These results suggest that during a severe influenza outbreak more than half of responding Alberta physicians may be available and willing to work; however, in a severe pandemic, these numbers may drop due to their own illness, or unforeseen circumstances. Men appear to be more willing to continue working than women. There may be differences according to country of origin, due perhaps to different cultural acceptance of risk or perception of duty.
The corrected response rate for this survey (22%) was low despite sending three letters in sequence; therefore, there may be response bias, and we cannot know in what direction this would affect the results. Because of the ethics committee ruling, we were unable to contact a sample of non-responders for a comparison with responders. However, the gender composition of the responding group reflects the demographic features of the primary care physician population in Alberta, and sample size is adequate to demonstrate clear differences in gender responses, so these findings likely reflect reality (Table 1). Sample sizes are small for differences between physicians from different origins, and for urban/rural differences, so power to demonstrate difference is limited and small biases due to differential response rates could affect the findings substantially. Further, we performed multiple comparisons, so if a correction for multiplicity was applied, some differences would be regarded as non-significant. Conclusions from comparisons between the sub-groups thus reflect the opinions of the survey participants and potentially not the views of the family physician population overall, so should therefore be viewed with caution.
Despite these limitations, there is a degree of consistency among the responses that raises concerns about physicians’ willingness to work during a pandemic. Some writers on this topic assert that physicians and other healthcare workers have moral, ethical, and legal obligations to continue working despite increased risk to themselves and their families , though others point out that most health care workers did not volunteer to be “heros” . In Canada, physicians are expected to adhere to the Code of Ethics published by the CMA . These guidelines do not provide definitive directions to physicians regarding whether to work during a pandemic. Each province has its own statute that can conscript physicians to treat patients during a declared emergency. Alberta has the Emergency Management Act, but there has been minimal recent public or professional discussion about this act and its implications . Though the law could compel doctors to work, it is unlikely to be effective, and any legal action would likely not commence until well after the need were past.
These are only answers to a questionnaire about a hypothetical, though nonetheless imminently possible threat at the time it was distributed. It is impossible to know what would actually happen until faced with the real crisis: doctors might indeed stay at their posts to a greater extent than they answer in this questionnaire, or they might have over-stated their likelihood of working. Previous studies worldwide have also explored the willingness of physicians to work during a severe pandemic, and found similar responses. Not all healthcare workers willingly accept the increased risk associated with their profession, but in a German study, physicians were more willing to work than those who were not in direct clinical care . A qualitative study in the United Kingdom found that most physicians felt an obligation to work during a pandemic, though there were barriers to their willingness and ability to work . Fear of infecting their families was a common concern, as well as barriers to finding childcare in order to continue working [11, 12]. Barriers to obtaining personal protective equipment (PPE) , and concerns about contracting influenza caused some reluctance . Fear of social ostracism for themselves and their families was also a concern for physicians in Singapore ; such events occurred in the SARS epidemic in Toronto , and may have affected Canadian physicians’ responses in our sample. Ultimately the only valid test of actions is to see what happens when an epidemic occurs: but these findings correspond with the limited data available in recent epidemics [5, 6].