A strategy to approach patients who don’t believe in vaccines

Childhood vaccination remains controversial among some non-physicians, in spite of being nearly universally recommended by physicians. If you spend some time on Google you will discover a whole world of websites where the issue, long settled in the medical community, is vigorously debated among non-experts. Of course a large component of this controversy is fallout from the now thoroughly debunked claims by Andrew Wakefield that there was a link between vaccines and autism, but I have practiced long enough, and know enough medical history, to know that parental fear and misinformation about vaccines was present before Wakefield, and certainly long before the Internet.

So physicians are not uncommonly faced with the task of trying to convince parents to vaccinate their children. The standard way to do this is to present the information about vaccines in a calm, non-confrontational way that both respects parental autonomy and does not belittle their concerns. That can be a tough thing to do. The American Academy of Pediatrics even offers advice about how best to do it. The bottom line is really quite simple. All medical procedures carry risk. We always the weigh the risk of doing the procedure against the risk of not doing the procedure. In the case of vaccines, the risk is infinitesimally small; the benefit is large. So that calculation favors vaccination.

What interests me is the interpersonal dynamic in which a physician is trying to convince a skeptical parent to vaccinate their child. And that led me to a fascinating post on a political blog called The Non SequiturThe issue is this: what happens when people with incorrect information are convinced they are correct, are then given the correct information, but then an argument ensues anyway. Of course we don’t want to argue in the examining room, but the principles are similar. Here’s the gist of it:

Research by Nyhan and Reifler on what they’ve termed the “backfire effect” also suggests that the more a piece of information lowers self-worth, the less likely it is to have the desired impact. Specifically, they have found that when people are presented with corrective information that runs counter to their ideology, those who most strongly identify with the ideology will intensify their incorrect beliefs.

It’s a form of digging in, I suppose. When we encounter this problem, what should we do about it? It’s a bad strategy just to say the same thing over and over again, and it’s certainly bad to do so in an increasingly louder and more disparaging voice. The approach that seems to work best is to dial things down a notch or two, something that skilled negotiators have always known. The author uses a couple of boxing metaphors, which again aren’t quite what we’re up to in the examining room with a child and her family, but they make good sense.

We argue like boxers wildly throwing powerful haymakers that have no chance of landing. What if instead we threw carefully planned jabs that were weaker but stood a good chance of connecting?

Sometimes what we think are the most obvious, overwhelming arguments in our favor are those that threaten the other side the most.

Constantly going for the knock out argument is a bad strategy primarily because it’s bad argumentation.  Such moves are very likely to distort the views of the person you’re trying to convince and in so doing alienate them.  What’s better is the slow accumulation of evidence and the careful demonstration of the truth or acceptability of your beliefs.

Looking at things this way makes a lot of sense to me, and would help make a parent a collaborator rather than an adversary. But how could that work in practice?

One approach that I’ve found useful is to talk about the concept of relative risk. Non-physicians don’t think about risk in the same way physicians do. Parents want no risk; physicians would like that, too, but realize there is no such thing.

The notion of risk is pretty abstract — it helps to think of specifics. According to the Centers for Disease Control, the overall risk for a serious side effect from two common vaccines, DaPT and MMR, is about 1 in a million at worst, more likely about 1 in 10 million. By comparison, the risk of being hit by lightning is, on average, about 1 in 700,000 per year, yielding a lifetime risk (if you live to be 80) of 1 in 3,000. Over the last 20 years on average around 50 people die each year from being hit by lightning.

Most parents would make sure their child was not out in a lightning storm, so perhaps a more relevant statistic is the risk of being killed in a car accident. Parents these days put their children in car seats, which has greatly improved safety, but they still head out onto the highway without thinking about the risk. And the risk is not trivial: anyone’s average lifetime risk of dying in a car accident is 1-2%, and car accidents are the leading cause of death in children ages 2-14.

If you spend a little time researching you can find mortality statistics for a host of everyday activities, things parents do with their children without even considering the risk. The object, of course, isn’t to scare parents; rather, it is to put vaccine risk in an understandable perspective. This approach is more likely to be a useful strategy to convince them than going for the heavy, “knockout punch.”

And, if you’re a parent skeptical about vaccines, I hope I’ve given you a different slant on the issue.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must FaceHow to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

email

Comments are moderated before they are published. Please read the comment policy.

  • ninguem

    Should I get a pony keg or a full keg for this thread?

  • Anne-Marie

    Maybe this could be looked at as a conversation that can happen in increments across more than one visit? Unload some thoughtful ammunition, give ‘em time to think about it; lather, rinse, repeat.

    • http://urbandoctormom.com/ urbandoctormom

      Indeed. I start the vaccine discussion at the first newborn visit, usually when the child is 3-5 days old. At every subsequent visit, a little bit more is discussed until the 2 month visit when the vaccination schedule starts.

  • ErnieG

    My advice– spend time on patients who you can help. If they don’t want vaccines, give them a hand out explaining the benefits, and move on.

    • lynneb

      That doesn’t help. All it does is leave parents with a false sense that vaccine refusal is “legitimate”, and lets the unvaccinated population grow, which endangers a lot of people, including many who have no choice in the matter.

      • ErnieG

        In this country, it is “legitimate” for any adult to 1) believe what they want and 2) refuse medical treatment. In my experience, patients who do not want a vaccine, well….don’t want a vaccine, based on fixed false beliefs I will never change.

        • lynneb

          It isn’t “legitimate”, however, to:
          1. refuse a child the standard of care, to the detriment of the child; or,
          2. endanger public health, as the destruction of herd immunity does, and as was established in the Supreme Court case Jacobson v. Massachusetts, 197 U.S. 11 (1905), where it was held that the state had the right to overrule individual choice regarding vaccination in order to protect the health of the public in general and those who specifically had no choice, such as infants.

          • ErnieG

            Then it really isn’t about having providers convince children to get vaccinated. Just force schools to vaccinate everyone. Force adults to get vaccinated outside of physician offices. Providers should not be the arm of the state to vaccinate.

          • lynneb

            That is a weirdly sideways direction to take, and not what we were talking about.

            The issue is that your initial comment, “If they don’t want vaccines, give them a hand out explaining the benefits, and move on”, is entirely too indifferent to the problem on the one hand, and may lend objections a false sense of legitimacy on the other. However, this isn’t about “forcing” people, and no-one except you has raised that. (I note that your suggestion that the state should step in and force vaccination to happen outside dr’s offices is also a dodge: it relieves GPs and pediatricians of having to deal with it, period.) My point is simply that non-vaccination is a real medical issue with wider repercussions, and providers have a responsibility to ensure that parents understand that.

            Obviously there are people out there to whom no argument or evidence ever matters. (I’ve met enough of them on the internet.) Taking time with these will make no difference. However, there is a much larger population of “fence sitters” who probably Googled stuff and hit the misinformation first, and have a real hesitation about vaccination because of the misinformation, but are not anti-vaccination fanatics. Ignoring these people, not having a real discussion and addressing issues of safety, efficacy and responsibility, will make problems far worse and inevitably, sooner or later, result in unnecessary harm to kids who have no say in the matter.

            So the tl;dr version is that your “force them” suggestion is unlikely, OTT and irrelevant to the issue at hand. But your initial suggestion to essentially shrug it off, instead, is nevertheless actually harmful. Real discussions need to happen.

          • ErnieG

            Nice try…the idea that giving a patient resources to make a decision using an information sheet outlining the risks, side effects, and benefits, using a relative risk model endorsed by the OP, is neither “entirely too indifferent to the problem on the one hand” nor “lends objections a false sense
            of legitimacy on the other.” It is a simple tool that providers have so that patients understand the importance of vaccine. There is no complacency, no shrug off, not “ignoring” the fence sitters. If the fence sitters are Googlers, then give them the correct Google terms for them to look it up, so the next time they come and you mention vaccines, they are better prepared, and you can help the ones who want it. The fence sitters will read the info, and hopefully turn. The stubborn ones won’t- you are only obligated to inform them and move on.
            The “weird twist” to my argument which seems to baffle you comes from a response to the non-sequitor to my suggestion of using hand-out literature somehow makes vaccine refusal not “legitimate” (whatever that means). People have rights, for which you state that is it not “legitimate” (whatever that means) for anyone to 1) refuse a child the standard of care or 2) endanger public health, citing a Court ruling which gives the State the right to overrule individual rights. This implies a legal obligation when you cite a Court ruling, which then logically turns from the role providers have in advising individuals to the legal obligation they have to vaccinate. In that case, I argue that if the State determines an obligation to vaccinate, then it should be the State’s role to provide it and force it, not pediatricians in the offices. So your point then becomes that physicians have an obligation to help the fence sitters who have mis-information. To which I say, along comes info from the provider, using literature.

  • Pat Brown

    I don’t drink, so I will bring a big pitcher of sweet tea as well as the popcorn, m’Kay?

    • GT

      As long as the pitcher of sweet tea isn’t more than 16 ounces. Otherwise we’ll be busted by the Bloombergians.

      • Pat Brown

        15.9 oz plus a 2 cm cube of organic ice from a Finnish fjord!

  • adh1729

    We have some interesting words written here — article and comments.
    How about some deeds. How about you round up 10,000 fully vaccinated persons and 10,000 fully unvaccinated persons — they are out there — and in a fully open and public way, document their health outcomes. Show to the world that the vaccinated people are not worse off in any significant way: no more allergies, autoimmune disease, asthma, mental retardation, seizures, cancer, heart disease, or any type of infectious disease, etc. (Stop focusing only on the outcome of the specific disease against which you vaccinated.) Why the fear of publishing the full truth? Are you afraid of the truth? Why weren’t such studies published 20, 50, or 100 years ago?
    As things stand, all your rhetoric reduces to hot air. No intelligent person should believe you. The threats of force unmask you as the totalitar1an social1sts which you actually are (whether you know it or not.)

    • Martha55

      I’ll pick 10,000 from the almost 200,000 that die every year from the measles. I agree they don’t have to worry about asthma…

      • adh1729

        There are not 200,000 deaths from measles annually in the United States. You are smoking crack.
        You seem to believe that it is a big joke that nobody knows if our vaccine program is safe, and nobody cares. We are supposed to trust a bunch of “experts” blindly, and they possess no definitive data.

  • Chiked

    Interesting. Never new that. Thanks for the information.

  • adh1729

    If you want to understand what vaccinating really means, then you need to follow the vaccinated individuals long term and compare them to completely unvaccinated individuals. We have not had a huge, entirely unvaccinated population in the US for about a century. In the 1800s, many people refused vaccination (it was only smallpox in those days); a number of physicians
    in those days went on record stating that both cancer and heart disease occurred in a much higher incidence in persons vaccinated for smallpox, by their own anecdotal observations. So what did the governments do? They used the power of the law to compel vaccination (and no, they never laid the question to rest regarding the
    possible long term adverse consequences of the vaccine.)

    The 3rd world has its own set of problems, and does not approximate the US. There may be untold deaths from measles in the 3rd world now; but the rate of serious adverse events from measles in the US just prior to MMR & co was quite small, in healthy/well-fed children — read Robert Mendelsohn on that point — I have.

  • adh1729

    I completely understand your point about looking where there is no herd immunity to realize fully the consequences of not vaccinating. However, as I said, we in the US can do so much better than the 3rd world in terms of hygiene, refrigeration, nutrition, education, public health, etc etc. I don’t know how much the 3rd world really can show us about how to do things here.

  • Bruce Scott
  • dontdoitagain

    Part of the problem is being FORCED to accept vaccines that are of dubious value, like the Guardasil. It becomes harder and harder to have your child vaccinated when medical people throw in this kind of stuff. Then there are the endless and myriad “pandemic” scares about some new kind of killer flu, when the reality is, it hasn’t happened. Even nurses didn’t want the flu vaccines. Around here there was an outbreak of Whooping Cough. The powers that be were hysterically trying to get us to get our children re-vaccinated for this horrible disease…until it was discovered that the “outbreak” was among those vaccinated. Do you remember the tainted vaccines from China? All of this adds to our skepticism.

    • Victoria Kulli

      Wait. What’s wrong with Gardasil? I mean besides protecting women (and men) from a disease that can cause anal, vulvar, vaginal and penile cancer?

      • adh1729

        Yes, just assume because Gardasil holy water was blessed by the sacred mother, therefore it could never cause any harm.
        The true effect of Gardasil on cancer rates will require a lifetime of follow up. You jump to a lot of unwarranted conclusions.

  • Bruce Scott

    No, you can’t post there.
    Comments on that article have been closed for years. Of course, the anti-vaccination claims you are spreading have been debunked for years too.

  • Bruce Scott

    Oh, and I call Gish Gallop.

  • lynneb

    Alice, yes, that case overruled religious exemptions, and that was also reinforced by another Supreme Court case, Zucht v. King, 260 U.S. 174 (1922).

    Where there is a medical reason for exemption, these do not apply, however, and that was part of of the original ruling.

  • lynneb

    Alice, most “highly educated non-immunizers” are people with a BA in a liberal arts subject, not anyone with a scientific background or understanding. People with a better understanding of clinical trials and relative risk, are more frequently among the majority who get the full vaccine schedule, because they understand how and why that schedule was arrived at.

    What you may not understand is that most vaccines were developed by independent academics or academic teams, and only bought by a pharmaceutical company after they were demonstrated in early trials. The vaccines are an extremely low-profit item, and companies do not want to invest in a product that will cost them more than they would ever gain from it.

    • adh1729

      Discussing the personal characteristics of vaccinators vs. nonvaccinators — or the honesty or ethics of Wakefield — or the morality or anatomic characteristics of Jenny — is all trash. It carries no weight at all. Let’s blow away the rhetorical dust.
      There is *no scientific evidence at all* regarding the long-term health impact of our vaccine program. We are asked to accept the program on faith. The establishment might be able to end their clinical trial at 4 weeks, but last I checked, parents were taking care of disabled children for decades.
      Vaccine programs have been faith-based for centuries. And that is a crying shame, when scientific study could easily have been done long ago, and it was not done, for no explicable good reason. (See my original post on this thread from several days ago.)

  • adh1729

    Of course anecdotes aren’t scientific. The evidence pro-vaccine, by the way, is anecdotal. You should understand that my original post was asking for (!!) a scientific study — the best that we could do in 2013.
    You make the statement that my car probably contributes more to cancer than do vaccines. How do you know this, when the true long-term impact of our vaccine program is completely unknown? You can’t compare 3.1415927 and x, if x is totally unknown.
    I didn’t advocate blanket non-vaccination. I advocated a full, public disclosure of the comparative health outcomes of currently vaccinated and unvaccinated individuals. I advocated science, not rhetoric. I am not rooting for any team — I have 4 children — I actually want to know the truth.

  • adh1729

    “Cancer has increased since the industrial revolution”: well, by all means, let’s figure out why and try to stop it. I have wondered for years whether our modern society is committing a slow suicide with our modern lifestyle and technology — why don’t we turn our science and technology towards ameliorating the situation?

  • Clare Kirk

    Thank you for this article. However, surely, since vaccinations are “optional”, whereas an activity such as driving in a car is essential for most people, risk should be presented as the relative risk of vaccinating vs. not vaccinating, rather than the risk of vaccinating (without any explanation of the benefit) vs. doing a completely separate activity?

  • lynneb

    It isn’t dogma to accept the safety findings of multiple studies. In order for a “physician or expert” to be taken seriously about “dangerous ingredients”, they will first have to demonstrate that the previous studies demonstrating vaccine safety and vaccine ingredient safety are wrong, and that those ingredients are dangerous. When and if such concerns can be backed up with data, they are taken seriously. When the data don’t support the assertion, then the “expert” in question is ignored.

  • adh1729

    I just read the full text of your article on PubMed Central. There is plenty of praise for the wonders of vaccination, and precious little raw data. Only about 90 unvaccinated children were evaluated. They were not followed into adulthood. Endpoints are things like eczema, colds, and tummy aches. No raw data is given for more serious disease states. If this is the evidence for the safety of the vaccine program — it is pretty weak. Obviously with 90 individuals in one group, statistical estimation of comparative disease incidences will be next to impossible. The authors don’t bring any attention to the inconclusive nature of their analysis. Whatever. Now that you have me started, I will look at the rest of the literature that I can access. (Reference 20 doesn’t look much better: it analyzes allergic outcomes in toddlers. You know, people usually get a lot older than 2.)

  • adh1729

    “Is that how little understanding you have of the field?” Have you seen the 20 million children and teenagers walking around chattering and texting on cell phones? Do you think we have 50 year follow up on that particular experiment, exposing immature individuals to microwave radiation and various electromagnetic fields? We don’t. Yet our society blithely steams on into the uncharted ocean, making innocent children into guinea pigs.
    Is that how little understanding you have?
    You know, it is a foolish thing to assume a person is stupid, just because that person questions the status quo.

  • adh1729

    Vaccination may be warranted under certain circumstances. At the current time, the risk/benefit ratio is simply unknown, because the establishment decided that we just need to take it all on faith. I am a practicing, board-certified MD who graduated from med school with honors — I studied all those diseases you mentioned and 1000 others. I am aware that disease is bad; you don’t need to remind me.

  • GT

    Like Dr. Wakefield?

  • adh1729

    1. The correct verb is “cite”.
    2. “It’s possible that getting small pox prevents cancer”: you seem to be confusing a) getting smallpox; and b) getting vaccinated for smallpox. These are 2 very different things.
    3. I never said that smallpox vaccination conclusively causes cancer. I merely cited the opinions of a number of practioners from the 1800s who believed that way. (See, e.g. p 45 from “Vaccine Safety Manual”, Neil Z. Miller, 2008; the quotes are scathing.) I questioned why the issue had never been studied in a convincing manner, seems as we have had 2 centuries to do the research. Yes, such research would require nearly lifetime follow up; it would surely be complicated by significant heterogeneity; randomization would be next to impossible — but any knowledge is preferable to none. As it is, we are flying blind.

  • adh1729

    You mention that “the smallpox vaccine is being tested as a treatment for cancer.” Again, may I point out a giant distinction: a substance or entity may cause cancer, and it may also have some efficacy as a treatment for cancer (as glaring examples, consider medical radiation and certain forms of chemotherapy.)
    Just because a substance might have some anti-cancer activity, you are entitled to assume nothing regarding its possible carcinogenicity.

  • adh1729

    ” Don’t forget to include some pregnant women in your study.” You know, back in the day, people came down with childhood illnesses when they were children. I should hope 6 year olds weren’t getting pregnant.
    I personally had mumps and chickenpox in the early 1970s, as a small child; I did fine and so did my siblings. My parents were not alarmed in the slightest over the illnesses; it was as if we all had had the common cold.
    I grant that if a 12 year old boy had never gotten mumps, if a 12 year old girl had never contracted rubella, or if a generic 12 year old had never had chickenpox — then might we have serious reason to consider vaccination. These illnesses can cause serious problems in older persons. They did not typically cause problems in small children, and life-long immunity resulted.

  • adh1729

    You can’t end a study at 4 weeks, and say that you have all the answers. You can’t design a study with a fraudulent placebo, and say that you have any answers.

  • Martha55

    Study…

    Long-term health effects of repeated exposure to multiple vaccines

    ” no associations with lifestyle, vaccine exposure, or medical conditions were

    found.”