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Presenteeism: A Public Health Hazard

Are you a good worker? Do you work hard? Do you care so much about your job that you show up to work even when sick?

Well if your answer is yes, and you work in health care, you may be a public health hazard.

An important article in the Journal Of General Internal Medicine illustrates the potentially serious public health hazards of presenteeism, or showing up to work even when sickness compromises your ability to do your job. The lead author was Dr. Eric Widera, from the UCSF Division of Geriatrics (and GeriPal!). Co-authors included Drs. Anna Chang and Helen Chen.

Dr. Widera presents a compelling case of a nursing home gastroenteritis outbreak that lasted 24 days and was prolonged by staff members coming in to work sick. Gastroenteritis outbreaks, in which numerous patients develop an illness characterized by nauseau, vomiting, and diarrhea, are very common in nursing homes, or any setting in which people live closely together (such as cruise ships or college dorms). In healthy people, the symptoms can be highly distressing, but are usually self-limited. But in very frail nursing home residents, gastroenteritis can be dangerous.

Over the first 3 days of the outbreak, 10 nursing home residents and 5 staff members became sick with what proved to be norovirus---a form of gastroenteritis known to be supercontagious. Usual infection control procedures were instituted, and one would have expected the outbreak to run its course. However, by the end of the first week, despite recommendations to the contrary, it became clear that ill staff were coming to work. Often symptoms were not reported until employees had arrived for, and somtimes completed, their shifts. When it became clear that voluntary measures to prevent presenteeism had failed, the local health department stepped in to enforce "back to work" rules. By the end of the outbreak 35 residents and 24 staff had fallen ill with gastroenteritis.

Widera notes that nursing homes may be particularly susceptible to staff-resident-staff transmission of infectious diseases because the frailty of nursing home residents requires close physical contact between residents and staff. Unfortunately, in many nursing homes in the US, staff are not adequately paid, and may lack benefits including adequate sick leave. Financial difficulties may be make it hard to take time off from work.

However, physicians may be the worst presenteeism abusers. Widera cites a survey of British physicans in which 87% of general practitioners and 58% of hospital consultants said they "definitely would not" stay home if they had a severe cold.

When I was a resident, the culture was such that you came to work unless you physically could not get out of bed. Virtually all my fellow houseofficers and I had stories of how we on some occasion did just that. I hope that culture has changed.

Widera and colleagues have made an important contibution by telling the story of this outbreak. I strongly suspect similar episodes occur daily throughout the US, but we won't be able to prevent these occurences if we don't share these stories and learn from them.

by: [ken covinsky]


Alex Smith said…
I didn't miss a single day of residency. I wore a mask when I was sick. I didn't want to "let down" my colleages by missing a day and having someone come in to do "my work." I broke my wrist at one point (playing basketball), but didn't miss a day. I remember performing a lumbar puncture with one hand.

In retrospect those decisions was rather narrow minded. I think that in medical training we sometimes prioritize being a "team player" and "getting the work done," over the well-being of patients at times.

On the other hand, the lumbar puncture went smoothly, and the colds I had were probably contained with the mask and assiduous hand-washing. The risks of presenteeism occur on a spectrum that varies with the severity of the illness, risk of spreading disease, and available measures to prevent spread of infection.

The nice thing about this paper is it provides some emperical data about the potential costs to patients and staff of presenteeism for norovirus diarrhea. I'm not sure the risks/benifits are as clearly worked out for the common cold.
Dan Matlock said…
Working when sick! It's kind of a "damned if you do, damned if you don't" thing. Residency is particularly hard because some poor resident gets called in for jeopardy. I missed one day in residency while in the ED. I had a bad gastroenteritis, which I obtained in the ED for sure. During my next shift, I got a mild tounge lashing by the ED attending who wasn't fond of us 'soft' medicine interns anyway.

The flip side, I have a friend who teaches engineering at a college in town. The school had a policy that anyone who called in with the flu during the "bird flu" scare would be excused from whatever they missed. Surprisingly, there were sharp spikes in cases of the "bird flu" during mid-terms and again during finals. While we cannot prove causation, there was clearly an association between exams and the bird flu.
Lindsey Yourman said…
In addition to resident social culture, institutional regulations are also conducive to working while sick. I remember on my Peds rotation in the NICU when my Chief Resident came to work sick. She said she could not miss a day because she needed to use her limited number of sick days for her children (she was also a mom). She said that if she went beyond her sick days, she would have to make up the work at an infeasible, inconvenient time.

On an elective, a quarter of the team had a mild upper respiratory infection which they spread among themselves . . . yet no one missed a day, even though we were interacting with patients.

For me personally, I was confronted with the dilemma when I became sick on my sub-internship. Luckily, I had an exceptional resident who strictly enforced minimal patient contact and made me go home as early as possible. Had she not done that, I would have been worried about the team's evaluation of my performance (for those who don't know, sub-i evaluations are important for residency acceptance). Makeup days would have been difficult, if not impossible, to arrange within my rotation schedule for the year.

It is clearly our professional responsibility to place the well-being of our patients over the personal inconvenience or image damage that results from missing work. However, individual integrity seems an unlikely singular realistic and effective solution to the problem. There needs to be institutional incentives and leeway that minimizes penalty for residents and students missing work for sickness. Such a system may not be wise in other professions (such as "bird flu" example above :)), but in medicine, it may be central to good patient care. Given the peer pressure to be a good "team player," residents seem unlikely to abuse a system that allows them to miss work when sick . . . at least the residents that I know . . .
Eric Widera said…
I would agree with Lindsey on this one. The physician's psychological makeup is thoroughly entrenched in a triad of compulsiveness that includes doubt, guilt feelings, and an exaggerated sense of responsibility (Gabbard,JAMA, 1985). These complusive traits keep us coming in to the hospital even though we may be coughing up a lung. The only way to make physicians not come to work is to force them to do otherwise.

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