Anti-Vaxxers

[TheFatMan]

Greetings,y

Pre-PA here with a quick question that I am sure has been touched on before, but I am very interested to see how people handle their anti-vaxxer patients. Seeing as many PA's are in primary care, I see it as at least partially the duty of the PA to increase vaccination rates for public health. I have met PA's and docs who have said "doesn't bother me, they have their choice," and others who laugh at them (not in person, obviously). I have only seen in a small sample of occasions how providers approach those opposed to vaccines (and usually it has been something minimal like not getting the flu shot since it "gets them sick".) 

 

Is anyone willing to discuss their approach to the anti-vaccine patient? I feel in the coming years, how the MD, PA and NP approach these patients might have major implications on public health. I am aware that simply stating facts and citing studies does not do it, what do you do?

[Joelseff]

What can you really do besides education and being persistent?

 

U can't hold them down and force them to get one.

 

I give them info and talk specifically about the sequela and dangers of Flu and its effect on a community. I mention herd immunity in lay terms and I talk about it at every visit during the season and a little before. I actually have had a handful who have changed their minds and actually got one this year. But you'll always have the ones who really are suspicious of vaccines and to some extent Medicine and you gotta take the bad with the good at the end of the day.

 

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[TheFatMan]

I understand you can't hold them down and force them, but at what point do you lose patience, or have you ever? Do you have a go-to "speech," or do you just ask them questions about their concerns.

Has anyone here practiced during an outbreak?

Thanks everyone for your time.

[Marinejiujitsu]

I seen a study regarding antivaxers more likely to vaccinate if you dont pressure them meaning they will come around :)

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[mgriffiths]

Not sure what you mean by an outbreak...I was practicing last year during the flu - and it was bad.  I had 12 patients die and over 25 others hospitalized for pneumonia, and I'm in a pretty rural, small-town area.  Granted, all 37 of those were older with several comorbidities, but still rough.

Sometimes I unfortunately don't take the time to discuss vaccines, as the time is not always available.  But, I try to ask the patient (or patient's parents) what their concerns are regarding vaccines.  The majority don't want to answer me, but I push a bit.  Surprisingly, many don't know why they refuse vaccines.  They haven't done "research," they don't even feel strongly about it, they just "just don't know" and therefore choose not to as they feel that not doing it is safer when you don't know.  Those are the ones that I will spend time with discussing statistics, herd immunity, and will even respond to the more common "anti-vaxxer" concerns.  I would say that I around 2/3 will eventually agree to vaccines.  The ones who are vehemently against vaccines I have less patience for.  I am much more direct and make it clear the "science" they quote is ridiculous.  I am not rude, but I also don't just sit and listen to their ridiculousness.  After approximately 30 seconds I end the visit and move on because otherwise they would begin also telling me about their crossfitveganismessentialoilherbalwrapcancercure.

Maybe I'm an exception, but I have found that patients respond to respectful authority.  This includes vaccines, antibiotics, pain meds, etc.  Granted it's not universal, I have experienced many combative patients, but as said above - I don't argue.  I don't get angry with the patient, I don't raise my voice, I don't intimidate (I'm a 240lb male previous wrestler/football player), but I'm also not going to allow a patient to verbally abuse me.  Far too many providers take this abuse and it's astounding.

[GetMeOuttaThisMess]

I just give them the  looks and keep going.  Enough said.

[lkth487]

I will try to approach the subject at each visit with parents.  Sometimes it works - most of the time, I've found that it doesn't.  I've taken care of kids who've died because they were unimmunized.  I tell them those stories sometimes.  I am not sure if it helps.

[jmj11]

I work in a practice where vaccinations rarely come up. However, there are many other fake-medical information that I have to fight against daily. When someone says they don't "believe in western medicine," and have been using alternative treatments (and they are still suffering) I ask them, "So, how has the years of natural treatments working out for you?"

But the anti vaccination really piss me off. The reason is, that early in my career I had the opportunity to work in the developing world where I saw great suffering as the result of the lack of vaccinations. I saw a kid die from tetanus and saw kids with measles.  Stupidity kills. I was disappointed when the CIA used a vaccination doctor in the very town I had worked in, in Pakistan, to get DNA from Osama's kids. The reason is, I knew that the local paranoids would shut down the vaccination program there, and in many places of Pakistan, they did.

[rev ronin]

There's plenty of things you can do, assuming of course that polite education has failed.  And, of course, none of these should be used on people with medical contraindications--they get treated on the basis of what they CAN have, not what we'd like them to have:

1) Not certify sports/school physicals for teens until proof of vaccination is provided.

2) Tag-and-track unimmunized folks.  Require them to wear masks while in the clinic for their, and everyone else's, protection.

3) Post the clinic's position on scheduled vaccines publicly.

4) Refuse to accept refusals.  Every visit, every non-immunized patient will be offered an opportunity to get all appropriate yet unadministered vaccines. Patients may only stop such questions by getting the relevant immunizations or terminating care.

... You get the picture.  If you've got plenty of business and can afford to lose customers (they're not patients if they're not following your treatment regimens...) then you have a lot more flexibility to intentionally alienate patients and "brightsize" your panel by removing those simply not on the same page.

(Of course, there are plenty of other things, like smoking and DM II care, where there are plenty of opportunities to deal with patient non-compliance, but I never treat a failure of willpower the same as a willful failure to engage with good medical advice)

 

[lkth487]

I did a pediatrics residency - and one of my colleagues from residency is in a practice that makes all vaccine refusers sign a form at every visit, stating they know the risks and harms of their choice.  I am not sure how that effective that is.

Two of my colleagues who graduated with me specifically sought out and joined a practice that refuses all anti-vax patients.  I am not quite sure how I feel about that, but I understand where they are coming from.  If parents won't listen to their physicians on this issue, how can there be trust about anything else?  On the other hand, it's not the child's fault and I wouldn't want them to turn to people who peddle in complete nonsense for their primary care because those are the only people who take those patients.

I don't have the right answers or have any bright ideas, unfortunately.  Other than keep doing your best to inform people at every visit...

[thinkertdm]

For crying out loud, these aren't patients, they are customers.  And the customer is always...well, you get the picture.  A mad customer is heard the most.

Ps I'm being facetious, but that's the way our bosses, the administrators, think 

[quietmedic]

One pediatrician I know made such parents fill out a waiver releasing the doc from any liability should their child become ill or dead. Worded it as morbidly as possible. He had a big practice though and could afford to lose patients who refused to sign.

[Guest JMPA]

On 12/13/2018 at 12:49 PM, rev ronin said:

There's plenty of things you can do, assuming of course that polite education has failed.  And, of course, none of these should be used on people with medical contraindications--they get treated on the basis of what they CAN have, not what we'd like them to have:

1) Not certify sports/school physicals for teens until proof of vaccination is provided.

2) Tag-and-track unimmunized folks.  Require them to wear masks while in the clinic for their, and everyone else's, protection.

3) Post the clinic's position on scheduled vaccines publicly.

4) Refuse to accept refusals.  Every visit, every non-immunized patient will be offered an opportunity to get all appropriate yet unadministered vaccines. Patients may only stop such questions by getting the relevant immunizations or terminating care.

... You get the picture.  If you've got plenty of business and can afford to lose customers (they're not patients if they're not following your treatment regimens...) then you have a lot more flexibility to intentionally alienate patients and "brightsize" your panel by removing those simply not on the same page.

(Of course, there are plenty of other things, like smoking and DM II care, where there are plenty of opportunities to deal with patient non-compliance, but I never treat a failure of willpower the same as a willful failure to engage with good medical advice)

 

completely unethical, intolerant, rude, and unlawful.

[rev ronin]

6 minutes ago, JMPA said:

completely unethical, intolerant, rude, and unlawful.

No, yes, maybe (depending on how it was done), and really, how?  Seriously, if anything I've proposed is in any way unlawful, I'd love to hear about it before I actually do any of it.

[rev ronin]

10 minutes ago, JMPA said:

completely unethical, [...]

So, let'd do a deep dive on this one:  Which cardinal medical ethical principle do you think I'm violating?

Beneficence?  Nonmaleficence?  Those are complete non-starters as long as I'm not trying to force people with medical contraindications to get the shots they're not supposed to. Autonomy? The patient can go anywhere and do anything they want: I just would opt not to participate in it. Justice? Everyone gets treated the same!  Now, if I gave waivers to a bunch of rich, whiny white women, that would definitely be a justice violation.

[lkth487]

3 hours ago, JMPA said:

completely unethical, intolerant, rude, and unlawful.

It is not illegal to refuse a patient if they don't accept vaccinations.  As for dismissing them, usually ethically you have to do your best to make sure they find someone else.  I don't believe it to be unethical to outright refuse a family who won't immunize their children, though it may be a gray line because it's not a child's fault that their parents are like this, and you might be driving them towards someone who will peddle other unscientific nonsense.  But does the pediatrician have an ethical responsibility also to protect the other patients in his or her practice - those who might be too young, or have legitimate reasons that they cannot get immunized (kids with cancer, immunodeficiencies, etc)?

[sas5814]

[CAdamsPAC]

I'd like to know,how many of the anti-vaxxers have their pets vaccinated?

[TheFatMan]

39 minutes ago, CAdamsPAC said:

I'd like to know,how many of the anti-vaxxers have their pets vaccinated?

Some actually believe their pets have autism from vaccinations.

[CAAdmission]

On 12/16/2018 at 11:20 AM, JMPA said:

completely unethical, intolerant, rude, and unlawful.

I'm not sure that's the case. If someone wants to willfully do stupid things that will potentially complicate their life, complicate your practice, lead to bad outcomes and drive up healthcare costs, I'm not sure a clinician is obliged to go along for the ride. As providers we enter into a contract with our patients regarding their care. Either party can violate that contract. Why go to a healthcare provider if you are going to ignore their advice? You obviously don't trust their judgement.

I told my accountant that I was embezzling money from my job and that I had under-reported my income to the IRS for the last 10 years. He won't be my accountant anymore.

[mgriffiths]

On 12/16/2018 at 11:20 AM, JMPA said:

completely unethical, intolerant, rude, and unlawful.

Several have replied to this already, but wanted to give another scenario...

What about an uncontrolled diabetic who does not take their medications as directed, never makes lifestyle changes, etc., etc?  Yeah, I know this describes the vast majority of diabetics, but I am not required to continue with that patient, especially as it is obvious I am not able to "reach" them.  They don't trust me, therefore it is more likely they will have a better response to someone else's advice that hopefully will help them make some changes to improve the control of their chronic disease.  Discharging a patient does not have to be (and should not be) vindictive.  It's about pushing the patient to find a provider they ARE willing to work with and take advice from.  Just substitute vaccines into the previous paragraph, or whatever condition/medical decision you would like.

This all is especially true when our billing (think INCOME) starts being linked to our "success" with controlling HTN, A1Cs, etc., etc.

[AlexPM]

How you handle "Anti-Vaxxers" also depends on the type of practice you are associated with.

In corporate  medicine you have to follow corporate rules,  If you own your own practice you do what you think will get people to listen.

Being politically correct may be necessary at times but other times you need to be brutally blunt for things this important.

 

http://www.fischerfamilymedicine.com/  see  "our view on vaccinations" on top of page 

[lkth487]

3 hours ago, mgriffiths said:

Several have replied to this already, but wanted to give another scenario...

What about an uncontrolled diabetic who does not take their medications as directed, never makes lifestyle changes, etc., etc?  Yeah, I know this describes the vast majority of diabetics, but I am not required to continue with that patient, especially as it is obvious I am not able to "reach" them.  They don't trust me, therefore it is more likely they will have a better response to someone else's advice that hopefully will help them make some changes to improve the control of their chronic disease.  Discharging a patient does not have to be (and should not be) vindictive.  It's about pushing the patient to find a provider they ARE willing to work with and take advice from.  Just substitute vaccines into the previous paragraph, or whatever condition/medical decision you would like.

This all is especially true when our billing (think INCOME) starts being linked to our "success" with controlling HTN, A1Cs, etc., etc.

All of that, plus an uncontrolled diabetic is not a threat to the other patients in the waiting area.

[mgriffiths]

53 minutes ago, lkth487 said:

All of that, plus an uncontrolled diabetic is not a threat to the other patients in the waiting area.

Good point.

[jmj11]

Knowing human nature, the Anti-vaxing movement will not go away until tragedy strikes. When a belief system is based upon an emotional belief system, reason and science do not matter. They will always dismiss it as the "The Great Western Medicine Conspiracy." But when disaster hits home, anti-vaxer looses a child, then they will "repent."

I had a patient who her and her husband ran a health food and supplement store in Seattle. They were totally against western medicine. Then her 28 year old husband came down with AML leukemia. They were expecting to live to 100 because they only ate organic, etc. He died before turning 30. They both totally reversed their view of Western Medicine and she snickers when someone suggest taking a supplement for some magic health benefit.