Pulse
Disruptive Docs
Why do doctors tough out illness?
No one would deny that working while sick, also known as presenteeism, is firmly entrenched in medicine. Doctors tell stories about seeing colleagues “pushing through”—coughing and sneezing in the lounge, and popping acetaminophen or ibuprofen to keep symptoms from intensifying.
There’s other evidence as well. A study published in the September 15, 2010, issue of the Journal of the American Medical Association, for example, found that nearly 60 percent of 537 residents from 12 hospitals reported they had worked while ill at least once (a third said that they had worked sick more than once) during the previous year. Ironically, those who tell patients to take it easy and rest when they’re ill rarely do so themselves.
Why They Go to Work
There are multiple reasons for presenteeism in health care. One is that it’s taught. “Historically, doctors have been macho in their approach to things thinking, ‘We have to be there for our patients’ or ‘Who is going to be responsible for our patients when we are gone?’” says Louis Ling, M.D., associate dean for graduate medical education at the
Sick Leave
U.S. workers took an average of 14 sick days to care for themselves or a family member in 2007, according to the latest numbers from the Agency for Healthcare Research and Quality. The agency also found that
- Workers ages 55 to 64 years took an average of 18 days off a year compared with 10 days for those ages 16 to 24;
- More women than men miss work because of sickness (38 percent of female workers versus 30 percent of males); and
- Twenty-six percent of uninsured employees took sick leave as compared with 36.5 percent of privately insured workers and 32 percent of people with public insurance.
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University of Minnesota and associate medical director for education at Hennepin County Medical Center. “Residents cannot be blamed for that mentality. They’re only following what we, as their role models, have all bought into.”
Guilt may be another factor that encourages doctors to work sick. “Both nurses and docs have a tremendous concern that if they stay home sick, they will be piling more work onto their already-overburdened colleagues,” says Greg Poland, M.D., director of the vaccine research group at Mayo Clinic.
Financial motivations also crop up when doctors contemplate whether to ride out an illness in bed or at the bedside. “Most of the physician groups I know of are paid for their productivity, which incentivizes them to come to work because they are compensated according to how many patients they see and how many procedures they do,” says Robert Moravec, M.D., medical director at St. Joseph’s Hospital in St. Paul. “When you’re sick and you’re working within that payment structure, it can become difficult to talk yourself into staying home.”
The Public Health Imperative
Currently, there are no national policies or state rules to help physicians gauge when they should call in sick. “We’re trying to recognize that physicians have the scientific background to make that decision,” says Kristen Ehresmann, R.N., M.P.H., director of the Minnesota Department of Health’s Infectious Disease Epidemiology, Prevention, and Control Division. “We know that if we came up with guidelines for doctors staying home, they would feel offended.”
Ehresmann would like physicians to think about one more thing when they start coming down with the sniffles—the public’s health. “When they come to work sick, they are putting their patients at risk. They are exposing patients to their illness, and in many cases, those individuals are more vulnerable than the general population. That makes presenteeism a public health problem.”
At the moment, though, the decision whether one should go to work or stay home is predominantly a personal one that involves providers gauging their energy level and forming realistic perceptions about their ability to carry out their professional duties. That said, physicians don’t always get it right, and a comment from a peer may nudge someone to exercise better judgment next time.
When Moravec comes face to face with a colleague who’s coughing and sneezing in a hospital hallway, he doesn’t hesitate to speak up. “If I see someone who is sick, I have zero trouble telling him or her … to wear a mask,” he says, adding that he thinks physicians understand that his motive is protecting patients. He admits it’s not the best method because it relies on an accidental meeting, but he thinks it works. “Anecdotally, I have seen more physicians accepting those practices to prevent transmission of illnesses to their patients,” he says.
A Shot in the Arm
A more effective strategy for protecting patients is vaccinating health care workers against influenza. Poland cites studies published in the Journal of Infectious Diseases in 1997 and Lancet in 2000 demonstrating that vaccination of health care workers reduced mortality rates among elderly patients in long-term care facilities by as much as 40 percent. “In contrast, when health care workers do not get vaccinated and come in sick, data show that the mortality rate of the ICU patients they care for increases 30 to 60 percent,” he says.
Despite the demonstrated effectiveness of vaccinating health care workers, the Minnesota Department of Health notes that only about 70 percent of health care workers in the state get vaccinated (nationally, the rate hovers around 50 percent). Last winter, a Minnesota Medical Association (MMA) task force evaluated flu vaccination policies among health care workers statewide. Although the group opted not to seek legislation mandating that Minnesota health care workers get vaccinated, it did recommend that the MMA work with the Minnesota Department of Health, the Minnesota Hospital Association, and other organizations to promote awareness of the importance of getting vaccinated and encourage hospitals to adopt and implement policies on influenza vaccinations for medical staff.
From this recommendation came the Minnesota Department of Health’s FluSafe program, which was implemented this fall. FluSafe recognizes hospitals and nursing homes that attain influenza vaccination rates of 70 percent, 80 percent, and 90 percent among their employees. More than 180 out of 519 eligible facilities have enrolled in the voluntary program thus far.
Poland believes that FluSafe is just a start, however. For a decade, he has been pushing for mandatory flu vaccination of all health care workers in Minnesota and nationally. In the past year, a number of national organizations—including the American Academy of Pediatrics, the American College of Physicians, the American Medical Association, the National Patient Safety Foundation, the Association of Professionals in Infection Control, and the Society of Hospital Epidemiologists of America, to name a few—have shown support for mandating that health care workers get flu vaccinations. (Conspicuously absent from the list is the American Nurses Association, which supports flu vaccination programs but is not advocating for a mandatory policy at this time.) “Momentum is building,” Poland says. “Many of the best medical institutions already have mandatory policies, and I think we’ll see the tide change dramatically in the next year or so.”
With no law currently on the books to make flu vaccines mandatory for Minnesota health care workers, health care organizations are tackling the issue themselves. Children’s Hospitals and Clinics of Minnesota has had a mandatory influenza vaccination policy for the last four years. Only clinical staff who have a medical contraindication may decline being vaccinated; those individuals are required to wear a mask in patient care areas.
HealthEast encourages its medical staff to receive a flu vaccine unless they have a medical contraindication and asks physicians to fill out a declaration form stating that they have been vaccinated. Those who have not are asked to wear a mask at all times while caring for patients.
Since HealthEast implemented the policy last year, Moravec has witnessed vaccination rates jump from 45 percent to more than 60 percent. Although HealthEast is still developing its program—it’s still exploring what consequences to issue to those who do not comply—Moravec feels confident that they are heading in the right direction. “We may not have the perfect process, or the perfect identification method, or the perfect consequences for noncompliance, or even the perfect vaccine, but we are still working toward improvement,” he says. “That’s the key—not letting perfect get in the way of progress.”—Jeanne Mettner