• Do No Harm: When Is a Physician Too Sick to Work?

    A recent study published in JAMA Pediatrics found that the vast majority of physicians have gone to work sick -- even though we know we shouldn’t.

    Included in the study were attending physicians, nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists and nurse midwives who work in a hospital setting, although some also worked outpatient. Ninety-five percent of respondents acknowledged that working while sick puts patients at risk, yet 83 percent reported working while sick during the past year. The study, which was initiated by a hospital's infection control staff, was done in an attempt to determine why we do this.

    A physician looks at a digital thermometer. More than 80 percent of health care professionals go to work while sick -- despite the risk to patients and colleagues.

    The leading reason given for working while ill was not wanting to let colleagues down (98 percent) followed by not wanting to let patients down (92 percent) and the need for continuity of care (69 percent).

    System-level challenges were found to be at fault, as well.

    There also were complaints about sick leave policies -- either the lack thereof or the inability to utilize sick leave because of logistical difficulties or because no other providers were available for coverage. Overall, study participants generally noted that it was simply easier to work while sick than to overcome these barriers.

    We have created a culture where working while ill -- despite our better judgment -- is not only accepted but expected.

    The study's conclusion noted that more research is needed regarding what specific illnesses constitute danger to patients. In other words, when are we too sick to work?

    We all can probably think of times when we or a colleague should have stayed home, with some situations being more reckless than others. However, we rarely make our sick colleagues leave, and sometimes I think that would be the only way one of us would admit to being too sick to work.

    Resident presenteeism has been studied, and the results aren't pretty. The Accreditation Council for Graduate Medical Education mandates that programs have sick leave policies, and some programs have a back-up call schedule, someone who is on call to be on call, so the difficulty of finding a person to cover is eliminated. But personally, even when I have been in such a situation, I didn’t use the back-up resident; I kept working.  

    Intern year I was sitting at a computer typing an H&P when I felt I’d been shot in the neck. I had just finished rounding, the attending was sitting beside me and for a few minutes I tried to keep typing as if nothing had happened. But then he asked me a question, and I had to turn my whole body to look at him. I realized this was not just a little neck pain. This was going to stick around awhile. I thought it was probably just because I was tired. I had flown back from an AAFP meeting less than 24 hours before that call shift, my last one on this service for the month. I took some ibuprofen, which prompted the attending to ask if I felt OK. Of course, I replied with something to the effect of, "Yeah, I'm good."

    He left for the night, and a few hours later I found myself walking through the hospital with my eyes barely open because the light made my intense headache much worse. I was walking as if I was trying to sneak up on someone so as not to jar my head with each footstep. I met up with my senior resident for the night to discuss an admission, and he asked, "Are you having meningitis right now?" My answer, "I hope not."  

    A couple of hours later I was at home with a fever and vomiting, realizing that regardless of what I had hoped, this was likely viral meningitis. I had been exposed to multiple patients with a few different types of viral meningitis, and mine resembled enterovirus. I still have hearing loss and a new respect for people with chronic migraines.  

    We collect these stories like they are something to brag about, but we should be embarrassed. I worked under residents who told stories of starting IVs in the call room on each other because they had been vomiting for so long that they were more dehydrated than most of the patients we were admitting. One of my ER attendings finished a shift with appendicitis before signing himself in for treatment. These were my role models, people I respected and wanted to respect me.  

    But just as the JAMA Pediatrics article concluded, there needs to be a threshold we do not cross. There is a point at which the risk to the patient is too great for us to go to work just because we can manage to put one foot in front of the other and walk through the door. Unfortunately, this behavioral pattern we display as physicians goes beyond being sick. It runs throughout every part of our training and later our obligation to function as essential employees who drive through the snow, go to work when there is no power, and treat patients in disaster settings. We go to work when people need us because it's what we do.  

    More well-constructed studies about disease transmission from physician to patient would be great. But at the same time, we are doctors, and we know what is contagious. We know when to tell patients not to go to school or work, despite sitting there working in the exam room with the same diagnosis as the patient.  

    I am motivated to work when sick if patients would otherwise not be seen. That is a deal breaker for me. But I expect my nurse to stay home if she is sick. During a flu epidemic this past winter, I had her swab herself three different times in one day hoping one would turn positive because I suspected she was too sick to work. I didn’t think I could convince her to go home otherwise.  

    Flu is a good example of a success regarding medical sick leave. Everywhere I have worked there has been a policy that if you test positive for the flu, you are off work for five days -- no exceptions. That is evidence that we can make sick doctors go home when the risk is too great to the patients and staff.  

    Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.


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