We need to rethink professionalism

A new study in JAMA Pediatrics (free full text here) should make hospital epidemiologists and infection preventionists cringe. All physicians and advanced practice providers at Children's Hospital of Philadelphia were sent a survey on presenteeism. Of the 929 providers surveyed, 58% responded.

The big findings were as follows:
  • 95% felt that working while sick puts patients at risk
  • 16% would come to work with fever 
  • 30% would come to work with diarrhea
  • 5% would come to work with vomiting
  • 56% would come to work with acute onset of respiratory tract symptoms
  • Asked several ways, >90% stated they would come to work while sick out of a sense of professional obligation
What I find most interesting about this paper is not how often sick healthcare workers come to work (though it's a big problem), but why they do so. And once again, professionalism rears its ugly head. Professionalism revolves around expectations and norms set by the profession. It seems to me that if we viewed this more through the lens of humanism rather than professionalism, we'd be better off. From a humanistic standpoint, which holds a universal rather than parochial view, all would agree that individuals who are ill with potentially contagious diseases should not come to work (doesn't matter whether you're a doctor, a teacher or a plumber). Similarly, in the white coat debate, professionalism drives the argument that physicians should wear a white coat. Humanism would dictate that attire should be practical, comfortable, safe, and personally desirable. Several years ago, Judah Goldberg wrote a great essay in Academic Medicine that I often quote and recently re-read on the conflict between humanism and professionalism. It really crystallized for me the differences between the two philosophies, which are often in conflict, and once the differences are made clear, it's easy to see the corrupting influence of professionalism. It's worth a read.


  1. Good points but you seem to have confused professionalism with misplaced behavior. Professionalism would dictate that you act is a way that protects your patients, colleagues and profession. Which coming to work vomiting doesn't. I hope my colleagues act professionally.

    Dr. Jason, A "professional" pediatric anesthesiologist

  2. Thrilled to see a mention of our study on one of my favorite blogs! I’d also like to say that as a sociologist, I really appreciate your interpretation of our findings (and cite to the Goldberg article – which I think is a very important piece). Most of the press coverage we’ve gotten has focused on the frequency with which physicians and advanced practice clinicians come to work sick – this is not news. We know from the literature and anecdotal reports that this is common. Our goal in this study was to really try to understand the factors that shape the decision to work while sick. The strong cultural norm we uncovered that clinicians “come to work unless they are dying” can be thought of as a way for clinicians to illustrate their dedication to patients – i.e. they would sacrifice their own safety and comfort to be there for their patients – which could, depending on your perspective, be considered a highly professional behavior. While the intention behind this is good, I would argue that we need to reframe working through illness as unprofessional behavior instead of evidence of supreme dedication.

    More than anything though, we found that the decision to work while sick is shaped by complex competing priorities – that yes, stem from culture, but also from systems, production pressures and the reality that sometimes it is not clear what constitutes “too sick to work.” This gets back to my favorite quote from the Goldberg article – “Ultimately, the more clarity we can present to our students about the multiple, and sometimes competing, dimensions of medical practice, the better we will empower these fledgling physicians to balance them with grace and with insight.” (715)


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