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.
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.
Robert Wachter, MD blogs regularly at Wachter’s World.