Presenteeism

Beata Chami, COC, MA, Organizational Psychology (biography, no disclosures)

What frequently asked questions I have noticed

Have you ever felt unable to make it to work, but disregarded the idea completely? These days, a common question either asked or assessed by healthcare organizations is to uncover the reason behind why doctors become unwell in their professional roles. Research suggests that there are a number of drivers associated with physicians feeling unwell, including presenteeism, which I studied closely. For the purposes of this research, presenteeism is defined as showing up to work when too unwell, or when experiencing other events that might compel absence (Chambers, 2015; Evans, 2004; Johansson & Lundberg, 2004).

Data that answer these questions

I did a qualitative study of BC physicians to determine the factors related to presenteeism behaviour. In-depth interviews explored the reasons for physician decisions to attend work when unwell or for other reasons that should have compelled them to stay at home. I evaluated how the physician’s role identity and workplace dynamics influenced their decisions. Professional and cultural norms were, unsurprisingly, important. However, other issues, such as thresholds of illness, and emotional responsibility factors emerged as additional reasons.

Workplace factors were the most cited reasons for physicians going to work when unwell. These included difficulty finding coverage for shifts, anticipation of workload upon return, and concern about the comprehensiveness of care that patients would receive in the physician’s absence.

Professional and cultural norms served as the second most frequent reason for presenteeism. Physicians’ felt that medical culture dictated that there was no tolerance for them to fall ill, and those who took time off were perceived as ‘weak’.

The study’s participants never referred to mental health problems as a valid reason for a physician to stay home from work.

Gender-related expectations also played a part. The female physicians interviewed expressed that they did not want their colleagues to think that by allowing a woman into medicine meant that the regular medical standards and expectations would not be fulfilled. The acknowledgement of this theme is alarming, particularly in the 21^st century, as there are numerous movements and initiatives promoting equal rights among both genders, particularly in the professional realm. For this reason, women in medicine can often shoulder a greater burden in needing time away, and can deal with a disproportionate burden of the repercussions of having done so. Our study found that female physicians experienced a great deal of stress balancing their maternal and professional duties. Statistics Canada indicates that women tend to take on most family-related responsibilities, such as child rearing and domestic work (Milan, Keown, & Urquijo, 2011). This results in women being more challenged in maintaining a work-life balance.

Finally, nearly all physicians cited the emotional obligation and duty of care they had to their patients, despite having a justified reason for taking leave. They went to great lengths to accommodate their patients and maintain the implicit promises that they had made regarding their health and well-being. For many physicians, the more vulnerable their patient population, the more they downplayed their own challenges by comparing themselves to patients’ circumstances.

What I recommend (practice tips)

1) Start with you & your team

The best place to start from is yourself: recognizing this mal-adapted behaviour, and role modeling the corrected behaviour among your peers in the workplace. This will in turn initiate the cultural shift in your work environment.

A key cultural norm in medicine highlighted within mine and other studies is that ‘doctors do not get sick’ and so their peers and the public often scrutinize their absence, even when faced with critical circumstances such as illness or family emergencies. This seems to be deep-rooted enough that physicians are unable to recognize when colleagues on their team are unwell and need to take time off to take care of themselves before their situations worsen.

In order to ameliorate medical culture, it is important that senior staff and management actively address presenteeism behaviour and send staff home when they are unwell, while openly discussing the rationale behind these decisions with their team when they are made (Rhodes & Collins, 2015). This leadership will help set a precedent for physicians in that work space, which will address presenteeism behaviour by demonstrating appropriate reasons for medical staff to stay home when feeling unable to attend work. It might also be helpful to identify like-minded physician champions on your team that will join you in communicating these changes in conduct.

2) Strategies for the office

Clear, written guidelines that state the expected threshold for work absences would serve as an objective measure of “being sick enough,” and might help relieve feelings of guilt when staying home. For those who need to cancel and reschedule clinics, information on best practices and pertinent information to pass on to locums would be helpful (Chambers, 2015). For medical students and residents, senior staff can actively address presenteeism and role model the appropriateness of taking leave when needed (Rhodes & Collins, 2015). Also, constructing a flexible resource pool of physicians who could cover non-rostered duties, and who would be available to cover unanticipated sick leave (Tan et al., 2014).

3) Engaging in systemic change

As a physician, your experience of the healthcare system and how it influences engagement in presenteeism behaviour has the potential to highlight the need for safer healthcare policies and practices. Therefore, advocacy for systems-based changes may reduce the occurrence of this phenomenon. It is no secret that influencing systemic change is a complex process; however, there are a number of organizations and committees within the medical community that have already established rapport with health authorities and governmental bodies regarding the improvement of physician health that can help:

1. Supporting Facility Engagement: http://www.sscbc.ca/physician-engagement/supporting-facility-based-physicians. As part of the Physician Master Agreement, we have a first of its kind in Canada initiative that supports engagement between physicians working in a facility and who are members of the medical staff, and Health Authorities. The aim of the initiative is to improve the working environment and ultimately patient care. Each hospital site has their own Facility Engagement group, and physicians are welcome to join whoever site they hold medical privileges.
2. Doctors of BC’s Regional Advisors and Advocates (https://www.doctorsofbc.ca/regional-advisors-and-advocates) are local team members in each region of the province whose role is to advocate for members, as well as to inform both members and key partners about the services and supports provided by Doctors of BC and to connect them with the right people. Other programs: https://www.doctorsofbc.ca/working-change.
3. The Physician Health Program (PHP) (https://www.physicianhealth.com) provides support, referrals and counselling for physicians in BC experiencing challenges such as relationship stress, mental health, career and life transitions, substance use, concern for colleagues, occupational health, and financial issues. PHP has a 24 hour helpline: 1.800.663.6729.
4. The Canadian Medical Association’s Wellness Ambassador Program provides an introduction to health policy and advocacy for medical students, residents and physicians in their first 5 years of practice. The program helps strengthen the next generation of medical leaders by engaging Canada’s newest physicians and physicians-in-training in discussions about emerging health issues, medical technologies and service models. To join the Ambassador Program visit: https://www.cma.ca/cma-ambassador-program.

References and/or Additional reading

1. Chambers C. Superheroes don’t take sick leave: Presenteeism in the New Zealand senior medical workforce – a mixed-method study. Published November 2015. Accessed April 25, 2019. (View)
2. Evans CJ. Health and work productivity assessment: state of the art or state of flux? J Occup Environ Med. 2004;46:S3–S11. DOI: 10.1097/01.jom.0000126682.37083.fa. (View with CPSBC or UBC)
3. Johansson G, Lundberg I. Adjustment latitude and attendance requirements as determinants of sickness absence or attendance. Empirical tests of the illness flexibility model. Soc Sci Med. 2004;58:1857-1868. DOI: 10.1016/S0277-9536(03)00407-6. (View with CPSBC or UBC)
4. Milan A, Keown LA, Urquijo CR. Statistics Canada. Families, living arrangements and unpaid work. Published November 2011. Accessed April 25, 2019. (View)
5. Rhodes SM, Collins SK. The organizational impact of presenteeism. Radiol Manage. 2015;37(5):27-32. (View with CPSBC or UBC)
6. Tan PCM, Robinson G, Jayathissa S, Weatherall M. Coming to work sick: a survey of hospital doctors in New Zealand. N Z Med J. 2014;127(1399):23-35. (Request with CPSBC or view with UBC)

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Presenteeism

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