Presenteeism: Too many doctors feel they have no choice but to ‘keep going’

When mental wellbeing is poor, it is important that doctors feel supported to take time off to recuperate,
writes Dr Rob Hendry

Doctors have always been notoriously reluctant to take time off when they are sick; we are somehow programmed to just ‘keep going’. This is not distinct to Ireland and is something we see in members and colleagues around the world.

At Medical Protection Society (MPS), we recently surveyed more than 500 doctors in Ireland about presenteeism in the medical workforce and one doctor who took part commented that the culture of presenteeism in healthcare “makes it difficult to take time off unless you are physically unable to get out of bed”. I expect this will ring true for many reading this article.

Many others said the pressure to keep going despite ill-health is self-driven, as patients will lose out if they are off sick and colleagues’ workloads will increase.

It comes as no surprise to me that doctors are putting their patients’ and colleagues’ needs above their own – especially during a time of extreme pressure on resources.

What I found particularly concerning from our survey, however, was that a large proportion of doctors (63 per cent) said they continue to work despite not feeling mentally well enough to do so.

There were a variety of reasons for this, including feeling guilty for adding to colleagues’ workloads (56 per cent), feeling that patients rely on them (42 per cent), because of staff or rota shortages (44 per cent) or because of pressure to clear waiting lists (31 per cent).

For those who are working in small teams, or are sole practitioners in rural locations, it can also simply be a matter of there being no-one else to step in.

When mental wellbeing is poor, it is important that doctors feel able and supported to take time off to recuperate or seek support. Not doing so could exacerbate the issue, result in them taking more time off in the longer term, or even leaving the medical profession altogether.

Patient care

Working despite not being mentally well enough can also impact on patient care and our survey shows the ways this can manifest. For example, many of the doctors who took part said working when not feeling mentally well enough had contributed to a lack of empathy with patients (64 per cent), a loss of concentration (67 per cent), being more fearful of making mistakes (59 per cent), and practising defensive medicine (48 per cent).

One survey respondent said: “My main concern is making a mistake that seriously affects patient outcomes that would have been avoided if I had been well. This leads to increased time writing notes, double checking, etc. It leads to rumination and anxiety regarding patient interactions.”

Half (50 per cent) suspected working while not mentally well enough may have contributed to a lower standard of patient care, and one-in-five (19 per cent) felt it may have led to a missed or incorrect diagnosis.

Another survey respondent commented: “I’m aware that if I’m not mentally on top of things I am more likely to make mistakes in patient care or forget to follow up on patients. I really worry about this and worry about patients’ wellbeing and my own medico-legal risk – but most of all I dread that feeling I get when I realise I have forgotten to do something. It really increases my stress and undermines my confidence.”

Working environment

Working despite not being mentally well enough can also have a negative impact on relationships at work. Over a third (34 per cent) said it had contributed to a breakdown in relationships or conflict with colleagues and a similar amount (31 per cent) said it had contributed to a negative impact on team functionality.

Worryingly, 46 per cent of the survey respondents felt that taking time off for mental wellbeing issues was not deemed “acceptable” where they work. One doctor who took part in the survey described their employer’s attitude to mental wellbeing as “neanderthal”. One said they feared admitting to a mental health problem could have a deleterious effect on their future career. Another said they have “pushed their mental health issues aside” as they feel this is expected of them.

No-one should feel that taking time off work to deal with mental wellbeing issues is unacceptable. Presenteeism – particularly in a profession where it is so deeply ingrained in the culture – is a complex issue to solve, but it is clear to me that much more could be done to enable and support all healthcare workers to take time off when they are too mentally unwell to work – without fear, guilt, or stigma.

This includes exploring a range of measures to build in additional capacity and resilience, so doctors can take time off when they need to.

Worryingly, 46 per cent of the survey respondents felt that taking time off for mental wellbeing issues was not deemed ‘acceptable’ where they work

Some 94 per cent of those who took part in our survey believed such measures would be helpful in reducing presenteeism. One doctor said: “If the system had more built-in resilience to cope with doctors taking sick time off, it would be a great help. We have all seen and experienced the strain it puts on us and our colleagues when folks are off sick – none of us want to be the cause of that strain.”

The provision of accessible mental wellbeing support resources is also key in tackling presenteeism. Those working in both HSE and private healthcare settings should have counselling, peer support networks, and specialist support available to them as standard. This would help to tackle issues early on and enable doctors to continue to care for patients safely.

Independent mental wellbeing services, such as the Practitioner Health Matters Programme, are equally vital and can provide a lifeline for many who are struggling to cope, but they often rely on donations. We believe the new Government should help to ensure they are properly funded and safeguarded, so healthcare professionals are always able to access confidential, specialist help outside of their place of work, without fear of repercussions from their employers.

Retention

In the draft Programme for Government, there was a lack of detail in terms of plans to tackle the deteriorating mental wellbeing of the healthcare workforce, however, we would urge the new Government to look closely at this issue. It is critical in retaining the workforce and requires some long-term thinking.

At MPS, we know that the pressures and demands healthcare professionals face are having a significant impact on mental wellbeing and we would like to remind members that they have access to a counselling service, as part of their membership, for work-related issues such as stress, burnout, anxiety, and conflict. Members can access telephone support 24 hours a day, seven days a week, and face-to-face counselling sessions can also be arranged. The service is completely confidential and independent of MPS.

More information can be found here: www.medicalprotection.org/ireland/wellbeing