The doctor will sneeze you now

A year ago, it would have seemed absurd for a medical resident to call out sick with nothing more than a cough and congestion.

It’s different now. The calculus of cold symptoms has changed.

When one of us recently woke with a sniffle, she wondered if she should stay home. She logged into her computer and saw that ten patients expected to see her in clinic that day, including several who had been waiting to see her since before the pandemic began. Her next open slot was more than a month away.

This resident faced a tough decision: come to work and potentially put others at risk, or call out sick and delay care for her patients.

“Presenteeism” is the feeling of obligation to come to work while sick. In the era of COVID-19, this poses a unique challenge to health care workers as COVID-19 can present with minimal symptoms, similar to those that providers used to shrug off routinely.

Presenteeism is not a new phenomenon. For years, health care providers have faced the dilemma of how sick is too sick to care for the sick. A 2017 study in the American Journal of Infectious Disease found that 4 out of 10 health care workers would report to work with flu-like illness. In a 2015 survey of physicians and advanced practice clinicians, 80 percent reported working while having symptoms of infection while simultaneously believing working while sick was risky for their patient’s health. While there are no conclusive data on the rates of COVID-19 transmission from health care workers to patients, it is notable that health care workers had “12-times higher risk of testing positive for COVID-19 compared with individuals in the general community”, even with adequate personal protective equipment (PPE) access.

There are several reasons why health care workers come to work despite feeling unwell. There is a strong culture of responsibility among health care providers – such as the medical resident with the cold symptoms felt – to ensure that every patient who needs care can receive it.

Strained hospitals and clinics pressure workers to come in, even if symptomatic. One recent example of this is illustrated in a May 2020 email from the surgeon-in-chief at New York-Presbyterian Hospital to his staff that stated “sick is relative,” and that workers would not be tested for COVID-19 or excused from work unless they were exposed and “symptomatic to the point of needing admission to the hospital.” Individual workers may also feel financial pressure to return to work sooner than is deemed safe, due to limited sick leave or reduced household income as spouses and other family members are laid off.

To be sure, medical providers are not easily replaceable, and health care systems have limited backup pools. There is an enormous backlog of patients whose care was delayed during the spring and summer months. When a provider calls out sick, there is a cascade of downstream effects that can adversely affect the function of the entire system.

The limited flexibility of the health care system facilitates the mentality of presenteeism amongst providers and administrators. This has never been more true than during the COVID-19 pandemic. Some might argue that if a provider is wearing PPE, what is the harm in coming to work with a sore throat? Others might say that it is our sacred duty to care for the sick, irrespective of our own health. But even if we do our best to mitigate risks, there is no foolproof way to completely eliminate the risk of transmission between healthcare workers and patients. By exposing patients to a potentially deadly infectious disease, we violate our oath to first do no harm.

Administrators should lead by example and call out when sick, while also encouraging providers to do the same. Furthermore, there needs to be system-level changes that support better sick leave policies. Health care systems can support providers by expanding back-up pools to ensure patient care is not harmed by a provider’s absence.

The culture of working while sick in medicine is potentially harmful to both providers and patients. These system-wide changes ultimately need to support a culture where providers feel supported to call out sick. It should not be a sign of weakness to follow the same advice we would give to our patients.

Thomas Holowka, Laura Glick, Neeraja Kannan, Haley Lynn, Anna Reisman contributed to this article.