Case Scenario

Even when I'm not feeling well, I usually choose to work at the clinic rather than call in sick, which would force my patients to cancel their appointments or add to my colleagues' workloads. Often, I just have a mild viremia with no symptoms other than headache and fatigue. However, on one recent occasion, I felt terrible and was coughing and sneezing continuously. I worried about infecting everyone around me, including our staff and patients, but I went to the clinic anyway. I washed my hands thoroughly many times that day, but was that enough? When I got up close to perform a funduscopic examination, I felt I was putting the patient at risk.

Our clinic typically is understaffed. So when I call in sick, the receptionist has to scramble, and patients who may have waited weeks to see me are turned away or somehow squeezed into my colleagues' already full schedules. If I were to call in sick each time I do not feel well, I probably would lose my job eventually, because I seem to be particularly susceptible to many of the viruses that my patients bring into our office.

Calling in sick has a visible impact; simply feeling sick has no direct consequences. Because of this, I choose the option with the fewest immediate problems for everyone—I go to work.

But, should physicians call in sick? If yes, under what circumstances, and at whose cost? And, if not, what measures should we take to protect ourselves and those around us?

Commentary

Many practical factors mitigate against a physician taking a sick day. For physicians in private practice, the economic considerations are great because office overhead and staff payroll costs continue during their absence. Even salaried physicians are subject to the powerful physician work ethic that says we are here to serve and care for patients. In other words, “You need to be here.”

As to the question of whether physicians should call in sick, like the other return-to-work decisions we make for patients, this involves balancing risks and benefits. What is the risk to you if you go to work? What is the risk to your patients? What will happen if you do not work? Can colleagues cover your office calls? Can acute calls be referred to the emergency department or a local urgent-care facility? Can routine office visits and examinations be rescheduled?

If you had active tuberculosis, there would be no question—you would stay home rather than create a public health hazard. If you had chickenpox or another significant infection with well-known infectious risks to pregnant or immunosuppressed patients and coworkers, you also would stay home, and you would feel justified in doing so. In fact, you would be negligent if you did otherwise.

There are some situations in which going to work is out of the question. For example, for persons who traveled to China, Hong Kong, Vietnam, Singapore, or Toronto in April of 2003 and had a fever and dry cough within 10 days of return, severe acute respiratory syndrome (SARS) was a consideration.¹ If, during the three weeks after a smallpox vaccination (even if you kept the site covered with an impermeable dressing), you were to develop a fever and generalized rash, you would not want to expose your patients to vaccinia virus, which can be spread by direct contact.

However, where minor acute viral illnesses are concerned, there is no social stigma attached to working while sick. In fact, because there is a negative connotation or a perceived “wimp factor” for physicians who don't work in this situation, minor illnesses present a greater dilemma. Some observers describe this perceived need of physicians to portray an unrealistically healthy image as a source of personal stress and a barrier to appropriate self-care.² The recent case of a physician in the Midwest who was symptomatic with active tuberculosis but continued to work with what he thought was persistent bronchitis³ illustrates a worst-case consequence of this attitude.

Not only patients are susceptible to nosocomial spread of gastrointestinal infections, but also physicians and other health care professionals. During respiratory disease outbreaks, the attack rate for infection is up to 45 percent for influenza, 50 percent for respiratory syncytial virus, and 25 percent for adenovirus.⁴ What can be done to prevent this spread?

Various authorities have developed infection control guidelines⁵ that restrict health care employees from working while sick, and some hospitals have adopted these guidelines to prevent nosocomial spread of infection. Some hospitals apply these restrictions to their medical staff as well. Usually, these policies are implemented after an infectious outbreak has been linked to a physician an epidemiologic investigation. The Joint Commission on Accreditation of Healthcare Organizations encourages hospitals to apply such infection-control policies to their medical staff as well as their hospital employees. These guidelines were developed for inpatient settings.⁶ The extent to which they apply to outpatient care is not defined. Following are some relevant examples.

GASTROENTERITIS

Restriction from patient care and the patient's environment is recommended for personnel with diarrhea or acute gastrointestinal symptoms, regardless of whether a viral or bacterial origin is suspected.⁶ The highest concentration of infectious agent in stools or emesis occurs during the acute phase of gastroenteritis.

NORWALK VIRUS

Enteric pathogens may be spread by contact with contaminated objects or environments, but airborne spread of Norwalk virus appears to be likely.

SALMONELLA OR SHIGELLA INFECTION

If Salmonella or Shigella infection is present, restriction from contact with high-risk patients such as newborns, immunocompromised patients, or the elderly is indicated until resolution of the symptoms or carrier state.

VIRAL RESPIRATORY INFECTIONS

Viral respiratory infections may be spread nosocomially. They include adenovirus influenza, parainfluenza, rhinovirus, and respiratory syncytial virus.⁶ Restricting a health care worker who is ill from the care of high-risk patients during community outbreaks of influenza and respiratory virus may be prudent.⁶ Influenza is transmitted by direct deposition of virus-laden large droplets onto the mucosal surfaces of the upper respiratory tract during close contact with an infected person. Spread by droplet-nuclei or small-particle aerosols (airborne transmission) is also possible. Transmission by virus-contaminated hands or fomites is less likely. The period of greatest communicability is the first three days of illness. Nosocomial transmission between patients and health care personnel is well recognized.

GROUP A STREPTOCOCCUS

Physicians infected with group A streptococcus should avoid patient contact until after at least 24 hours of effective antibiotic treatment.

PERTUSSIS

Physicians with an acute cough lasting more than seven days, especially if accompanied by paroxysms of coughing, inspiratory whooping, or post-tussive vomiting, may have pertussis. They should not work until they have had five days of antibiotic therapy. Because immunity from childhood vaccination wanes after five to 10 years, most adults and teens are susceptible.

Pertussis is not a rare disease. Of coughs lasting more than two weeks, up to 25 percent may be due to pertussis.⁷ Physicians who have been exposed to a person known to have pertussis need antibiotic prophylaxis. Physicians who are exposed and develop symptoms of unexplained rhinitis or acute cough may have pertussis and could spread it to patients. This illness could be life-threatening to unimmunized newborns encountered in practice, so it is recommended that physicians avoid patient contact pending medical evaluation and treatment.⁴

PREVENTION

From the standpoint of prevention, what can you do to avoid becoming ill and thus avoid problematic decisions about work activities? First, you can make sure you are up to date on all vaccine-preventable diseases like measles, mumps, rubella, and varicella.⁸ An annual flu shot is strongly recommended. Vaccination can not only decrease your risk of influenza but may also decrease the incidence of other upper respiratory infections.⁹

If you must work while ill, be attentive about using all of the infection-control practices available. Good hand-washing is a must, especially after using a handkerchief or lavatory, before and after each patient contact, and after removing gloves. Soap and water are needed for visible soiling. Otherwise, either soap and water or a waterless (alcohol-based) hand rub may be used.¹⁰ Some physicians find the alcohol-based rub to be more convenient. A soap-and-water washing should last for at least 15 seconds, covering all surfaces of the hands and fingers. Liquid, leaflet, and powdered soap are acceptable, or even bar soap, if it has not been sitting in a puddle of water. When you are using an alcohol-based hand rub, follow the manufacturer's directions.

If symptoms are predominantly respiratory, consider wearing a surgical mask or a high-efficiency particulate respirator (N96 mask) to contain the secretions that can aerosolize during coughing, sneezing, and talking. You may look unusual wearing such a mask, but your appearance lets your patients know that you care about their well-being.

Masks are widely accepted for infection control purposes in Asia, but in the United States, use of a mask by a physician outside the hospital has been rare. We are now introducing a cultural change into our outpatient center by asking that coughing patients in the waiting areas put on masks. This step was stimulated by SARS concerns, but it is also useful for tuberculosis, influenza, and other conditions. Some emergency departments now request the use of masks. Patients have been receptive, probably due to concerns about the early influenza season this year and extensive media coverage.

If we can educate patients to wear a mask to protect others, perhaps they will come to expect the same consideration from their physicians. By wearing a mask, we are not only caring for patients while we are ill, we are diligently protecting them from our infections. Some patient education may be in order; perhaps an explanatory sign at the front desk might help. Then, if a patient is asked to wear a mask while the physician rules out an infection of concern, it will not be a new concept to the patient.