In April 2021, I came across a Twitter thread started by Dr. Mark Reid (@medicalaxioms), which began as follows: “One thing we don’t teach you in med school or residency is how to call in sick.”
Dr. Reid shared a story from his past about not leaving the hospital after he’d found out about the sudden death of a family member. He reflected on the possible reasons he had remained at work (it was the only behavior ever modeled for him) and how we, as a profession, can do better in the future (we need to change the culture).
I found myself drawn not only to his story but to the numerous comments and retweets from others. Physicians and trainees shared the times they had stayed at work despite similar tragedies. Many commented about missing funerals and taking shortened (or no) bereavement leave due to the pressure to work instead. Many also shared stories about receiving some version of “The Speech” during med school or the start of internship. You know, the one where the chief or the attending tells you there’s no calling in sick unless you’re dead.
Collectively, from this thread, I learned that we physicians work not only through the deaths of family members, but many other heartbreaking scenarios. Acute illnesses of family members (even our own children). Deaths of friends or colleagues. Divorce. Personal acute illnesses including MIs, appendicitis, and viral syndromes necessitating rounding while being hooked up to IV fluids. And for women, working through ovarian torsion, ovarian rupture, active labor, pre-eclampsia, and miscarriages.
The overwhelming emotion I experienced from reading this thread was one of sadness, for the way we dehumanize ourselves — but also one of relief. Because for the first time, I didn’t feel alone about something from my past.
About 15 years ago, I had a miscarriage at work and didn’t tell my colleagues — working through it instead. When I saw the blood in the hospital bathroom toilet, I knew it signaled the end of the pregnancy, although I hoped it might somehow still be OK. I secretly called my ob/gyn, who arranged an ultrasound for the end of the day.
I finished out consult rounds in a daze, without telling anyone what was going on, and then crossed the street to outpatient radiology. The ultrasound confirmed a miscarriage at 9 weeks, and I was given a prescription for mifepristone — to “empty the contents of the uterus.” I took it on the weekend — of course, so I wouldn’t miss any work — and endured pain that rivaled “real” labor. (Before this, I’d had one successful pregnancy and delivery to compare to.) And then went back to work on Monday.
No one at work knew, and I pretended to myself like nothing had happened. I didn’t allow myself any space to grieve or have compassion for what my body was going through physically. I didn’t want to. I wanted to be superhuman and get back to work. Because that’s what we’ve all been trained to do.
It took me years to recognize I’d internalized a deep shame about this loss and this time in my life. For the “failure” of my body. And I’d always felt very alone with it. But coming across others sharing their experiences made me realize: Of course I’m not the only physician who’s been through something like this.
I’m far from the only woman (physician or otherwise) to have worked through a miscarriage. Yet, I’d never heard of anyone sharing this before. Why is that? Why do none of us talk about it?
Approximately 25% of women in the U.S. will experience a miscarriage. Having a medical degree does not provide us an exemption from biology. In the end, we are human, not superhuman, even if we’ve been trained to think otherwise. Half of us have female bodies; even if at work, we’re often made to feel we’re supposed to hide that fact.
Many of the comments in the Twitter thread were more hopeful stories of physicians and trainees sharing times when their workplace did support them with time off. Some people reflected on how they might have taken time off, only they didn’t know how to ask for it — or didn’t even think to do so — because of the medical training culture. This is exactly what I recall thinking back then. I was physically capable of work (I wasn’t dead), so according to “The Speech,” it never crossed my mind to ask for time off.
As I read through more of the comments, I re-lived other occasions I’d been guilty of working when I shouldn’t have been. In a later pregnancy (I would go on to have a total of six pregnancies — three ended in miscarriage — and have three living children), I suffered from hyperemesis gravidarum. To help me keep working, one of our clinic nurses would start a peripheral IV in my arm and infuse a liter of saline each morning. Then, another liter again at lunch, and sometimes, if I hadn’t been able to keep anything oral down all day, another liter again after my last patient. (This arrangement occurred after I went to the department head only after a friend convinced me I was more ill than most of my patients. I asked for medical leave. His “solution” was the daily IV fluids plan.) I remember one day when my sleeve slipped up while examining a patient, and I was terrified she’d seen the IV in my arm. But she either didn’t see it or politely didn’t ask.
Another time, my father had an MI, and I didn’t go see him in the hospital. I got the call as I was heading into the clinic. He’d been stabilized, and both of my parents told me to stay at work, that they didn’t need me to come. He’s thankfully well now, but I still feel guilty that I didn’t leave my practice to check on him in the hospital. My excuse was that I was the only oncologist in my rural practice at the time. If I’d have left, patients wouldn’t have received their chemotherapy. But how much could my mind have been on my work that day?
Lastly, years ago, I was flat-out denied time off to go to a grandparent’s funeral (a common occurrence in the Twitter thread comments). I accepted this as the status quo. After all, it wasn’t a first-degree relative.
So, what does the future hold? Currently, there seems to be a lot of talk about whether COVID-19 has changed the culture — not just in medicine, but in the U.S., in general — of “toxic presenteeism.” For the first time, if we feel ill, we’re told to stay home — with symptoms that wouldn’t have raised an eyebrow to show up and work through in the past. Symptoms which we would have, in fact, been expected to work through in the past.
My hope, moving forward, is that “The Speech” — about continuing to work through anything and everything short of total physical incapacity — will disappear from medical culture forever. It doesn’t make us stronger people, or better doctors, to deny our frailties. We, too, have human bodies. These bodies bleed, grieve, give birth, miscarry, fall ill, and sometimes fall apart. Same for the people we love. We would be lesser people — and doctors — if we continue to deny that. Or worse, deny that it affects us.
How have you shown "toxic presenteeism" as a clinician? Share in the comments.
Jennifer Lycette, MD, is a medical oncologist in rural community practice on the North Oregon Coast. Her perspective essays have been published in NEJM, JAMA, JCO and more. Dr. Lycette was a 2018–2019 Doximity Author, a 2019–2020 Doximity Op-Med Fellow, and continues as a 2020–2021 Doximity Op-Med Fellow. You can find more of her writing at on her website, and follow her on Twitter @JL_Lycette. Opinions are her own.
Illustration by April Brust