rcdavis Posted March 22, 2011 Share Posted March 22, 2011 Refusal to stop self destructive behavior? Abuse of staff, yourself? Stalking your kids because you will not prescribe pain Meds ( currently happening to a ED MD friend of mine)? Medical non compliance? How about refusal of vaccinating their kids? This is the article that got me thinking: Should Pediatricians Stop Treating Children If Parents Refuse Vaccination? By: HERSCHEL R. LESSIN, M.D., AND JOEL FRADER, M.D.,*| 02/14/11 Not rated yet. Be the first who rates this item! Click the rating bar to rate this item. Vaccine Refusal Violates Core Beliefs and Endangers Everyone Prevention of childhood illness is the heart of a pediatrician’s mission. Immunization refusal violates that mission, putting everyone at risk: child, pediatrician, other children, and society as a whole. If we allow families to remain in our practices unvaccinated, we are giving tacit approval to parents that refusing vaccines is just fine. It is anything but fine. **** Dr. Herschel Lessin irst, the child is at risk to acquire deadly diseases with which few pediatricians have any familiarity. Second, others in your office are at risk. If an unvaccinated child contracts vaccine-preventable disease and comes to your office for care, every patient you see that day is potentially exposed. This is not a hypothetical situation for my practice and many others around the country. Third, pediatricians are put at risk. In the above situation, I must call every patient exposed, upset them, and provide services to their kids that would never have been needed had the parents of the index case been responsible. Furthermore, if I allow unvaccinated patients in my practice, I must remember to ask every ill child whose parents call me whether they have been vaccinated. I must consider invasive septic work-ups that I have not done in decades for simple febrile illness. Refusal to vaccinate is a marker for noncompliance with medical advice. If the parents don’t believe me when I tell them vaccinations are safe and important, are they any more likely to accept my advice about diet, illness, or medications? What if the unvaccinated child contracts a preventable disease? The parents might file suit, claiming that they were inadequately informed about the benefits of the vaccine or the risks of refusing it. Last, vaccine refusal is a danger to society and a public health hazard. When a large enough population is unvaccinated, herd immunity is lost. One only has to witness the many infants who died in the recent pertussis outbreak in California – a hotbed of anti-immunization fervor – to realize the impact. The American Academy of Pediatrics has a somewhat different outlook on this issue. They discourage discharging patients solely because of vaccine refusal. However, they do acknowledge that the relationship might not be able to continue if there is a high level of distrust or major differences in the philosophy of care. For me, it comes down to whether you can have a relationship with a family when their choice not to vaccinate goes against pediatric core values and puts so many innocents at risk. I don’t believe that I can have a functioning doctor-patient relationship with parents who aren’t willing to accept my advice about such a core issue as keeping their children safe from potentially deadly diseases. I have practiced in an era when these diseases were common. I do not wish to return. Being codependent with the baseless and disproven anti-vaccine movement is not a choice we should be willing to make. Dr. Lessin is a pediatrician in Poughkeepsie, N.Y., and is a member of the AAP Committee on Practice and Ambulatory Medicine. Dr. Lessin serves on the advisory boards of several vaccine manufacturers including Merck & Co. Novartis, Pfizer, and MedImmune. He is also a member of the speakers bureau for GlaxoSmithKline. Staying With Patients Builds Trust Pediatricians rightly feel proud of progress made in primary prevention of infectious disease through immunization. Vaccines make up a huge portion of the backbone of primary care pediatric practice. Thus, families who refuse to have their children immunized challenge a basic tenet of modern practice. We can understand a pediatrician’s frustration and even anger when parents invoke nonrational or irrational reasons to decline recommended vaccination. Does the refusal justify asking the family to seek pediatric care elsewhere? No, it does not. Dr. Joel Frader **** While most support universal immunization, we must admit that vaccines are neither 100% effective nor 100% safe. We cannot guarantee each child will benefit, and some children will have adverse reactions. As long as enough children are fully vaccinated for a given threat, typically around 85%-90% of the target population, the community will maintain herd immunity, limiting disease spread. While the 10%-15% not vaccinated have a "free ride," that is, they get the public health benefit but do not incur the risks of immunization, the still-high vaccination rates permit some latitude in personal, if idiosyncratic, parental choice. Keeping families that refuse vaccinations in one’s practice permits the pediatrician to continue to develop a professional relationship and build trust with the family. Our experience suggests that many parents modify their anti-vaccine stance with continued discussion and education. Some families appreciate the pediatrician’s acceptance of their beliefs which, in turn, leads to greater openness to changing their views. More important, the children of anti-vaccine parents deserve expert pediatric care. Their pediatricians need to be especially mindful of and vigilant about an increased risk of serious infection when these children have febrile illnesses. Physicians who fully embrace or even encourage anti-vaccine attitudes and "collect" families of unimmunized children might harbor other less-than-fully scientific views, compromising the vigilance and care that ill, nonvaccinated children deserve. Pediatricians who turn away at risk children and families may unwittingly deprive especially vulnerable patients of the best available care. It surely does not feel good to do less for a patient than our rigorous and demanding scientific standards demand. However, we constantly make choices involving how much to do. We fret over how extensive an evaluation to do for what usually turns out to be a common, self-limited problem and not the potentially disastrous "zebra" we – and the parents – fear. We administer a 10-day course of antibiotics for an infection that some may treat for 3 weeks. Providing care for unvaccinated children does not differ fundamentally from other actions where we intervene less than some might claim is "optimal." Many factors influence our decisions to limit treatment: family resources, our own resources (time/effort), and family beliefs and preferences (say, to avoid ionizing radiation or use watchful waiting in a child with fever and middle-ear effusion). The troubling question is whether withholding care violates an ethical imperative. In the case of vaccine refusal, it’s more gray than certain. Dr. Frader is the A Todd Davis Professor of General Academic Pediatrics and professor of medical humanities and bioethics at Children’s Memorial Hospital and Northwestern University, Chicago. Dr. Frader said he had no relevant financial disclosures. Just throwing it out there. v/r davis Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 23, 2011 Moderator Share Posted March 23, 2011 I draw the line at assaulting me or my staff. that gets you a b52, medical clearance then admission( if legitimate reason for behavior) or arrest. I can't see d/c of a child whose parents refuse to vaccinate them. it's not the kid's fault that the parents are idiots. I would have them sign a waiver that they were offered vaccination and refused listing all possible consequences, much like an ama form. Link to comment Share on other sites More sharing options...
cecilia Posted March 23, 2011 Share Posted March 23, 2011 would you also d/c patients that smoke? tan? eat at mcdonalds? where does it end? A parent should have the right not to be forced a procedure on their child. We as medical practitioners can only inform them of the pros and cons. But the final decision is theirs. Maybe because outcomes are so varied. If a child doesn't get vaccinated, you can't predict what will happen. There is a whole spectrum of possibilities...from nothing happening his/her entire life to dying. Now, if you are talking about a toddler having pneumonia and parents refusing to allow treatment, then....that's a problem. This was just in the news...kid died because parents wanted to pray the disease to go away. That is criminal. Link to comment Share on other sites More sharing options...
Rob77 Posted March 23, 2011 Share Posted March 23, 2011 None of the pediatricians will see unvaccinated kids by me. I'll see them but I'm honestly getting tired of dealing with their parents irrational behavior. We dismiss folks mainly for drug seeking, failing random drug screens, habitual no shows, and non compliance with treatment. As an example I had a pt who was an insulin dependant diabetic who stopped all of her meds and refused any intervention. She also told me that I caused her to have diabetes. I dismissed her, I cannot take part in someone wanting to kill themselves. Link to comment Share on other sites More sharing options...
bradtPA Posted March 23, 2011 Share Posted March 23, 2011 In our pain management patients multiple negative drug urines, or cocaine pos urine, get them a quick discharge Link to comment Share on other sites More sharing options...
rcdavis Posted March 23, 2011 Author Share Posted March 23, 2011 would you also d/c patients that smoke? tan? eat at mcdonalds? where does it end? A parent should have the right not to be forced a procedure on their child. We as medical practitioners can only inform them of the pros and cons. But the final decision is theirs. Maybe because outcomes are so varied. If a child doesn't get vaccinated, you can't predict what will happen. There is a whole spectrum of possibilities...from nothing happening his/her entire life to dying. Now, if you are talking about a toddler having pneumonia and parents refusing to allow treatment, then....that's a problem. This was just in the news...kid died because parents wanted to pray the disease to go away. That is criminal[/b]. cecelia.. You argument turns back on itself. Unvaccinated child MAY NOT get pertussis or measles or polio, and if gets it, MAY NOT die. But certainly is then put at risk by his parents, and certainly places others at risk... Not all pneumonias in toddlers are fatal.. In fact, most are not...so why criminalize the pneumonia parents and not the parents who place their child at risk by not vaccinating.? Link to comment Share on other sites More sharing options...
marilynpac Posted March 23, 2011 Share Posted March 23, 2011 Parents are not vaccinating due to the controversy and many parents are home schooling. This is just some of what I hear. We did not d/c them from our practice. We would d/c a family after the third noshow/nocall. As for non compliant....many, many, patients fit into this catagory, usually when it came to ABX dosing. Once the patient started to feel better, stopped the ABX, and saved some for the next time illness struck them or someone in the family. As for owing money...in this economy almost everyone owes money somewhere, however habitual it would go to a collection agency. Someone abusive to staff...we would tell them our office can't do anymore for them where would they like their med records sent...end of story. Link to comment Share on other sites More sharing options...
Contrarian Posted March 24, 2011 Share Posted March 24, 2011 Refusal to stop self destructive behavior? [Nahh not initially but it really depends on what the Behavior is...] Abuse of staff, yourself? [Not tolerated... Gotta Go RIGHT NOW...!!!!] Stalking your kids because you will not prescribe pain Meds (currently happening to a ED MD friend of mine)? [Not tolerated... Gotta Go RIGHT NOW...!!!! and ready for the "GlockTalk."] Medical non compliance? [Nahh... would still try to form a "therapeutic Alliance"] How about refusal of vaccinating their kids? [Gotta Go RIGHT NOW...!!!! "Herd-Immunity" is important...!!! Not gonna expose my staff & other patients to the germs they are carrying/brewing. Nor am I gonna allow them to monopolize my time and the time of the staff dealing with easily preventable illnesses. Especially so in a highly "capitated" practice environment] Just My initial thoughts Contrarian Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 24, 2011 Moderator Share Posted March 24, 2011 Refusal to stop self destructive behavior? Nah - refer to psych - as long as not committable - then refer/section to ER Abuse of staff, yourself? call police if they do not leave the property immediatly - they get a letter saying they have 30 days to get a new doc and then we stop writing all medications - no second chances Stalking your kids because you will not prescribe pain Meds ( currently happening to a ED MD friend of mine)? call police - file reports - press charges - suggest hospital take out a no trespassing order against them - ZERO tolerance Medical non compliance? I would have no practice if I d/c over this....... How about refusal of vaccinating their kids? I would have to think hard - I am not in ped's but my belief is that EVERYONE should get vaccines (the overpriveldged stupid american thinks that vaccines are more dangerous then the diseases they prevent - no excues - I have yet to meet someone that has had the true flu not get vaccinated every year there after) ....... further thinking - I would d/c the patient - i don't want to enable this type of behavior and they can go find someone else to provide care to them - they in fact are harming the community through their actions.... Did everyone realize the British Doctor who had one study trying to link autism to vaccines finally just admitted it was all made up - he did if for the money - and Britian took his medical license away.... No shows - x3 and d/c - can be liberal on this but my time is valuable and patients learn what they can get away with - draw a hard line in the sand them make the occasional exception for those that deserve it - but the 26 yr old that is on public assistance who lives one block away who routinely no shows because they overslept - see ya bye bye..... Humm see above...................... Link to comment Share on other sites More sharing options...
Joelseff Posted March 24, 2011 Share Posted March 24, 2011 http://www.cnn.com/2010/HEALTH/09/17/california.whooping.cough/index.html Link to comment Share on other sites More sharing options...
Firemedic13 Posted March 25, 2011 Share Posted March 25, 2011 I agree with the second part of the article. If you turn them away, and others do too, they are less likely to EVER get their kids vaccinated. Putting up with them is the best way to help the kid in the long run. Link to comment Share on other sites More sharing options...
marilynpac Posted March 25, 2011 Share Posted March 25, 2011 The philosophy of our practice was not to punish the child for the ignorance of the parents. By d/c the child out of our practice would be doing just that. Instead educate the parents about the benefits of vaccinations...eventually most of them come around due to the fact that you can't enter a school system without proof of immunizations. Link to comment Share on other sites More sharing options...
Firemedic13 Posted March 25, 2011 Share Posted March 25, 2011 The philosophy of our practice was not to punish the child for the ignorance of the parents. By d/c the child out of our practice would be doing just that. Instead educate the parents about the benefits of vaccinations...eventually most of them come around due to the fact that you can't enter a school system without proof of immunizations. Yeah... though that depends on the state. In some states (I am looking at you, New Mexico) make it ridiculously easy to get a religious exemption for this. But you are right... even if the parents wanted to most places (even NM really) will end up forcing them to get their kid immunized at 4 or so. In many cases I would think this could be to the providers advantage.... Ie: Parent- "I don't want my kid vaccinated because I think it is more dangerous than whooping cough. Also, I am an idiot." Provider- "The schools will require it. It is better to start now and space it out over the coming years than to stick them 33 times at age 4. And yes, you are an idiot." Though I do have to say, a few of the vaccinations these days are absurd. Hep B? Really? My kid isn't having sex, isn't using IV drugs, wasn't in daycare, and my wife had been immunized already and is breastfeeding. Does she really need it on day one? No. That can wait a couple months or even years. Link to comment Share on other sites More sharing options...
cecilia Posted March 25, 2011 Share Posted March 25, 2011 i guess what i meant was, pneumonia that was not getting better and the child clearly needed antiobiotic treatment Link to comment Share on other sites More sharing options...
sbellin Posted March 27, 2011 Share Posted March 27, 2011 I find it interesting that patient non-compliance is the second most popular reason to discharge a patient. I don’t think the decision by a parent to not vaccinate a child is anymore valid a reason to discharge a patient then one that does not follow treatment recommendations. Patients that continue to smoke are participating in self-destructive behavior but I’m betting that they don’t discharged. I think in general if patients aren’t following treatment recommendations it is the responsibility of the provider to try to work out the solution. Yes, this may mean they leave you behind as a provider but maybe your patient/provider relationship is not one made in heaven and they may find a better fit with another provider within your group; you could try to facilitate this change and not just cut the rope and let them go. Part of the providers’ responsibility in patient care is to ferret out the nuances that make each person tick and tailor their care plan to them; to do otherwise is just cookbook medicine. Link to comment Share on other sites More sharing options...
just_me Posted March 27, 2011 Share Posted March 27, 2011 Non-compliant patients waste time....they take spots that people who actually do care about their health should have. Also non-compliant patients put healthcare providers at risk for litigation. Now with proper documentation the provider may win hands down, but the time and money invested in the litigation as well as the stigma is absolutely not worth it. This is also just my personal preference but I wouldnt work in a peds office that saw children whose parents choose not to have them vaccinated. So the children who are vaccinated "should" be protected from the ones who arent BUT what about infants that come into that office, premature babies and such? What about those that already have a compromised immunity system and now they are eing exposed to these children? No it is not the childs fault...I blame the parents. I do not agree that by NOT seeing these children we are creating parents who will never have their children vaccinated. I think if more pediatricians said NO then parents would find they have no choice but to comply (unless it is truly a religious reason which is a different topic with me as well) Link to comment Share on other sites More sharing options...
Hemegroup Posted March 27, 2011 Share Posted March 27, 2011 I did an elective Peds preceptorship of 9 weeks, in addition to my 5 week rotation, so I saw a bit of this. The parents who didn't want to vaccinate ... it's important to remember that the reason they made that decision is out of care for the child. Even the die-hards eventually came around, albeit on an extended schedule of shots. Firemed, HBV can be transmitted in households through saliva that is contaminated with blood and then comes in contact with mucous membranes. Link to comment Share on other sites More sharing options...
lucysmama Posted March 28, 2011 Share Posted March 28, 2011 During our didactic year, we were given our first Pediatrics lecture by a very well-respected Pediatrician at the end of which she actually advised our class to dismiss patients who did not vaccinate. I was horrified, for all the reasons listed above. If we are to develop a trusting relationship with our patients, we can't expect them to do everything we tell them to, nor should we. We can only tell them what we know and believe and then hope they will make good choices. It is not our jobs to have patients obey us, it is our jobs to work with them so that we can care for them. I felt her position was not only disagreeable, but irresponsible - telling a class full of young students that is is not only OK, but preferable to dismiss their patients on a disagreement. Wow. Link to comment Share on other sites More sharing options...
just_me Posted March 28, 2011 Share Posted March 28, 2011 During our didactic year, we were given our first Pediatrics lecture by a very well-respected Pediatrician at the end of which she actually advised our class to dismiss patients who did not vaccinate. I was horrified, for all the reasons listed above. If we are to develop a trusting relationship with our patients, we can't expect them to do everything we tell them to, nor should we. We can only tell them what we know and believe and then hope they will make good choices. It is not our jobs to have patients obey us, it is our jobs to work with them so that we can care for them. I felt her position was not only disagreeable, but irresponsible - telling a class full of young students that is is not only OK, but preferable to dismiss their patients on a disagreement. Wow. She specifically say "dismiss them for not listening to you when you tell them to vaccinate" or did she give you reasons why she felt you should?. You feel its irresponsible because of some reasons posted here....maybe she felt it was the responsible move for the same reasons listed in the first part of the article. In all honesty, while its certainly the parents perrogative to do as they wish, its the providers job to do their best to protect all thier patients. Do you simply consider one over the whole? Link to comment Share on other sites More sharing options...
just_me Posted March 28, 2011 Share Posted March 28, 2011 I find this conversation about vaccinations interesting. Some feel its wrong for a provider to say "if you dont want to vaccinate you need to find another provider thats ok with that".....do those same people feel that way about providers that refuse to perscribe birth control---that these providers should do whatever the patient wants because its their job or what about turning someone away because you dont want to accept their insurance? Link to comment Share on other sites More sharing options...
Contrarian Posted March 28, 2011 Share Posted March 28, 2011 Since the provider isn't suppose to be Paternalistic/Maternalistic... should they just accept this as the patient's choice " since we can't expect them to do everything we tell them to, nor should we," and "It is not our jobs to have patients obey us, it is our jobs to work with them so that we can care for them." What about dismissing a patient because they LIKES to get high... off anything and everything (Weed, Glu, OxyContin, Spice, Bath-Salts, Meth, Heroin, Vicodin, Benzos, Etoh, etc) and pulls out ALL stops (manipulation, deceit, crime, etc.) to accomplish that goal....??? Should the non-addiction medicine specialist just accept this as the patient's choice..?? Contrarian Link to comment Share on other sites More sharing options...
marilynpac Posted March 28, 2011 Share Posted March 28, 2011 The reasons that some providers don't Rx birth control and others do isn't always clear. My PCP doesn't Rx any female hormones at all. When I asked him about it he said that when synthetic female hormones came out that is when he started seeing a dramatic spike in female cancers...he doesn't want to help that along. Despite HRT being heart beneficial he feels that there are other ways to help the heart besides HRT...it just has too many risk factors for too many women. So he refers it out. As for not accepting certain insurance and accepting others, it has to do with the filing process and the complications that go with it. Some insurers just take forever to pay the health care provider and if there is anything out of place...then the process has to start all over again. So many rules and regulations that the docs just feel it's too much of a hassle to be bothered with it. You may not like that answer but remember you're in the medical field and no one has promised you a rose garden...sometimes it's just a day of thorns... Link to comment Share on other sites More sharing options...
just_me Posted March 28, 2011 Share Posted March 28, 2011 What Im getting at is just as the patient has a choice so does a provider. Either you get your kid vaccinated or go somewhere else.... Either you have an insurance I take, pay cash or go somewhere else... If you want BC you need to go somewhere else.... Is a provider irresponsible for saying any of these to a patient (well its illegal to say the second one to an ER patient...) no its not. Inconvenient....yes, but wrong....no. When you go into business for yourself you shoudl have the ability to run things your way (within legal boundaries ofcourse) Your PCP made his choice based on his own reasons, some make the same choice based on religious reasons and its their choice to make. Inconvenient as it maybe, the patient choice have other choices. Same with insurance...my physician chooses not to accept insurance because its a hassel.....is he irresponsible because he tells those that want to use their insurance to find another provider? No, its his choice and if they dont like it...they can find a provider who does accept their insurance The reasons that some providers don't Rx birth control and others do isn't always clear. My PCP doesn't Rx any female hormones at all. When I asked him about it he said that when synthetic female hormones came out that is when he started seeing a dramatic spike in female cancers...he doesn't want to help that along. Despite HRT being heart beneficial he feels that there are other ways to help the heart besides HRT...it just has too many risk factors for too many women. So he refers it out. As for not accepting certain insurance and accepting others, it has to do with the filing process and the complications that go with it. Some insurers just take forever to pay the health care provider and if there is anything out of place...then the process has to start all over again. So many rules and regulations that the docs just feel it's too much of a hassle to be bothered with it. You may not like that answer but remember you're in the medical field and no one has promised you a rose garden...sometimes it's just a day of thorns... Link to comment Share on other sites More sharing options...
marilynpac Posted March 29, 2011 Share Posted March 29, 2011 Boy did you say it. Now when this new healthcare goes through, the choices are going to be less and less. Link to comment Share on other sites More sharing options...
Joelseff Posted March 29, 2011 Share Posted March 29, 2011 What Im getting at is just as the patient has a choice so does a provider. Either you get your kid vaccinated or go somewhere else.... Either you have an insurance I take, pay cash or go somewhere else... If you want BC you need to go somewhere else.... Is a provider irresponsible for saying any of these to a patient (well its illegal to say the second one to an ER patient...) no its not. Inconvenient....yes, but wrong....no. When you go into business for yourself you shoudl have the ability to run things your way (within legal boundaries ofcourse) Your PCP made his choice based on his own reasons, some make the same choice based on religious reasons and its their choice to make. Inconvenient as it maybe, the patient choice have other choices. Same with insurance...my physician chooses not to accept insurance because its a hassel.....is he irresponsible because he tells those that want to use their insurance to find another provider? No, its his choice and if they dont like it...they can find a provider who does accept their insurance Wow!!! I actually agree with you Just_Me!!!:;;D: LOL But you are right, we as providers have a choice and like Marilyn's PCP, can opt to refer vs be part of a tx/modality we personally (idealistically, religiously, etc.) disagree with. Link to comment Share on other sites More sharing options...
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