For most workers, being sick means staying home. However, physicians face a much more complex decision. Staying home might protect patients, but it could have unintended negative consequences for other patients.
Results of a recent survey published in JAMA Pediatrics indicate that nearly every physician respondent agrees there is potential risk for patients when physicians come to work while sick. Okay, that’s pretty straightforward.
But almost as many, 83%, say they do it anyway—at least once a year. Why?
“I think part of it is a kind of professionalism and a desire to help their patients,” says Robert Wachter, MD, professor and interim chairman of the department of medicine and chief the division of hospital medicine at UCSF Medical Center
. “And they feel like they’re still helping more than hurting. I think part of it is when you spend part of your day with really sick people when you’re a little sick it’s not that bad. And you sort of compare yourself to your patients and realize you’re in better shape than they are.”
Wachter explains that during his training as a physician, he and his colleagues were put through paces that most other fields of employment would never consider. For example, Wachter says that during training he worked 100, sometimes 110, hours a week. Today, the most a resident can work is 80 hours a week.
“If the criteria for calling out sick was not feeling at 100%, I would never have come to work,” he says. “I never felt 100%. I didn’t even have time to catch my breath or do my laundry. And I think that becomes part of an iron man complex. That’s the time when your professional culture is established.”
There’s also the aspect of peer pressure to some degree. According to the survey, 98% of physicians were concerned about letting their coworkers down. However, 64% added they were concerned about being ostracized by their colleagues.
Mark Pinkerton, MD, assistant professor of pharmacy practice at Cedarville University’s School of Pharmacy, and a former family physician for more than 20 years, has experienced the dilemma of when to call out and when to come in first hand.
“In some professions, if you miss the work, you just delay the work another day,” Pinkerton says. “In medicine, you miss a day of work, who does the work? You might have somebody to do it, but then you’re overloading your colleagues—especially if it’s a small practice. So what’s the balance?”
The average worker often receives a set number of paid sick days each year, if employed by a sizeable organization. Many believe that’s the same system for physicians, but Pinkerton says that’s not the case. He says that most physicians are paid by production, and that very few are on salary. He learned that the hard way a couple of years ago.
“The company I worked for had its reimbursement based on the RVU, or relative value units,” he explains. “What that does is it evens out the playing field. If I saw 100% welfare and you saw 100 percent of the best-paid insurance, we would get paid the same. And so it keeps people from cherry picking.”
But when Pinkerton’s wife was ill and spent three days in the hospital, he took three days off from work—and lost one-third of his salary for that month.
“I dropped down a tier,” he explains. “If you work harder they’ll reimburse you more. Well, because of that third day out it caused me to drop down a tier, and I lost a third of my salary that month.”
Wachter says that being a physician is a profession that “doesn’t care about nights and weekends.” When a patient is sick, the expectation is that the doctor will make himself or herself available.
“Even if I’m not feeling up to speed, it’s my job to do right by the patients,” Wachter says.
But he knows where to draw the line. If he knew that there was a 50% chance that coming to work was going to make one of his patients sick, he wouldn’t come in. “That’s the complex stew that is going on in your brain when you wake up at 6:30 in the morning.”
Adding to the complex decision-making, says Pinkerton, is that “the first of the morning patients may be sick themselves and driving a great distance only to arrive and find out you’re sick. That doesn’t help them.”
Wachter says the discussion surrounding when a physician should call out is a good one. He believes it’s important to at least try to raise the consciousness among physicians to think about whether they’re doing the right thing.
“You think you’re being a good person by coming in, but maybe not,” he says. “Maybe your patients would be better off if you didn’t come in. Many of these decisions live on the margin, so setting a social norm about this is helpful. And if you’re on the cusp of deciding what to do, maybe you should stay home.”