Perspectives on Safety
In Conversation With… Jeffrey Starke, MD
Editor's note: Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and served as Infection Control Officer at Texas Children's Hospital for 22 years. We spoke with him about so-called presenteeism in health care and its impact on provider and patient safety.
Dr. Robert M. Wachter: How long have we been using the word presenteeism, and what does it mean to you?
Dr. Jeffrey Starke: In health care, no one has been using the word presenteeism very much at all. If so, it has been extraordinarily recent. Even in other industries, it has only been about 10 or 15 years since the word has been introduced. We certainly have known for decades about physicians, nurses, and other health care workers coming to work when sick. In fact, often it was considered a badge of honor that we have IV poles and that we do whatever we have to do to be at work and help our patients. Only recently have people started to wonder whether that is a good thing or not.
RW: What have we come to learn from other industries as they have thought about the consequences of people coming to work when they're not well?
JS: Most of the work in other industries has centered on productivity. Some studies over the last 10 or 12 years have estimated a ratio of as high as 10-to-1 lost productivity from presenteeism as opposed to absenteeism. We're all used to dealing with absenteeism. If you're not there, you're not productive. That is very easy to measure.
But people's productivity changes if they're at work while they're ill. For health care, we think of illness in terms of contagious illnesses, but these can be other illnesses. It can be complications of a person's chronic disease. It can be depression or other mental illness of some kind. Or it could be acute symptoms like we would see with respiratory viral infections. When ill, people work at best probably 50% to 70% of their normal capacity. The lost productivity and economic implications of that are enormous. Further studies have shown if those same workers take a little bit of time off and address their problems or symptoms, in fact their productivity very rapidly returns to normal. This is a huge economic issue for many businesses in the United States.
RW: Given that it has those economic consequences and business is often ahead of health care in thinking through some of the issues around workers and productivity, how do some of the leading businesses outside of health care approach this issue?
JS: Businesses are just now beginning to approach it. There have been several excellent articles in the Harvard Business Review and in other business publications talking about this topic. Some of the more forward-thinking businesses are looking at their workplace policies, at their absentee policies. They are trying to promote better health care within the system, making more medical care available (even on site) so people can go and take care of whatever they perceive their problem to be. I think many businesses are way ahead of health care in this regard.
RW: What is it that drives health care workers to come to work when they shouldn't?
JS: I'll speak for physicians, although I think nurses and respiratory therapists and others feel the same. We have a great stake in wanting to do what is right for our patients. We think what is right for our patients is to be there and to be there helping them. So, the major driver is our innate desire to do the best thing for our patients and colleagues. The problem, especially for physicians, is the way health care is structured—without much of a backup system. That is true whether you are in private practice or working in the hospital. Those of us in academics tend to be assigned a month on call, and there really is not any kind of a backup. We feel like we're imposing on one of our colleagues if we do call in sick. A lot of this is cultural. It's ingrained in us very early. It has been passed down from one generation to the next. It's what we've observed and what we've been brought up with.
RW: I was wondering whether you'd say that there is a generational change? Residents now have duty hour restrictions and more of an emphasis on admitting that you're sick, admitting that you're impaired, and calling a supervising physician when you're not sure. Do you feel like the cultural piece is changing a little bit?
JS: I'm not sure. It might be. I look at our younger physicians, either physicians in training or other physicians as well. They are doing more shift work, but even with shifts, if you're assigned to a shift if there is not much backup, you're still the person who's supposed to be there during that time. I do think sensitivities are changing somewhat. The problem, however, is that the culture of the institutions is not changing. Providing backup systems when people are not able to work at their full capacity is lagging behind right now in health care. I know very few health care institutions that are doing that well.
RW: Coming to work when you're ill has infectious and noninfectious implications. What are the particular issues around infectious diseases that might be different in health care than someone coming to work in a business when they're ill?
JS: The noninfectious impact is not only lost productivity but also the propensity to make errors, especially if you're not mentally completely with it. I don't mean to diminish other businesses, but if you're sitting behind a computer and you make an error or some numbers are off, that's one thing. But if you're in health care and you're not all there because you're ill and you are making errors in drawing up drugs or calculating doses, those errors can literally directly hurt people and do so right away.
The infectious impact is people who come to work when they're sick who can then pass on the infection not only to patients but also to their fellow health care workers who then can become ill. Influenza is the prime example. Even in the best hospitals that don't have mandatory influenza vaccination (meaning you're fired if you don't get it), at least 10% of health care workers are still unvaccinated. It means 1 out of every 10 health care workers who go into a child's room in my hospital have not had their flu shot, which I happen to think is immoral and even unethical. Articles have been published that lay out the legal, moral, ethical, and medical framework for why mandatory flu vaccines should occur.
RW: I wrote one of those articles actually.
JS: As did I. I coauthored the policy paper for the American Academy of Pediatrics with Henry Bernstein. Those principles have been established; still people don't always do it. Sometimes they have legitimate reasons in their own minds, but we do say, "First, do no harm." Another problem is that even mild illnesses in a healthy worker can be devastating for immunocompromised patients. Even if you do go to work when you're ill, you can do things to protect patients, particularly the most vulnerable patients. The idea is recognizing that people are going to do that and educating them about what can they do to minimize the carnage, if you will.
RW: Like what?
JS: It's all common sense. First, for certain illnesses, you have to stay home. You have pink eye; you stay home. You have diarrhea; you stay home. You have fever; you stay home. You cannot work well when you have those things. The most common are nonfebrile respiratory infections, which can obviously be many different viruses. Number one is just good respiratory toilet. The most important thing is good hand hygiene. If you are responsible for medically vulnerable patients, don't see them. Switch with somebody else. Ask, "Would you see my transplant patient for me? And I'll go see a couple of other people for you." You have to work as a team, employ common sense, and stay away from people who could be most adversely affected by your illness.
RW: How well does wearing a mask work?
JS: Masks get wet and don't work very well after about 10 to 15 minutes. When hospitals require people to wear masks if they did not get an influenza vaccine, I call that the Scarlet A. That's all that is. It's punitive. It's not actually protecting anybody very well. It's mostly punishment and an inducement to get people to take the flu vaccine.
RW: What have we learned about organizations that have tried to address this with education and policies? What has been the experience?
JS: The experience has been very mixed. At my own institution, we were having difficulty getting what we thought were an adequate number of people vaccinated for influenza. Our administration did not want to make it mandatory in the sense that people would get fired if they didn't take it. So, we ended up paying people to get it. What I mean by that is our employees have a bonus at the end of the year and it's an all-or-none bonus. If the staff collectively reaches a certain threshold, then everybody gets that piece of the bonus. If not, no one gets it. Traditionally, all those bonuses were based on financial performance at the hospital. But we first got hand hygiene put in there, and it worked so well that we did it for influenza vaccine. Our threshold was 90% and we went above 90% when we started doing that, so everybody got that piece of the bonus. So that's one option.
We also found out we had very punitive sick policies for employees. When people were sick more than a couple of days, they had to go to their doctor and get all kinds of notes, etc. That was a real barrier. People said, "I cannot stay out the extra day because I'm going to have to go spend money to go to my doctor." For larger health care institutions, providing onsite care can be very helpful for a couple of reasons. It allows people to go in and be professionally assessed in a fairly convenient way. Also, it can help an institution in that, if people are going to their own health care facility, they can notice trends. They can notice an outbreak among the staff, if they're seeing similar kinds of signs or symptoms. Just looking at absentee days itself, which is usually the only measure anybody has, can be very helpful.
RW: You mentioned that one of the reasons that people in health care tend not to stay out when they should is the absence of backup systems. What does a good backup system look like? I'll give you a quick anecdote on my end. In my division, the majority of our faculty are women and for our first few years we had absolutely no plans for when women became pregnant. And each time it was a scramble. At some point, I said we cannot predict who is going to become pregnant, but we can predict that people will. We need a plan. Turns out it's a fairly predictable number, even though you have no idea who it's going to be and when. So we built in enough staffing so that we could deal with it. It meant that there were rare times when we were "overstaffed," but at least we were prepared for it. I imagine the same thing is true here. You could probably project how many people will be out at a given time and staff for it. I wonder if anybody's doing that and what a policy looks like.
JS: My hospital is definitely doing that. You can easily look at absenteeism, and you can find out (for nurses, respiratory therapists, and others) at what times facilities have float pools. The float pool is an extra little bolus of people who can fill in. Physicians often have backup call schedules. If you truly are a unique physician and you're the only one who does what you do, that's one thing. But the truth is very few of us are really in that position. By having backup schedules, it means that another person is at risk and it means they can go about their daily stuff, but they may end up getting called if a person ends up being ill. So it's not always an emergency. It can be more predictable. The hospital or company or practice has to financially support that so that the schedule has more flexibility.
RW: Are you finding that as organizations wake up to this issue, they are becoming more willing and are able to put the money into creating those schedules?
JS: Just starting to. That is actually where the more shift-based approach to medicine can be helpful, because that enhances scheduling somewhat. For instance, my wife for many years ran the pediatric emergency medicine at our place. They tend to work more in shifts, as opposed to infectious disease when we're on service. They have an elaborate backup call schedule that they can pull in. But you also have to create the culture that it's okay to use it. Obviously, everyone's always worried somebody might abuse it, and of course that's a possibility. But the truth is that doesn't happen that often because most of us still have that strong acculturation, you only use it when you need to. If we're all helping each other, then you're sick one day and I help you. Then I'm sick another day and you help me. That's how you create that culture.
RW: Is there evidence of the harm that people cause when they come to work ill?
JS: Very little has been published, and we desperately need it. Other businesses have been talking about presenteeism for 10 to 15 years. But in health care, we've just been talking about it for the last few years. Different institutions and facilities will need different approaches, but we should at least be able to describe what tends to work, what doesn't, and people's satisfaction with it as well.
The other thing we should do is educate families. I remember very distinctly a mother, she was one of those mothers who might by some people be labeled as tough because she was demanding and protected her child. If a health care worker went into that child's room and had any kind of symptoms, she would kick them out. I don't blame her. She was absolutely right. Her child was immunologically vulnerable. I do think educating patients and families as well as health care workers can be helpful too.
RW: Do you see differences among medical specialties? Do surgeons approach this issue differently than internists, for example?
JS: I have no data, but I do have two sons who are completing surgical residencies. I'm not sure it is all that different. The problem is if a surgeon has scheduled surgery, that's their surgery to do. Sometimes a surgeon will come in and say to a family, "I had emergencies. I was up all night. This is an elective procedure. I'd rather postpone it." I think that's terrific. That's courageous, and we need to do the same thing with illness or anything that could possibly affect your performance.
RW: How do you see fatigue and its issues interacting with issues around presenteeism and impairment? Is it just a different version of the same thing or is it a very different issue?
JS: No, it's extremely similar. In fact, I think a lot of the fatigue probably comes from illness. I mean we all poop out faster when we're ill. It may just be that we've been up a bunch or we're under stress, but certainly a medical illness or a mental illness is one of the major stresses that can lead to fatigue. No one argues about the effect of fatigue on performance and how dangerous that is for patients if health care workers are fatigued. That is the whole point: if you're sick, you have the same diminution in performance that you often have when you're fatigued. We've already made some progress with fatigue, and equating those things is exactly the right answer.
RW: Some who read or listen to this will say this is more evidence that medicine is going to hell in a hand basket. In the old days, doctors had this intense commitment to their patients and would slog through the snow to get in to do the work they needed to do and work when they're tired, work when they're sick. Now we're creating this shiftwork mentality. These readers may say "Sure, this is all fine if you're going to work in a box store, but medicine is different fundamentally." How do you react to that?
JS: This may be one of the areas where this transition to shift work may actually improve performance. Those doctors who slogged through the snow and so forth were extraordinarily dedicated, and most often there was nobody else who could do it. So they felt "Well, even if I'm not at my best I'm better than nothing," which is often the alternative. In modern American health care, except maybe under extraordinary circumstances (very small towns, rural medicine), that should no longer be the alternative. Physicians today, young physicians, care just as much about their patients as any other generation did. People who say that are asking the wrong question. The right question is: given what we have and who we are, what is the very best we can do for our patients? Working when you're sick is absolutely not the very best that we can do for our patients, period.
RW: Great. Anything else you want to talk about?
JS: I do want to talk about the whole issue of physicians and productivity. One of the other changes that has occurred along with the shift work is now physicians are being held much more responsible for their productivity as measured in a variety of ways. Especially if the physician is now working for a health care institution, be it a hospital or an HMO or something else, almost all of us now are being measured on our productivity. The study published in JAMA Pediatrics in 2015 showed that was one of the major concerns of the physicians. If they missed time because they were sick, it would knock down their perceived productivity and it would hurt them either financially or perhaps even in job security, promotion, and other ways. That needs to be addressed. That's part of the culture. If you are literally being hurt financially, in terms of promotion or anything else because you're ill—be it an acute febrile illness or because you have a chronic illness flaring up—obviously that makes no sense whatsoever. Institutions have to change their policies and look differently at how they measure productivity. We haven't even started to address that.
RW: That's a great point. You take all the cultural dimensions of not showing weakness and then your work RVUs [relative value units] drop and your pay drops and you're no longer pulling your weight. Well, you can see why people would be reluctant to pull the cord here.
JS: Absolutely. And according to this study, that is exactly what is happening at that particular institution. Anecdotally, many people have told me that they feel that same way. So ironically, that's the shift. It used to be about our obligation toward the patient. But now it's almost more the obligation toward the institution that is monitoring us and paying us. I would argue that is not a healthy shift at all. The medical care institutions need to catch up with some other businesses in the world and realize that this is a real issue, and they need to not only protect the workplace for the patients but also in essence to protect their employees.
RW: You hope that the trend toward paying some attention to employee satisfaction and burnout may be helpful here. You could imagine that might move the pendulum back in the other direction.
JS: Absolutely. So much is being written now about physician burnout across many different specialties. Pediatrics has a very high rate of people perceiving that they're having symptoms of burnout. A lot of that does have to do with being measured for productivity and what is expected of them. It has become a vicious cycle. Those same people that are rating all of us need to help us account for the fact that at times our productivity will be diminished by illness or perhaps some other form of stress. I think the kinder, gentler organizations will be the ones that figure out how to deal with that.