The results of our study suggest that many medical students, resident physicians, and faculty physicians feel a professional obligation to fulfill work responsibilities even when they feel sick. This sense of duty is often motivated by a desire to avoid burdening colleagues with more work, avoid appearing lazy or weak, and avoid negative repercussions for themselves. All three of these motivations appear to be more common in residents and students than among faculty. Our results describe a willingness to work when sick that is consistent with previous studies of healthcare professionals in terms of general prevalence [8,9,10,11,12,13,14,15,16,17], and in terms of specific motivations to avoid burdening colleagues with more work [8, 9, 11, 16, 17], avoid appearing lazy [17], avoid negative repercussions [16], avoid having to make up work [8, 9, 17], in addition to an implicit or stated sense of duty to patients [8, 16, 17].
We did not expect to find, however, that one third of our participants felt obligated to work with influenza-like symptoms (fever, myalgias, cough), that approximately a quarter of our participants would work despite having had vomiting or diarrhea within the last 8 h, and that 13% reported they would work with a fever > 101.5 F. These data suggest that a substantial proportion of residents and students (and some faculty) are so motivated to fulfill their work responsibilities that knowledge of the potential infectiousness of a condition is not by itself enough of a reason to prevent them from working with patients.
Our study’s focus on symptoms of influenza deserves careful attention, since influenza can serve as a paradigm case to assess attitudes toward sickness presenteeism among healthcare professionals in light of established clinical and epidemiological knowledge and guidelines for prevention. The CDC guidelines are clear: healthcare professionals who have fever and respiratory symptoms should not work with patients and should be excluded from work until they are afebrile for at least 24 h [26]. Despite such clear recommendations, there is evidence to suggest that over 40% of healthcare professionals with influenza-like illness work when they are sick [11, 12]. Though influenza virus is not the only potential microbe that healthcare professionals might transmit to their patients [23, 27, 28], it is concerning that the hallmark symptoms of such a well-known virus are not sufficient to keep some healthcare professionals from working with patients, despite widespread efforts to reduce the risk of influenza transmission in hospitals through behavioral measures and vaccination programs aimed at promoting patient safety [29, 30].
The results of our study demonstrate an ethical tension between an obligation to work and an obligation not to harm. Most of our study participants affirmed a variety of reasons for why they would work when feeling sick with a potentially infectious condition, even as they also affirmed reasons for why physicians in general have a professional responsibility to remain at home when feeling sick with what might be an infectious disease. These reasons to stay home focused on the need to be able to function well and to avoid spreading infections to patients or colleagues. However, these cautions about avoiding harm to patients and colleagues were qualified by the prevalent belief that if precautions can be used to avoid the spread of infection, physicians have a professional responsibility to work while feeling sick with a potentially infectious disease. The inclination to use such precautions in sickness presenteeism can be seen as an attempt to resolve the ethical tension by reconciling the duty to care with the duty not to harm [8, 10, 16]. The question remains whether such attempts are ethically justifiable and scientifically sound in the given circumstances of a particular case.
Our study included a particular focus on the attitudes of medical students and resident physicians with respect to their status as trainees, and several differences between these trainees and faculty physicians were observed. First, the general sense of professional obligation to fulfill work responsibilities when sick was more common in residents and students than in faculty. Second, residents and students were more likely than faculty to express an intention to work with influenza-like symptoms. Third, and perhaps most concerning in relation to training pressures, residents and students were more likely than faculty to want to avoid negative repercussions or appear lazy or weak, and most students and residents would be motivated to work when feeling sick in order to avoid a negative evaluation by a superior. These last findings reflect a perceived need to meet others’ expectations despite risks to patients and burdens to oneself. The frequencies of these attitudes in our study were higher than has been reported by other authors: 20% of students had concerns about evaluations in the study by Veale et al. [19] and 12% of residents were concerned about appearing weak in the report by Jena et al. [21] We also note with concern that only a minority of students and residents in our study indicated they would seek guidance from their superiors to decide whether they should work when feeling sick with a potentially infectious condition. This lack of deference to those whose professional responsibilities include both patient and trainee welfare may further reflect a desire to avoid negative repercussions. It also suggests an unwillingness to share accountability for an important decision – a problem that has also been observed outside of training environments (59% of clinical staff in a New Zealand hospital did not seek professional advice about sickness presenteeism decisions) [9].
Our study had limitations. First, although the survey was anonymous, social desirability bias may have led some participants to give answers that were perceived to be more socially acceptable. Second, answers to hypothetically-phrased questions may not predict actual behavior. Third, the absence of information from non-respondents raises the possibility of bias in our sample due to a response rate of 44%. Fourth, because our surveys were performed in 2012–13, there is the possibility our data may not represent current attitudes; however, this possibility seems unlikely, given that the most recent studies on sickness presenteeism (whose data were collected between 2014 and 2015) have continued to show similar prevalence rates (41%–88%) and motivations [8, 10, 11, 16]. Fifth, except for questions about “a cold” and “the flu”, we did not query participants’ attitudes toward working when ill with other specific infectious diseases whose greater or lower risks of transmission might have led to additional insights into the impact of transmission risk on decision making. Lastly, our participants were based in a single academic medical center in the US, and the resident and faculty physicians were proportionately fewer in number and represented only three specialties (Internal Medicine, Pediatrics, and Family Medicine), so our results may not be generalizable to physicians in other specialties, other practice settings, or other countries. Regarding the potential for specialty-based differences, although one study of resident physicians found no difference in rates of sickness presenteeism among different specialties (surgery, obstetrics/gynecology, internal medicine, pediatrics) [20], another study showed that surgeons were particularly sensitive to the impact on patients when procedures have to be rescheduled because of illness among surgeons and that both surgical residents and staff were more likely (than internal medicine colleagues) to report sickness presenteeism and less likely to be pleased when a sick colleague stayed at home [18].
