As the worst flu epidemic in nearly a decade sweeps the U.S., here’s a message that more Americans need to heed: stay home if you are sick. Sadly, that’s a hard sell, especially in medicine.
Doctors routinely show up for work when they are sick. I’ve done it myself, seeing patients while I had pneumonia, or suffering with severe hip pain. And I’ve been complicit many other times, watching physician colleagues work through similar and sometimes worse illnesses without demanding that they go home.
Of course, none of us want to spread illness and harm our patients. So we tell ourselves it will be fine if we just wear a mask and gloves, take ibuprofen, and march on through the day.
Why do we do this? In part it’s because we are trained in an environment that traditionally expects stoicism and has little room for showing vulnerability. One survey showed that more than 80 percent of physicians and advanced practitioners reported working sick at least once in the preceding year.
In an unscientific survey, I asked physicians I knew to share examples of coming to work despite being sick. One told me about being diagnosed with pneumonia one day and seeing patients the next day. Another described going to work in the intensive care unit during the aftermath of food poisoning and needing to vomit every so often before being told to go home.
I also heard this story: “I had gastroenteritis while at work and soiled my underwear and my scrubs. So I fashioned new underwear out of a surgical mask, like a bikini, then I got a new set of scrubs and continued working.”
Physicians hang on to stories like these as battle scars and are proud of having survived the episodes. But the reaction from people outside the medical profession is often horror and disbelief. They are hard-pressed to understand why this is normal behavior and why clinicians would put their patients in jeopardy.
The reasons we do this are multifactorial and complicated. We need to understand them in order to shift the culture.
Colleagues who told me stories about working while sick also told me their rationales for doing it. Here are three of them:
- “The show must go on. You can’t ask another doctor to do your work. Best to just finish up and then leave. Especially when you are a trainee.”
- “The wait list for my clinic is too long and I didn’t have anywhere to reschedule patients who were waiting for months and months.”
- “I didn’t want to show weakness; we are expected to work through being sick.”
These statements mirror what a team from Children’s Hospital of Philadelphia learned in its “working while sick” survey. The reasons clinicians gave for doing that included not wanting to let down colleagues or patients, concerns about staffing, fear of being ostracized by colleagues, and worries about the continuity of care.
Changing the working-while-sick culture won’t be easy. It needs to happen in multiple spheres. Institutions and hospital organizations must have adequate systems in place that allow physicians to stay home. This could include rescheduling non-emergency cases in the hospital or having a more robust sick-call system. And patients need to understand that, just as they get sick and can’t work, the same is true for their doctors.
Even more important, the medical profession needs to remove the stigma attached to staying home when sick. It is not equivalent to weakness. We must challenge ourselves and each other to not think poorly of colleagues who choose to stay home because they are ill. In addition to decreasing the spread of illness, the goal should also be to advocate for the well-being of physicians.
Creating this culture change is especially important during the training of young physicians, when the pressures to meet expectations are greater than ever. In fact, the Accreditation Council for Graduate Medical Education recognizes this and expects trainees to be “fit for duty” as a core competency of professionalism. At a minimum, this means being rested and alert. But it also means not spreading illnesses to patients. As is the case in so many industries, though, requiring a behavior has little impact until the culture supports it.
I’m not suggesting that physicians should bail on going to work at the first sign of the sniffles. But pain compromises us, and communicable diseases are more communicable among people who are already seeking medical attention.
Physicians have a tremendous responsibility to their patients and to each other to stay home when sick. Doctors, more than anyone, have an obligation to tread thoughtfully around patients and their colleagues who treat patients. They also have a huge opportunity to begin changing this martyr culture for workers in other fields.
In the midst of this or any other flu season, medical professionals who stay home when sick can limit the spread of illness, and may even mean the difference between life and death for some patients. Doctors are known for advising sick patients to “stay home, get some rest, and drink fluids.” They need to follow that advice themselves.
Angira Patel, M.D., is assistant professor of pediatrics and medical education and a member of the Center for Bioethics and Medical Humanities, both at Northwestern University Feinberg School of Medicine; a pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago; and a Public Voice Fellow through The OpEd Project.
Dr. Patel,
Within the context of the recent, severe flu outbreak, this article provided a unique perspective on the working environments of physicians. Encouraging a culture that praises doctors for continuing to practice while sick fosters a toxic professional environment that could have detrimental effects on their long-term health and eventually lead to physician burnout. If these physicians are going through such extraordinary lengths, such as “vomiting every so often” just to continue practicing, what does that say about the job environment? How much do we value the well being of our doctors? You mentioned that one of your colleagues rationalized their actions by stating that they did not want to deny care by rescheduling patients. However, if doctors continue to work while sick, the possibility of burnout is high, thereby persuading them to leave medicine all together and ultimately reduce care provided to patients. As Dr. Robert Wah, the former president of the American Medical Association (AMA), once expressed: “The most important patient we have to take care of is the one in the mirror.” It is also interesting to note that physician fatigue is correlated with upticks in pandemics. A study conducted by Medscape showed that from 2013 to 2017, infectious disease physician burnout rate increased 15%, which correlates to the 2014 Ebola outbreak and the immediately followed Zika virus. This year’s sudden increase in the flu virus could potentially mean higher exhaustion rates in physicians, as well.
You pointed out that this harmful culture needs to be amended through the training of young physicians. I agree that reform within the youngest generation of doctors is especially important as the mentality acquired during early stages of internship can be used as a baseline for future practice. A recent policy change dictated that residents could now work as long as 24 hour shifts; however, this greatly diminishes their prosperity as it can morph their attitudes’ to focus only on accomplishing the job, rather than ensuring their own well-being or effectively attending to patients. My proposal is that we revert back to only allowing residents to practice a maximum of 16 hours per shift, in order to sustain a environment that can not only produce effective work, but also establish a culture that encourages physicians to take better care of their own health. I also advocate for smaller institutional changes within hospitals that can transform the current culture. The Mayo Clinic’s Physician Well-Being Program was able to support their physicians by offering increased support for clinical work and instituting programs that encouraged connectedness and support among staff. Hopefully, other hospitals will also be able to adopt those types of practices. Fortunately, the AMA has a resource in place to help: Steps Forward is a website that has step-by-step instructions for other hospitals to create their own physician wellness programs. The quality of care given to patients will be exponentially greater if there are concrete systems in place that protect the health of the physicians.
I’m embarrassed to say that I took only 1/2 day of illness during my years of practice. After falling down deep stairs, when I was lying on the x-ray table, my colleague on call had come into the x-ray room to see my situation. He was part of my IM group but not my physician and I was in a solo office. He quickly said, “You’ll do fine with ice and some ibuprofen.” He pointed out I was on call the next day. After he left, I learned that I had fractured C-6 and C-7. After hearing his comments, I did my weekend call at home on my own, despite pain meds. Then, on Monday, I got a friend to bring a geriatric chair that elevated the seat. Between visits I would lie back briefly. I did this for weeks. Dumb, yes! But my colleague denied help for me and I didn’t know what to do.