Presenteeism Among Resident Physicians

To the Editor: Despite recent Centers for Disease Control and Prevention guidelines urging health care personnel with flu-like illness to avoid working,¹presenteeism (working while sick) is prevalent among health care workers.² Ill health care workers can endanger patients and colleagues due to decline in performance or spread of disease. Resident physicians may face unique pressures to work when sick and lack time to seek health care. Using a multihospital resident survey, we determined self-reported presenteeism rates and associated factors among residents.

In August 2009, anonymous surveys were sent by 2 authors (D.C.B. Jr, S.R.D.) to 744 residents in postgraduate year (PGY) 2 and 3 in general surgery, obstetrics/gynecology, internal medicine, and pediatrics at 35 programs in 12 hospitals selected for varied geographic, size, and governance characteristics. Using a 50-item survey that broadly evaluated residency training, residents were queried regarding their prior academic year (2008-2009), “Were there occasions that you think you should have taken time off for illness, but did not do so?” Presenteeism was defined as a resident endorsing “once” or “more than once.” Residents also were asked, “Did your schedule permit adequate time to see a physician regarding your health?” using yes/no responses. Results are presented by the training year assessed in the survey. χ² analysis using SPSS version 14 (SPSS Inc, Chicago, Illinois) was used to compare rates of presenteeism and adequate time for physician visits by PGY status (PGY-1 vs PGY-2), sex, medical school location (United States vs other), specialty, and hospital. Statistical significance was defined as P < .05. This study received institutional review board approval and waiver of written consent.

Overall response rate was 72.2% (537/744). Hospital response rates ranged from 48% to 100%, with 5 hospitals more than 90%. Of responders, 57.9% (95% confidence interval [CI], 53.6%-62.1%) reported working while sick at least once and 31.3% (95% CI, 27.2%-35.2%) more than once in the previous year. Inadequate time to see a physician during the prior academic year was reported by 52.9% (95% CI, 48.5%-57.1%).

Residents were more likely to report presenteeism during PGY-2 than during PGY-1 (62.3% [95% CI, 57.1%-68.4%] vs 51.7% [95% CI, 45.6%-57.9%], respectively; P = .01) (Table). Rates of presenteeism or time to see a physician did not vary by sex, specialty, or medical school location. Except for one outlier hospital in which 100% of residents reported working when sick, presenteeism rates did not vary significantly across hospitals (range, 51.3% to 72.3%; χ² = 5.89, P = .83). Although respondents and nonrespondents could not be compared due to anonymity, presenteeism rates did not vary by hospital response rate.

Despite major residency reforms over the last decade to ensure resident and patient health, rates of resident presenteeism were high and similar to rates observed in 1999.³ The higher rate of reporting working when ill among PGY-2 vs PGY-1 residents may reflect a greater responsibility toward patient care, consistent with higher presenteeism rates among workers who believe their duties are not easily substituted.^4,5 The lack of factors associated with presenteeism suggests it may be pervasive. The presence of an outlier site suggests that hospital culture could play a role. Many residents reported inadequate time to see a physician in the previous year, highlighting challenges residents face in caring for themselves. Study limitations include reliance on self-report, inability to distinguish between infectious and noninfectious illness, and potential bias from H1N1 influenza cases during survey development.

Residents may work when sick for several reasons, including misplaced dedication, lack of an adequate coverage system, or fear of letting down teammates. Regardless of reason, given the potential risks to patients related to illness and errors, resident presenteeism should be discouraged by program directors.

Author Contributions: Dr Baldwin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Jena, Baldwin, Daugherty, Meltzer, Arora.

Acquisition of data: Baldwin, Daugherty.

Analysis and interpretation of data: Jena, Baldwin, Daugherty, Meltzer, Arora.

Drafting of the manuscript: Jena, Baldwin, Daugherty, Arora.

Critical revision of the manuscript for important intellectual content: Jena, Baldwin, Daugherty, Meltzer, Arora.

Statistical analysis: Jena, Baldwin, Daugherty.

Obtained funding: Baldwin, Daugherty.

Administrative, technical, or material support: Baldwin, Daugherty, Arora.

Study supervision: Jena, Baldwin, Daugherty, Arora.

Funding/Support: This study was funded by the Accreditation Council for Graduate Medical Education.

Role of the Sponsor: The funding source had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Additional Contributions: Meryl Prochaska, BA, University of Chicago, and Patrick Ryan, MD, ACGME, provided research assistance, for which they were paid.