Study: Resident Physicians Work Even While Ill

Sept. 15, 2010
A new study reveals that three out of five resident physicians surveyed came to work in the previous year while sick, possibly exposing their patients and colleagues to suboptimal performance and, in many cases, communicable disease.

The survey, which involved multiple hospitals, found that 60 percent of residents – physicians who have completed medical school and are getting on-the-job advanced training in hospitals – worked while sick at least once during academic year 2008-2009; one-third did so more than once. At one hospital, 100 percent of residents reported working when sick. More than half of resident physicians surveyed said they didn’t have time to see a doctor.

“Hospitals need to build systems and create a workplace culture that enables all caregivers, not just residents, to feel comfortable calling in sick,” said study author Vineet Arora, M.D., MAPP, associate professor of medicine and associate director of the internal medicine residency program at the University of Chicago. “Their colleagues and their patients will thank them.”

The phenomenon – known as “presenteeism” and defined as workers being on the job but not fully functioning because of illness – has attracted interest in the business world. Studies suggest presenteeism can cut productivity by one-third. Some estimates claim that these workers cost U.S. companies $150 billion a year, more than absentees, medical care and workers on disability combined.

While medical researchers have been slower to focus on presenteeism, the few studies conducted of this phenomenon among health care workers, where the risk of exposing patients is an added hazard, indicate that the problem is widespread.

Working Sick

“The H1N1 pandemic made us think more about this,” said co-author Anupam B. Jena, M.D., Ph.D., resident in medicine at the Massachusetts General Hospital. “We noticed that if residents called in sick, people questioned their motives; and if they came in sick, people questioned their judgment. The real issue is what is best for patient care. Is a doctor who knows the patient but is not at his best as good or better than a healthy but unfamiliar physician? And how often does presenteeism in medicine occur?”

In August 2009, with swine flu in mind, Arora and Jena piggy-backed onto a survey led by DeWitt Baldwin, M.D., at the American Council for Graduate Medical Education. The survey involved 744 second- and third-year residents in 35 programs at 12 hospitals. Key questions included: “Were there occasions when you think you should have taken time off for illness, but did not do so?” and “Did your schedule permit you to see a physician regarding your health?”

Sixty percent of the 537 who responded reported working while sick at least once and 31 percent at least twice. Those with additional experience, who had been second-year residents during the reported year, were slightly more likely to work when sick, with 62.3 percent responding that they had done so in the past year.

The choice of specialty (surgery, internal medicine, obstetrics/gynecology or pediatrics) made no significant difference. Women were no better behaved than men and foreign medical graduates were comparable to those from U.S. medical schools.

The lack of demographic or specialty factors associated with presenteeism “suggests it may be pervasive,” the authors noted. The one outlier, a hospital with 100 percent noncompliance, “suggests that hospital culture could play a role.”

Who is the Presentee Worker?

Presentees are not slackers, and in fact are usually employees who take their work seriously. Factors that encourage presenteeism include high-performance jobs; the difficulty of finding replacements; a strong sense of teamwork and obligation toward colleagues; and the culture of loyalty to and concern for vulnerable clients. This list could be a job description for residents, who have been taught since medical school that making personal sacrifices for the sake of their patients is honorable.

Unfortunately, presenteeism in the health care setting sometimes carries the added risk of exposing patients to the presentee’s disease.

“Knowing your patient well doesn’t compensate for being infectious,” suggested Jena. “If it’s contagious – for example a viral cold – or if it’s enough to cloud your judgment, stay home.”

”Residents may work when sick for several reasons,” the authors concluded, “including misplaced dedication, lack of an adequate coverage system, or fear of letting down teammates. Regardless of reason, given the potential risk to patients related to illness and errors, resident presenteeism should be discouraged by program directors.”

This research was published in the Sept. 15 issue of JAMA.

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