Most Doctors Give In to Requests by Parents to Alter Vaccine Schedules

02vaccine-articleLargeA wide majority of pediatricians and family physicians acquiesce to parents who wish to delay vaccinating their children, even though the doctors feel these decisions put children at risk for measles, whooping cough and other ailments, a new survey has found.

Physicians who reluctantly agreed said they did so to build trust with families and to avoid losing them as patients.

The survey, published Monday in the journal Pediatrics, asked a nationally representative sample of 534 primary care physicians in 2012 how often parents in their practices postponed one or more vaccinations for children younger than age 2.

The Centers for Disease Control and Prevention advises that children be vaccinated for 14 diseases before age 6 on a schedule, which entails roughly 29 shots, sometimes several at once.

Ninety-three percent of doctors reported that in any given month, they had been asked at least once to delay vaccines. A fifth said more than 10 percent of parents in their practices had asked them to delay vaccines.

One-third of doctors said they acquiesced “often” or “always”; another third gave in only “sometimes.”

Such deference is in keeping with today’s doctoring style, which values patients as partners, said Dr. Paul A. Offit, a pediatrician specializing in infectious diseases at the Children’s Hospital of Philadelphia, who was not involved in the study.

“At some level, you’re ceding your expertise, and you want the patient to participate and make the decision,” he said. The downside is that “you have to be willing to stand back and watch them make a bad one.”

Too many doctors compromise on vaccines, instead of mounting a passionate plea, Dr. Offit said.

“It is sad that we are willing to let children walk out of our offices vulnerable to potentially fatal infections,” he said. “There’s a fatigue here, and there’s a kind of learned helplessness.”

Part of the problem is the lack of a proven strategy to guide physicians in counseling parents.

“Unfortunately, we don’t have a solid evidence base in terms of how to communicate to patients about vaccines,” said Saad Omer, an epidemiologist at Emory University. “A lot of approaches are wisdom-based, not evidence-based.”

Dr. Omer said that he did not sanction the use of alternative vaccine schedules, but that he understood why primary care physicians keep treating these patients — just as doctors do not kick smokers out of their practices when they fail to quit.

“Physicians recognize it’s not ideal, but they’re saying, ‘Let’s continue this relationship’ to the family,” he said.

The American Academy of Pediatrics advises doctors to keep skeptics in the fold, lest the doctors lose the opportunity to educate, cajole or persuade them.

Physicians in the survey reported trying various strategies, like telling skeptical parents that they had immunized their own children, or warning them that outbreaks will continue if too few people are fully vaccinated.

A disproportionate amount of time is spent discussing vaccines during doctor visits, the survey also found. For hesitant parents, counseling can take 10 to 14 minutes or longer — more than half of the average 18-minute visit.

Guidance on safe sleep or toilet training is being crowded out, the study authors said. Forty percent of the doctors reported that dealing with changes to vaccine schedules had decreased their job satisfaction.

In late February, Dr. Nivedita More, a pediatrician in Rancho Santa Margarita, Calif., sent letters ending her relationship to parents who refused all vaccinations.

“If they aren’t getting their act together to even start the process, I’ll discharge them within 30 days,” said Dr. More, a board member of the Orange County chapter of the pediatrics academy.

By contrast, her stance on vaccine delays is much more flexible. “I do allow that most times,” she said. “The reason is, ultimately they will get vaccinated.”

Many of those parents are simply hoping to limit the number of shots their children receive at once, she added, and are willing to accept combination vaccines.

But “the people who didn’t want to vaccinate at all — I had a really hard time converting them,” she said. “They are never going to change.”

In the midst of the current measles outbreak, which began nearby at Disney parks, Dr. More said she also felt the need to safeguard vulnerable patients in her waiting room from unvaccinated patients. Infants in particular do not get their first measles-mumps-rubella shot until age 1.

Dr. Allison Kempe, the study’s lead author and a pediatrician at Children’s Hospital Colorado, thinks the time has come to acknowledge that the idea that “vaccine education can be handled in a brief wellness visit is untenable.”

Dr. Omer said doctors should be paid separately for vaccine counseling in cases where a “substantial proportion of time is being spent on vaccines.”

In addition to compensation, Dr. Kempe said, vaccine counseling should begin during a woman’s pregnancy, and pro-vaccine parents — perhaps even celebrities — should star in marketing campaigns to help “reinforce vaccination as a social norm.”

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