Influenza and Audiologists: Mitigating Harm to Life and Wallet

Today wraps up a 3-part series on flu vaccination by looking at  private versus public sector efforts to vaccinate and protect, being mindful that we need to protect not only ourselves and our patients, but our professional livelihoods as well.  It’s a perfect blend of Economics and Ethics and, I’d like to point out, Marketing.  If it were me,  I’d put a big sign at the front desk and also include it in my internet and print information with wording like this:  

Our Practice is Dedicated to Your Safety.  All staff are fully immunized against Infectious Diseases, INCLUDING THIS YEAR’S FLU. 

The Show Must Go On. Rockettes get their flu shots in 1963.
The Show Must Go On. Rockettes get their flu shots in 1963.

 Bullet points so far, with key terms in bold or italics:

  • Economic Burden
    • Influenza wreaks general economic havoc on a nation. In the US, annual costs run to multi-$Billions even in a “good” year.  
    • Businesses, including hearing healthcare practices, are hard hit economically by flu outbreaks, due to reduced worker productivity from absenteeism, presenteeism, and substandard performance.
  • Ethical Burden
    • Hearing healthcare workers who fail to take “all reasonable measures” to ward off flu put their workplaces and their patients at unnecessary risk for financial and physical harm.
    • The Codes of Ethics (CoEs) of all our major professional membership groups contain “do no harm” language requiring members to exercise “all reasonable measures” to protect their patients from unnecessary risk.  
    •  Patients and co-workers are hit hard physically by exposure to those with flu.  Flu vaccination is a reasonable measure.  Hearing healthcare workers who skip vaccination violate the Harm Principle and behave unethically by exposing themselves, co-workers, and patients to unnecessary risk.  

Can Public Policy Implement the Harm Principle Effectively?


Not entirely.  It’s too controversial except in widespread emergencies.  As anticipated by Mills’ Harm Principle, efforts to forge public health policy for the Greater Good run the risk of violating individual rights. An intriguing snapshot of the argument by “The Ethicist” parses the argument:  individuals in the workplace are ethically charged, but not obligated, to get flu shots.  A standoff of sorts is the result in influenza vaccination programs for healthcare workers.  Immunization is recommended, made available at no charge, but rarely mandated as a condition of employment. Some workers forego the recommendation, despite the education; some claim infringement of their employee rights when it’s mandated.   Employee rights are nice but they are not helpful– indeed they’re downright harmful– to patients who go to a healthcare worker for a chronic problem (e.g., hearing) and leave with a life-threatening problem (e.g., flu, pneumonia).  

Despite some laws and “extensive public education,” not even half of healthcare workers (however you define them) got vaccinated for flu in 2009 — another season in which the twice-as-deadly H3N2 virus predominated.{{1}}[[1]] Harris, K.M. et al. Influenza Vaccine – Safe, Effective, and Mistrusted. N Engl J Med (2010) 363: 2183-2185.[[1]] That same year, New York upped its regulations, making annual flu vaccination a precondition for employment for healthcare workers in hospitals, home health agencies, and hospice facilities.  That was quickly snuffed out when a state judge issued a temporary restraining order suspending its application. 

Governments must consider and balance societal versus individual rights and arrive at policies that respect the rights of both.  The Greater Good argument for mandatory vaccination or quarantine is reserved for times of local, state, or national emergency.  Until such a time, the government stance is typified by the words of a recently-quoted California county health officer:

“I want people to do it, but I wouldn’t order them to.” 

Can the Private Sector Implement the Harm Principle Effectively?


Yes, for the most part.  If you own your practice, you can require employees to be vaccinated against communicable diseases as a condition of employment, though you need to check whether the state(s) in which you practice has law(s) permitting employees to opt out.  If you or your staff are affiliated with a JCAHO-accredited hospital or other facility, you may fall under the accreditation requirement (effective 1/1/2007) that those facilities must offer annual, on-site influenza vaccinations to licensed independent practitioners.{{2}}[[2]] See Occupational Safety and Health Administration (OSHA) Fact Sheet.[[2]]

From my reading, it looks like the best approach is to make annual flu vaccination a condition of hiring and continued employment.  That’s because voluntary programs with free vaccination and educational components generally do not increase vaccination rates of physicians and nurses in hospital settings, who paradoxically have among the lowest vaccination rates of any group.  Only about 40% of healthcare workers get vaccinated each year, according to the CDC.  There’s no data on Audiologists, but there’s also no reason to expect they would behave differently from doctors and nurses.

Virginia Mason Medical Center (Seattle), is the poster child for mandatory flu vaccination, which it imposed on its 5000 employees several years ago.  Their vaccination rate jumped from 55% to 98% in 3 years.  That stellar result didn’t keep the courts from halting the program until the hospital went through collective bargaining with the nurses’ union.  But, other private hospitals continue to follow Virginia Mason’s lead, lawsuits or not.  Last month, an Indiana hospital fired 8 workers, including 3 longtime nurses, who refused mandatory flu vaccinations.  

Can Audiologists Implement the Harm Policy Effectively?


Yes, at least in private practice, both financial and physical harm can be successfully mitigated.

Financial Harm. Few of us deal with unions or collectively bargain, which makes our HR economic risk very low for mandating vaccination programs.  The economic incentives are high, at least by my hypothetical scenario with made-up numbers.

 Say you and your staff of 2 march over to Walgreen’s and pay top dollar (maybe $40/ea) for the shots, for a total cost of $120 expensed to the business.  With about a 60% vaccination protection rate, one of you probably succumbs and stays home 4 days.  Worker productivity suffers:  the practice loses 3 diagnostic exams/day and  4 hearing aid sales, for a total gross revenue loss of  around $4500 after cost of goods is subtracted.  Total cost to the hypothetical practice:  $4620.  

Conversely, you skip the vaccinations and save $120, but 2 employees (you’re one!) get the flu and stay home 4 days each.  Assuming you’re no more productive than your employees, worker productivity loss is now $9000, minus $120 saved in foregone vaccinations.  Total cost to the practice:  $8880.  

Bottom Line:  Your practice’s policy of mandatory vaccination saved $4180 in gross revenues.  Mandatory flu vaccination is your economic policy of choice.

Physical and Financial Harm.  Despite your mandatory flu shot policy, one employee got the flu.  That worker was physically harmed despite your practice making all reasonable efforts to protect.   The good news is that you and your other employee didn’t.

Even better, only 1/3 of your patients were exposed — and probably only for part of one day — to the poor Audiologist with the flu.{{3}}[[3]]Of course, these are ballpark estimates and there’s no way to know exactly who was exposed, whether they were also exposed elsewhere, and whether they had gotten flu shots themselves.  The point of this wholly artificial illustration  is to get a feel for the dimensions of the problem.[[3]]  A week later, those folks are mostly walking around upright, not calling to cancel their hearing aid consults or hearing aid fittings.  Total harm effect:  Little or no physical harm to patients, one employee down, CoE compliance, negligible effect on your practice’s economic health.  

Conversely, failure to vaccinate resulted in two felled by flu.  You and one of your workers were physically harmed, perhaps as the result of your practice’s failure to make all reasonable efforts to protect.  

The bad news is that you are sick sick sick.  Even worse, 2/3 of your patients were exposed for at least part of a day.  Some of them got the flu and maybe they got it in your office … you’ll never know for sure.  But a week later, those folks are canceling left and right.  You lose two hearing aid consults and, at best, you have to delay several fittings.  Patients, staff and you have experienced physical harm. Your practice takes a financial hit that may give you a cash flow problem in the next few weeks.  

Bottom line:  Your practice’s policy of mandatory vaccination saved at least one staff member and an unknown number of patients from physical harm.  You and your staff behaved ethically according to CoEs.  Your policy protected the practice’s cash flow and gross revenues.  Mandatory flu vaccination is your practice’s Ethical and Economic policy of choice.  

 photos courtesy of Louise McCoy/The Epoch Times and Allure Magazine, January 2013 issue p 22


About Holly Hosford-Dunn

Holly Hosford-Dunn, PhD, graduated with a BA and MA in Communication Disorders from New Mexico State, completed a PhD in Hearing Sciences at Stanford, and did post-docs at Max Planck Institute (Germany) and Eaton-Peabody Auditory Physiology Lab (Boston). Post-education, she directed the Stanford University Audiology Clinic; developed multi-office private practices in Arizona; authored/edited numerous text books, chapters, journals, and articles; and taught Marketing, Practice Management, Hearing Science, Auditory Electrophysiology, and Amplification in a variety of academic settings.