In Marcus Welby, M.D., the early-'70s medical version of Leave It to Beaver, hospitals were depicted as sterile environments with shiny equipment and starched bed sheets. More recent medical dramas have gotten dirty: E.R., House, and Grey's Anatomy are a lot more likely to feature episodes in which a patient is admitted with a broken leg and later gets infected by flesh-eating bacteria. While not all TV medicine reflects real life (it's not that common to call a code black in order to extract a ticking time bomb from a patient's abdomen), new studies are published every month on hospital-acquired infections. Not even celebs are immune: According to reports, Michael Jackson suffered serious infection after his most recent nose job.
This raises an important question: Why do people get infected while in the hospital? The first and most obvious answer is that hospitalized patients are sick and vulnerable because their immunity is compromised. But hospitals are also dirty places that can (and do) serve you up a side of microbes along with that lukewarm bouillon. Hospitals house hordes of people with infections together in close quarters, and bugs are bound to spread. While some of this can be prevented through infection control, doctors frequently don't do a great job of washing their hands or their stethoscopes between patients. But there's another reason, which no one who works in a hospital likes to talk about: Doctors tend to show up to work sick.
Now, why would a doctor dare come to work with a contagious disease and examine my grandmother with germy hands?
Coming to work ill is part of the culture of medicine. A favorite saying on surgical wards is "We're rounding with you, or we're rounding on you"—if you're missing work, you better be so sick that you're admitted to the hospital. Sick doctors have been known to do rounds while dragging IV poles and receiving fluids for GI illness. Gross, but it happens. This culture of work-first/self-second may not be such a terrible thing: Patients want dedicated doctors who study hard and won't sleep unless their patients are tucked in. But this hard-nosed culture can cause problems, especially when overtired doctors make mistakes because a cold has stuffed up that same hard nose.
In some hospitals, working while under the weather is basically policy. Some hospitals have been reported to fire workers who take too many sick days. Residents on a well-known hospital's internal medicine service are allotted two sick days per year. Any more than that, and they work an extra week. When a poor doc wakes up coughing and achy on what would be her third sick day, there's no real choice: She sucks it up and hobbles to work. One would hope that she would wash her hands more diligently that day, but there's still a good chance some hapless patient will catch whatever she's got. In all likelihood, the otherwise healthy M.D. will recover without a problem. But the newly infected patient, who was already sick, might not be so lucky.
Hospitals may promote this culture in part because of the limitations on hours that residents can work. Unfortunately, the guidelines can make already tight schedules even more packed. When people call in sick, sometimes a healthy but sleepy member of the team has to come back to work, or a disgruntled doc gets called in from a much-needed vacation. Either way, the sick doc at home—sniffling and coughing through The Price Is Right—feels bad because he just screwed over a colleague. The next time he comes down with something, he might try to tough it through his shift.
This culture of working sick isn't limited to doctors and hospitals. Other high-intensity professionals are loath to miss a day. But a banker showing up sick to the stock exchange is far less worrisome than a doctor coming to the hospital with the flu, which can kill a patient who has a compromised immune system. Some would argue that coming to work sick is better than the alternative. When doctors don't show up, their patients must be cared for by others who may not know important details of their medical history, possibly leading to medical errors. But the same arguments were made when rules came down forcing doctors in training to work fewer hours: Despite less continuity of care, patients didn't fare any worse.
In the end, it conjures images of Snow White and the Seven Dwarves: You might think you're getting Doc, but instead you get Sneezy, Sleepy, or even Dopey.
What's the solution? The first thing we can do is change the culture. Calling in sick should not be seen as wimping out. Unfortunately, cultures—even toxic ones—are incredibly stubborn. Another possibility is to alter the rules: Build greater redundancy into the system so that the two-day-only sick rule is not needed. A reduction in resident work hours should be coupled with an increase in the number of residents or other staff (such as physician extenders who can fill in). Also, an on-call backup person should be required on all services.