Why doctors and nurses should be required to have flu shots

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.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • http://twitter.com/Meryl333 Meryl at Beanstalk

    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.

    • http://www.caduceusblog.com/ Deep Ramachandran

      I don’t really understand your argument. You state that there is not evidence to support vaccination, (I disagree) as if you are engaging in a scientific discussion. But then you somehow equate the the idea of vaccination to Nazi’s, don’t you think that there’s just a bit of hyperbole there? And what’s with the forced chemo. . . that is not mentioned anywhere in the article!

      • http://twitter.com/Meryl333 Meryl at Beanstalk

        Deep – I am an attorney and fully understand the what it means to present “evidence”. When evidence is bought and paid for… influenced by the industry that makes billions from it … it would be suspect in court. In fact, it is suspect by a large number of respectable doctors. Disregard of facts contrary to the pharmaceutically pushed propoganda is considered “disruptive”.

    • http://www.facebook.com/jacqui.maurone Jacqui Ballan

      Another conspiracy nut.

  • Close Call

    Nice post. We implemented a mandatory vaccination policy at our hospital last year. All those who didn’t get vaccinated got to wear a little white mask… so it wasn’t really mandatory. But it was a VERY powerful motivator.

    Compared to having to wear a scratchy, uncomfortable mask during your entire shift… a little shot isn’t that bad. It’s funny how many people conveniently ignored their “philosophical” and “religious” objections to vaccination when they were threatened with having to wear a mask.

    • http://twitter.com/Meryl333 Meryl at Beanstalk

      I know plenty of people who get terrible reactions from your “little shot” mr/ms anonymous. Forcing people to get injections is ugly. Medical mistakes kill enough people each week to fill four jumbo jets. Maybe you ought to focus on HEALTH care instead of forced drugging.

      • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

        Well, did it ever occur to you or your clients that hospital work was not necessary if such a strong objection was felt to the hospital’s policies (mandatory vaccination against the flu)? As far as I know, employees are free to find work and have contracts that do NOT require them to do things they feel morally and ethically obligated against doing. Would you agree?

      • http://www.facebook.com/jacqui.maurone Jacqui Ballan

        So are you suggesting we do away with vaccines all together? I can also walk outside and get hit by a bus. Perhaps I should never ever leave my house in the off chance something bad might happen. People let paranoia take over the role of common sense even when the benefits clearly outweigh the risks.

  • http://www.facebook.com/docmeehan Jim Meehan

    Kevin, I can accept your premise that if you want to work in a hospital you might have to accept vaccination. However, I’m a physician that would rather NOT work in the hospital if it means I have to be vaccinated. Okay, the whole truth is I don’t want to, and I don’t have to, work in the hospital.

    I also don’t like injecting polysorbate (Tween) 80 and other untested as injectable agents included in these vaccines. Are you sure you have done the due diligence on the additives in these vaccines. I know that thimerosal has mostly been removed from vaccines, but is any level of mercury in the body acceptable? There are plenty of reputable sources that suggest NO level of mercury is acceptable.

    I’m a little disappointed to see you so dogmatic on this issue. I usually enjoy your opinion, even when it doesn’t agree with mine. However, on this issue, you seem to have bought in to the establishment doctrine, a doctrine that has plenty of pseudoscientific rationale paraded as fact.

    • Close Call

      “Is any level of mercury in the body acceptable?” is like saying is any level of secondhand smoke or being exposed to car fumes while walking down the street acceptable? Unless you want to live in a bubble, it’ll be really hard to live a mercury free life.

      And remember, being a doctor isn’t good for your health. I think back to residency training… is any level of sleep deprivation acceptable? Are any number of finger sticks acceptable? Is any exposure to tuberculosis acceptable? We knew those risks coming in. Being a doctor is risky.

      And even with 60% vaccine efficacy, I would still want my nurses and doctors to be immunized against the flu. And if you don’t want to get immunized, then wear a mask during flu season. I’m all for you having a “mercury-free” life, but wearing a mask because you refuse to get vaccinated is the least you can do. It means you care.

      • http://twitter.com/Meryl333 Meryl at Beanstalk

        60%!!! And that ‘s the pharm numbers. The number of reactions are minimized because doctors brush them off as non-causal. 60!!!? Practically a coin toss. When injected people get the flu, that is brushed off as well. PRECAUTIONARY principle should be used. And it’s not.

      • http://www.facebook.com/docmeehan Jim Meehan

        Close Call you need some help with your logic. Whether I choose to live in a bubble or not, how would intentionally increasing my exposure to a known neurotoxin make any sense?

        I guess you know nothing about Tween 80, so you decided to brush that point off and focus on mercury. It is unfortunate that so many physician ideologues unthinkingly accept the dogma and indoctrination, and fail to do the research on these vaccine preservatives, adjuvants, and other ingredients. You talk about wearing a mask as evidence of caring. I submit that understanding exactly what it is you are injecting into the arms of your patient’s might be a far more important measure of caring.

        Perhaps you are jaded and bitter. Your language suggests some other psychopathology. For example, I doubt that they are “your” nurses and doctors. We abolished slavery long ago and human trafficking is illegal. Perhaps you should quit entertaining your ego, quit pretending you know it all, and care enough to dig into the research and spare all “your” people the punishment your ignorance creates.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Appreciate the candor of this article. It’s not about the flu per se. It’s about following orders. Clinicians should not question the p-value, or the evidence. They should just be disciplined and do what they’re told to do, because it’s about “saving lives”. I was watching A Few Good Men the other day…. same argument.

    • Guest

      The medical journal The Lancet found that only 2.7% of non-vaccinated adults caught the flu, which means that 97.3% of them did not. Among vaccinated adults, only 1.2% did not catch the flu. This means our big national vaccine drive will keep a whopping 1.5 people out of 100 from catching the flu.”

    • http://twitter.com/Meryl333 Meryl at Beanstalk

      “following orders” in this situation needs to be questioned. The medical journal The Lancet found that only 2.7% of non-vaccinated adults caught the flu, which means that 97.3% of them did not. Among vaccinated adults, only 1.2% did not catch the flu. This means our big national vaccine drive will keep a whopping 1.5 people out of 100 from catching the flu.” ( and that’s worse than a coin flip)

      • kjindal

        For some % of car accidents, wearing a seatbelt will not have saved the driver’s life. Therefore we should stop using seatbelts (and certainly stop MANDATING their use). Same can be said for infant carseats, gun laws, etc.

  • http://www.caduceusblog.com/ Deep Ramachandran

    Dr. Wachter, great article. I agree that health care workers should be vaccinated against the flu. However, as you see from comments on this and other vaccine related articles, there is much misinformation, skepticism, and paranoia when it comes to any vaccination policy. I think any movement to increase vaccination rates among health care workers should begin with education and then be followed by consideration of a mandate. Simply mandating the policy without also providing education and countering misinformation about why it is the right thing to do will, I think, create much antipathy, firings, and even more paranoia on the part of the public.

    • http://twitter.com/Meryl333 Meryl at Beanstalk

      Who supplies the “education”.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    What happens then to the healthcare workers that refuse to get a flu shot because of medical reasons? People who have Guillane-Barre can’t have this shot at all. And I know that there are others out there that for medical reasons absolutely can’t get a flu shot and that is among the general public. My mom met someone who is a nurse that for medical reasons can’t get a flu shot. What are these healthcare workers supposed to do?

    • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

      At the hospital I spend most of my time at employees either had to get the vaccine or sign a statement explaining why they refused it.

    • http://www.facebook.com/jacqui.maurone Jacqui Ballan

      They have to wear a mask. At least where I work.

  • http://twitter.com/InpatientMed InpatientMed

    There is a serious problem here that I think remains over looked. A few years ago New York State mandated that all hospital employees be vaccinated against H1N1. Now as a general rule I get the flu shot and encourage my patients to do so as well, but I don’t like to be told what to do.

    Regardless, I swallowed my pride and rolled up my proverbial sleeve, but here is the problem. I was asked to give consent to the vaccination. Now, how can one really give consent to something if it is done under duress. In this case, the threat of termination of employment. My consent wasn’t given freely, it was coerced and that is the problem.

  • http://twitter.com/InpatientMed InpatientMed

    There is a serious problem here that I think remains over looked. A few years ago New York State mandated that all hospital employees be vaccinated against H1N1. Now as a general rule I get the flu shot and encourage my patients to do so as well, but I don’t like to be told what to do.

    Regardless, I swallowed my pride and rolled up my proverbial sleeve, but here is the problem. I was asked to give consent to the vaccination. Now, how can one really give consent to something if it is done under duress. In this case, the threat of termination of employment. My consent wasn’t given freely, it was coerced and that is the problem.

  • azmd

    I would be much more impressed by all of these stellar reasons to get the flu vaccine had not our chief stood up during morning meeting a couple of months ago and said: “You should all get the flu shot because it’s a nightmare to arrange coverage when any of you are out sick.”

    I suspect that the number of patient lives saved by clinicians being vaccinated for the flu is miniscule, but the benefit to the healthcare institution in sick time off saved is quite substantial. Let’s all be honest about the agenda here.

  • doc99

    A well-respected senior Obstetrician in the northeast is now in a physical rehab unit, thanks to Guillain-Barre Syndrome after a “flu shot.”

    • http://twitter.com/InpatientMed InpatientMed

      Did he/she consent to this “required” preventive therapy?

    • http://www.facebook.com/jim.sylvester Jim Sylvester

      I’ve only been an RN about 10 years, but I’ve had 2 patients who developed GB after a flu shot (both were in their early 40′s and previously very healthy and physically fit.) I’m not going to take a change on developing an autoimmune disease for a vaccination that is admittedly only 63% effective anyway.

  • mark reinholtz

    wearing a seat elt has no side effects comparable to the flu vaccine

  • http://www.facebook.com/jacqui.maurone Jacqui Ballan

    I agree. As an ER nurse I always get the vaccine. As health care professionals we should be held to a higher standard

  • http://www.facebook.com/jacqui.maurone Jacqui Ballan

    I used to get the flu nearly every year. I started getting the flu shot in 2000. Haven’t had the flu since.

  • http://www.zdoggmd.com ZDoggMD

    Brilliant Bob!

    To which I add this: One Injection, A Flu Shot Anthem http://youtu.be/IbXJJyUVowk

  • http://ClinicalPosters.com/ ClinicalPosters

    My doctor glibly touts his abstinence from flu shots and has told me that it’s unnecessary even after, with a history of flu, I request a shot. Fortunately, my healthcare offers free shots without a doctor’s appointment.

  • traumadoc

    sorry dr. bob, i have to disagree with you and many other pro-shots…i happen to be a dr. without borders for over 25 years and this is overhyped. please do not force this down the throats of medical persons or anyone for that matter. i have probably more exposure and experience than you will ever have .sir.
    our society is shoving a lot of things down the public’s throat more than ever. if my institution wants to fire me ,or, my nurses, than so be it! it is their loss not mine. i had a very bad reaction once to the flu-shot. i do not wish it on anyone!!! that is my opinion, sir!

  • Justsayno!

    Once again, doctors rush to whore themselves to defend Big Pharma. In any of these articles that push vaccinations, you don’t see them mention that the United State ranks far behind other countries in the quality of healthcare received for the amount of money we spend.

    A 2010 report from the Commonwealth Fund ranked countries of comparable wealth and levels of modernization in terms of their national health systems, a ranking which found the United States falling flat. Despite paying more for health care than any other country in the world, the US ranked at or near the bottom in terms of access, quality and cost – measures that have a real impact on our individual and collective health and pocketbooks. The fact that our national health system is wildly inefficient, ineffectual, and segmented in absolute and relative terms is well known.

    The Cochrane Collaboration who is the gold standard for analyzing healthcare related data has stated on 9/8/2010, that we conclude that there is no evidence that only vaccinating healthcare workers prevents laboratory-proven influenza, pneumonia, and death from pneumonia in elderly residents in long-term care facilities. I work in a healthcare facility and many of my cohorts who subjected themselves to the flu vaccine, did indeed catch the flu.

    According to the Vancouver Sun:
    “Researchers, led by Vancouver’s Dr. Danuta Skowronski, an influenza expert at the B.C. Centre for Disease Control, noticed in the early weeks of the [2009 H1N1] pandemic that people who got a flu shot for the 2008-09 winter seemed to be more likely to get infected with the pandemic virus than people who hadn’t received a flu shot. Five studies done in several provinces showed the same unsettling results.”

    ABC News reported:
    “There is renewed controversy surrounding influenza vaccines, with some studies showing people immunized against the seasonal flu might have been at greater risk during the swine flu outbreak…

    ‘What was a bit surprising when we looked at some of the data from Canada and Hong Kong in the last year is that people who have been vaccinated in 2008 with the seasonal or ordinary vaccine seemed to have twice the risk of getting swine flu compared to the people who hadn’t received that vaccine,’ [Professor Collignon from the Australian National University] said.

    Case in point: research published in the Journal of Virology3 in November of 2011 also confirmed that the seasonal flu vaccine may actually weaken children’s immune systems and increase their chances of getting sick from influenza viruses not included in the vaccine. Further, when blood samples from 27 healthy, unvaccinated children and 14 children who had received an annual flu shot were compared, the former unvaccinated group naturally built up more antibodies across a wider variety of influenza strains compared to the latter vaccinated group.

    Here are just some of the ways vaccines can impair and alter your immune response:
    Some components in vaccines are neurotoxic and may depress your immune response or cause brain and immune dysfunction, particularly heavy metals such as mercury preservatives (thimerosal) and aluminum adjuvants.
    The lab altered vaccine viruses themselves may also affect your immune response in a negative way.
    Vaccines may alter your t-cell function and lead you to become chronically ill.
    Vaccines can trigger allergies or autoimmune disorders. Vaccines introduce large foreign protein molecules into your body. Your body can respond to these foreign particles in a way that causes an allergic reaction or triggers autoimmunty, especially in persons genetically or biologically vulnerable to allergy and autoimmunity.
    Getting a flu shot can affect your cardiovascular system because vaccination stimulates an acute inflammatory response in your body, which also could become chronic.

    According to one report, 112 million Americans had been vaccinated against the flu by late 2012. Walgreen’s recently reported they’d administered 5.7 million flu shots so far this season — up from 5.3 million in 2012.11 The fact that many flu shot recipients are still coming down with serious influenza should be a testament to the ineffectiveness of the flu vaccine — not a selling point for it… Especially when you consider the fact that the vaccines available this year are a good match to the actual influenza type A and B strains in circulation.

    A recent Activist Post by Janet C. Phelan points out just how ridiculously bad a lot of the reporting passing for “news” is today:

    “In an article entitled, ‘Flu reaches epidemic level in U.S.,’ says CDC, reporter Sharon Begley pumps up alarm concerning the virulent and epidemic nature of the current flu sweeping the country. However, the report admits it lacks documentation of the very numbers it purports to use to buttress its claims.

    While the Reuters article, published on January 11, solemnly announces that a pandemic is officially at play when the flu achieves a rate of 7.2 % of deaths during a time period, it also earnestly states that there is no definitive count of the total deaths caused by the flu. Wait a minute here… So the exact percentage of deaths caused by flu is known but the number of flu deaths is not? HOW IS THAT POSSIBLE?

    To force any individual to take any vaccination against their will and threaten them with the loss of their livelihoods is ludicrous. This is a blatant violation of their rights and freedoms as granted by the Constitution.

  • http://www.facebook.com/jim.sylvester Jim Sylvester

    I’ve only had the flu vaccination once- in 1996 when I started college. Three days later I got the flu. I’ve never had the vaccination since, and I’ve never had the flu since. I have been an RN for just 10 years, but I’ve already taken care of 2 patients who developed Guillain–Barré syndrome just after a flu shot.

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