Presenteeism: Symptom of an ailing practice model for Canadian physicians?

It is widely recommended that individuals who are sick should stay home from work (1). The primary intention for such a practice presumably is to protect the welfare of the individual worker. Most notably relevant to our discipline is the concern surrounding the spread of infection to co-workers and patients and the population at large (2). However, in some cases, individuals who are sick do not heed this recommendation to stay home and continue to work. In this article, we review some of the underlying concepts and evidence surrounding the effects of this “presenteeism” with specific reference to infectious diseases and Canadian physicians.

Presenteeism may be defined as the act of individuals who are sick (or who have a condition otherwise resulting in underperformance) presenting to and/or continuing to work (3,4). There are many potential reasons for individuals who are sick continuing to work. These are not limited to income loss, lack of replacement staffing, concerns about resulting burden on patients, clients, customers, or co-workers, and competitive disadvantage. Potential reasons for presenteeism vary to a degree by occupation and workplace environment. Physicians notably cite difficulties in finding replacement workers, continuity of patient care, and professional and organizational culture as major contributors (4–6).

Physicians are recognized as high-risk groups for presenteeism (3). There is a paucity of data about the occurrence and determinants of presenteeism, specifically among Canadian health care workers including physicians. In one survey conducted among pediatric resident trainees in Canada, 61% of respondents reported an illness within the previous 2 months, and 97% of these individuals continued to work (7). Surveys conducted in the United States indicate that almost one-half of health care respondents report working with influenza-like illness, with higher rates observed among those working in hospitals and among physicians (8). Data from the United Kingdom indicate that physicians take one-third to one-fifth as many sick days as other health care workers (9). In a survey conducted in a tertiary care hospital in New Zealand, 82% of physician respondents reported presenteeism (6). One Swedish study of general practitioners found higher rates of presenteeism were reported in females, citing workload and concern for others as determinants for women, as compared to financial and capacity concerns for men (10).

For many physicians, there are major disincentives to be absent from work for non-disabling illnesses. Most Canadian physicians are paid through fee-for-service models, whereby days off will result in full loss of income. Also, in many cases, a net loss may further result since the requirement to pay for office overhead remains while absent. It is our anecdotal experience from working in different areas of Canada that physician understaffing is commonplace. As a result, opportunities for coverage by another physician are often very difficult, if not impossible, and a physician absence would lead to cancellation of patient care services or transferring patients to crowded emergency departments or other institutions. Even in the case where there may be urgent coverage offered by a colleague, in areas that do not have the luxury of a generously staffed service the sick physician will inevitably feel obliged to “pay back” such covered days that could, in turn, lead to loss of previous holiday or leisure time, or excessive after-hours or on-call work.

Presenteeism can have a number of adverse effects (4). Paramount is the adverse impact on morale and the overall health of the sick individual. Working while sick can be a major contributor to burnout, and neglect of health conditions could lead to subsequent amplified adverse effects on personal health. Working while sick increases the chance for medical errors. Also, specifically with infectious diseases, the potential to cause harm through the transmission of pathogens to at-risk patients and co-workers is a major consideration.

Presenteeism has been well studied with respect to influenza, particularly in terms of the risk for transmission to patients and co-workers as well as for the associated productivity losses (8). Based on a systematic review, it is estimated that approximately 20% of weekly contacts occur while working and that an average of 16% of influenza transmissions overall occur in the workplace (1). An American study estimated that 12% of H1N1 influenza transmissions were workplace-related and 5 million influenza-like infections were attributable to a lack of paid sick leave in 2009 (11).

There is much less data quantifying the effect of presenteeism with the spread of other infections. A range of other respiratory and gastrointestinal viruses, as well as bacterial infections including Clostridioides difficile infection, can be spread in the workplace. In one illustrative example, Widera et al reported on a norovirus outbreak at a 100-bed long-term care facility (2). In this case, an infected health care worker was among the index cases with three residents. More than 40 subsequent cases occurred among residents and workers, and a number of workers were discovered to be working while sick. Although the outbreak appeared to have ended after approximately three weeks, a further case in a presentee worker was identified and associated with three more sick residents. Implementation and enforcement of strict “stay home while sick” rules ended the outbreak.

As previously noted, there are major disincentives for most Canadian physicians to take unexpected days off due to non-disabling illness. Our experiences suggest that short-term physician sick leave for acute illnesses are truly rare events and presenteeism is the norm. Quite simply, our duty for patient care coupled with lack of replacement staff, potential burden on co-workers, and risk for “payback” grossly outweigh the miserable experience of working while sick—although, in reality, this should not be considered in any way a reasonable or justifiable practice.

So, what needs to be done to minimize physician presenteeism in Canada? We should first examine our own culture of “responsibility.” As physicians, we willingly accept a degree of personal sacrifice to help our patients. We do, however, need to look carefully at the line that divides what reasonable professional responsibility might be balanced against both real and perceived patient needs. Indeed, one of us vividly recalls an experience in training where our attending physician was admitted to hospital and continued to round on his inpatients with his IV pole in tow.

A second major consideration is that we need to have enough human resources to allow a degree of “luxury staffing” such that when a physician needs to take a few days off work due to illness this does not result in crisis or impairment of patient care. Furthermore, when we require some days off work due to illness, we cannot either feel obliged personally or professionally to pay this back through overbooked clinics, make-up call, or loss of holiday time.

A third consideration is that we need to be granted at least some of the basic protections that employed workers enjoy, including limits on workload, shift durations, paid sick leave, and protected holiday time. Perhaps in the interim, until such items may be awarded, within our own physician groups we should at the very least have an explicit written agreement in place to offer an action plan for coverage of sick colleagues. It also seems reasonable for medical leaders to confidentially survey their colleagues as to whether they have committed presenteeism, to explore its determinants, and to design and implement means to reduce its further activity.

Most physicians in Canada practice within a publicly funded, privately delivered model of care whereby physicians are private enterprises with revenue that is almost exclusively from government fee-for-service payments. We are led to believe that this is a “best of both worlds model” that has the merits of independence and autonomy of practice coupled with essentially guaranteed payment for services rendered. There are likely many physicians who feel this way. However, we contend that this model is mainly responsible for physician presenteeism that, in turn, is a symptom of the practice model that is failing many of us. Hypothetically speaking, how many physicians who were working as employees of an organization that paid a salary commensurate with skill and training, ensured adequate physician-to-patient ratios, had standard 8-hour work days with set breaks, and employer-sponsored sick leave, pension, and medical and dental plans would choose to present to work sick?

Competing Interests:

The authors have nothing to disclose.

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