Introduction

Illness Presenteeism (IP) is generally defined as the practice of going to work while experiencing poor physical or mental health [1] which can range in severity and acuity [2]. Although present in many professions, IP is more prevalent among healthcare workers (HCWs) compared with non-health-related occupations [3,4]. According to the 2010 European Working Conditions survey, 40% of the general population engaged in IP in the year prior to the study [5]. Similarly, a 2010 study of HCWs in New Zealand found that IP occurred in 48.7% of respondents. Remarkably, when compared to other HCWS including physiotherapists, nurses, and social workers, physicians were found to have the highest incidence of IP at 76.9%. Some studies report even higher numbers, with up to 80–90% of physicians reporting IP [6,7]. Thus—despite the potential adverse effects on patient care through the spread of contagious diseases, medical errors, worsened physician-patient communication, and decreased workplace productivity and efficiency—physicians appear to be the most frequent and notable “culprits” when it comes to IP [3,8,9]. Problematically, although it may also impair physicians’ and trainees’ personal health [9,10], IP has largely been overlooked in reforms or interventions aimed at addressing the well-being crisis in medicine.

The cultural milieu of medicine may provide some insight regarding higher rates of presenteeism among physicians specifically. Physicians sometimes identify as “anomalous patients”, viewing themselves as distinct from “ordinary patients” because of inherent power differentials in the patient-physician relationship [11]. Field et al. have recently shown that attending and resident physicians were reluctant to recognize the negative impact of working while impaired by fatigue despite evidence pointing to problems with patient care [12]. The competitive work environment seen in medicine may have a role to play in IP as well [13]. In a comparative study of IP among physicians in four European countries [14], a higher prevalence of IP was seen in Italy when compared to Sweden, Norway, and Iceland. Attendance and productivity pressures may account for differences. Using publication output as a surrogate measure, the higher prevalence of IP in Italy was associated with a more competitive work climate, with Italian physicians reporting more than twice as many published articles as physicians in other countries. Given these sociocultural factors within medicine, it is unsurprising that IP is also prevalent among physicians in training [15,16].

While IP is a longstanding practice in medicine, recent events have sparked renewed interest in this phenomenon. Physician health and well-being have accrued more attention in recent years, with a heightened focus to improve residency curricula and more research being conducted on burnout prevention and wellness [17,18]. In addition to this, the recent onset of the coronavirus disease 2019 (COVID-19) pandemic raised the stakes of transmitting a respiratory illness [19]. Indeed, during the height of the pandemic, policies were enacted that strictly forbade physicians from presenting to work sick to prevent infectious spread [20].

Existing research on IP has explored different aspects, including its prevalence [12], significant reasons and risk factors leading to presenteeism [2,3], and its associated consequences such as the potential compromise of patient safety due to impaired judgment, decreased functioning, job burnout, and loss of work productivity [9]. Three recent reviews focused on specific aspects of IP but precluded a fulsome understanding of this phenomena within the medical education context. The first is a narrative review [1] that summarized risk factors and economic and health consequences of IP in HCWs. Some contributing factors identified included the values entrenched within medical culture such as competitiveness, the idea that HCWs never fall ill, lack of medical resources, and strict sick leave policies [1,3,21]. However, this narrative review from 2019 provided a limited overview of the topic, restricted the search to a single database (PubMed), used limited search terms, and did not use an information specialist. The second systematic review [22] focused on specific questions on how to measure both the contributing factors to and outcomes of IP among hospital physicians and nurses. It provided a comprehensive tally of measurement instruments and workplace-related theoretical frameworks used in some studies they reviewed, it provided limited insight into the problem. Finally, a third review was not limited to physicians and studied IP with infectious illnesses in various occupations (this included HCWs of which some studies involving residents and medical students were included). While it provided insights on the self-reported motivations for infectious IP, the heterogeneity within the study limits our ability to translate these findings within a medical education context. Thus, although recent reviews on presenteeism do provide some insights, they were either of poor methodological quality [1] or were of narrow scope [3,22] and consequently did not provide an overview on the general state of the literature regarding IP among physicians. Moreover, these reviews primarily highlighted HCWs in general rather than focusing on physicians and physician trainees. They also do not account for pandemic-related shifts in IP perceptions and behaviorsIP in medicine demands attention, but thoughtful and robust research depends on first understanding the current state of knowledge. And while reviews on IP exist, their scope does not sufficiently capture a clear understanding of IP within the medicine and the medical education context in the current social context described above.

Materials and methods

We will use the Arksey and O’Malley scoping review framework [24] with additional insights from Levac and colleagues [25]. We will follow the PRISMA-ScR checklist (S1 File) for reporting scoping reviews [26].

Discussion

To our knowledge, this will be the first scoping review exploring the illness presenteeism amongst physicians and physician trainees. The identification and data synthesis will involve several databases including MEDLINE(R) ALL (OvidSP), Embase (OvidSP), APA PsycInfo (OvidSP), and Web of Science to reduce the risk of potential missed publications. This will be supplemented by relevant grey literature that will enrich our data further. To clarify, while we realize the scope of grey literature is limited, the organizations chosen were what the authors were most familiar with as it was not feasible to do a search of every international physician organization. The study will adhere to the steps outlined by Arksey and O’Malley and the PRISMA-SCR checklist to ensure rigour in our review. This study will be limited to English-language studies which may limit generalizability and bias results. This review may not find solutions to the phenomenon of IP but may better define the literature and the problem to contextualize future studies.

IP is a challenging issue in medicine and medical education as it deals with complex tensions and interactions between the health and wellbeing of physicians, their colleagues, and their patients. This phenomenon affects most physicians and is relevant to the current discourse of physician wellbeing and the COVID-19 pandemic. We anticipate that our findings will not only inform future research but will also raise awareness about—and challenge—sociocultural norms and behaviours like IP that may impair the well-being of physicians and trainees alike. Our scoping review may reveal structural biases or inequities that advantage and disadvantage certain individuals when navigating decision-making around whether to presenting to work when sick.

Supporting information