It is Tuesday morning, and I drag myself out of bed after a very restless night. It is day number three of a syndrome of fatigue, headache, and moderate productive cough. I have been on service for eight days of a two-week stretch; I am hoping to “make it to the end of the week.” I convince myself I am “not that sick” and head into work for a long day of rounds, after two cups of coffee and 600 mg of Motrin. Throughout the day, I try to hide my cough from my residents and students, and especially the nurses and my patients. I have a pocket full of cough drops and a cup of ice water at hand to stifle any coughing fits that could reveal how I actually feel. This is not the first time I have come to work only “half well.” I convince myself I am not contagious, as long as I wash my hands and control my cough. Without a fever, how could I possibly justify calling in a colleague to cover for me?
I am not alone in my psychological justifications for coming to work. A recent JAMA Pediatrics article found that 83% of clinicians admitted to coming to work while sick, while 95% admitted to knowing that it could be dangerous to their patients.1,2 The study surveyed approximately 500 attendings and 250 advanced practice providers at the Children’s Hospital of Philadelphia. A substantial minority of providers (9%) admitted to coming to work sick at least five times in the past year.
The reasons these providers gave for working in spite of being ill likely ring true with each and every hospitalist in the field: They were concerned about 1) letting down their patients or 2) hospital staffing in their absence. Most providers also expressed concern about the continuity of care for their patients in their absence. Most also admitted that they feared being ostracized by their colleagues and believed that there were unwritten but real expectations for them to work regardless of personal illness.
Historically, physicians and other healthcare providers have been widely believed to be relatively immune to mundane ailments, by themselves and by others. How incredibly rare it is to hear, “Sorry, your doctor is sick; we have to reschedule your visit.” Even when afflicted by physical impairments, physicians have long considered it more “honorable” to work through these infirmities than to resign to physical limitations and ask for help.
Misguided or Mishandled
This sense of duty starts early in medical training and continues throughout a physician’s early career. I discovered this firsthand during my internship after suffering a stress fracture in my foot. I woke up one morning with significant foot pain and swelling but hobbled through rounds without a word spoken about my limp. By the afternoon, I could hardly bear weight on my foot, so one of my fellow interns suggested I limp over to the orthopedic clinic; thankfully, they saw me the same day, diagnosed the stress fracture, and fitted me in a walking cast. The next day on rounds, when I asked my attending if we could take the elevator up the two floors to the next patient, he looked annoyed and said I could meet them there; they scurried up the stairs. For the next few weeks, I never missed a minute of work but kept trailing behind and missing key pieces of presentations and information from rounds, having to hobble back and forth to the elevator between floors.
The lesson I quickly learned back then was that if I was not “fit for duty” with any sort of physical ailment, it was clearly my problem to make up for my deficits, because the work expectations would go unchanged. Although a stress fracture did not put my patients at risk, the experience sent a strong message: Regardless of the impact on patients, it is always better to come to work than to stay home, whatever the type or degree of affliction.
The JAMA Pediatrics study did find substantial differences in the types of symptoms that would keep a provider at home: While 75% reported they would come to work with a cough and rhinorrhea, 30% would come with diarrhea, 16% would come with a fever, and only 5% would come with vomiting.
To be honest, this sounds about right in comparison to what my threshold would be, and it is about what I would accept as reasonable from a colleague. I do hope that if I were “really sick,” with fever and/or vomiting, I would have the good sense to stay home and ask for coverage, and I hope my colleagues and I would support each other in these decisions.
The study really gets at the sociocultural factors that steer physicians into making such decisions, based on the conditions for being excused that they think are socially acceptable. I suspect these are similar to those that other industries would also consider acceptable. But, of course, the difference is that workers in other industries are less likely to cause harm to large numbers of vulnerable and innocent “bystanders.” Adding to the problem, there is no good “definition” for what is “too sick”; although it is complicated and varies by person, the definition should at least take into account the level of potential contagion and risk to patients.
The authors suggest that, in order to remedy this longstanding situation, open dialogue needs to take place among physician groups to reduce the ambiguity about what is appropriate. A good start would be the generation of clear policies that restrict providers from coming to work with specifics signs/symptoms.
As hospitalists, we should all discuss the article within our groups and honestly determine in advance what our “code of conduct” should be for illnesses, based on our provider mix and our patient populations. (Decisions for ICU, medical-surgical, or oncology may vary.) This would reduce ambiguity and create new social norms about when to stay home. In addition, administrative and provider group leaders need to show strong leadership and support for such policies and ensure adequate staffing in the event of appropriate callouts. Such policies need to ensure that callouts are equitable and non-punitive. These relatively simple measures would go a long way in reducing the risk of illness among ourselves and our patients.
- Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: A mixed methods analysis [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0684.
- Starke JR, Jackson MA. When the health care worker is sick: primum non nocere [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0994.