Present imperfect: Doctors in training work even when ill, study finds

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.

Comedian Woody Allen has been quoted as saying that 80 percent of success is showing up. "If that's true, then the other 20 percent may be having the sense to know when to stay home," said study author Vineet Arora, MD, MAPP, associate professor of medicine and associate director of the internal medicine residency program at the University of Chicago. "Hospitals need to build systems and create a workplace culture that enables all caregivers, not just residents, to feel comfortable calling in sick. Their colleagues and their patients will thank them."

The phenomenon -- known as "presenteeism" and defined as the problem of workers being on the job but not fully functioning because of illness -- has attracted a good deal of interest in the business world. Studies suggest it can cut productivity by one-third. Some estimates claim that presentees (a term coined by Mark Twain in 1892) cost U.S. companies $150 billion a year, more than absentees, medical care and workers on disability combined.

Medical researchers have been slower to focus on the issue, however. A PubMed search on September 1, 2010, turned up 7, 704 articles touching on absenteeism but only 193 that mention presenteeism. Yet 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.

"The H1N1 pandemic made us think more about this," said co-author Anupam B. Jena, MD, PhD, 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?"

So in August 2009, with swine flu in mind, Arora and Jena piggy-backed onto a survey led by DeWitt Baldwin, MD, 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 note. The one outlier, a hospital with 100 percent noncompliance, "suggests that hospital culture could play a role."

Presentees are not slackers, clocking the hours but working at half speed. These are employees who "do not take their job lightly," according to a review article on the problem in the Harvard Business Review. "Most of them need and want to continue working if they can."

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. "Not many professions come with that kind of pressure," said Jena.

Unfortunately, presenteeism in the health care setting sometimes carries the added risk of exposing patients to the presentee's disease. A recent case report in the Journal of General Internal Medicine followed the course of a viral infection in a nursing home where affected staff members continued to work. This helped spread the infection to other patients, staff and the workers' families. "As voluntary measures to prevent presenteeism failed," the JGIM authors note, "the local department of public health mandated enforcement of 'back to work' rules."

"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 JAMA letter authors conclude, "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."

The American Council for Graduate Medical Education (ACGME) funded the study. Additional authors were DeWitt Baldwin Jr., MD, of the ACGME; Steven Daugherty, PhD, of Rush Medical College; and David Meltzer, MD, PhD, of the University of Chicago.