What is behind physician’s approach to immunizations?

Based on the number of comments from my last post on immunizations, this is a topic in which many people are interested.  I had no intention of arguing for or against immunizations, though not surprisingly some of the comments did take up that issue.  My goal was to bring attention to what I think is an improper and unfair approach by the majority of the medical community towards those who choose to not follow the standard schedule.  Based on the number of comments; I hit the nail on the head, that many parents have had unpleasant interactions with the medical community over the issue of immunizations.  In that post, I indicated that I have an opinion as to the reason for the hardline stance by most of the medical community on this issue and several asked that I expand on this, so here goes.

First of all, it is NOT because they make money from the vaccines.  I have seen this claim on forums, but it is just not true.  In fact, practices are happy if they do not lose money on immunizations.  The reimbursement by insurance companies barely cover the cost of the vaccine, much less all of the labor that goes into administering them. Vaccines are not a profit center for doctors.

The biggest reason doctors push immunizations is they really believe immunizations are critical to maintaining good health.  It is what they are taught throughout their training.  Numerous experts and professional organizations take the position that without the widespread use of vaccines, serious diseases would be rampant.  With all of this training and expertise supporting the use of vaccines, it just does not seem logical to them that a rational individual would object to their use.  Therefore, they conclude that anyone who objects to immunizations has to be either crazy or uneducated.

Secondly, they believe their role is to protect children.  Since, it is common knowledge that immunizations are so beneficial, it is critical that they do their best to overcome the objections of those parents who stand in the way of the children getting optimal health care.

Thirdly, the vaccines are not 100% protective.  Some individuals do not develop adequate protective antibodies when given the vaccines.  Therefore, if too large a portion of the population does not get immunized and thus the incidence of the disease increases, these immunized, but unprotected individuals are put at unnecessary risk.

Fourthly, the very palpable fear among physicians of being sued  has dramatically altered the way all physicians practice.    If a child ends up with brain damage following the administration of a vaccine according to guidelines, that physician is under no risk of being sued.  If a family tried to seek damages, it would be covered by the Vaccine Injury Act.  On the other hand, if a child is not immunized per parental choice and comes down with pertussis, for example, and has a bad outcome, the physician would be very exposed to the risk of being sued.

Next, we unfortunately live in a highly regulated society.  Every aspect of our lives is now controlled by some government entity or entities.  With regulatory agencies breathing down the necks of physicians it is problematic for physicians if a significant part of their patient population is not following the CDC guidelines.  This is even more true for those practices which are owned by hospitals and today most practices are owned by hospitals.

Last on my list is that it takes significantly more effort to care for families who do not follow the standard schedule.  If a child is brought in for his/her two month visit and just gets their shots according to the schedule, it is a very simple thing to roll out the typical two month shots and give them.  In contrast, dealing with a parent with concerns about vaccines or figuring out a schedule for those selectively vaccinating takes a significant amount of time.  Physicians are under significant time pressures, so anything that requires that they spend more time with a patient can put them on edge.

My last post was trying to promote a better understanding of those who do not immunize.  This one, is trying to improve understanding of the physician’s viewpoint.   I am not arguing for or against any of these opinions, just letting people know what is behind physician’s positions.

My next post will discuss why I give patients the freedom to choose.

Observations on the Immunization Controversy

Anyone involved in the healthcare of children knows there is a growing number of parents who are selectively immunizing or not immunizing their children at all.  The medical establishment is becoming quite alarmed about this trend and becoming rather unpleasant towards parents who are questioning the benefits of immunizations.

It has become an increasingly frequent experience for parents, who have concerns about the safety of vaccines, to have very negative encounters when interacting with the medical system.  These interactions range from being treated as ignorant weirdos who need to be properly educated, to the outright refusal of care.  We are, sadly, now at the point where a majority of pediatric practices refuse to care for children who are not immunized according to the official recommendations.  Here is a typical vaccine policy from a pediatric practice (http://milestonepediatrics.com/vaccine_policy.html)

My practice has the philosophy that parents, not the medical establishment, should be the ones choosing how or if they will immunize their children.  It is a matter of freedom, which to me, takes precedence over the science of immunizing.  I am personally in favor of vaccines and all of my children have been immunized according to the standard schedule.  However, I believe it is wrong for a physician to coerce a parent into vaccinating, when they are uncomfortable with it.  I believe each of us has the right to make our own decision and then we have to live with the consequences of that decision.  It grieves me, when I see the guarded or fearful look come into the eyes of a parent when I start asking questions about a child’s immunization history, because they are afraid of what will happen when I discover they are not immunizing according to the established rules.

This philosophy of freedom first, has certainly led to a boom in our pediatric practice as parents have sought a place where they can get medical care for their children, without having to endure an unpleasant doctor-parent interaction.   I now have had a significant amount of experience with selective and non-immunizers and I have some observations I would like to pass on to providers of health care to children:

  1. These parents are NOT ignorant.  In fact, many of them are far more educated about vaccines than most pediatricians.  Most physicians would argue they have misinformation and one can discuss the accuracy of the data on either side of this issue, but the issue is not a lack of education.  It is ridiculous and insulting when providers browbeat these parents over and over about the issue of immunizations.
  2. These parents are NOT weirdos.  These are very engaged, critically thinking parents, who are trying to protect their children from unnecessary risk.  The fact that a majority of the medical establishment does not agree with their conclusions does not make them weirdos or troublemakers.
  3. These parents are NOT unconcerned about their children’s well being.  They are every bit as committed to their children’s health as the parents who willingly go along with the standard immunization schedule.  They have simply come to the conclusion that the risk to their child from immunizations, especially at such a young age is greater than the risk from the rare diseases that we are immunizing against.  Again, one can disagree with their conclusion, but it does not make their motives wrong.
  4. I do not understand the reasoning, when a doctor says he/she will not take care of an unimmunized child because he/she is concerned about the child having proper medical care.  They claim that immunizations are absolutely critical to the well being of children, but then if a parent refuses to immunize, they tell the parent it is better for the child to have No care than to not have care the way they deem appropriate.  How is no care better for the child, than unimmunized care?  There are all kinds of areas where patients do not comply with our recommendations.  Why are immunizations treated differently than any other area of “non-compliance” where we take care of patients to the best of our ability within the context of that individual’s environment?  (I have my theories, but that is for another posting.)
  5. Informed consent should apply to vaccines, the same as any other medical procedure.  A major tenet of contemporary medical practice is “informed consent”  The theory is that a patient is given the risks and benefits of any intervention and the patient then chooses whether they want to undergo the procedure or not.  How is it “informed consent” when one does not have the right to say “No”?  No intervention, including immunizations, is risk free and yet parents are only ever given the positives of vaccines, never any potential risks.  That is not informed consent.
  6. There is a tremendous sense of disproportion on both sides of this controversy.   Every time a parent  puts their child in a car, they accept without hesitation, the risk that the child could be injured or killed during that trip.  At the same time,  those same parents agonize over the potential risk that a vaccine poses to the child, even though that risk is only a fraction of the risk we assume by putting our child in a car.  I am not arguing that a parent should not consider risk and benefit when it comes to vaccines, but I do not think vaccines are as dangerous as some would have us believe and parents need to keep things in perspective.  Pro vaccine advocates are just as guilty of overstatement.  To listen to the rhetoric, one would think that if a child is not immunized, they WILL get sick with one of these illnesses which we immunize against.  This is just not true.  Thankfully, these disease are all very uncommon and very few children, immunized or not, will develop them.  One can argue, that they are rare as a result of successful immunization programs and for some this is undoubtedly true.  At the same time, regardless of the reason, the low incidence of these illnesses does impact the risk-benefit calculations.
  7. Unimmunized children are NOT sicker than immunized children.  There are no studies comparing outcomes of immunized vs unimmunizing children and unfortunately this kind of study will never be done.  However, as I mentioned earlier, I have lots of partially or unimmunized children in my practice.  I can say, unequivocally, that these children are not sicker than the immunized ones.  In fact, they are in the doctor’s office far less than their immunized counterparts.  I do think they are at a slightly increased risk from vaccine preventable illnesses, such as pertussis, but that is a risk these families have chosen to take, over the risk from the vaccines.  For every other illness, they are not sicker and for a few reasons may be healthier.
  8. Unimmunized children are not a danger to immunized children.  Some argue that forcing children to be immunized or ostracizing those who are not, is for the purpose of protecting all of those children who are immunized.  Again, I question the logic.  In the first place, immunizations protect against very specific, but uncommon illnesses.  Since these diseases are so uncommon, it is highly unlikely that an unimmunized child will contract these illnesses and transmit them to immunized children.  Then if the vaccines are such successful sources of protection against disease, then even if an immunized child was exposed to a vaccine preventable disease through an unimmunized child they should be protected from getting the illness.  The reality is that these outbreaks that one hears about is mostly among immunized individuals and has little to do with a child.  This is not an argument against vaccines as vaccines do protect a majority of their recipients and even when an immunized person gets one of these illnesses it tends to be milder.  However, it is an argument against the emotional response of treating unimmunized children like lepers.
  9. You catch more flies with honey, than with vinegar.  The vast majority of parents who come in opposed to immunizing their children do eventually at least partially immunize their children.  They are mostly looking for a physician who will listen to their concerns and allow them the time and freedom to move forward with immunizations when they feel comfortable and not be forced into a one size fits all mold.  They are very put off with the condescending, even hostile treatment they get at many physicians offices.  If the real goal here is to keep children as healthy as possible, treating these parents respectfully will get much more accomplished.  By badgering unsure parents into immunizing, you will get some more children immunized, but you will also build walls and resentment with those parents.  For those parents who are sure they do not want immunizations at this time, they will just disappear from health care all together and that is not improving the health of the children.
  10. Physicians should be scientific about vaccines.  It astounds me how unscientific many physicians are about immunizations.  A scientist is always questioning and testing assumptions.  A true scientist looks at all possible explanations.  Very few physicians, who take adamant stands about the value of vaccines, have actually studied the subject.  They just quote what they were taught in medical school and accept the recommendations of the professional organizations as gospel.  If evidence arises that contradicts the assumptions, they just toss it away as irrelevant.  Obviously, we cannot independently study every topic with which we deal.  What I am asking is to keep an open mind, as we should with all subjects.

There is no question it takes significantly more time and energy to openly deal with this issue, but if our role as physicians is to be advisors and healers to our patients, it is right that we do so, regardless of the decision they ultimately make.