A tough choice: Who gets the shot?

The waiting room of my office is now filling with patients who come in without appointments to see if I have stock of the flu shot. My phone is ringing incessantly with the same question. The truth is that I have managed to acquire five vials -- each with 10 doses of the precious stuff -- from my usual supplier, but I don’t tell anyone this, trying to avoid a stampede.

Most of my patients will do fine without one, but knowing that there’s a scarcity has clouded people’s reason. The flu is blamed for approximately 36,000 deaths every year and 200,000 hospitalizations, but most of these patients are very sick to begin with. Among those who are hospitalized for the flu, it is pneumonia or bronchitis, not the flu, that more than half the time makes patients the sickest and can kill them.

I offer my elderly and chronically ill patients a vaccine against pneumonia, which I have in ample supply, but even when they take it, they hardly seem reassured. The lucky few who do get the flu shot don’t flinch from the needle puncture, but sigh with an almost palpable relief as the protective serum surges into their muscle.

My usual flu vaccine supply, like that of most of New York’s private practitioners, originates with Chiron Corp., the company whose license was suspended in Britain for having contaminated stock. Most of the remaining vaccine (from Aventis) went to corporations, hospitals and supermarket chains.

I am now bound by public health authorities to give the vaccine I do have to the very old, the very young, the very sick, pregnant women and close contacts of these groups, including healthcare workers. This is a good policy, because I have so little.

Within this policy, I have set my own sub policy -- only to give it to those who already have an appointment and the sickest who call in. Like many other doctors, I set aside office visits in the early fall to give these vaccinations, and I have neither enough appointments nor flu shots for the panicked many. The health authorities don’t know what the effect of the vaccine shortage will be on this year’s flu season, but people are worried.

I reassure those who aren’t at great risk, and I save some of my 50 shots for my office staff, my pregnant wife and my elderly parents. For the first time in years I am compelled to ration supplies, which causes me to properly consider which patients are most susceptible to serious infection.

I decline to charge higher rates for giving an older patient the shot, not only because I am prohibited by Medicare from doing so but because it has never been my habit to exploit a patient’s predicament for cash.

On a recent night, I make a rare house call, taking a vial to Long Island. One of my chronically ill patients is an old friend who is housebound with a bad leg, and I drive out to see him. He is relieved to see the syringe, the alcohol pad and, especially, the vial. But afterward, as I am getting ready to leave, he stops me.

“Can my wife have one too?”

On cue, she is standing in the doorway, a woman in her early 50s, eager for a flu shot, but not qualifying for one.

“No,” I say. “I can lose my license for giving this out to the wrong people. Think of the people who are really at risk.”

She is ready to give up, but he isn’t. “Can’t you make an exception?” he pleads.

The tension is so great that I actually drop the precious vile. I think I hear it crack when it hits the floor, and I feel certain I have broken it. They both peer at me anxiously as I bend to pick up the magic elixir and retrieve it as it is rolling away. Luckily, the contents are intact.

“OK,” I say. “Maybe she qualifies. You’re at high risk, and she’s a close contact. I can give her a shot.”

They sigh, thank me repeatedly, more than they did the last time he was treated successfully for pneumonia.

I feel good, like a medical Robin Hood. It is only afterward, driving home, that I think of my dwindling supply, and consider a fragile patient a few weeks from now who won’t be able to get a shot because of the one I’ve just given away.

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Marc Siegel is an associate professor of medicine at New York University School of Medicine. He can be reached at marc@doctorsiegel.com.

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