Making Clinicians Get Flu Shots: More Important Than Simply Preventing the Flu

I was recently speaking to the clinical leaders of a mid-sized hospital, and a senior administrator posed the question, “should we require our doctors and nurses to get flu shots?” The answer, I said, is yes, and it isn’t just to prevent the flu. It’s to get into the habit of making our folks do the right thing when it comes to patient safety.

Preventing the flu is very important. In the face of a significant bump in flu cases, in the last couple of weeks we’ve seen several states declared public health emergencies. Hundreds of hospitals have placed restrictions on visitors, including banning kids from visiting their parents. These are prudent steps: influenza can be an unpleasant inconvenience for a healthy person, but, for older and immunosuppressed patients, it can be a killer. The CDC estimates the number of yearly deaths from flu to be in the thousands; in a bad year like this one, it’s likely to be in the tens of thousands.

While one would hope that the professionalism of clinicians would drive them to vaccinate on behalf of their patients’ welfare (and most do – CDC data shows that about two-thirds of hospital workers get the vaccine), it’s not enough.

Sorry folks, but this one should not be a choice. It should be a mandate.

At UCSF Medical Center, where I work, we began requiring vaccination three years ago. Clinicians can refuse the vaccine, but if they do they must wear masks throughout flu season – for infection prevention and, I suspect, to act as an awkward disincentive. Along with the requirement, we make it easy to get vaccinated – during flu season, you can’t walk down a hospital hallway without bumping into someone wielding a needle. We now vaccinate about 15,000 individuals yearly. The program has been highly effective, with overall vaccine rates over 90%, and, according to my Occupational Medicine colleagues, no recent cases of clinician-to-patient (or visa versa) transmission, versus several per year in the pre-mandate days.

NY State Health Commish gets flu shot

While we’re in the minority, we’re certainly not alone in taking a more hard-line approach to vaccination. A 2011 CDC survey found that more than 400 US hospitals (about 10 percent) now require flu vaccine for employees; 29 of them fire unvaccinated employees. According to a recent Associated Press report, in the last few months, at least 15 nurses in four states have been fired for refusing vaccines. Beginning this year, the Joint Commission is requiring its accredited hospitals to have a program to promote healthcare worker vaccination and demonstrate incremental yearly improvements, with a goal of a 90 percent vaccination rate by 2020. Medicare now requires that hospitals report their healthcare worker vaccination rates, and it plans to make these data publicly available (on hospitalcompare.hhs.gov) in the next couple of years.

Some healthcare personnel object to the vaccines because they are worried about side effects (which are rare) or efficacy (the vaccine is 62 percent protective). (In fact, an early-release article in today’s JAMA refutes all the usual arguments.) Yet the larger objection seems to be a philosophical, libertarian one. One nurse in Indiana who was fired for refusing the vaccine spoke of “the injustice of being forced to put something in my body.”

Arthur Caplan, an ethicist at NYU, strongly disagrees. “If you don’t want to do it, you shouldn’t work in that environment.” Adds Paul Offit, chief of infectious diseases at Children’s Hospital of Philadelphia, “It’s not your inalienable right to not get a vaccine if you’re helping care for vulnerable patients.”

I strongly agree with Caplan and Offit. The average hospitalized patient – who has a reasonable likelihood of being older and immunosuppressed – will see up to 50 different healthcare workers each day. Any one of them with the flu can put their patients at risk, and not all of them will have full-blown symptoms to warn them to stay away. Patients giving their trust to healthcare professionals have a right to know that we have done everything within reason not to compromise their health further.

And this is why vaccination is more important than preventing flu alone. It is also among the most straightforward areas in which we can test questions of accountability as they pertain to patient safety.

For much of its history, medicine has been organized as a cottage industry, one in which the customers were the doctors, not the patients. Hospital CEOs were well schooled in the science of keeping the doctors happy, and they did this by giving us the best parking spots, providing free donuts, allowing us complete discretion over the kinds of equipment we needed – and being highly reluctant to enforce any rules whatsoever. Whether the rule was isolation precautions, using a surgical checklist, hand hygiene, or engaging in respectful behavior toward colleagues, hospitals – particularly community hospitals that don’t employ their physicians – have operated under an odd golden rule: “Don’t piss off the docs.”

After decades of being pampered, many physicians have come to believe that rules and requirements are fine for others, but not for us. Atul Gawande captured this well in The Checklist Manifesto. “All learned occupations have a definition of professionalism, a code of conduct… [with] at least three common elements,” he wrote: selflessness, an expectation of skill, and an expectation of trustworthiness. Gawande continues:

Aviators, however, add a fourth expectation, discipline; discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon [of medicine, where we] hold up ‘autonomy’ as a professional lodestar, a principle that stands in direct opposition to discipline… The closest our professional codes come to articulating the goal [of discipline] is an occasional plea for ‘collegiality.’ What is needed, however, isn’t just that people working together be nice to each other. It is discipline.

Hospitals have traditionally been far more willing to enforce rules on nurses, partly because they do employ them. But the massive nursing shortage of the past decade created some reluctance to enforce many rules on nurses as well. In many hospitals, we see lax dress codes, poor hygiene, and other expressions of a new wariness to challenge nurses on anything that might cause them to jump ship.

So, in many hospitals you had a dynamic in which the institution was primed to coddle both doctors and nurses. And the result was real reluctance to enforce much of anything – even practices that everyone agrees are essential to patient safety.

Of course, the world we live in is changing quickly. As hospitals – and ultimately physicians – are held accountable for their quality and safety (via public reporting, payment changes, and enhanced regulatory and accreditation standards), they’ll find themselves under far greater pressure to mandate certain evidence-based practices. The hospital that is fined for failing to implement a surgical checklist or that loses money due to high nosocomial infection rates will ultimately realize that it simply must mandate – and then enforce – certain sensible safety practices. But with virtually no tradition of doing so, hospitals are trying to figure out where to start. Do they first get serious about hand hygiene? Isolation precautions? Mandating civil behavior? Or flu shots?

In each of these cases, because we’re so uncomfortable mandating anything, the perfect becomes the enemy of the good. Too many clinicians have learned to say, “I don’t want to do that” in code, instead saying, “What’s the p-value?”: passive aggressiveness wrapped in the garb of evidence-based medicine. And so another year goes by in which we “strongly encourage” the practice, despite the fact that uniform adherence will save lives.

This is why flu shots are such a perfect starter, a “gateway drug” to a future state in which healthcare leaders have sufficient courage to identify certain practices that we all should be doing, to say just that, and then to enforce it. Flu shots are highly (though not perfectly) effective, they carry essentially no risk, they protect our vulnerable patients, and they help ensure that we have an intact workforce in the face of flu epidemic.

Plus, having the flu is a drag.

So let’s require flu shots, not just to prevent flu but also to begin to shift our culture to one in which we actually require people to do things when they are the unambiguously right things to do. At UCSF, we’re not perfect, by any means, but we’re getting better. Along with mandating flu shots, we now require physicians to participate in Maintenance of Certification in their primary specialty, we have released several disruptive physicians for behavior that would have been tolerated in the past, and we are experimenting with using cameras to observe hand-washing behaviors.

And you know what? The world hasn’t ended, our clinicians haven’t left in droves, and our patients are safer.

As Henry Kissinger once said, “weakness is provocative.” When it comes to mandating that we do what we can to keep our patients safe, we have been weak – and provocative – for too long. Overcoming the politics (yes, and the union rules and the logistics) and requiring flu shots is a nice way to start changing our culture.

And, as a nice bonus, we’ll save some lives at the same time.

20 Responses to “Making Clinicians Get Flu Shots: More Important Than Simply Preventing the Flu”

  1. Trevor January 18, 2013 at 8:18 pm #

    “If you don’t want to do it, you shouldn’t work in that environment.”
    Good point.
    We watched a British TV documentary on a Trauma Center in New York. At least one of the staff crowded around the trolley, on one occasion, was grossly obese. So, I’m guessing that obesity becomes a simple physical hazard to others in tight situations where access is paramount. Not to mention the hazard posed to the obese person in getting around swiftly, say, during an evacuation drill.
    I’d like to know if *any* health-care institution has addressed the problem of obesity in staff, and has been gutsy enough to say something like “If you weigh more than 300 pounds, don’t expect to work in ED”.

    • Sharon January 20, 2013 at 5:59 pm #

      Here Here!

  2. Brad F January 18, 2013 at 8:50 pm #

    Bob
    My contrarian take:
    http://blogs.hospitalmedicine.org/SHMPracticeManagementBlog/?p=6588

    Actually, not my take per say–towing the line when indicated not at issue–but whether the flu vaccine an intervention of absolute certitude (efficacy).

    I will review the JAMA article, but in scanning, appears to be rebuttals to the usual refusniks, and their associated misplaced beliefs.

    Brad

  3. Menoalittle January 19, 2013 at 2:03 am #

    You express an Interesting and totalitarian perspective, Bob, especially the part about “disruptive” physicians and MOC.

    Until the benefits, if any, and adverse events and unintended consequences of the intervention are known, you may be doing as much harm as good. That goes for heparin DVT prophylaxis in all comers, and CPOE devices for all orders, and transition of care documents that unto themselves are diseases that need to be treated.

    Besides, how many of UCSF’s workforce actually got sick with the flu this year and in past years? And, how many patients at UCSF actually acquire the flu while they are hospitalized at UCSF, this year and in past years?

    Best regards,

    Menoalittle

  4. Mt Doc January 19, 2013 at 5:07 am #

    Personally I have obtained a flu vaccine yearly because I am afraid of transmitting flu to one of my elderly patients, and I think it’s a good idea for health care workers to be vaccinated for this reason, but agree with Brad F that the efficacy of the vaccine has been oversold as have so many other things we have been told to do. A Cochrane review in 2010 looking at this subject in LTCF’s stated “We conclude there is no evidence that vaccinating HCWs prevents influenza in elderly residents in LTCFs”.

    But this blog is not really about the flu vaccine, is it?

    The tone of your article is that physicians and nurses are a recalcitrant undisciplined bunch who have to have mandates to function properly. In my opinion it takes a lot of personal discipline to adequately care for patients, which job at least in my experience often has required more than the current daily and weekly hour limits currently set for house staff (we could get into long discussions about this subject but that’s another issue). It required sticking with the patient until the patient was out of trouble and no longer needed your presence or until the doctor or nurse was relieved, which for all of us has meant missing meals, sleep and family events. The men and women who have done this are hardly undisciplined. Nurses are ROUTINELY asked to come in on their days off for staffing shortages. Indeed, we have all seen doctors working when they really shouldn’t have been – I’ve observed one cardiologist who was hospitalized rounding on his patients while pulling along his IV pole, another physician caring for patients three days after a cholecystectomy and another rounding in a wheelchair the day after knee surgery. This was probably not an ideal thing to do but these individuals felt a duty to their patients which overrided their own needs. Most physicians (and other health care workers) that I know are very concerned about the quality of their work for personal and professional reasons, not because of a regulatory body or rule set from above. At least in my institution surgical checklists, central line placement protocols and handwashing protocols were initiating with very little resistance.

    Referring to aviation I was involved in one disaster where a commercial airliner caught on fire and made an emergency landing. This was on a Sunday afternoon but by the time the last patient was processed there were more physicians who presented to the ER to help out than there were patients. I think most of us are pretty tired of being compared to airline pilots. If they decrease the throttle on an airplane they can guarantee what will happen. If I give a medication to ten different patients all of them will react differently and some adversely. I’ve also not seen a pilot asked to fly more than one plane at a time. Please quit using this analogy, it only goes so far.

    I suspect there are a couple of reasons physicians want some evidence that some new mandate has objective value. First, it is not true that we don’t have enough mandates in our lives. If you TRULY believe that you should get out into the trenches for longer than a month or two every year, preferably in a nonacademic center where you’re not one of the movers and shakers. You won’t feel so “coddled”. Or, stick with a nurse when s/he does the admitting paperwork. Second, all of us have had a list of things pushed down by the experts which have turned out to be dead wrong. What is standard of care one year is shown to be wrong at a later date – beta blockers used to be contraindicated in chf, there was once a big push for postmenopausal estrogens to possibly prevent CAD, and rosiglitazone and COX-2 inhibitors were supposed to be such a great drugs, to give a few examples. Look at the recent mammogram and PSA wars, or the recent Cochrane review regarding treating hypertension with systolics less than 160, or the recent news about increased hip fractures in older patients in the first few months after initiating antihypertensives for a few more recent controversies.

    Personally I think health care workers should be vaccinated for reasons I’ve mentioned above. It would be great if you could give your employees good enough reasons to get vaccinated to produce the desired result without the need for a mandate.

  5. Stan Jackson, MD January 19, 2013 at 11:09 am #

    What are “disruptive physicians” exactly? Is there such a thing as disruptive administrators and BOD? An example of that would be the circumstances involving the termination of Dr. Kessler. One could also question the disruptive administrators who partnered with the GE Centricity folks with impacts that have been kept opaque.

  6. Perth Amboy January 19, 2013 at 2:20 pm #

    Bob,

    Have the outcomes, costs, and length of stays improved at UCSF since UCSF made MOC mandatory? What happens to the older doctors who have the wisdom to manage patients better than the book worms, but do not take or can not “pass” the exam? Are they deemed disruptive or they simply kicked off the staff?

  7. Craig Slater, MD January 19, 2013 at 4:12 pm #

    Well said! Seventeen years as a hospital chief medical officer have given me the opportunity to see too many of my medical colleagues put their own narcissistic needs before the safety of patients. It has been frustrating at times, and demoralizing at other times. I do believe that the culture of medicine is changing, albeit too slowly. I agree with you that the mandatory flu vaccination issue is truly a patient safety issue. Pity that some physicians are incapable of seeing it that way.

    • Wertheimer, MD February 24, 2013 at 12:55 am #

      I think that we as physicians should lead by example with regards to mandatory vaccinations. However, I also believe that narcissistic habits such as chronic over eating with resultant obesity doesn’t bode well for ongoing efforts to deal with the epidemic of type 2 diabetes. We make a difference by adhering to vaccination efforts because we know it will decrease patient exposure and subsequent acquisition of communicable pathogens. We also make a difference when our body appearance is consistent with current ideal BMI guidelines. Food for thought. No pun intended.

  8. Michael Mirochna, MD January 19, 2013 at 6:53 pm #

    The Kissinger reference is distasteful. A man responsible for so much death should never be referenced in a healthcare discussion even to make a point.

    I wished we picked our battles better.

    I agree with mandatory flu vaccination for all healthcare workers BUT, the evidence isn’t presented well and isn’t the strongest case for legislation from above. We should know things like the NNT for cases prevented, deaths prevented, etc… BEFORE mandating the vaccine. In order to practice evidence based medicine, don’t we need to practice evidence based medicine?

    Why not start with a hand washing battle first? Mandatory hand washing or you are fired? Wouldn’t that be more justifiable and save more lives than mandating a flu vaccine?

    • Bob Wachter January 19, 2013 at 7:21 pm #

      I agree that hand hygiene is another practice whose enforcement needs more teeth. I made this point in a New England Journal of Medicine article (with Peter Pronovost) in 2009: http://www.nejm.org/doi/full/10.1056/NEJMsb0903885

      Re: the other arguments against this, if I were a hospitalized immunocompromised patient or an 80-year-old with heart failure and I was going to have a week of close contact with 30-40 providers per day, I would want to know that those providers had done what they could (within reason, and at essentially no risk to themselves) to keep me safe. If they all did so voluntarily, terrific. But the evidence says that voluntary programs don’t work very well, leaving such patients vulnerable.

      The arguments that each clinician should be able to decide for him/herself whether to get the shot holds water if they are the only victims if they get sick. In this case, they are not (at least potentially). So an informed decision regarding whether to get vaccinated would have to take into account not only the clinicians’ preferences but those of their patients as well. Given the extraordinary low risk of the shots, the reasonable efficacy (the best data says they’re 60% protective), and the fact that we have chosen a profession in which our first obligation is to keep patients safe, I stand by my argument.

  9. Mary Thomas, CMIO January 19, 2013 at 9:52 pm #

    Your argument is reasonable, but make it easy for busy professionals to get the shot, unlike the useless ppd production show for the omnipresent tuberculosis. The computer geeks ought to be able to tell you how many patients catch the flu while they are hospitalized. Let’s truly make meaningful use of the otherwise expensive, cost accelerating, user unfriendly of unproven safety, but mandated workflow management systems and study the epidemiology of hospital acquired fle. You will find that 15x more patients catch c diff in hospitals than the flu. While you are at it, calculate the number of mistakes and adverse events facilitated by the electronic records and ordering management systems.

  10. Mt Doc January 20, 2013 at 2:29 am #

    Unless I’ve missed something none of the commentors has come out against flu shots for health care providers. Some have pointed out that the efficacy of this is unclear and you can argue about whether it should be mandatory given this (By the way, this discussion is going on in the British Medical Journal as well). No one has said the shots are a bad idea.

    Is there a hospital out there that doesn’t emphasize handwashing? I did see an article in Infection Control Today a few years ago looking at nurses and hand hygeine. In the study nurses did not always wash their hands. However, if they touched the patient or came in contact with skin, body fluids, etc they virtually always did wash up. The failures usually occurred when the nurses had only verbal contact with the patient. I try religiously to follow the guidelines but have to admit I sometimes slip up when I go into a room and just report lab tests or don’t contact the patient. This is not good, but does it really matter that much? As far as I know universal precautions are standard of care. Don’t all hospitals have infection contol committees where nosocomial rates are tracked? The point is that I see most doctors and nurses trying to do a good job and have have gotten a sense of disrespect for these people in this blog lately. Heck, even the most selfish docotr has no desire to deal with line sepsis or a postop wound infection.

    Civil behavior should start in the academic centers where house officers are taught. I have known some academic physicians whom I would place on a pedestal for compassionate, wise medical practice and were true mentors. Unfortunately I have known many who despise the local “LMD’s”, make no bones about stating this to the house staff, and get their kicks out of belittling the house staff. I’ve worked in hospitals where there was a good relationship between the staff and administration and others where there was a lot of conflict. Things work much better when there is mutual respect.

  11. Lori Smith, DO January 20, 2013 at 2:34 pm #

    http://www.bizjournals.com/sanfrancisco/blog/2013/01/ucsf-medical-center-throws-a-great.html?page=all

    $100 million over budget and a year late is hardly accountable. It is downright disruptive conduct by all concerned, especially from the corner suites. Think, just think, of all of the medications you could provide to the indigent with just the income of that sum invested at 5% per annum. I would be concerned that several of those “released” for disruptive behavior suffered retaliation for complaining about the adversity of your new IT infrastructure and the incompetence of the leadership team. When are you going to report on the bad things that happened to patients from your new and experimental system of care?

  12. Sharon January 20, 2013 at 5:57 pm #

    I work as a hospitalist in an academic health center where the vaccine is not required. I have been vaccinated yearly, am healthy, and this year contracted the flu in spite of the “60% effective vaccine”. I worked ill with fever and cough for two days before help could be found. My boss reluctantly agreed to the 48 hours off that I eventually took. Throughout my years of practice I have seen many of my colleagues work while ill, which is in itself a safety hazard. Might I suggest that you include, in your comments regarding us unruly physicians, the need to remove healthcare works with febrile illness from the work environment in a timely manner?

  13. Michael F. Mirochna, MD January 22, 2013 at 2:26 pm #

    here’s a PLOS article about some cost reductions when flu vaccine was given for free in a canadian province. This is the type of info we should be talking about… http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000256

  14. Meryl Steinberg February 5, 2013 at 4:48 pm #

    You are immersed in a culture that is fed science that is paid for and heavily influenced by pharmaceutical industry. And that kind of “science” is not science. One must follow the method. Forced cancer treatments, forced vaccines? How convenient for the stockholders of the pharmaceutical companies. A real money maker. There is simply not sufficient proof that the vaccines are effective and yet there are dangers inherent in taking the shot. I shudder when read of the pharm and medical experiments that went on in Nazi Germany. I shudder at the pronouncements of forced chemo and vaccines to do “what is right” for patients. Do what is right is to not have nurses underpaid and overworked so we can get loving care and good sanitation.

    • CL May 2, 2013 at 12:18 am #

      I agree!

    • Brian February 19, 2014 at 8:26 pm #

      I would like to invoke Godwin’s Law after the above comment involving the Nazi party.

      Sorry, Meryl, you’re on the losing end of that invocation.

      Here’s a link, for convenience:
      http://en.wikipedia.org/wiki/Godwin%27s_law

      By the way, get your flu shot. It’s not perfect. But an ounce of prevention is worth a pound of cure, and quite a few people are dying from flu this season.

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