After stepping down from my clinical work in November, I received a lovely card from one of my patients thanking me for being his doctor and expressing his hope that ‘my new doctor will be as nice as you’. Six weeks on, and we are no closer to finding a replacement, nice or otherwise! So, while I don’t regret cutting back on my work and dropping my clinics, I do feel both saddened and frustrated: my decision is leaving my patients unsupported, my colleagues stretched, and my secretary struggling to troubleshoot and keep things ticking over. I knew this was a possible, perhaps even likely scenario, but inevitably I feel some responsibility for that.
And yet, I am not indispensable.
Why doctors don’t take sick leave
A leader in this week’s BMJ highlighted how doctors tend to have much lower sickness absence rates than other healthcare workers (typically 1-1.5% compared to 4-5% for all healthcare staff). There are many reasons why this might be so, but one of the most significant ones is a culture in which doctors avoid taking time off sick so as not to let others down – whether their patients or their colleagues. This is admirable to a degree, and yet it betrays a deeper, potentially destructive culture of indispensability. We have a tendency to believe that the service won’t function without us. That, in turn, feeds a driven-ness that leads to long hours, apparent busyness and a kind of bizarre pride in always being overstretched.
This isn’t limited to doctors but seems to be a culture that pervades all professions.
It seems to me that this is an inherently dangerous and damaging culture. Clare Gerada, medical director of the Practitioner Health Programme, commented that
“a common personal impact on doctors who are ill is that what goes isn’t their competence, it’s their compassion for patients”
Being overstretched
I suspect the same is true, not just for doctors who are ill, but for all of us when we are overstretched. We can carry on performing our roles, but find it hard to offer that human touch: something that has perhaps been reflected in some of the scandals in care homes for the elderly and vulnerable adults in recent years.
I suspect that another element that goes by the board when we are overstretched is humility. When we are constantly struggling to get things done it becomes increasingly difficult to acknowledge our own limitations, to take time to reflect, to learn and improve, to accept our need of others. And ultimately, to recognise and value the very real contributions that we, uniquely, bring.
Ultimately what goes is also competence, though typically this comes some way down the line. The reality though is that a driven culture of indispensability threatens effective working and patient safety. I still remember the feeling, half way through a 104 hour shift as a junior doctor, sitting at a nursing station to calculate a drug dose, and realising that I couldn’t even think straight enough to carry out a simple 2-digit addition without the aid of a calculator, and recognising just how easily I could make a potentially fatal mistake.
That is why I am supportive of my junior doctor colleagues in their dispute with the government over a new contract. The proposed industrial action is not just about pay – I would find it difficult to defend if it were – but about patient safety, and about challenging this pervasive culture with all its inherent dangers.
Challenging the culture
And I, too, will continue to challenge it, in my small way, by attempting to live and work in a way that isn’t indispensable. I know I will continue to feel some responsibility for the gaps created by my cutting down my hours. But I know, too, that since doing so I have felt more motivated and inspired, and been able to give myself more fully to those aspects of my work which are continuing. I hope, ultimately, that will be of far greater benefit to my colleagues and to the children and families I am seeking to serve.