I just responded to a New York Times “Armchair Ethicist” chat about pediatricians who refuse patients who don’t fully immunize. I realized my comment on their site belongs here on the blog. (my comment is number 79 but also copied below).
What do you think about pediatricians who refuse patients who don’t follow the AAP schedule? Do you disagree with me? Would you be more comfortable seeing a pediatrician who refused those families who chose not to immunize to protect your children? Have you, or someone you know, ever been kicked out of a pediatrician’s practice?
I’m a pediatrician (w a master’s degree in bioethics) and mother to 2. I will always keep my practice open to vaccine-hesitant families. However, the waiting room risk (unimmunized kids & risk to vulnerable populations–ie infants, those too young for vaccines, and immunocompromised children) is a good one and the only compelling reason to close to patients who refuse immunizations in my opinion.
But it’s not a good enough reason for me to send families away who have questions and hesitations about the AAP/CDC schedule. All children deserve a pediatrician versed in immunization benefit/risk & deserve an expert in conversation w their parents to foster insight & understanding. Frankly, if waiting room risk is the concern, there are ways to create separate waiting rooms for kids “up to date” and kids who are not.
Great thing is, only about 10% of families use alternative vaccine schedules. In a recent Pediatrics article, only 2% of families who used alternative schedules refused all vaccine altogether. So although this is a large issue in pediatrics and parenting, the majority of families do vaccinate on time or nearly on time. I don’t want to lose sight of that.
I practice in WA State. We lead the nation in exemptions for vaccines (over 10% of kids w exemptions vs only 2% nationally) and have recently put into place a law that requires families to consult with a health care provider prior to an exemption. It was designed to avoid exemptions out of convenience. This hopefully opens up the opportunities for discussions with parents & pediatricians!
We all want the same thing: healthy children, healthy communities. Fostering conversation and diminishing a context of “war” or opposition about immunizations is an important step. In my experience, most parents end up immunizing their children over time even when they start out as refusers. The group of full refusers is fairly small. So allowing all kids into my practice feels like a great opportunity.
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Melissa Arca, M.D. says
Wendy,
I agree with you 100%. I honestly could not have said it any better. I love that Washington has a law requiring consultation prior to exemption from vaccines. Yes, more appointments and work for you, but a dedicated visit to discuss vaccines? Awesome.
Here’s my comment regarding refusing to see patients who don’t immunize:
“I think it’s sad that once again this has turned into an us vs. them argument. Reading through the comments, a \”let’s segregate them for our own good\” mentality seems to have prevailed when speaking of unvaccinated children. In my opinion, what a missed opportunity to educate and reach parents who may be on the fence about vaccines. In my experience, once a certain level of trust is established, parents are much more open to discussing and then vaccinating their children. Simply shutting our doors on them doesn’t help anyone and certainly in the long run, does nothing for our herd immunity either. Don’t get me wrong, I feel strongly about the efficacy and importance of childhood immunizations. I also feel strongly that this is exactly my job as a pediatrician, to weather these storms, educate, and support families through these issues. “
roger gates says
I don’t have an issue with docs who refuse to see these people and don’t really see it as an ethical issue. Where do you draw the line? Can patients choose to follow/not follow any guidelines/treatment programs and still expect a particular doc to continue to see them? It’s certainly fine if you want to treat these people, your choice. But, I see the anti-vaccination point of view ignorant, anti-science and dangerous.
Erica Armstrong, MD says
We live next to a community with one of the highest whooping cough outbreaks in the country over the past year, and we’ve had a mumps outbreak at a local college. I have to say, with a newborn arriving any day now, this makes me nervous. I’ve done everything I can to protect her with immunizing myself and all family members who will be visiting, but the one thing that still makes me nervous is taking her to that first doctor’s visit at one week old. I wonder if my newborn (too young to be vaccinated) and I will be sitting in the same room with electively unvaccinated children who may spread whooping cough/flu/measles/mumps/etc to my baby. I feel the same as you in that I think it is our duty to educate patients who are resistant to vaccines, but at the same time, with my own baby coming soon, I can appreciate physicians who do what they need to to keep other patients safe.
alison says
Our pediatrician’s office reserves the first hour of the day for newborns – this was a HUGE relief to me as we took both of our boys for their 3 day and 3 week well visits. Maybe you can ask to come in first thing in the morning before germs have a chance to spread?
Wendy Sue Swanson, MD says
Dr Erica/soon to be new mom (!!),
I get your worry. And I had the same feeling with my boys. Can you find out ahead of time if they have a special newborn waiting room? Our boys’ pediatricians’ office did — we were able to use it for all well child appointments until they were 6 months of age.
Oddly, we had a “healthy or well” waiting room in our office. We recently had to get rid of it due to too many complaints from patients over the past months about places to sit, segregation of seating, etc. I seriously don’t get it…but just writing it makes me think about revisiting the idea tomorrow when I arrive at clinic.
Erica Armstrong, MD says
Thanks Dr. Wendy and Alison! Great ideas – I will ask about “newborn hours.”
Dr. Wendy, new to your blog, but have to say, I really enjoyed reading through some of your posts today! You are so very articulate and have a talent for educating without offending. I also like how you stick to evidence-based principles and recommendations from the AAP. Well done! Looking forward to following along 🙂
Stephanie says
As a Mom who lives in a community where I worry a lot about non-vaccinators, the separated waiting rooms made me feel a lot better when I was taking my infants into the pediatrician. Now that my kids are a bit older and have had at least the first of the series of all of their vaccinations I don’t worry as much, but it was such a relief for those first few visits.
Kimberly says
Well stated! I am a firm believer in informed decision making and greatly appreciate my pediatrician’s willingness to listen to my concerns and respect my choices just as I am willing to listen to her recommendations and consider her input.
I do think that both pediatricians and parents need to be honest and up front with each other about their preferences, beliefs and choices and why. Parents can always choose another pediatrician if they disagree to the point it’s not a trusted relationship. Likewise, pediatricians can politely suggest parents may want to choose another pediatrician if their views on any matter of well/ill child care differ significantly.
Wendy Sue Swanson, MD says
Kimberly,
I agree with your take in spirit but I have found it very difficult to advise families in the past that I felt I “wasn’t a good fit” for them. In the past I did tell a family that I felt they would better with a different pediatrician (they always declined to follow my advice from vaccines to other issues) and the mom felt that I was giving up on her. It was a terrible feeling. I wasn’t giving up on them but firmly believed they would be happier with a different pediatrician, one who was more aligned with their thinking and style. It took confidence and knowing my particular strengths after 5 years in clinic to say something. But in reality, it has left me feeling pretty crummy in retrospect. Would be difficult for me to do that again.
So yes, makes great sense but very difficult to execute in real life.
Ora says
I am a family-child nurse with 40 years of practice (master’s degree and working on my PhD), and I agree with and appreciate Dr. Wendy’s comments above. I am personally (for myself and my fam) “noncompliant” with immunization schedules, with solid reasons. It seems to me that she makes HEALTH and HEALTHCARE work better for everyone. My nurse’s cap is off to you, doc. A neighbor(mom) and I discussed this very topic last Friday. I shall refer to you for her 3 children.
Natasha Burgert, MD says
A little late to the party, but here the response I added to the NYT chat thread:
“One mom brought her baby to me two-weeks after delivering at home. She told me she just wanted a doctor to look at the baby once, and that she wanted no other care after that.
One dad brought in his 2-month old daughter to her well child visit, knowing he was scared to vaccinate her that day.
One mom brought in her infant baby with her own schedule she organized and planned based on her knowledge of vaccines. She agreed one shot that day.
One set of parents emailed 9 pages of information from the NVIC, and asked me to guide them through the maze.
All 4 of these infants are fully vaccinated today because I believe a physician is an educator, a partner, and advocate for children and their families. If these families had chosen a different place for their care; they may have been refused the opportunity of time to develop a legitimate, real, and honest relationship with a doctor. Examples, like these in my practice, fuel my fight to protect all kids from vaccine-preventable disease. No matter how they enter my door.”
Michael Kruse, PharmD says
I’ve been a hospital pharmacist for more than 10 years. In pharmacy school I remember lectures that said “we” were the most approachable health professional. You can see 3 pharmacists in an hour by driving from one corner to the next corner and another block down the street. Hopefully they provide good advice. You can’t see any other health professional in that time. The problem is the pharmacists don’t get a dime for this time. And isn’t that the problem for physicians who would like to spend 15 extra minutes to provide the valuable education described by Dr. Burgert? Dr. Swanson – I heard your talk last month at the Cerner Health Conference in Kansas City. I loved hearing from a colleague in my same generation of health professionals. You hit on this same point about time spent with patients. Health professionals, in general, don’t have enough time with their patients.
We all need to make money. One of the reasons I practice in the hospital is that I’m paid for every minute of my time. I go on rounds, antibiotic dosing, warfarin dosing, TPN dosing, etc. I get to choose how long I spend on each of these functions so that patient gets my full attention until the job is done correctly. Why isn’t medicine set up more like this where we are all paid to provide services and education to our patients until the job is done correctly? I believe the fee-for-service model fails to provide real healthcare to our patients. This vaccine confusion where celebrities influence patients more than health professionals is a symptom of a very sick healthcare system. Kudos to Dr. Burgert and any other physician that takes the time.
Karen says
Well said Dr. Swanson; while I support in theory parents who refuse/delay/or schedule immunization on a different time frame; I will also tell them they are speaking to someone who has been around long enough to have seen children with Hemophilus Influenza sepsis as well as pneumococcal sepsis prior to these immunizations being available. I’ve also seen infants on ventilators from whooping cough gone bad. So I tell parents when they ask me about immunizations that I am biased simply because I’ve seen the disease in action. It only took a few hours to go from a talking/bit cranky child to near death’s door, with one child losing his lower limbs. Certainly, these episodes were not all that common, but it only takes one child to make an impact in your mind. These days, no one sees or hears of the consequences of bacteria roaming around in the blood stream and it’s effects on children because of immunizations. The one child who is not immunized and becomes ill with H-Flu sepsis because the parents didn’t want their child to get the HIB vaccine….will make an impact on that parent’s mind who will then wonder “should I have made that decision?”. But that is after the fact and may result in life lasting consequences. Like I said, I’m a bit biased; only because I’ve seen what can happen….
Docbarb says
Wendy,
I am an older pediatrician with ties to Seattle and have always enjoyed and respected your blog. I feel more confidant in the future of our profession with younger pediatricians like you around. In this one area I have to disagree. In the past I have practiced In the setting of frequent HIB and pneumococcal meningitis, meningococcemia, a serious measles epidemic and now a worrisome increase in pertussis. I practice in a semi-rural area and many of the vaccine refusers in my practice have no reason beyond what they have heard from friends or read on suspect Internet sites. Try as I might, science does not enter into the equation for these families. I spend untold extra time on counseling and give out literature and even books on the subject. If after two or three visits they have not been convinced to at least try an alternative schedule I point out that they obviously do not trust my advice as a pediatrician as well as causing a potential danger to infants and immunocompromised patients in the waiting area. I suggest they find a new pediatrician. At that juncture many do agree to immunize their children. I feel bad about those other lost opportunities and hope another physician has the patience to continue their education. This is the point of view of a cranky older pediatrician and the other 9 peds in my practice.
Wendy Sue Swanson, MD says
Docbarb,
I get it. I can imagine feeling like you do. But where I am in my practice and what I do in all parts of my life (parent, see patients, write, speak, tweet, blog) this is where I am. But I really do get your vantage point and I certainly respect it. I’m lucky enough to never have seen HIB epiglottitis or meningitis, although i have cared for children who have been left with side effects.
I worry about our waiting rooms. And I worry about our communities knowing and remembering that no single vacccine is 100% effective. That my boys (or my patients) are at risk because of the choices of other parents.
When I went into practice 5 1/2 years ago, I had no idea how much time I would spend with families talking about the benefits and risks of vaccines. I thought I’d talk about it, but not to the degree that I do. I have had visits extend 20 minutes past the allotted time because a family and I were really talking about opportunity. This has happened over and over again. Sometimes they leave me feeling entirely exhausted or frustrated. And I provide extra counseling early single day—way outside the normal time. I do my charts late at night because of it sometimes. And I trust you do, too. In no way do I believe our differing stance on this issue translates to a degree of compassion or commitment to education. I get that we all work really hard at this.
And like Dr Natasha, most of the time these lengthy (and sometimes heated/emotional) conversations pay off. The family knows far more about immunizations, I know far more about them, and the baby/child often gets immunized and protected.
Thanks for your comment.
Viki says
I worry about waiting rooms, too. I’m fairly certain my son caught RSV at the pediatrician’s office while we were there for his well check visit. I wouldn’t be surprised if another child caught it from him in the next couple days because, not realizing how sick he was, we boarded a crowded airplane. Same child caught the flu just weeks after getting his flu shot from a waitress at Red Robin who clearly should have called in sick. He caught that nasty, nasty stomach virus that went around last Spring from the Children’s Bellevue clinic when we went in for an unrelated medical concern. Of the 5 patients we saw on the Dr’s screen, ours was the only one who wasn’t there for stomach flu. Somehow, we’ve been exposed to hand, foot, and mouth disease twice now at playgroup and haven’t caught it yet. There are plenty of viruses to catch that one can’t protect against. Viruses one can catch that immunizations don’t fully protect against. If my pediatrician can fire me for refusing a flu shot and putting her patients at increased risk for flu, then should she fire me because my kid got the flu despite the shot? Is it my good faith compliance that counts to the doctor or the child’s actual immune response? Should she gather data on the parents’ vaccine compliance or take titers to assess her patients’ actual immunity. Risk management seems like another way to polarize the vaccine debate. By herding the vaccine hesitant people together in vaccine hesitant practices, you’re helping trigger outbreaks.
Cara says
Thank you Dr. Swanson for another great post! As a pregnant mom and elementary school teacher, I worry about what my kids will be exposed to despite my faithfulness in following the vaccine schedule. It actually really ticks me off when one of my students comes to school with something like chicken pox that could have easily been prevented, then spreads it to another student that gets it despite having the vaccine. My husband’s doctor and I just tag-teamed and convinced him to get his Tdap booster for the sake of the baby. My 3 year old held his hand. 🙂 I had never thought to ask about the pediatrician’s waiting room, but that will be something I will definitely ask when I take my newborn in for his well baby checks. I really appreciate your balanced advice as a mom, and as a pediatrician who knows the research!
ElizabethS says
Vaccines make children sick.
Jess Nye says
I’m writing a proposal paper for my English 101 class, and I stumbled onto this site. My proposal was going to be that unvaccinated patients presenting with symptoms of infectious illness be excluded from general waiting areas. That way infants and immunocompromised patients would be less likely to be exposed to VPD’s without the expense and other logistical problems of creating/maintaining separate waiting rooms, and unvaccinated kids would still have access to medical care. We have to propose a specific solution, and I was going to propose
1. A parent of a symptomatic, unvaccinated child would check in and get a pager from the front desk of the office (if they don’t have a cell phone- if they do, they could call the office from the parking lot to let someone know they’ve arrived.)
2. The parent would then return to their vehicle to wait with their child to be paged (or called) by the nurse or medical assistant when an exam room became available.
3. The pager would be returned to the nurse/M.A. when the patient was escorted to an exam room (ideally through a private entrance,) and the pager would be disinfected by wiping it down with alcohol, and returned to the front desk.
4. Ongoing classes and workshops on vaccine information and safety would be advertized to patients. Pediatric infectious disease specialists and/or primary care pediatricians would give presentations and be available to address questions. This would be funded by pharmaceutical companies as an educational expense.
Would this be feasable? Would it address infection-control concerns?
Michael Lee says
I agree that you should put a warning in your pediatrician offices that there might be unvaccinated people in there. This is no different from having two waiting rooms for sick and healthy kids. Herd immunity is a real thing even though vaccinations are getting less common.