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Driven by a traditional work culture that underscores their responsibility to patients and commitment to coworkers, physicians will show up for work symptomatic and sick, even if they have laboratory-confirmed influenza, researchers reported recently in San Diego at the 2015 IDWeek conference.1
In an anonymous electronic survey of medical students, residents, fellows, and attending physicians, 96% said they would work despite cold symptoms; 78% would report despite diarrhea; 55% despite vomiting; and a surprising 36% despite test-confirmed influenza.
Among those with fever, 84% would work despite fever up to 100.9°F; 49% despite fever of 101-102.9°F; and 24% despite fever ≥103°F. The physicians’ willingness to enter immunocompromised neutropenic patient rooms was 47% for cold symptoms; 29% for diarrhea; and 13% for fever ≥101°F.
The 474 physicians responding included 88 medical students, 193 residents, 40 fellows, and 153 attending doctors. Surgeons and emergency room physicians were the most likely to show up regardless of condition. While the interdepartmental findings may vary by institution, the overall finding of physicians willing to work while sick is probably similar in other facilities, says Shruti K. Gohil, MD, one of the authors of the study and associate medical director of Epidemiology & Infection Prevention at the University of California Irvine School of Medicine.
“We got a pretty good slice of the pie with a 61% response rate,” she tells Hospital Infection Control & Prevention. “I do think in many different institutions that the general themes — not the interdepartmental parts — but the general themes of physicians coming to work [sick may be occurring]. Intuitively, that was not surprising to me.”
Hospitals need to have clearly stated policies with the support of physician leaders outlining when sick doctors are expected to stay home. For example, the policy developed at Cal Irvine in light of the study calls for physicians to stay home if they have any of the following:
It goes without saying that physicians working with an infectious disease pose risks to patients and coworkers. Of course, as physicians, the respondents were presumably well aware of this. Yet less tangible factors combine to coerce doctors — particularly those with less training — not to miss work even if sick. For example, there were significant differences in willingness to work despite confirmed influenza by training level, with residents most likely (36%) and attendings least likely (9.1%) to work if ill.
Reasons cited for working while ill included:
Distinguished epidemiologist William Schaffner, MD, who was not part of the study, gave a personal example of this phenomenon in Nashville this year at the annual conference of the Association for Professionals in Infection Control and Epidemiology.
“Before you get sick [with influenza] you are already transmitting infections to others,” said Schaffner, professor of preventive medicine at Vanderbilt University. “The only way to prevent that is to be immunized on the front end. There’s also this issue about ‘when I’m sick I’ll stay home.’ Yeah, good luck with that. We all know that doesn’t happen. People come to work while they are sick. I remember vividly when I was a resident I had influenza and I had a temperature of 103. I was a macho young guy and sure enough I showed up ready to go to work and do my shift. My chief resident took one look at me and wisely sent me home. Having done that, I know that others do that. Healthcare workers do come to work sick. It happens so frequently that they have a name for it — presenteeism.”
In the physician survey, 70% of respondents identified the following key factors that would improve their willingness to stay home if ill:
In the absence of such policies, infection preventionists should be aware that their physicians might be caring for patients despite having fever, diarrhea, vomiting, or flu-like illness. Again, fixed protocols and a supportive work culture are needed to lower the risk to the patients and co-workers of these presentee physicians. Gohil agreed to elaborate on the findings in an interview with HIC, which has been edited for length and clarity.
HIC: Was there a reason you focused on physicians rather than healthcare workers in general? Is there an indication in past research or anecdotally that physicians are more likely to work while ill?
Gohil: We knew that physicians have a strong work ethic and the culture of medicine is somewhat different than that of other professions. The consequences of absenteeism in our work can really have significant impact. If you think historically about the profession [including times when] both hospitals and physicians were few and far between, you can see that the culture is to work long hours regardless of our own personal needs. Sometimes our work necessitates absolute concentration on our patients and their needs, and this can be at the expense of us paying attention to our own needs.
HIC: The most surprising finding to me was that more than a third (36%) of physicians would work with test-confirmed influenza. That suggests that the infection control community has yet to make a convincing enough case that infected workers can transmit flu to vulnerable patients and supports the argument that mandatory vaccinations are necessary.
Gohil: Absolutely — getting the flu vaccine is important, as is keeping all of healthcare workers highly compliant for vaccines for preventable illness such as measles. Measles is the most contagious virus that we know of. Keeping you titers up and complying with all occupational health policies are critically important for this reason. This is not just related to willingness to work, but as a healthcare worker keeping yourself healthy is critical.”
HIC: Those that would enter the room of a neutropenic patient included 29% with diarrhea and 13% with fever ≥101°F. Given that those symptoms could reflect transmissible infections, should hospitals have policies specifying that symptomatic healthcare workers should not enter neutropenic rooms?
Gohil: “In our hospital, [our policy is] you don’t go into the room of a neutropenic patient if you are actively symptomatic. We found there were a few too many that would still go in and see their patients. This means we have to do a better job of educating our doctors and letting them know under what circumstances is it allowable to go into patients rooms. What patient-related factors and what sickness-related factors are involved in making that determination?
Suppose you happen to be the only physician who can take care of a patient. Maybe you are in a rural part of the country, you happen to be sick, but you are the one that can help someone. There are things you can do by taking precautions. We need to identify what precautions you need to safely manage care, assuming you are not so ill that you have heavy secretions and you are highly infectious to others. If you are just getting over a cold, could you wear a mask and wash your hands a lot? We don’t talk about this much, but as a profession we can begin a dialogue. We need to educate our doctors and give them more guidance.
HIC: The willingness to work with flu seemed to decrease with more training. Was that trend reflected in the other symptoms?
Gohil: The same groups, such as fellows, residents and students, reported more of a willingness to work while they were sick versus the attendings — the attendees being the ones highest in rank. Those three groups tended to be more concerned about their superiors thinking less of them if they called in sick. They reported a sense of duty and of guilt if they didn’t come in. They thought that their patients might suffer if they didn’t come in, and importantly, they thought that they would burden their coworkers if they didn’t come in. They thought there wouldn’t be enough coverage if they were out and all of the work would go their colleagues.
HIC: Emergency medicine and surgical departments reported the highest willingness to work if ill. Is there a mindset or work culture in these two settings that could explain this?
Gohil: We wanted to know if there were interdepartmental variations and we found this. We didn’t explore further as to why — that needs to be the next step in our work, to examine what departments’ culture is contributing to working while they are sick. Each facility may have their own [variations] by department.
HIC: Can you provide an example of the supportive culture needed to influence physician willingness to stay home if ill?
Gohil: We have policies not to come into work in a general way, but we asked our physicians what would help them change their willingness to come into work even though they are actively ill. They believe that any supportive means is helpful. [This could] range from a simple email from leadership reminding staff that the hospital supports them staying home if they are sick, to a set protocol about what they are supposed to do when ill.
There are a whole range of illnesses out there that are problematic. For example, when you get a cold the first few days you are highly communicable, but if you develop a cough that lingers for couple weeks [it doesn’t necessarily] mean you are infectious to another person. It gets really blurry as to when is it ok to come in, when is it not? While many if not all [hospitals] have policies that support healthcare workers staying home if they are ill with communicable diseases, as physicians we want to know exactly what symptoms should I be looking for to stay home versus going ahead and working. Clearly our trainees, our students, and our residents don’t want to do anything wrong by showing up to work while they are sick. They just want to know what is the line? What is the threshold?
HIC: So for the younger doctors, is it a matter of education or fear of the consequences of missing work?
Gohil: That is a really important question. I think it is matter of education and I think it is a matter of them understanding that their leadership supports them. They want to look like they are working hard and are willing to do whatever they can for patients. Just letting them know that there are certain circumstances in which you are doing more harm than good by coming in. This kind of messaging is really simple and helpful. Something we have done at California Irvine is show our interns and medical students the results of this study. And the leadership of the housewide residency programs and their program directors publicly stated during those presentations that they support the residents and interns staying home if they are sick. If they have a question about this, if they have a concern that they can be infectious to other people, we tell them to call your attending before you show up at work and review your symptoms. Or go to occupational health or your primary care doctor before you come to work. We will support you doing that, and that simple statement said so much. We have also had housewide communications that let all of our staff know that we support them if they are sick. Before the flu season starts, we wanted them to be [aware] of this. I think it will have an impact.
Financial Disclosure: Senior Writer Gary Evans, Associate Managing Editor Dana Spector and Nurse Planner Kay Ball report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Patrick Joseph, MD, is laboratory director of Genomic Health Inc, CareDx Clinical Laboratory, and Siemens Clinical Laboratory.