Moderator ventana Posted February 15, 2012 Moderator Share Posted February 15, 2012 SHIRLEY S. WANG Pediatricians fed up with parents who refuse to vaccinate their children out of concern it can cause autism or other problems increasingly are "firing" such families from their practices, raising questions about a doctor's responsibility to these patients. Medical associations don't recommend such patient bans, but the practice appears to be growing, according to vaccine researchers. Enlarge Image Close Adam Bird for The Wall Street Journal Dr. Allan LaReau in Michigan stops treating families who refuse to vaccinate their children. 'You feel badly about losing a nice family,' he says. In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason. By comparison, in 2001 and 2006 about 6% of physicians said they "routinely" stopped working with families due to parents' continued vaccine refusal and 16% "sometimes" dismissed them, according to surveys conducted then by the American Academy of Pediatrics. "There's more noise among pediatricians, more people willing to argue that it's OK to do this versus 10 years ago," said Douglas Diekema, a professor of pediatrics at the University of Washington in Seattle. Dr. Diekema wrote the AAP's policy on working with vaccine refusers, which recommends providers address the issue at repeated visits, but respect parents' wishes unless it puts a child at risk of significant harm. Most pediatricians consider preventing disease through vaccines a primary goal of their job. The Centers for Disease Control and Prevention and AAP issue an annual recommended vaccination schedule, but some parents ask if their child's immunizations can be pushed back or skipped altogether, pediatricians say. Enlarge Image Close While rates for several key inoculations in young children rose between 2009 and 2010, according to the CDC, lower immunization rates have been blamed as a factor in U.S. outbreaks of whooping cough and measles in recent years. Parents often voice concerns about autism or that their child's immune system may be overwhelmed by too many vaccines at once. Worries about a link between vaccines and autism arose because some parents noticed their children regressed, or lost some skills, around the time of their vaccinations at two years of age. Another concern centered on the former use of mercury as a vaccine preservative. Numerous studies since have dispelled these concerns among scientists. Rather, scientists say, it is more likely that autism symptoms begin showing up around the same age children are vaccinated. The rise in patient firings reflects another factor. As patients have become savvier and more willing to challenge doctors, physicians have become increasingly reluctant to deal with uncooperative patients, said Arthur Caplan, a bioethics professor at the University of Pennsylvania. In addition, doctors may feel financial pressure to see more patients and so have less time to contend with recalcitrant ones. The version of Adobe Flash Player required to view this interactive has not been found. To enjoy our complete interactive experience, please download a free copy of the latest version of Adobe Flash Player here For Allan LaReau of Kalamazoo, Mich., and his 11 colleagues at Bronson Rambling Road Pediatrics, who chose in 2010 to stop working with vaccine-refusing families, a major factor was the concern that unimmunized children could pose a danger in the waiting room to infants or sick children who haven't yet been fully vaccinated. In one case, an unvaccinated child came in with a high fever and Dr. LaReau feared the patient might have meningitis, a contagious, potentially deadly infection of the brain and spinal cord for which a vaccine commonly is given. "I lost a lot more sleep than I usually do" worrying about the situation, he said. "You feel badly about losing a nice family from the practice," added Dr. LaReau, but families who refused to vaccinate their kids were told that "this is going to be a difficult relationship without this core part of pediatrics." Some families chose to go elsewhere while others agreed to have their kids inoculated. Pediatricians disagree about what their duty is to these families. "The bottom line is you should try to do whatever you can to maintain the family in the best care," said Michael Brady, chair of the pediatrics department at Nationwide Children's Hospital in Columbus, Ohio, and a member of the AAP's immunization committee. "If they leave your practice, they're probably going to gravitate toward another practice with unhealthy practices." It's hard to imagine an outbreak of smallpox today. But for centuries the deadly virus wiped out entire populations. WSJ's Christina Tsuei reports on how the discovery of vaccines (with the help of cows) eradicated the disease and led to the prevention of many other diseases. Other physicians say they rarely have had luck persuading vaccine opponents to change their minds. David Fenner and his 20-plus colleagues at Children's Medical Group in Rhinebeck, N.Y., discuss vaccine concerns but ask families to leave if they don't comply by a certain point. Dr. Fenner said he tells new families, "You've been bombarded with information before you came here, some accurate and some not." Iif a family refuses to vaccinate after a discussion of the issue, he tells them "there are so many things we're not going to see eye-to-eye on." So far, the practice has fired a couple of families per year since it implemented the policy about five years ago. Pamela Felice, who lives in an Atlanta suburb, had difficulty finding a pediatrician for her two children though they have waivers from a previous pediatrician exempting them from school requirements for immunizations. Her older child had gastrointestinal trouble and regressed development after receiving vaccines, she said, which she believes were related to the shots. Ms. Felice received a letter from her pediatrician a few years ago stating that because the family chose not to vaccinate, it needed to find another doctor. She called four or five other practices but none would agree to an appointment after she told them she was opposed to vaccines. The family ended up with an elderly family doctor who said he had "seen it all" and was willing to treat the children if they got sick, Ms. Felice said. "A doctor should feel obligated to discuss [potential vaccine] risks with any parent who wants to discuss them," said Ms. Felice. Link to comment Share on other sites More sharing options...
ToppDog Posted February 15, 2012 Share Posted February 15, 2012 Doctors have the right to fire patients for all sorts of reasons... in my opinion, the providers have just as much of a right to discharge these patients from their care, as the patients have to refuse that care. Let them agree to disagree & go their separate ways. The problem arises when there are not enough providers/patients to go around & they are stuck with each other. Link to comment Share on other sites More sharing options...
CAAdmission Posted February 16, 2012 Share Posted February 16, 2012 Why would anyone want these morons in their practice? They will just increase your workload and healthcare expenditures. Americans are happily free to make stupid decisions. Let them enjoy the consequences... Link to comment Share on other sites More sharing options...
sk732 Posted February 16, 2012 Share Posted February 16, 2012 We were discussing this in the ER the other day - won't discuss the case in the open, but suffice to say someone almost ended up getting a full septic workup as a result. I find it interesting that the article says parents/patients are getting savvier...if they were, they'd actually read the real studies vs the top 5 Google hits which all say this stuff is bad. I've given up yelling at people - I just give them the facts to make sure their decisions are in fact properly informed. Chances are, I'd look after the kid if they got sick...the look the parents have when they realize they might have harmed their child by their own ignorance usually makes the "I told you so" you so desperately want to blurt out pretty much unnecessary. As for firing patients, we'd do it to adults who spend too much time in our offices asking for advice then doing the exact opposite because they didn't hear what they wanted to hear or get what they wanted to get and continue being noncompliant, so why wouldn't you do the same to someone doing it to the rest of their family? I guess the only real difference is the kids can't make the decisions for themselves, so they pay the price for their parents' stupidity and get caught in the middle. Interestingly, my SP's last couple cases of autism were in non-immunized children...I wonder who or what the parents are blaming it on. SK Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 16, 2012 Administrator Share Posted February 16, 2012 Ooh, goody! I think I'll first fire all the smokers--it's disgusting, unhealthy, and they should know better by now. Then, the people who are obese--well, at least those who have a BMI higher than I do! Diabetics who come in with any A1c over 8? Toast. Finally, maybe I'll get rid of those who have non-monogamous sex. But I guess I'll keep the BASE jumpers, because they won't be gradually damaging their bodies, just increasing the risk of a sudden death. Interesting thought experiment, no? At what point does a decision become so obviously bad that clinicians have an ethical leg to stand on in refusing to care for patients? If we say that vaccines cross the line into that obviousness of wrong, counterproductive health behavior, what else is over that line? Does it move when society changes its mind on things? What about when science does? Link to comment Share on other sites More sharing options...
ToppDog Posted February 16, 2012 Share Posted February 16, 2012 It's a two way street. Just as patients can be so restrictive that nobody is willing to see them, so can a provider be so restrictive that he soon has no patients. Link to comment Share on other sites More sharing options...
CAAdmission Posted February 16, 2012 Share Posted February 16, 2012 Ronin, I know you are being satirical, but in reality, you describe a good situation. Wouldn't it be great to care for a panel of primarily healthy people? People who follow good advice, eat a good diet and take care of themselves? If I worked in IM I would certainly fire smokers. At the first visit, the conversation would go something like this: "Smoking and not exercising are probably the two worst things you can do for your health. I understand that smoking is a terrible addiction, and I am prepared to do anything you need to do in order to help you quit. But in establishing a therapeutic relationship, you and I are forming a sort of contract to act together in your best interest. If you cannot hold up your end of the contract, I am afraid I will no longer be able to be your healthcare provider. So you have 18 months - with my help - to find a way to stop smoking." Link to comment Share on other sites More sharing options...
crystaltide Posted February 16, 2012 Share Posted February 16, 2012 Let's also keep in mind that a parent that doesn't allow immunizations for their child affects more than just themselves and their child. It's a matter of community health as well, which I think is something that every provider should have an interest in. Link to comment Share on other sites More sharing options...
Just Steve Posted February 16, 2012 Share Posted February 16, 2012 Ooh, goody! I think I'll first fire all the smokers--it's disgusting, unhealthy, and they should know better by now. Then, the people who are obese--well, at least those who have a BMI higher than I do! Diabetics who come in with any A1c over 8? Toast. Finally, maybe I'll get rid of those who have non-monogamous sex. But I guess I'll keep the BASE jumpers, because they won't be gradually damaging their bodies, just increasing the risk of a sudden death. Interesting thought experiment, no? At what point does a decision become so obviously bad that clinicians have an ethical leg to stand on in refusing to care for patients? If we say that vaccines cross the line into that obviousness of wrong, counterproductive health behavior, what else is over that line? Does it move when society changes its mind on things? What about when science does? Because the chain smoking obese diabetic philanderer won't be spreading preventable diseases that carry high risk of death to other non suspecting members of your waiting room and community. However, I would not be opposed to some sort of guideline/recommendation of due diligence to ensure that the patient received vaccine education presented at their appropriate cognate level. Google is unencumbered by science. We as providers lack that advantage so we have to win the hearts and minds of our patients with other methods. If after my best attempts to persuade my patient go unneeded, I feel I have a duty to protect my other patients. Yes there is "herd immunity" so one patient can't turn into the next Typhoid Mary but the risk of dismissing a non compliant patient may not outweigh the reward of keeping them on your panel. Disclaimer: I am not yet a PA. It is just easier to think/type in the first person. Link to comment Share on other sites More sharing options...
vaston Posted February 16, 2012 Share Posted February 16, 2012 Ooh, goody! I think I'll first fire all the smokers--it's disgusting, unhealthy, and they should know better by now. Then, the people who are obese--well, at least those who have a BMI higher than I do! Diabetics who come in with any A1c over 8? Toast. Finally, maybe I'll get rid of those who have non-monogamous sex. But I guess I'll keep the BASE jumpers, because they won't be gradually damaging their bodies, just increasing the risk of a sudden death. Interesting thought experiment, no? At what point does a decision become so obviously bad that clinicians have an ethical leg to stand on in refusing to care for patients? If we say that vaccines cross the line into that obviousness of wrong, counterproductive health behavior, what else is over that line? Does it move when society changes its mind on things? What about when science does? All of these situations are illustrations of people making decisions for their own health. Vaccinations are choices being made by parents for someone else's health. These children can't make decisions on their own. They rely on medical professionals and their parents to make educated decisions that best protect them and the community around them. An innocent child/infant not receiving vaccinations due to a stubborn parent is not analogous to a diabetic choosing to eat foods that keep their A1C elevated (not to mention being non-compliant with their insulin/metformin/whatever). It is not analogous to adults choosing to BASE jump. BTW, many elementary schools now will not allow children to attend if they do not have up-to-date immunization records. Is that fair? Absolutely. Link to comment Share on other sites More sharing options...
user1234556 Posted February 17, 2012 Share Posted February 17, 2012 Ooh, goody! I think I'll first fire all the smokers--it's disgusting, unhealthy, and they should know better by now. Then, the people who are obese--well, at least those who have a BMI higher than I do! Diabetics who come in with any A1c over 8? Toast. Finally, maybe I'll get rid of those who have non-monogamous sex. But I guess I'll keep the BASE jumpers, because they won't be gradually damaging their bodies, just increasing the risk of a sudden death. Interesting thought experiment, no? At what point does a decision become so obviously bad that clinicians have an ethical leg to stand on in refusing to care for patients? If we say that vaccines cross the line into that obviousness of wrong, counterproductive health behavior, what else is over that line? Does it move when society changes its mind on things? What about when science does? I think these examples are really irrelevant. The age you are when you're receiving vaccinations is that of a minor. The parents are making this decision with the child having no real knowledge or input. It's completely different to be a grown adult and refuse them for yourself, but it's not right for a parent to make that decision for a child who may very well grow up to disagree with that decision, or, god forbid, acquire one of the diseases they should've been vaccinated against. Not to mention, a provider has no control over what a patient eats when they leave or whether they smoke despite their warnings- all they can do is GIVE those warnings, which they are responsible for. However, a vaccination is something they CAN control- they can administer it in the office and that's that. edit: sorry, the poster above me said basically the same thing and I hadn't read it first. Link to comment Share on other sites More sharing options...
smileygirlnic Posted February 17, 2012 Share Posted February 17, 2012 Rev Ronin--Excellent point. Thanks for making it. One thing that comes to my mind when reading these posts is that parents who smoke, for example, can and often DO have a very detrimental effect on their children--for example, when you see a car go by with the driver's window down an inch and a cigarette lit in their hand with kids and /or babies in the back amidst the smoke cloud. How sad. And I am sure that is not a one-time occurrence. Those poor kids...besides the fact that their potential to grow up and smoke also is much higher than kids whose parents do not smoke. I see the argument and point of this article for sure. We personally vaccinate our kids, but we also have friends who are against it. Then I also have friends whose perfectly healthy and exclusively breast-fed baby died two years ago from ADEM within a week after getting immunized (and getting sick within the first two days after the shots). Coincidence? Only God knows I guess. Extremely sad regardless. Our pediatrician simply told us that "the benefits of immunization outweigh the risks". I can see why this is not 100% comforting for some. Just my two cents as a parent of five. Nic Link to comment Share on other sites More sharing options...
vaston Posted February 17, 2012 Share Posted February 17, 2012 Rev Ronin--Excellent point. Thanks for making it. One thing that comes to my mind when reading these posts is that parents who smoke, for example, can and often DO have a very detrimental effect on their children--for example, when you see a car go by with the driver's window down an inch and a cigarette lit in their hand with kids and /or babies in the back amidst the smoke cloud. How sad. And I am sure that is not a one-time occurrence. Those poor kids...besides the fact that their potential to grow up and smoke also is much higher than kids whose parents do not smoke. I see the argument and point of this article for sure. We personally vaccinate our kids, but we also have friends who are against it. Then I also have friends whose perfectly healthy and exclusively breast-fed baby died two years ago from ADEM within a week after getting immunized (and getting sick within the first two days after the shots). Coincidence? Only God knows I guess. Extremely sad regardless. Our pediatrician simply told us that "the benefits of immunization outweigh the risks". I can see why this is not 100% comforting for some. Just my two cents as a parent of five. Nic As a parent myself, I trust that my children are safe when they are at the pediatricians office. If an unimmunized child shows up to the office with pertussis and they are around other infants in the waiting room who have yet to be immunized (<2 months old) then your office has needlessly exposed these children to a harmful (read: deadly) disease. If you choose to work with unimmunized children in your office you are potentially risking the health many of your very young patients. I personally don't think it's worth it. I'm sure if you ask the parents of infants that have yet to be immunized, they would agree. I am 100% on the side of the pediatricians here. http://www.nytimes.com/2010/06/24/us/24cough.html Link to comment Share on other sites More sharing options...
Contrarian Posted February 17, 2012 Share Posted February 17, 2012 Things have surely changed.. Link to comment Share on other sites More sharing options...
andersenpa Posted February 17, 2012 Share Posted February 17, 2012 BIG WHEEL!!!!!!! Sweet...... and I was expecting a more comprehensive reponse from you C, since I've seen your feelings on this issue here previously..... but the pic did not disappoint... Link to comment Share on other sites More sharing options...
vaston Posted February 17, 2012 Share Posted February 17, 2012 My Big Wheel was all black with a red pinstripe down the side and red wheels. I remember wearing out probably 4 front wheels on that thing. My current 'Big Wheel' is a Ford Focus SVT hatchback with a 6 speed manual short shift transmission. Unfortunately I had to sell my other one, a Honda VTX 1300 with 3in pipes that went all the way back to the retro rear fender. You can change the vehicle, but not the adrenaline :) (that got off topic real quick) Link to comment Share on other sites More sharing options...
Contrarian Posted February 18, 2012 Share Posted February 18, 2012 ... (that got off topic real quick) Nahh... It IS actually on topic... Us kids who had "Big-Wheels or Green-Machines," "Lawn Darts," and the other dangerous toys, survived sitting in hot cars for hours... with the windows rolled up and riding THOUSANDS of miles without wearing seatbelts in smoke filled cars, being operated by often impaired drivers who ate red meat. Thing is... we were all innoculated against the dangerous communicable diseases that had previously decimated populations worldwide. I'm a STRONG/Staunch advocate of "Patient Autonomy"... Thing is... the idiotic parents making these poor choices for their child (and putting everyone else at risk) aren't the patient of focus at the time of these decisions... Its unfortunate that the child could catch a preventable life altering/ending disease because their parents are stupid... but the reality is that children the world over have been subject to the consequences of their parents poor choices for eons. One only need to reflect on the morning of August 6, 1945. At 8:16 (USAAF released the munition from the rack at 8:15 A.M.) those children below were victims of their parents poor choices. Schitt happens...!!!! So I said all that to say... There is a shortage of healthcare providers. One provider can only care for a limited number of patients in a lifetime. As a provider, I'd much rather spend MY time caring for those who believe what I'm telling them, and trust my insight, judgement and therefore follow my recommendations ... in good faith... as best they can. I abhor wasting time in exam rooms "debating" pathogenics, pharmacodynamics, and pharmacokinetics with "unlearned" and ill-prepared lay-folks. Don't believe what I'm telling you... BYE-BYE...!!!! Want to play "debate club" in the exam room... BYE-Bye...!!! Want to expose me, my team/staff, and my other patients to easily preventable communicable diseases and disorders... Bye-BYE..!!! Go waste someone elses time...!!! Go expose them and their other patients to that petrie dish... I have... on several occassions "dismissed" patients that I sensed thought appointments at a providers office was some kid of "sport" and/or simply used these apointments to validate their notions that they too could have been a clinical healthcare provider. Personally, I don't have the time, tolerance, inclination, or patience for it. Go away..!!! Just my thoughts... Contrarian Link to comment Share on other sites More sharing options...
haeriphos Posted February 18, 2012 Share Posted February 18, 2012 I agree with the sentiments expressed in the article, but I don't like the idea of "punishing" the child for the parents' poor choices. I also don't like the idea of exposing the rest of a waiting room to an infected child. Maybe I'll make them wait in the coat closet to minimize the risk. Or have them wear a mask that says "MY PARENTS DIDN'T VACCINATE ME SO YOUR KIDS ARE AT RISK" when they come in. Link to comment Share on other sites More sharing options...
CAAdmission Posted February 18, 2012 Share Posted February 18, 2012 Amen Contrarian. The curse of the clinician is to spend a disproportionate amount of time caring for morons. Want to resolve this issue fast? Do it through insurance. If you want to smoke, fine - but you will have to pay for treatment for any cardiopulmonary conditions out of pocket. No vaccines? Great. If your kid gets tetanus or diphtheria, it's on your dime... Link to comment Share on other sites More sharing options...
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