Dear Director: I’ve called out sick a couple of times this winter and now my boss and colleagues are giving me a hard time. Aren’t I allowed time to recover from my illness?
“No matter how I feel, my job is to show up to work. The doc giving me sign out decides if I can take sign out or if I need a bed in the ED.” A program director said this to me a couple of years ago when we were talking about showing up to work sick. While I appreciate his work ethic and hope my docs generally follow the same philosophy, the reality is that during cold and flu season, no matter how immune we think we are, some of us will get sick and probably not be able to make it in to work. While there are plenty of jobs that you can call out from, our job is a little different, since most EDs can’t work without the doc; and typically, we don’t have a good backup plan in place to make sure the ED is appropriately staffed. Throw on top of that the macho attitude that gets ingrained into us during residency (we can work through anything), that we usually want the clinical hours (and the accompanying dollars we’re paid), and that we don’t want to inconvenience our colleagues and have them change their plans during their day off to cover for us, and you can clearly see why most, if not all of us, have been at work and thought we were more sick than a large portion of our patients. If you’ve done this long enough, you probably remember the days of going into work early to get a couple liters of IV fluids and Reglan and Zofran and then leaving your hep-lock in during your shift so you could recharge if necessary. I certainly don’t see that happen nearly as much as I used to. With the hospital’s emphasis today on metrics related to productivity and the patient experience, perhaps you should be close to peak performance level, or at least not feeling like you should be a patient, when you come to work. Complaints from patients about doctors with drippy noses, sneezing on them, or having rigors probably won’t look good either. Plus, I’d hate to make a mistake that could lead to a bad outcome because meds made me sleepy or because I felt so crummy that I wasn’t able to concentrate.
Are you infectious?
Before deciding to work, perhaps the first question we should be asking ourselves is, are we infectious and could we make our patients more sick? I’ve had the flu once and literally felt like I’d been run over by a truck. I couldn’t have worked if I had wanted to (fortunately I was off for a few days) but it’s not in anyone’s interest to have someone with the flu working in the ED. Although you’ll be contagious for several days, you probably need at least a day or two off. In fact, the CDC recommends that healthcare workers should be afebrile for at least 24 hours before returning to patient care if the illness was comprised of a fever with respiratory symptoms. There are days where we work with ailments like colds, sore throats, GI bugs, and conjunctivitis and we don’t feel sick enough to call out. You’re still probably contagious, and while your hospital may have a policy against working when you have certain illnesses, these are the days that, if you’re working, you need exemplary hand hygiene and probably a mask, so you don’t infect other patients.
People who call out for non-infectious situations usually have a reason related to pregnancy or trauma. Whenever we’re planning ahead for the mom- or dad-to-be, we’ve always generated a volunteer call sheet to cover each shift after the 37th week, in case the baby comes before maternity or paternity leave starts. That way, there are no surprises. I’ve also probably had about half a dozen docs during the last 10 years who have broken something while skiing. It’s usually a wrist and our biggest concern is whether they can intubate and thus work a single coverage night shift safely. Fortunately for our logistics considerations, there’s usually a couple of days notice for these types of injuries. I’ve also seen several docs with lower extremity injuries who needed to use scooters to get around the ED and several more with severe back pain, one of whom was wheeled around in his desk chair the whole shift. While taking off a day at the onset may have been necessary, it wasn’t realistic or necessary to take off for their entire recovery. The key point was that they did not work while on opioids or any other medication that could impair judgment. I did have one doc work up his own right lower quadrant pain. Without missing a step with his patients, he registered as a patient, had blood work and a CT scan showing appendicitis, and called the surgeon. Surgery was scheduled for after his day shift ended. He was off for the next couple of days, so it was all pretty fortunate, timing-wise.
In one incident, I got called at 3:15 a.m. Our 7 a.m. doc had just called out sick. He had gone to the ED near his home the evening before but it wasn’t until 3 a.m. that the docs there decided to admit him for IV antibiotics for his diverticulitis. That night, I didn’t know the details of why I was being called in, but it came with the territory. I was the on-call doc for the upcoming day, not because I was the chair, but because our group assigns a doc each day to cover such emergencies (as well as high volume surges). Every ED has some sort of on-call coverage. Typically, callouts are handled by a call to the ED secretary or the group chair, who then calls around to the other docs and asks if they can take the shift. Most chairs pick up more than their share of these open shifts, but realistically, they can’t pick up them all. I remember asking one doc at 6 p.m. in the evening if he had had a beer yet. When he said, “No,” I said, “Great, we need you to work now because Dave went home sick.” As I surveyed colleagues around the country, it appears that most groups don’t have a formal on-call process, with the default being the chairman and the ED secretary calling docs. As I said, my current group does use call. We probably get called in less than 10% of the time, and it’s been a savior for the last-minute callout when the flu hits someone. At least one former chair I spoke with was against a call system. As he put it, he thought if it was too easy to call out, more people would do it, and he wanted his docs to work their shifts. A different chair recently told me that in the first month they implemented a call system, it was used nearly 50% of the days. That seemed crazy to me and was certainly unsustainable from an employee satisfaction point of view. This led to group discussions and creating a culture of how call should be used and the doctor’s individual responsibility for covering his or her shifts. I’ve worked in four hospitals. The two bigger groups had call, the two smaller groups did not. Unless you have a big pool of docs to cover call, it can be quite burdensome. Taking call twice a month in addition to 15 shifts seems fine to me but if you’re in a smaller ED with only six docs, taking five calls plus your shifts can be quite onerous; so unless you have a big group, call may be very dissatisfying and very challenging to schedule.
Assuming you don’t have an on-call doctor, I think the first step, unless you’re unconscious or have your head in a toilet, is to try to get your shift covered yourself. Send a group email, call a colleague, suggest a trade, etc. Early notification is also key. If you’re not feeling well at 8 a.m. and unsure that you’ll be able to work your 4 p.m. shift, call your medical director before noon instead of at 3 p.m. I’d much rather start working on a tentative plan and have a few hours to make phone calls then be rushing to get things together over an hour, which typically means having docs stay late and perhaps getting another shift in early. Remember to pay it forward. If you’ve called out before, think about volunteering to pick up the next shift that opens at the last minute even if it means cancelling some plans on your day off. After all, it’s likely someone cancelled his or her plans to cover your shift. Unless your job says it’s okay to call out for a sick child, make sure you have childcare in place when you’re scheduled to work and your child is home sick from school.
What can your boss ask you?
Unless you call out sick often, it’s unlikely that your boss will want a note from a doctor or will ask too many questions. Though most of us will just say we hope you feel better, the law does allow bosses to ask follow-up questions about your illness and when you might be back to work. The exception to this is if your absence is related to a medical condition protected under the Americans with Disabilities Act—someone with a baseline physical or mental impairment. Even in this case, the boss can ask about the ability to perform work-related tasks and when the person would be able to come back to work.
The shift needs to be filled and since most docs don’t want to inconvenience their colleagues, we work sick. I’m not advocating for having a threshold so low you’re calling out for a scratchy throat or a little cold. But we’re human, so sooner or later, each of us will get sick enough that we can’t work. If you know you won’t be able to do your shift, try to fill it yourself or make a trade so that you don’t lose hours. If you’re too sick to do that, give your boss as much notice as possible. If you don’t have a call schedule, it’s worth a discussion to see the positive and negative effects of implementing a call schedule for your group. And if you’re contagious and working, put on a mask.
Only in EM…”I did have one doc work up his own right lower quadrant pain. Without missing a step with his patients, he registered as a patient, had blood work and a CT scan showing appendicitis, and called the surgeon. Surgery was scheduled for after his day shift ended. He was off for the next couple of days, so it was all pretty fortunate, timing-wise.”
Well, I guess there was the Antarctic Research station doc who did her own breast biopsy since there was no other alternative!
I have another unrelated comment that will follow.
Mike mentioned asking a on-call doc whether or not he had had a beer before asking him to cover a shift that was unexpected. I am learning from docs in other specialties that this is a real issue in, for example, small communities with only one or two neurosurgeons. If one is in the OR and someone comes in needing a burr hole, which most neurosurgeons could do in their sleep; or else the patient will experience long delays for transfer to another facility and risk death, what is the ethical thing to do? I’m not sure I know the answer.
And speaking of alcohol, I think I had to leave duty once during my career for classic migraine with vomiting. The on-call doc was very angry to have been called to relieve me. When he arrived he had alcohol on his breath, which fact I duly reported to my supervisor. He did seem perfectly capable (I guess he was early into his nightly habit), so after assuring myself that he was not a danger on that occasion, since there was no one else to cover, the super had no other suggestion and I was incapable of seeing patients I was driven home. I was later reprimanded for sullying this doctor’s reputation by raising the issue, and he ended up replacing me in my position at the institution where our mutual supervisor was his longtime friend.
It subsequently became obvious to all that he had a problem. But in that instance, I paid a high price for my accidental early awareness. Again, I’m not sure that I know what else I could have done under that particular set of circumstances. Mike, perhaps you’ll devote a future column to these types of issues (and I apologize if you already have and I missed it!)
You raise very interesting questions. I’ve written a couple times about the “potentially” impaired provider who is at work and needs to be relieved of duty but I have not written about the standard for a consultant physician who may have had a drink. I don’t know if I have the answer or am qualified to write on what a standard should be for a physician outside of the emergency medicine, but I appreciate you raising the questions.
Funny story. I went to work one morning with acute RLQ pain and didn’t tell anyone until the ER doc I was relieving was long gone. I saw patients, ordered my CBC and CT scan, drank my contrast, and stayed npo. No narcotics or even Toradol [ our surgeon was not a fan!]. My CT was markedly positive. They called the surgeon who reprimanded me for working in such condition and ordered immediate surgery. A local physician was kind enough to cover the ER, and fortunately had ER experience. We were a small hospital and the idea of a call system was ridiculous. I was taught to never call in and in 22 years of emergency medicine I worked with 104 degree fever, passed 2 kidney stones, and persevered through multiple other maladies. I would welcome a call system for each hospital. We had one with the local docs when I was a director. Appreciated those docs!
I know by experience if you are willing to trade for a less desirable shift, it is usually no problem getting takers.
On the rare occasion one of us has a family emergency or illness, “critical time pay” is offered and the shift usually gets covered with the large financial incentive. I went into EM with the understanding that my time off is my own. I would not want to work at a shop where I couldn’t be out on my boat with no cell phone signal, or couldn’t be out of town on a golf course, or be at a wedding and not be able to have a drink knowing I could get called in at any time. If I worked at a shop like this, I would demand that if I get called in to cover a doc, I would then be able to request that other doc cover ANY one of my shifts upcoming shifts (Christmas, New Years Eve, weekend nights included) no questions asked to dissuade any docs from abusing the call list and perhaps get somoene a little under the weather to suck it up.
I do appreciate a moderate sized group where people are able to juggle to cover an absence. You hope people can ‘pay it back’ at some point. Last year, I had what I thought was a strep pharyngitis (it was) mutate into a paratracheal phlegmon and compress my airway within 36 hrs. I had my co-workers covering my shift for my ‘strep throat’…but finally realized that I needed higher level of care when I was attempting to concoct a home suction setup with my shop vac and PVC piping as I was unable to lay supine or swallow my secretions. I spent several days in the ICU stepdown on airway precautions.
I couldn’t possibly repay my co-workers’ generosity for the subsequent mandatory 10 days of needed coverage, but am grateful that the system existed. I scheduled my ‘elective’ tonsillectomy a year later instead of taking a planned vacation so as to minimize impact on the group. (Side note: tonsillectomy as an adult sucks.)
Really, though we pride ourselves on rugged individualism, we cut off our nose to spite our face by pretending we are above the very illnesses we treat. A backup system should always be in place but rigid enough to prevent abuses. Its not ‘if’….its ‘when’.