Reciting the Declaration of Geneva to enter the field of medicine can feel like a marriage pact.
In the last year, the COVID-19 global pandemic has operationalized the boundless limits of this pact as thousands of physicians have been on the front lines taking care of patients. By the end of last year, well over 2,900 health care workers had died due to COVID-19. The pandemic has also allowed presenteeism –the phenomenon of feeling like you must always be available to work despite personal challenges — to resurface in medicine.
Maybe it is time for some couples therapy.
Throughout this pandemic, physicians were expected to adapt to health care surges by working overtime amidst personal protective equipment shortages. Health care workers felt like they were under “extreme pressure for long hours without breaks.” Many physicians caring for COVID-positive patients actively separated themselves from their families in order to continue serving patients. In a message sent by one health system during one of the first pandemic peaks, providers were even directed to keep coming to work until they personally needed to be admitted. Besides directions from the system, what else motivated this dedication? A nurse working in New York cited an internal drive to push herself to work harder and longer than she was capable, even going to work while feeling ill.
Therefore, it is not just the external force of COVID that encourages the need to show up despite personal challenges. Rather, presenteeism is an innate part of the medical profession. In a JAMA study of resident physicians, over 60% reported coming to work while sick, and this presenteeism increased with each year of training. Another study in 2014 showed that while 95% of health care professionals understood that coming to work while ill was a risk to patients, over 80% showed up to work while ill at least once in the year before. Reasons for this behavior included not wanting to let other colleagues down and fear of ostracization from colleagues. Essentially, the culture of medicine expects providers to come to work unless very sick.
Presenteeism does not simply exist for seasoned providers; it seeps down the medical training pipeline and perhaps poses the greatest threat to trainees at the start of their careers. The fear of missing out as the “beginner on the team” can be paralyzing when there is so much important knowledge beyond us. Such pressure persists longitudinally, too, as trainees at every level fear that taking time off will appear as a lack of dedication to clinical education or will result in lower performance evaluations.
For novice medical students like myself, who started school semi-virtually in the COVID-19 pandemic, there is the extra stress of having fewer in-person patient care experiences and feeling obligated to maximize them. I report at a general internal medicine clinic biweekly, and one week in October I had my assigned shift on the Thursday afternoon before an exam. In addition to the universal stress that impending evaluations can trigger, I was not feeling well, although I had tested negative for COVID just the day before. Due to my symptoms, I seriously considered missing my clinic obligation.
Thankfully, I attend an institution that is very supportive of students, but I was still terrified of missing content. As the youngest student on my clinical team, I had almost nothing to offer and everything to learn. I did not want any of the older medical students, my faculty preceptor, or the administrative coordinators to wonder if I was feigning illness due to an impending exam. I also did not want them to perceive my absence as a lack of grit, something that seems to be central to most providers’ personalities. So, I showed up.
After loading up on medication, teary-eyed, I donned a mask and headed into the clinic. I was able to see patients and learn, but I was not performing as well as usual. Reflecting back, I feel I would have learned more and been more beneficial to the team if I had called in sick and rescheduled my shift. Additionally, when I went home, I was utterly exhausted and unable to do last-minute preparation before my examination.
It is clear that providers of all levels in the medical field prioritize taking care of patients, as demonstrated by dozens of my peers signing up to become COVID vaccinators days after receiving their vaccinations. Importantly, however, there is a distinction between a) providing care in a high-risk situation while maintaining personal wellness and b) feeling forced to work despite feeling ill.
Presenteeism can also add stress to the daily decision-making of providers and can exacerbate burnout. Providing care within a high-pressure framework can be dissatisfying and exhausting over time. The suboptimal performance that presenteeism cultivates also directly compromises the quality of care that is provided to patients. Patients are at risk of exposure to the pathogens that providers may carry while they are also at risk of experiencing medical errors that come with poor provider functioning.
The culture of presenteeism needs to be addressed, starting at the level of first-year medical students. Medical students should feel supported in taking a day off when they are unable to meet their obligations throughout their training. Preceptors and faculty members should engage in building inclusive institutional protocols related to student illness. The archaic fear that trainees may attempt to exploit excusal policies is null. We are entrusted to make medical decisions for our patients from week one. Can we not be entrusted to make such decisions about ourselves?
Trainees should also be educated on presenteeism to understand its relationship with burnout and learn about the negative effects that this cycle can have long-term. This can be facilitated through curricular seminars on presenteeism led by committees on wellness, which have already been instituted at some medical schools. This model can be expanded across the provider pipeline with employee wellness task forces and continuing medical education (CME) opportunities regarding presenteeism.
The COVID-19 crisis has provided a voice for health care workers and demonstrated the inordinate sacrifices that they make to care for patients. It has also shined a light on the toxic culture of presenteeism that systematically erodes agency in all levels of medicine from the moment we enter the profession. By educating students about presenteeism early in their training, we can change the culture of presenteeism and create a generation of physicians who consistently maintain a high standard of care — for their patients and for themselves. By reducing (and maybe eliminating) presenteeism, we can form a more compassionate health care community that looks out for its workers in addition to patients.
While we may “marry medicine” on day one, while we may care for our patients in sickness and in health until death does us part, we must also remember to prioritize our own wellness as individuals.