Sick enough? Doctors, illness and the scaffold

Some time ago, during a weekend on call, a young doctor called me to say that she was ill and probably needed to go home. When I went up to see her she was leaving the sluice, having just vomited. She had felt awful since waking up in the middle of the night. There was of course no question – “Go!” I said. She left, but reluctantly. There were tears in her eyes. She was embarrassed and ashamed. For being ill!

“But what about the jobs?” she asked. The list of tasks and patient reviews that she had picked up in the morning was enormous.

“Don’t worry, we’ll deal with it.” I said. But I knew we wouldn’t deal with it very well. There is rarely enough slack in a hospital, especially at the weekend, to easily accommodate the transfer of one person’s entire workload. As I watched her leave, encouraging her when she hesitated at the door, I thought oh dear, this is going to be a bad day. And it was, for everybody. There is no doubt that patients on the ward waited longer for the medical care that they needed that day, although I am equally sure that no-one came to harm.

I wondered what went through her mind when she woke up that morning? Perhaps…

‘I’ll manage…’

‘However bad I feel, the only thing that will really stop me is if I’m actually vomiting…’

‘Because I can’t not go in… I saw the handover list last night, there are 30 patients to see…’

‘… and they are worse off than me…’

‘You don’t call in, nobody does’

‘But what if I’m contagious – only if I’m vomiting… and I’ll be careful…’

‘They say we shouldn’t go in if we’re unwell, but they want us to, really…’

‘…because the work has to be done…the policy doesn’t account for that!’

‘I know how annoyed I feel when a colleague calls in sick… some just do it…’

‘I’m going in… I’ll see how it goes…’

 

In this post I am going to explore the decision to call in sick. Much has been written about the rather profound insights that doctors’ behaviour when ill provides, and I would strongly recommend Jonathon Tomlinson’s January 2014 blog post ‘When doctors become patients’ on the subject (of which a little more later). Here though, I wish to examine the milder end of the sickness spectrum, and specifically the apparent rise in short term junior doctor sickness.

 

Paradox

Why was it that the thought of going home made that doctor distressed? It is not usual for people in other walks of life to feel so upset when they have to take time off. Was it the thought of letting her patients down? I don’t think so. More likely it was a lack of confidence that the hospital would easily adjust to her absence, and a concern that chaos would ensue. Patients were at the centre of her thoughts, not as people, but as incomplete tasks that would create stress for her colleagues. Whatever the reasons, sickness was something that this doctor had clearly tried to stave off, until the inevitable viral emesis overtook her. Typical doctor!

Or perhaps I have got this all wrong – this doctor was actually atypical, because there is evidence to show that doctors are now taking more time off. According to a study performed in a single NHS Trust before and after the introduction of a 48 hour working week,

 

Taking into account the increase in trainee numbers, the proportion of junior doctors taking sick leave increased by 90% (p = 0.001), and the total episodes taken by 170% in the year following the implementation of EWTD-compliant rotas

During the study period, episodes of sick leave among junior doctors more than doubled with just over 1 in 3 taking leave in the year to August 2007 and nearly 3 in 4 the following year. The number of days taken and the number of repeated episodes of leave increased.

 

There appears to be a paradox here. On the one hand we know that doctors find it hard ‘be ill’ – Jonathon Tomlinson’s illuminating post (regarding chronic or more serious illness, including mental illness) describes internal blocks to accepting illness such as dissolution of the medical identity as healer, stigmatisation and shame. In the case of life changing illness there are even more subtle psychological factors at play, including loneliness and the insiders fear of modern medicine’s fallibility. Some of these probably apply to minor illness, albeit disruptive ailments that impair young doctors for 1 -3 days, but there is no denying that the threshold has dropped. Trainees are, in general, more comfortable picking up the phone to call in sick. What is the answer?

 

Presenteeism and indispensability

An Audit Commission report into medical staff sickness (2010) stated,

Another cost, closely associated with sickness absence but much harder to quantify, is ‘presenteeism’.

Presenteeism is the loss in productivity that occurs when employees come to work but function at less than full capacity because of ill-health. The cost of presenteeism could be as high as one and a half times that of sickness absence. This cost increases when the cost of staff turnover due to ill-health is considered.

The Boorman review interim report found that ’presenteeism is greater in those who work long hours and experience managerial pressure to return to work’. There is little available data on presenteeism but Boorman found that 71 per cent of qualified nurses and midwives in the 21-30 age group report presenteeism compared with 45 per cent of staff in the same age group in corporate services.

 

In my experience presenteeism (which I have interpreted as the tendency to come to work when ill, rather than the ‘cost’ of such behaviour) is driven not by external pressure, but by an internal sense of indispensability. Because healthcare workers are always busy and pressurised, this perception seems unavoidable. How can we not regard our presence as absolutely vital to the service?

Another illustration: although I minimised the concern for the experience of individual patients earlier, there are times when this does play on one’s mind. These are when the clinical commitment is a ‘one man/woman show’ with no prospect of internal cover. I remember arriving back from holiday a couple of years ago with a resolving, though still rather scary looking dose of conjunctivitis (picked up from a dodgy hotel swimming pool I think). The chance of getting a replacement at such short notice was zero, but the impact, of sending 16 or 17 patients away, was going to be huge. I visualised their expressions, and the difficulties they would face in rebooking within an over-pressed system. I decided, on their behalf, that they would rather have a hands-free consultation than be cancelled on the day. This was a classic case of perceived indispensability, in the context of a contagious illness for which occupational health would have had me quarantined!

If indispensability does feed presenteeism, could it be that trainees feel less indispensible now than before? I’m not convinced. Although shifts are shorter, they are probably busier. There is more to do on the ward, there are more frail and deteriorating patients, and the expectations of both patients and relatives are higher. Each team member is just a vital as before. This argument does not scan very well… but it does bring us to the idea of the ‘team’?

 

Team cohesiveness

The pre/post European Working Time Directive study comments,

Both shift work and reduced working hours may contribute to a loss of the ‘group cohesiveness’ provided by the traditional medical team.

This is conjecture, but it does chime with people’s general feelings. A vivid memory, for me, is the sense of team working that pertained during the early years of my training. At the end of attachments I pledged to stay in touch with various colleagues, strong bonds having been formed over several months in the forge of long hours, silly levels of fatigue and vital inter-dependency. Life has moved too fast to maintain all those relationships, of course, but the sense of fellowship at the time was real. Indeed, when I was a junior house officer my registrar said one day, ‘Take tomorrow off – we’re on top of things here. Take a Mental Health Day’. And how I enjoyed it! I would love to offer the same to my present day juniors now and again, but the idea of being ‘on top of things’ is laughable. Back then the team was fast… however, I’m not sure if this made me more or less likely to call in sick. If you know colleagues well, and they trust you in return, you may be more comfortable picking up the phone and excusing yourself. If you are part of a larger but more ephemeral team – brought together just for the weekend for instance – there may be less of an expectation that colleagues with whom you have an easy relationship will cross-cover without question or reproach. The ‘team’ in this case indicates a collection of individuals whom a rota has thrown together, not a group of mutually supportive colleagues. The leader of that team, the consultant, may not know who is on the team, so dispersed are modern shifts and responsibilities. Yes, there is less cohesion, but the link between that and a greater willingness to call in sick is not clear in my mind.

 

The scaffold

So far I have presented the internal debate that precedes the decision to call in sick as a battle of pro’s and con’s, but this neglects the person’s general state of mind. No enquiry into the subject of medical staff sickness can ignore mental wellbeing, and it is this (largely unspoken) issue that may provide the link. The rising problem of anxiety and depression among junior doctors has been described recently (in the BMJ)-

 

Head of the Practitioner Health Programme in London Clare Gerada has found that since the service began, an increasing number of doctors have presented with mental health problems — 195 in 2008/09, compared to 242 in 2012/13.

Significantly, Dr Gerada found that more than half — 55 per cent — of the patients presenting to the service in 2012 and 2013 were 25- to 35-years-old, while only 22 per cent were 46 or over.

‘It may be that job stress, rather than personality, pre-existing mental health problems or factors at medical school, are behind the mental health problems seen in newly qualified doctors.’

 

These small numbers represent a tiny proportion of the workforce, and do not explain sickness behaviour overall. But if it can be safely assumed that beneath those with manifest, admitted mental health symptoms there are hundreds and thousands more with sub-clinical or contained anxiety or depression, we can begin to understand how an individual’s threshold for calling in sick might fall.

A survey by the BMA (the 7th report of the ongoing cohort study) in 2013 found that 44% of 368 doctors thought that stress levels were ‘worse or much worse’ than they had been a year before, and one in five reported ‘unacceptable’ levels. 40% said that morale had worsened. The BMA said in response that working patterns had resulted in a ‘trial of endurance’. The stress that surveys like this elicit is hard to define. It is not necessarily a pathological thing, more an overtone, an absence of well-being, a reaction to never-met demand, or bewilderment at the Sisyphean nature of the task.

When you are sick, physically, the inclination to work depends on a more general sense of positivity towards the workplace, and a feeling that one’s efforts will be appreciated. If the individual feels unsupported, rarely acknowledged, an isolated cog in a huge automated machine, the likelihood of fighting what might be quite trivial or transient physical symptoms, and pushing them to one side, is likely to be smaller. If the supporting mental and emotional scaffold is weakened, the fortitude required to ‘push on through’ cannot be mustered. Perhaps this is the link between ‘team cohesiveness’ and the observed increase in sickness absence. There is mental disquiet, but it is rarely described in words – only absence.

 

Empowerment

Or, there is a more prosaic explanation… younger doctors have got over the traditional, undesirable trait of ‘illness-martyrdom’, of equating the acceptance of illness to moral weakness, and have instead been empowered to develop a more mature and assertive approach – I am ill, therefore I do not work. This suggestion is not backed up with evidence, but may be part and parcel of the generally welcome changes in medical culture that have flattened the hierarchy (a little), and made it easier for trainees to speak up and challenge their seniors. Training needs are vocalised. There is less awe and fear on the wards. Perhaps the thoughts of that (atypical?) young doctor should have been…

‘Face it, I’m ill… we all get ill.’

‘And if I don’t go in today, what will happen? Will anybody die? No.’

‘I’ve covered others, they will have to cover me – that’s life.’

‘I will feel guilty… perhaps that is just another part of being ill. It will pass.’

‘They know me. They know I wouldn’t do this if I didn’t feel absolutely awful…’

‘And if something happens, if the work is not done, and someone complains, then I’m sorry…perhaps it’s needed to demonstrate that we need more people, rather than working at maximum intensity all the time…’

‘You know I’m over-thinking this… where’s my mobile…’

‘Hello, Sam, sorry, it’s me Esther…I can’t come in today, I’m ill…’

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One comment

  1. Thanks for referencing my essay and for a typically thoughtful discussion.

    I think there are a couple of other issues.
    One is the loss of continuity of care. I’ve met trainee surgeons whose shift work means they won’t see a patient again after they leave the operating theatre and medical trainees who won’t review a patient they’ve admitted. As a junior doctor working hideous hours, one of the things that kept me going (and still keeps me going as a GP) is the enduring responsibility I have for patients. Without that, tomorrow is just another day.

    Another reason is the loss of continuity of professional relationship, explored by Duncan Caldwell http://onlinelibrary.wiley.com/doi/10.1111/j.1743-498X.2011.00456.x/abstract which you do discuss, but as well as undermining cohesiveness, it increases anxiety because trainees are less likely to have the supportive mentoring relationships within which confidence is gained.

    The final related reason is that assessment of students and trainees is so focused around competencies, that it completely fails to prepare doctors for the reality that the practice of medicine is complex, uncertain and ethically charged. Coping with this needs teamwork and time for discussion. The main factors that unite doctors that get into trouble are isolation and lack of insight, so a greater emphasis on team cohesiveness where anxieties can be safely and openly discussed is vital for the health and safety of patients and professionals.

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