Originally published in MedPage Today
by Emily P. Walker, MedPage Today Washington Correspondent
If parents refuse to vaccinate their children, it’s ethical and legal to dismiss the child as a patient, a pediatrician told attendees of the American Academy of Pediatrics meeting here.
“In the middle of treatment, you can’t just say, I’m done,” Gary Marshall, MD, of the University of Louisville (Ky.) School of Medicine, said during a session that addressed parental concerns about vaccinations and how pediatricians can respond.
But if it becomes obvious that you and the family will never see eye to eye on a specific issue, there’s no reason not to “fire” them, providing you follow the steps necessary to avoid charges of abandonment. Those include providing written notice that you will no longer treat their children and giving them a set time frame — at least 30 days — to find another physician.
Tampa pediatrician Marcy Baker, MD, said she has stopped seeing children because parents refuse to vaccinate them, and knows her colleagues are doing the same.
“We’ll work with them a little, but if they refuse to have the child vaccinated, we’ll discharge them,” she told MedPage Today after Marshall’s presentation.
She said that many parents want to discuss the potential harm of vaccines before their kids gets a flu or MMR shot, for instance.
Marshall said one of the most persistent — and endlessly frustrating — reasons parents give for not wanting to vaccinate their children is that “vaccines cause autism”.
He noted, however, that many studies have shown no link between childhood vaccinations and autism. He noted, too, that the lead author of the 1998 British study that originally suggested there was a link has been accused of fudging the data used in the study, and a federal court determined vaccines did not cause three children to develop autism.
But even though the autism link isn’t supported by science, Marshall said, celebrities and groups opposed to vaccinations get plenty of attention in the media and parents are influenced by them.
“This is like a train out of control,” Baker said. “Proving that autism is not caused by any of these things is not going to stop the train.”
However, Marshall does admit that vaccines are not 100% safe. For instance, for every 2,000 kids vaccinated with MMR, one additional febrile seizure will occur.
“How do we put that risk in perspective?” he asked. “People don’t think probabilistically. They have beliefs and they don’t think logically.”
Marshall did offer some tips for persuading parents who don’t want to vaccinate to change their mind:
* Start early. Hold group sessions with pregnant mothers and stress early the importance of vaccinations.
* Give patients books. Marshall recommends “Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure,” by Paul Offit, MD.
* Fight fire with fire. The antivaccine movement plays on parents’ sympathies by telling heartbreaking stories about deaths and illnesses in children. Marshall said he’s not above telling his own story about the child he encountered during his first rotation who was dying from Haemophilus influenzae type b, the leading cause of bacterial meningitis among children before a vaccine was developed.
Visit MedPageToday.com for more pediatrics news.
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How disheartening that pediatricians can now feel even more justified to blow off reasonable objections from parents, objections that are informed by real data and personal and societal risk-benefit assessments. It is surely more expedient to fire the family than to spend the time on a balanced discussion of, say the Varicella or the HPV vaccines. Another instance of “my way or the highway” — not a good time to be doing this.
http://evimedgroup.blogspot.com/2009/10/h1n1-vaccine-and-burden-of-proof.html
http://evimedgroup.blogspot.com/2009/10/are-vaccines-safe.html
Why do we physicians make this our proverbial “line in the sand”?
Should I fire patients who refuse to quit smoking? Or drink excessively? Or do not adhere to their diabetic diets?
The best we can do is recommend, it is up to patients to accept or decline.
Let the government force kids to get vaccines, not us.
I find the idea of “firing” patients an interesting one. Are they your employees, or your customers? Are they working for you or are you working for them? It’s indicative of the degree of authoritarianism in the medical profession that many doctors regard their patients as identical to employees and feel they have a right to boss them around or deny them medical care–”fire” them–if they refuse.
I’m not sure what the stats are for the US, but 50 percent of GPs in the UK intend to refuse the swine flu vaccine. I have read anecdotal reports of many American doctors and other health professionals who are also averse to vaccination, but no hard numbers.
http://www.pulsetoday.co.uk/story.asp?storycode=4123491
So perhaps the question should be what do we do about doctors who refuse to get themselves or their kids vaccinated? Should they be fired from their positions, or perhaps fired from the medical profession altogether? Should patients have the right to demand proof of vaccination from their docs, and report them to the authorities if they fail to comply or the evidence shows they haven’t been vaccinated?
When my oldest daughter was an infant (this is 20 years ago) we couldn’t get a coherent explanation from a physician about how the immunizations work, and what they change, if anything, in the body. All I got was their recommendation. I also couldn’t get a straight answer why it was recommended (in Canada) to get DPT before six months. And when we asked about risks, no one (we saw more than one physician on this question) told us the DPT shot was contraindicated if the baby had a fever even though the government advisory panel booklet did.
It’s difficult to trust people who just tell you what to think instead of providing information. Doctors who think their patients (or in this case guardians) don’t have the right to direct their own care should consider becoming mechanics, so the patient will do what it’s told.
I’m leery of firing patients as a means of dealing with the problem. The parents I’ve seen who have had this happen seem to have a high rate of gravitating towards quacks. Do doctors have an obligation to consider the consequences of their actions? If the parents are going to be antagonistic about everything, there’s nothing the doctor can do to help, and terminating the relationship may be appropriate. But what if keeping them as a patient means they’ll actually get real care when they are sick?
That said, I’m not a fan of the type of doctor often preferred by non-vaccinating parents: the “do what you want” doctor. Sometimes this is a doctor who is just afraid to be forceful, lest the parent leave the practice; sometimes, it’s laziness. I do think pediatricians have an obligation to advocate for vaccines and counter fears and objections.
Firing kids for this seems a bit harsh, but vaccine refusal can be a sign of parental unreasonableness and\or personality problems. So it does raise a red flag, but if the parents are otherwise OK I hang in there. If the parents show themselves to be magical thinkers on other aspects of health care, then I suggest they find a doctor who is more sympathetic to their worldview.
It’s a patient safety issue. Those health care providers that do not want to be vaccinated have the right to refuse, but they should also wear a mask for the next six months from parking lot to parking lot and be banned from the cafeteria, public toliets in the facility and inform all of their patients that they are not vaccinated. I would much rather take my kids to a pediatrician’s waiting room that has this stance. The pediatricians that are doing this are protecting the other patients in the waiting room in their practice.
Unfortunately, Jenga, the issue of vaccine effectiveness is not nearly as straight-forward as all that. There are no convincing data that the seasonal shot is all that great at preventing flu. There is certainly no data yet on the new vaccine — it has efficacy in that it produces an immune response, and we have to take on faith that it will translate into protection against the flu. However, given the potential for widespread harm from this illness and the general safety of the vaccine, it should certainly be widely used by the MDs.
More on flu vaccine effectiveness here, synthesizing work by the Cochrane Collaborative appearing in British Medical Journal:
http://evimedgroup.blogspot.com/2009/10/shaky-evidence-for-flu-vaccine-policies.html
I think firing patients based on vaccine rejection is a mistake. These are the parents who will then go looking to places like Bob Sears’ website for so-called “vaccine-friendly” practitioners–many, if not most, of whom appear to be outright quacks.
Better to attempt to maintain a dialogue, and ensure the kids are otherwise getting appropriate care and advice. (Of course, if the parents are resistant to science-based medicine in general, there may be no point in continuing the relationship.)
The majority of our current recommendations on vaccination are based on Level A-1 evidence. If we are to ignore that based on an editorial in the British Journal of Medicine, we might as well go back to giving patients arsenic, performing all surgeries with instruments in a pail of water and bleeding patients to rid them of evil humours. I wouldn’t risk the lives of my patients in the waiting room that are following level A1 evidence to appease those following the advice of Lloyd Christmas.
Level A1 evidence requires a randomized controlled trial. RCTs are notoriously poor in terms of generalizability and tracking long-term meaningful outcomes. In the case of the flu vaccine, while it is true that the level of evidence is A number 1, the outcome is a surrogate outcome not necessarily related to prevention of the disease.
In the case of the H1N1 pandemic and in the face of general safety of the vaccine, I argue that even marginal effectiveness is adequate. So I believe we are on the same side of the argument here.
And by the way since there is enough Dumb and Dumber in real life, I am not an aficionado of Lloyd Christmas advice.
paynehertze. The fact that physicians are required to give 30 days notice before ending a relationship should answer the question for you.
Personally I don’t fire vaccine-refusing families. I mean the little kid vaccines, of course, not adult flu shots etc.
I tell then I think it’s a lousy idea not to vaccinate the kids, I have my own kids, I vaccinate them…….sometimes personally. I walk the talk. I offer to modify the vaccine schedule, whatever it takes. And document like crazy of course.
All that being said, one thing I really, really feel strongly about, is the physician-patient relationship is voluntary. On both sides.
The Hippocratic Oath stipulates that “whatever house I may enter”……the doctor is supposed to behave in certain ethical ways. Implicit in that is the right to decline to enter the “house” in the first place.
The doctor-patient relationship is a two way street. Doctors have to be comfortable. I might also add that pediatricians have to become involved in creating the information that parents read online. The social space is dominated by antivax propoganda that could easily be countered if every member of the AAP contributed to the discussion.
I spoke with Dr. Marshall yesterday, and he was very distressed over the MedPage article. The headline is misleading – Marshall did not tell peds they should fire patients. Also, contrary to the story, he said there are reasons not to fire patients – it could drive them to chiropractors or DAN! doctors, which would further jeopardize the children. The AAP communications office called MedPage, and the headline was changed.
Given the ever growing number of people who refuse to vaccinate themselves and/or their children due to believing the various conspiracy theories (autism, thimerosal, squalene, etc.), self-interest makes for an even stronger case to get yourself and your children vaccinated. Especially children in schools, who are infectious disease vectors constantly being exposed to other infectious disease vectors.
How long before diseases that are a distant memory (polio, measles, etc.) come back, make their way through schools, and leave dead or disabled children in their wake?
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