Doctors drop families that refuse shots

Washington -- When Erin Flanagan-Klygis, MD, began her pediatric practice a few years ago, she was surprised by the number of families who came to her after being dismissed by other physicians. The reason? The parents refused to have their children immunized.

Thus, it came as no surprise to her that a recent survey confirmed that many physicians are becoming so frustrated by parents who refuse vaccines for their children that they said they would decline to care for them. She conducted this study with colleagues at Rush Medical College in Chicago, where she is now an assistant professor of pediatrics. It appears in the October Archives of Pediatrics & Adolescent Medicine.

Dr. Flanagan-Klygis is a strong advocate for vaccination, but she told parents that she would continue to care for these young patients regardless of this decision. "I had to do a lot of hand-holding and offer reassurances that I'd be willing to talk to them about their feelings concerning vaccinations."

The rate of unvaccinated children in the country has increased in recent years as more parents opt to forgo them for their children because of safety concerns. Often such anxieties are based on unscientific but dire reports of autism, autoimmune diseases and compromised immune systems as outcomes of vaccination.

Many states are also passing laws allowing families to receive philosophic exemptions from immunizations required for school entry. These exemptions supplement those given for religious reasons.

In response to these trends, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices is discussing the addition of an educational component to the exemption procedure to ensure that parents are aware of the potentially serious results of declining vaccines and aren't just seeking exemptions because it seems the easier path, said William Schaffner, MD, MPH, professor of preventive medicine at Vanderbilt University in Nashville, Tenn.

Decades ago, vaccination was a routine and generally unquestioned practice. It's a different story today. Dr. Flanagan-Klygis' study revealed that 85% of the 302 pediatricians who responded reported encountering a family that refused at least one vaccine during the previous 12 months. More than half of the physicians, or 54%, said they encountered a parent who refused all vaccines.

Although 39% of physicians surveyed said they would refer a family to another practice if the family refused all vaccines for their children and 28% said they would refer if certain vaccines were declined, it is not known whether any of the responding physicians had actually done so.

Meanwhile, parents expressed vaccine safety worries as well as concerns related to the administration of multiple vaccines at once in addition to philosophic and religious beliefs opposing immunization, according to the study.

In Dr. Flanagan-Klygis' experience, the questionable quality of some of the information parents had found on the Internet was unsettling. "I felt really frustrated that they were making a decision based on such bad information." After supplying parents with factual guides, she attempted to persuade them to reconsider. "Some did and some didn't," she said.

A matter of trust and education

For many physicians in the study, a parent's immunization refusal signaled a lack of trust in the doctor's judgment and demonstrated an absence of shared goals between physician and patient. Some reported that fear of litigation was another important consideration in a decision to sever a relationship.

The study authors cautioned against ejecting a patient from a practice. "Vaccine refusal is a challenge we should meet, not avoid," they write.

Physicians are ethically obligated to follow certain steps before terminating a relationship with a patient. The American Medical Association's Code of Ethics requires that patients be given sufficient notice and that other care be available to them, said Priscilla Ray, MD, chair of the Association's Council on Ethical and Judicial Affairs.

"The only physician in a community would not, I think, deprive a child of care," she said.

Although the frustration experienced by physicians is understandable, said Louis Cooper, MD, past president of the American Academy of Pediatrics, dismissing a family from a practice should be the exception rather than the rule. "For me, the bottom line in all this is that we need to rebuild our broad public trust in immunization."

Plus, the problem of noncomplying patients goes well beyond children and vaccines, noted Jonathan Temte, MD, PhD, an associate professor of family medicine at the University of Wisconsin.

"I look at it as being very similar to deciding to dismiss a patient because they are a smoker, or they are obese or they don't exercise enough." The better approach is to work with patients and help them to improve unhealthy behaviors, Dr. Temte said.

Persuading adults to get vaccinated can also be an exercise in futility, Dr. Schaffner said. Particularly frustrating is when health care workers decline a flu shot, he said.

Physicians and nurses often cite a lack of time and the fact that they don't like needles, Dr. Schaffner said. But the most frustrating reason is their erroneous belief that the flu vaccine can cause the flu.

"This myth is still alive and well," he said.