly motivated in their work and highly rewarded emotionally,” he says. “It’s a way of life. And I believe work is good for you—and a great healer.”

Keir Shiels, a paediatric registrar at Queen’s Hospital, Romford, east London, says that avoiding taking time off when unwell can have an impact on doctors’ lives outside work. “I’m often unwell on the days I have off, because the adrenaline from working in a stressed environment stops,” he says.

Stress effects

One particular problem is that doctors don’t always have insight into their own health and wellbeing, and this can affect their performance, says Nicola Lennard, medicolegal adviser for the Medical Defence Union. “Ill health can not only have a significant impact on doctors and their family but potentially on patients and can lead to safety issues,” she says. “This in turn can have a knock-on impact on doctors and add to their stress.”

Sometimes these high stress levels lead to doctors becoming mentally unwell or turning to drink or drugs, which can lead to mistakes in their care and expose patients to risk. “There are times when doctors are drinking more than they should be, and colleagues tend to cover up for them,” Hallstrom says.

Debbie Cohen, director of student support at Cardiff University’s school of medicine, says that thinking that you can’t take sick leave can affect doctors’ self esteem. “As an individual your perception that you can’t take time off when you are ill often relates to whether you feel valued and respected within the organisation you work in,” she says.

Cohen would like to see a shift in the culture currently preventing clinicians seeking help when they are sick and thinks they should receive the same access to care as their patients have. She says that doctors shouldn’t feel that obstacles are in their way, such as a lack of access to support, and shouldn’t be worried about issues of confidentiality about their health, even though such concern about confidentiality is “inherent to the nature of doctors.”

Access to occupational health

Shiels believes that better training in caring for people with mental health concerns would encourage better mental health among doctors too. He also wants better access to occupational health departments for doctors, and he points out that in some trusts any appointment has to go through a line manager. “We need open access to occupational health, with good counselling; and mental health awareness should be the norm, not an aspiration,” he says.

In recent years the lack of an occupational health service for general practitioners has been a particular concern for the BMA and the Royal College of General Practitioners. Earlier this year the chief executive of NHS England, Simon Stevens, announced that GPs would receive a national support service in April 2016, and discussions are under way with the BMA’s General Practitioners Committee and the royal college to help make this happen.

Be open with colleagues

Irritability, poor concentration, and difficulty in sleeping are also signs of stress, Lennard points out. If doctors are worried about their own health the GMC is clear that they should seek independent advice from a colleague or friend, Lennard says. As well as being mindful of their own health, doctors need to be mindful of their colleagues’ wellbeing and broach any concerns with them, she adds. Their colleagues should be “prepared to listen and act on those concerns and advise them to take independent advice,” she says.

And doctors should avoid self treating, Hallstrom adds, “because they don’t have the right clinical judgment outside their own medical expertise.” As Cohen says, “Take the leap and go and talk to somebody you can trust, because that’s what you would tell your patients to do.”

Clare Gerada: We need an independent body to support sick doctors

“Presenteeism,” the will to be at work even when you are ill, is embedded in the culture of medicine, says Clare Gerada, medical director of the NHS Practitioner Health Programme. “You find presenteeism, and the stigma associated with illness, is prominent in doctors. They carry on regardless,” she says.

She says that doctors often believe that if they take time off sick they are letting down not just their colleagues but also their patients. “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 me?”

Doctors who feel unable to take time off may lose their compassion, she adds. “A common personal impact on doctors who are ill is that what goes isn’t their competence, it’s their compassion for patients.”

The Practitioner Health Programme is a confidential London based health service for doctors and dentists. Practitioners who come to the service have considerable, often severe, mental health problems, similar to patients who present to NHS mental health services, Gerada says.

One of the extreme consequences of doctors not taking sick leave is that some, faced with insurmountable pressures, commit suicide. “I’ve seen cases of doctors taking their own life rather than face the shame of taking time off,” she says. “It is usually those who present in a crisis, such as a drink-drive offence, or who might have made an error at work.”

She argues that unless systems are put in place to safeguard doctors who are ill “sick records are likely to go up in five years’ time, because doctors are being treated like they work in a factory on a production line. And the more they have to behave like that, the more demand for care they will need.”

To tackle the problem of doctors feeling reluctant or unable to take sick leave when they should, Gerada calls for “an independent, arm’s length body to address the health and wellbeing of NHS staff.”

She says, “If doctors have stopped enjoying themselves, or if they’ve stopped enjoying contact with patients, or if they are drinking too much or self medicating, they should think about whether they might need to get help.”

Where to seek help

  • BMA Counselling and Doctor Advisor Service—Provides 24/7 emotional support for doctors

  • Support4Doctors—Support website run by the Royal Medical Benevolent Fund, with information on careers, training, health, and financial issues

  • British Association for Counselling and Psychotherapy—Helps you to find a counsellor or psychotherapist in your area

  • NHS Practitioner Health Programme—A free and confidential London based NHS service for doctors and dentists with a mental or physical health concern or addiction problem, in particular where these might affect their work

  • Medical Women’s Federation—Provides a safe and protective environment for women to speak out and be supported

  • Royal College of Psychiatrists—Has a vast range of resources to support people with mental health issues

  • Sick Doctors Trust—Provides information and support for doctors affected by drug or alcohol dependence


Cite this as: BMJ 2015;351:h6720



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