A recent paper in the BMJ1 reported on the fact that doctors take less sick leave than other healthcare professionals. Possible reasons for this include that doctors are maybe more healthy than the general population – they have discovered the secret of life and are keeping it all to themselves perhaps! Yet the figures for doctor health and wellbeing would not bear this out – given we have higher levels of addiction and suicide than the general population. The Practitoner Health Programme2 in London also reports ever-increasing numbers of doctors using their services and calls for more support for doctors.
It is indicative perhaps that we are more prone to hiding our ills and carrying on working with them, rather than not having them at all.
It could be that doctors feel under pressure to keep working despite being ill – turning up to work even when unwell – a condition known as presenteeism. The articles explain that this can be because they don’t want to let colleagues and/or patients down – who will see the 30 patients in the clinic if the Consultant or GP doesn’t turn up at short notice? Who will cover the rota, the on call, the shift of work, perform the operations or the list of endoscopy procedures that are booked in advance?
I have been guilty of this myself. As a trainee in general surgery, I developed severe lower back pain just as I was going off on Christmas holiday. I missed the early morning flight home from England to N.Ireland as it took me sooooo long to move and get ready due to the pain that was present when I woke up. I spent a week in agony at home and had some physiotherapy before leaving for the return journey. A Tens machine was applied but instead of relieving the pain it made it worse! I didn’t feel I could phone in sick when I had just been off on holiday so I hobbled into work and started doing a ward round with a bent back, swallowing pain killers as I went. The consultant took one look and sent me home!
If I ever had a cold or flu or sore throat /tonsillitis etc I just kept going, and attended work as usual – no matter how under the weather I felt. I know I am not alone in that either. I prided myself on turning up for work when unwell!
As a Consultant I developed cellulitis at my ankle from an open wound on my foot and had it tracking up my leg on a Friday afternoon when I was on call for the weekend ahead (meaning on call Friday, Saturday and Sunday through to Monday for all general surgical emergencies). Not only that, but more worringly, there was a purplish-black discoloured patch indicative of a serious infection. Yet I stood operating on a difficult case for several hours, my leg becoming more swollen, more painful and inflamed as I did so. I had started antibiotics but changed them to stronger ones when the discoloured patch appeared, informed also with the swab result showing an aggressive infection and I had input from the microbiologist as well.
But I did not take the weekend off on sick leave. I continued to work throughout the weekend – limping along the ward, seeing patients and doing what was needed. Who was going to cover me for a weekend at short notice? I didn’t want to land my colleagues in it as inevitably one or two of them would have had to cover as unlikely to get a locum at such short notice. On top of that I had all kinds of thoughts and beliefs about what people would say or think that were not helpful. Taking sick leave on a Friday afternoon before a weekend on call is not the most popular call in the medical arena! Whilst that is understandable on one level, on another we must ask why is the caring profession so uncaring towards itself and its members? Why are we so hard on ourselves and each other?
If I had been advising a patient, I would have told them to stay off work and rest with the leg elevated at home whilst taking the antibiotics or I might even admit them to hospital for IV antibiotics given the seriousness of the infection. Another physician who saw me hobbling in the corridor suggested I should be in hospital on IV antibiotics! So why did I have one rule for patients and another for myself? Why did I ignore the words of my physician colleague? Why did I not give the same prescription to myself for rest, care and elevation – and instead did the exact opposite – kept working and standing for a prolonged period operating – intermittently checking how far the lymphangitis (inflammation in the lymphatics) was spreading up my leg! It’s crazy!
Yet this is all part of the medical culture that says we have to put others needs before our own, to always put patients first – I could not just walk out and abandon the wards of sick surgical patients. It is part of the medical culture to be strong, to not show any weakness, to see illness and disease as something that patients get but to which we think we are immune. Part of the medical culture that says there is one rule for you the patient, and another for me the doctor – as if we are a different species of human being. There is a sense of being indispensible – that if we don’t show up, the job won’t get done at all – and that may be true in some instances especially where the notice is short. The pressure to not let down patients who are on an operating list or attending a clinic is significant.
Of course if I had been in a road traffic accident and totally incapacitated with a broken leg or something equally serious there would be no option but to be on sick leave and the hospital would have to find cover and like it or not colleagues or a locum would have to cover. But such serious situations are worthy of sick leave – there is no choice in the matter. But where do we draw the bar for sick leave for conditions that do not require hospitalisation or that have us significantly incapacitated? What is acceptable to take off for sick leave and what is not? How sick do we have to be to feel worthy of sick leave?
The figures show that presenteeism is a costly business – people turning up for work when sick are not doing themselves or their employers any favours. We can think we are indispensible and yet this is far from true – a hospital will keep working, someone from somewhere will be found to fill our shoes. No-one is actually indispensible. In the worst case scenario of a sudden death – the work goes on, the hospital goes on, the shoes get filled in one way or another. That is the fact of the matter – even though of course we may feel that no-one can truly fill the literal shoes of another and the unique individual qualities that they bring to the work that they do.
What I have come to see is that by continuing to work in these circumstances was actually a form of abuse – it definitely wasn’t the loving or caring option! It was abusive to my body to continue putting it in to situations that were more likely to exacerbate the ill rather than promote healing. If I had taken the weekend off the infection would have most likely cleared more quickly than it did and I would have been back to ‘normal’ earlier, not inhibited by the pain and inflammation.
Even though there can be these extraneous pressures of work demands and not wanting to ‘let the side down,’ so to speak, not wanting to put extra work or pressure on colleagues, not wanting to have lists of patients cancelled at short notice – what it really comes down to is how do I value myself, my body and my wellbeing. To be abusive to myself in this way, there has been a lack of true care and value for myself and my health – where I have put the needs of others first even though it has been detrimental to me. Had I truly valued myself, my body and my health then it would be a no-brainer that such circumstances warranted sick-leave.
Doctors are not a separate species of human being – we are subject to the same ills as the group of human beings we call patients. All doctors are potential patients and there needs to be greater acceptance of this fact by both doctors and patients. We are not infallible. We are human – we get sick – and we heal the same ways our patients heal….. and that can require time off work. There is no shame in that – it can simply be what is needed.
More than that we can also see that getting sick as a message from our bodies that we may have been over doing it, perhaps working too hard, not taking enough care of ourselves – and the answer to that is not to continue working harder, doing more of the same that led us to be ill in the first place! There is the possibility instead of engendering a more responsible way to live – such that we can hopefully avoid such ills in the first place by realising that all our daily choices impact our health and wellbeing. By addressing our daily way of living we can be more healthy, more vital and potentially have less need for sick leave in the first place. Whilst there are issues with the system that are adding to the stress of working in the NHS currently and that need to be addressed, we should not underestimate the degree to which we can improve our own health and wellbeing by our daily way of living.
The culture of medicine needs to change – but it only will when those within it change and realise the ills we are casting upon the profession by perpetuating these out-dated myths. Doctors are human before they are doctors – a medical degree does not confer immunity from illness and disease. If we do not have compassion for ourselves and our colleagues when sick then what really is the quality of the compassion we profess to have for our patients? It is a fallacy to think we can pick and choose who to turn on our compassion for. We cannot be selective when it comes to compassion – if we do not have compassion for ourselves then we cannot truly have compassion for another. Likewise, the more compassionate we are with ourselves, the more compassion and understanding we will have for all others – irrespective of the circumstances.
Like many things in life, rather than looking outwards and professing compassion for others, we need to first look within and have compassion for ourselves, to stop being so hard on ourselves and our colleagues – we do not know the full road another has travelled to be where they are today and that fact renders all judgment null and void. We have to dissolve such judgments against ourselves and others to be able to be truly compassionate and to provide a healing presence that allows another to be where they are, whilst knowing they are much more than the story or situation they find themselves in – whether they are a colleague or a patient – for we are all human beings first and foremost.
The caring profession needs to start with caring for itself first if it truly wants to provide a caring service for all.
1) Why doctors don’t take sick leave. K Oxtoby. BMJ Dec 2015;351:h6719
2)The Wounded Healer – why we need to rethink how we support doctors. C Gerada. BMJ careers July 2015 http://careers.bmj.com/careers/advice/The_wounded_healer—why_we_need_to_rethink_how_we_support_doctors
3) Why doctors need to resist ‘presenteeism’. K Oxtoby. BMJ Careers Dec 2015 http://careers.bmj.com/careers/advice/Why_doctors_need_to_resist_“presenteeism”