Published in the February 2016 issue of Today’s Hospitalist
AS THE FLU SEASON ramps up, Houston’s Texas Children Hospital, the nation’s largest pediatric hospital, is revamping its visitation policies. Children under 12 will no longer be allowed to visit, and all potential visitors will be screened for signs or symptoms of illness. Because illness affects clinicians as well as patients, the hospital is also retooling its staffing for the winter months, pulling in staff members who typically do nonclinical work to pitch in clinically instead.
“Some of the need for additional staff comes from how busy we get,” says pediatric infectious diseases specialist Jeffrey Starke, MD, who until recently headed up infection control at the hospital. “But some of the need is in anticipation of absenteeism.”
Additional staffing provides a cushion for nurses and techs who may need to call in sick, but it doesn’t help the doctors. That’s because in Texas, physicians can’t be employed by hospitals, so staffing contingency plans don’t cover them.
The irony, Dr. Starke points out, is this: “The higher your position, the more likely it is that there’s not someone to back you up. If you’re sick or have an emergency, you’re stuck finding another physician to take over.” And while his hospital’s staffing plans for winter are appreciated, they are also very recent, Dr. Starke points out. Just a few years ago, the hospital had in place what he considers to be a more punitive sickness policy, still a fact of life in many institutions.
“Having a system that can be activated gives doctors permission to be realistic about being ill.”
That kind of policy is part of the problem behind “presenteeism,” a term that refers to people who come to work when sick. But it’s also a fact of life in hospitalist programs that are chronically understaffed and have a hard time finding coverage for sick doctors on short notice.”If you missed more than two days with illness,” he says, “you needed a doctor’s note.”
Cultural norms When it comes to physicians working while sick, there appears to be a cultural expectation that doctors are supposed to work through their own illness. That appears to be the case from a study published last summer by JAMA Pediatrics that examined physicians’ attitudes toward working while sick.
According to the study, more than 80% of attendings and advanced practice clinicians surveyed at Children’s Hospital of Philadelphia admitted that they came to work sick (and with symptoms of contagious illness) within the previous year, while 9% copped to working while sick at least five times.
The vast majority (95%) believed they might be putting patients at risk. Doctors were the biggest culprit, with 99% saying they worked while sick because they didn’t want to let their colleagues down. Two-thirds worried that patient continuity would suffer if they didn’t come to work, while two-thirds (64%) said they feared being ostracized by colleagues if they called out. More than 60% pointed to “extreme difficulty finding coverage” and “a strong cultural norm to come to work unless remarkably ill.”
For Dr. Starke, who co-authored the editorial that accompanied the study, that cultural norm is changing, but slowly. From the point of view of infection control, “it should change immediately because health care workers get sick and transmit,” he notes. “We need to change people’s attitudes, but we also need to create better systems that allow people to act differently.”
Part of the problem, both the study and editorial pointed out, is the ambiguity around when physicians are too sick to come in. Julie Elliott, MD, a neonatal hospitalist who works at St. Vincent Women’s Hospital in Indianapolis, says that her hospital has a policy about when employees should either not work or should be sent to employee health services to be evaluated.
As for specific conditions, “certain things are hard line,” says Dr. Elliott. “You can’t show up in the NICU with bacterial conjunctivitis or a skin infection on your hands.” A common cold, however, is more nebulous. “There are so many degrees and it’s so subjective that it’s hard sometimes to make the right call.”
Common-sense rules Among hospitalists who treat adults, “Most of us would work through a cold or bronchitis,” says Albert Caccavale, DO, the director of Northern Arizona Hospitalists in Prescott, Ariz. “But most of us aren’t going to work through pneumonia.” According to Dr. Caccavale, who helped found the private hospitalist group in 2004, doctors coming to work when they’re too sick hasn’t been a problem.
He and his partners, he says, follow common-sense rules and know when to call out or trade patients at work. That’s because they can gauge the severity of what’s ailing them and can judge the risk they pose to patients. If he’s working through a cold, for instance, he makes sure to not treat immune-suppressed patients.
In Missoula, Mont., Charlotte Nelson, MD, the hospitalist section chief at Providence St. Patrick Hospital, says that she and her colleagues likewise take precautions if they’re under the weather but not ill enough to stay home. When she comes in with a cold, for instance, Dr. Nelson will try to steer clear of the oncology patients, even though they are part of a medical unit.
“You may wear a mask when you’re rounding, pay particular attention to hand hygiene and opt to trade off your neutropenic patients,” Dr. Nelson points out. At the same time, she says, “it’s not like a grocery store where if you don’t show up, it really doesn’t have an impact. Somebody has to cover you, and that’s why doctors may be more likely to push themselves to the limit” than people in other professions.
“It’s one of those things that we know we all do,” she adds, “and we probably all know that we shouldn’t. But most of the time, we minimize risk to others in favor of just going in and working.” Dr. Nelson notes that she and her colleagues share that attitude even though the group has for years maintained a jeopardy call system for illnesses and emergencies.
Even if physicians don’t always use such a system, having it in place should free some doctors from concerns that they’re forcing their partners to pick up their slack. That’s the conclusion of Eric Rice, MD, a hospitalist with CHI Health in Omaha, Neb.
“Having a system that can be activated when someone is truly ill helps alleviate that worry about letting colleagues down,” Dr. Rice says. “It gives them permission to be realistic about being ill.” At the same time, he admits, “there are always a couple of people who just don’t get that message. They come in too sick, and then we have to just tell them to go home.”
Building in back-up Dr. Elliott’s group in Indianapolis has thought about creating a sick-relief back-up system, but with only 10 physicians, its members feel they lack the critical mass they need to create one. The neonatal hospitalists work with a group of neonatologists to provide secondary coverage in the NICU, as well as covering the term and level 2 nurseries.
“After we do seven days in a row, we have an ‘easy’ week where we do only one or two night shifts,” Dr. Elliott explains. “We talked about making that person the designated back-up, but we voted that down.” The rationale behind that vote, she adds, is that after working seven days straight, people didn’t want to feel responsible for always being available.
“So we just left it as a kind of free-for-all,” she points out. “When someone calls in sick or something happens, we put out a mass text to everyone and say, ‘Can anyone help out?’ ” She adds that the system usually works out. “We do it as a trade because eventually, everyone will have to trade a shift.”
By comparison, Dr. Caccavale’s group in Arizona put a back-up system in place in its second year when NAZ Hospitalists had only six physicians, and one became ill. Today, the group’s 14 doctors rotate through back-up in their weeks off. Each commits to not leave town a few weeks a year. Because all the doctors are also shareholders in the private group, Dr. Caccavale says they don’t pay themselves a stipend for being the designated back-up. In addition, the system—which isn’t activated very often—is used only for illnesses and emergencies.
“If someone is out for an extended period of time, say more than three days, physicians who fill in for the additional shifts get paid on a daily basis, the normal shift pay,” says Dr. Caccavale. As for how the group handles census surges, “We all work through them.”
A stipend for taking back-up? In Missoula, Dr. Nelson’s group has 15.8 FTEs, which includes several part-time physicians. The group put its jeopardy system, which also isn’t used for volume spikes, in place six years ago.
“It became clear at that point that we were taking all of the medicine inpatients, and there weren’t any rounding outpatient docs any more,” says Dr. Nelson. “If somebody couldn’t get to work, it was really going to be a problem.”
In her group, jeopardy is initially assigned to doctors in rotating weeks off, “but there is a lot of trading that goes on.” The hospitalists earn a stipend for each back-up week, with doctors agreeing to remain no more than two hours from the hospital.
If called in, “we get paid an hourly rate,” she says, “which is our extra shift pay.” Mountain States Health Alliance (MSHA), a health system with hospitalists covering eight hospitals throughout Virginia and Tennessee, has several layers of back-up for physicians who may be too sick to work.
For one, says Amit Vashist, MD, MBA, system chair of hospital medicine, the group’s 25 advanced practice clinicians can provide back-up for the physicians. The 75 doctors work with the NPs/PAs in groups that range in size from six clinicians to 24. Also, the doctors are credentialed at all the MSHA hospitals in their primary state.
“We’re going to credential all our hospitalists in all our facilities so we can get a bigger boost,” Dr. Vashist says, pointing out that the farthest any two hospitals in the system are from each other is an hour and a half. Then there’s a jeopardy system in which doctors volunteer a month in advance to be back-up during their days off.
“About 25% of the physicians do 75% of those shifts,” he notes. The hospitalists who sign up aren’t paid unless they’re called in, “but we do pay them 1.5 times their normal shift rate to cover a hospital that’s not their primary site.”
Breaking up back-up weeks Dr. Vashist also points out that the physicians in his group don’t receive separate sick days and have to use some of their two weeks of paid time off if they call in sick. While he admits that the policy could give doctors an incentive to work when sick, he doubts it’s much of a factor.
“More than anything else,” says Dr. Vashist, “you don’t want to burden your colleagues.” (See “Doctors and calling in sick.“) Among Dr. Rice’s 50-member group in Omaha, back-up is mandatory, twice a year. The hospitalists are paid for taking jeopardy even if they’re not called in—and they sign up for only a few days at a time.
“You can sign up for Saturday, Sunday or Monday or Tuesday through Thursday,” he points out. “We break up the weeks because we know taking jeopardy is inconvenient.” But some administrations can’t or won’t incur the expense of paying doctors to just be available.
That was the case at Good Shepherd Medical Center in Longview, Texas, according to Sushama Brimmer, MD, the hospitalist medical director. The group put in a back-up system (mainly for spiking volumes) last year. But because doctors weren’t paid if they’re weren’t called in, the system “fell by the wayside,” Dr. Brimmer says.
“I think such a back-up system is hugely needed for any group, but it’s all in how you design it and what your group is willing to stomach.”
Staffing up Even without formal back-up, Dr. Brimmer notes that this winter is proving to be much less brutal than previous ones in terms of volume. That’s because the group also hired a night nurse practitioner and now brings in a second doctor on-call some nights, so group members aren’t pulling nearly as many extra night shifts as a year ago. In addition, the hospitalists have several new FTEs, bringing their number to 20.
“We’re no longer so understaffed, so that’s alleviated a lot of anxiety around having to do so many extra shifts,” Dr. Brimmer explains. Plus, she knows which group members want additional shifts. Finding back-up now is more reactive than proactive, and she’s “waiting on the other shoe to drop. But so far, we’re not feeling the lack of formal back-up as much as we used to.”
For Dr. Elliott’s group in Indianapolis, understaffing has been one reason why its physicians have been reluctant to opt for formal back-up. Because people have been stretched so thin, the thinking has gone, requiring everyone—other than those hospitalists who want to pull extra shifts—to rotate through a back-up system could be a real dissatisfier.
The first step toward providing some sick relief, Dr. Elliott believes, is to get fully staffed, and the administration is now approving an increase in doctors’ initial starting salary. “That’s going to help a lot in both recruiting and retaining,” she says. “It’s certainly a step in the right direction.”
As for changing the culture of medicine in which more doctors than should work sick, Dr. Starke from Texas Children’s says that his hospital has for years tracked its own rates of health care-related viral infections.
“I can tell you how many hospital-acquired flus, RSVs and adenoviruses we have in our hospital every year,” he says, noting that there aren’t many. “Those rates speak to not only the behavior of people who may be working when ill, but to how effectively you’re preventing infections being spread in the hospital.”
He believes that public reporting of such data will be a fact of life in the future. “Just as we’re doing now with bloodstream infections,” says Dr. Starke, “if we start reporting hospital-acquired respiratory viral infections, institutions will have a much more vested interest in making sure people don’t come to work sick.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
WHEN IT COMES TO PHYSICIANS’ WORKING when sick, Jeffrey Starke, MD, a pediatric infectious diseases specialist at Houston’s Texas Children’s Hospital, says that penchant is alive and well in medical culture.
“But I think it’s generational, frankly, and I’m not saying that as a kind of ‘when giants roamed these halls’ comment,” says Dr. Starke. “I think younger physicians are less tolerant of those kinds of impositions on their own health and personal life.”
However, Albert Caccavale, DO, a founder and owner of Northern Arizona Hospitalists in Prescott, Ariz., doesn’t see working while sick as an issue that’s unique to doctors. Instead, he says it’s the norm for all sorts of professionals. Further, as a member of a local private group in which all 14 hospitalists are shareholders, he believes that business ownership carries with it even more of a sense of responsibility to show up unless you’re really sick.
“If you own a convenience store, you don’t build in sick days for yourself,” Dr. Caccavale points out. “With ownership, there may come more of a sense of commitment and a tendency to work through things.”
But Amit Vashist, MD, MBA, who’s system chair of hospital medicine for Mountain States Health Alliance, a health system in which hospitalists cover eight hospitals throughout Virginia and Tennessee, thinks that clinicians face a very specific dilemma when they become ill.
“It’s in our DNA to perceive our role as someone who provides care, not one who receives it, and I don’t think we do a good job handling those aspects of our professional lives,” says Dr. Vashist. “When I’m ill, I feel really guilty if I’m not able to come in. I feel I’m letting my colleagues and my patients down.”
His group activates its back-up jeopardy system much more for volume surges than for physician illness, and Dr. Vashist says he keeps seeing colleagues who are driven by the same sense of commitment (or guilt). That’s because they—perhaps foolheartedly—brave Appalachian roads during blizzards when those roads haven’t been cleared.
“They show up at 11:30 or noon and do their full complement of patients,” says Dr. Vashist, who points out that day hospitalists just plan to spend the night at the hospital when they’re snowed in. “We have this discussion a lot about not coming in on such days because it’s potentially life-threatening to get here.”