One winter toward the end of my training, I came down with a cold. At first, the constant coughing and runny nose made me miserable; then they became tiring. To decrease the chances of spreading my germs, I had to tie on a mask every time I came into contact with patients, wash my hands so frequently my skin became raw and wipe down the phone receivers with alcohol when I answered a page. Unable to scratch, wipe or blow in the operating room without contaminating my hands, I learned that for a surgeon with a runny nose, there are no palatable options for the uncontrollable nasal effluvium; I had to wear two masks every time I scrubbed up for a case.
Within days of the onset of my symptoms, other clinicians on my team were felled with the same. For weeks, we passed the cold back and forth in what became a viral game of hot potato. Even if I felt well enough one day to breathe through my nose, taste the nursing station holiday cookies and laugh without spiraling into a coughing fit, I knew that it would be only a matter of days, if not hours, before I would become sick again, invariably with a virus that had mutated just enough in the interim to dodge any immunity built up during the last go-around.
The doctors and nurses on my team started referring to me as "the vector."
Nonetheless, I continued to drag myself in to work each day. I didn't want to desert the other doctors and nurses or my patients. And any time I was overtaken with a yearning to go home and crawl back in bed, one memory from medical school would quickly push that thought from my mind.
I had been a third-year medical student and had asked my senior doctor-in-training if I could go home because of an upset stomach.
"Sure, go on home," he replied, an impassive look on his broad face. "Just remember that I've never missed a day at the hospital in my life. They'll have to put me in the hospital to keep me from taking care of my patients."
Hacking, febrile or racked with the sequelae of chronic illnesses, doctors who are sick have continued for generations to see their patients. Although published reports for over a decade have linked patient illnesses like the flu,whooping cough and resistant bacterial infections to sick health care workers, as many as 80 percent of physicians continue to work through their own ailments, even though they would have excused patients in the same condition.
For many doctors and other health care professionals, such self-sacrifice is proof of their dedication and professionalism. Moreover, in what are often precariously balanced hospitals and practices, one individual's absence can inflict tremendous stress upon others. Overstretched colleagues are forced to shoulder additional clinical responsibilities, supervisors must solve impossible staffing challenges and, worst of all, patients are left with inadequate care.
Being present — it seems, anyway — causes fewer problems than being absent.
But over the last few years, researchers in the business world have begun to question this assumption. Instead of focusing on problems incurred by absenteeism, these researchers have analyzed the impact of what's been called presenteeism, or working despite being ill. And it turns out, at least in early studies, that those employees who choose to go to work sick are expensive. Presenteeism costs companies more than $150 billion a year in lost worker productivity.
Now, a report in the current issue of The Journal of General Internal Medicine examines the impact of sick workers in health care. Anchoring their analysis with a description of a nursing home outbreak of norovirus gastroenteritis, an infection that causes nausea, vomiting and diarrhea, researchers from the University of California, San Francisco, address an issue that goes beyond the business school matter of worker productivity. They argue that in the health care setting what is important is that the decision to continue working while sick contradicts a core ethical principle of medicine: primum non nocere, or "First, do no harm."
"The culture of medicine is so completely focused on self-sacrifice that when doctors come into work so sick they need intravenous fluids, it's considered a badge of courage," said Dr. Eric Widera, the study's lead author and an assistant professor of geriatrics at the University of California, San Francisco. "No one is standing up for the patient and saying, 'This is wrong.' "
Initially the nursing home infection described by Dr. Widera and his co-authors affected only one staff member and three patients. But over the course of less than two weeks it spread to an additional 22 staff members and 30 patients despite restrictive — but voluntary — measures like stricter hand hygiene and disinfecting procedures, limiting visitors, closing down the dining hall and suspending group activities and outings. Only after the local health department required sick employees to be medically cleared before returning to work was the outbreak finally controlled.
"People probably felt they were showing up at work out of empathy for their patients and out of the kindness of their hearts," Dr. Widera observed. "But they weren't thinking about the risks."
Resisting the pressure to go to work when ill can be particularly difficult for some health care professionals. Students, doctors-in-training and nurses may be afraid that their supervisors will frown upon any absence, regardless of the reason. "It's a sign of being soft," Dr. Widera said, "and they may get a tongue-lashing the next day from those in charge."
Fully trained physicians or nurses who work in a small practice or who may be the only clinician available may feel a heightened sense of personal responsibility toward their colleagues and patients, and their decisions necessarily end up more complicated. For these individuals, "going into work sick becomes a risk-benefit analysis that must be weighed carefully," Dr. Widera said. They may have to reschedule routine visits and limit patient contact to absolute emergencies, instead of what many clinicians have felt pressure to do in the past, "coming in then doing everything you would in a normal day because you are at work anyway."
Dr. Widera and his co-authors suggest that policy changes that include unrestricted paid leave and mandatory time off for sick health care workers, as well as increased redundancy in clinician staffing may help decrease presenteeism in health care. "We need to create a culture where patient safety is more important than making the ultimate sacrifice or maximizing efficiency," he said.
"Patients are happy just to have gotten in to see a physician," Dr. Widera added, "but they are basically cornered when that doctor is sick. The onus and responsibility for changing how we deal with presenteeism has to come from us. It has to come from within the health care system."
After I had struggled for a couple of months with that cold, the chief of my division at the hospital ordered me to go home, turn off my beeper and stay away from the hospital for 48 hours. I protested at first, as did a fellow doctor who was quick to grouse about being left with all the work to do.
But I finally got better. And within days, everyone else did, too.
