Article: Pediatricians discharging unvaccinated children

[Wayward son]

Article in The Star.

 

A lot of vaccine-autism comments in the comments section.

 

What do people think about pediatricians ending the relationship of patients who they feel have unreasonable, conspiracy-minded parents?

[ellorie]

I feel like this topic has come up a bunch of times before.

 

Personally I think that if there is nobody else able to assume care of the patient - absurd wait times, rural area - then the physician cannot discharge the patient. I think that's pretty commonly acknowledged.

 

As to the other, I am only a first year medical student, so perhaps my views will change a LOT when I am in practice/a clerk/a resident, but personally I like to think that I would keep the family on and continue to tell them my beliefs while also listening to theirs and acknowledging the feeling content.

 

I would hope that eventually, we could build a trusting relationship where they would feel comfortable changing their minds. And someone has to care for them, as much as possible. I would rather have them with me than running off to a naturopath (though they might do that anyway).

 

That said it also depends on the physician. If you are that uncomfortable with a patient to the point where you feel you cannot provide good care, you have an ethical responsibility to transfer them to someone who can.

[Mourning Cloak]

What do people think about pediatricians ending the relationship of patients who they feel have unreasonable, conspiracy-minded parents?

 

If getting hard-nosed about this prevented even one child in my practice (or maybe the classmate of my patient or maybe just some kid in the waiting room) from suffering permanent sequelae or dying, I'd consider it worthwhile.

[boodog]

A lot of these patients who do not believe in vaccines become very tiring on students, residents, and physicians alike.

 

Personally, I don't agree with discharging patients solely on this ground, as one is still able to provide excellent care to sick patients regardless of whether they are vaccinated.

 

However, I can see why pediatricians discharge patients who don't believe in vaccines because it does jade their opinions of such parents and compromises care.

 

Since a lot of them who refuse vaccines don't even need a pediatrician, I can completely understand the sentiment of these Ontario physicians.

[seeking1]

What do people think about pediatricians ending the relationship of patients who they feel have unreasonable, conspiracy-minded parents?

 

The parents have foolishly made their child into a potential vector for communicable illness(es). Even among children who are vaccinated, a number of them will receive no benefit from the vaccine. These children are at threat of being made ill by unvaccinated children.

 

Herd immunity is the only protective strategy, especially in a time when our antibiotics are increasingly becoming useless due to antibiotic-resistant bacteria.

[thebouque]

Why not make vaccination compulsory then?

[aaronjw]

Why not make vaccination compulsory then?

 

Because that begins to sound a lot like China, Germany, USSR, etc

[PAstudent]

I am on FM right now and almost daily I get some mom telling me she won't vaccinate her baby because it causes autism/MS/CF/Asthma/something else. These are usually the same moms that bring their baby in at least one or two times a week c/o every little thing you can possibly imagine. I often try to take this as an opportunity for patient education and find that the majority of moms honestly want to hear what I have to tell them and most of them change their minds and end-up getting their children vaccinated.

 

My understanding is that the situations in which this pediatrician (and others) will actually d/c a pt from their practice is when the aforementioned approach has failed repeatedly and you essentially have a parent who is refusing to allow you to properly manage your patient. Is this an ideal solution? Of course not! But I completely understand why it is being done and I hope that by taking this hard stance more of these children will end-up being vaccinated. That said, I believe that people should have a right not to be vaccinated and that parents should have a right not to have their children vaccinated even if it is bad for society as a whole (i.e. reducing herd immunity). Should we be educating and convincing? Yes. Should we be passing laws of mandatory vaccination? No. I'm all about personal freedoms.

[tooty]

If I were in family or peds, I would 100% discharge children whose parents refuse to vaccinate.

 

If they're not going to listen to my medical advice, they're wasting my time.

 

Just for entertainment, here are some idiotic comments to that article:

 

I listen to Mothers of Autism, not Science

 

Mothers of children with Autism who have said " my child was one way before vaccine , and no longer the same after vaccine." That is who I listen to. Science has not convinced me to vaccinate my child.They do not give full disclosure, all is shrouded in lies. I am not convinced.

 

I have 1 vaccinated child and 1 soon to be 2 unvaccinated children, I am NOT uneducated or ignorant or in denial. I am NOT a conspiracy theorist. I DO have a sister who at the current age of 22 has the mental capacity of an 18 month old and it was...get this...PROVEN to be as a result of the PERTUSSIS vaccination. Doctors should not have the right to refuse care based on a decision that is solely the decision of the parent!

[pheochromocytoma]

If I were in family or peds, I would 100% discharge children whose parents refuse to vaccinate.

 

If they're not going to listen to my medical advice, they're wasting my time.

 

Just for entertainment, here are some idiotic comments to that article:

 

Teeheehee thasss furny! Although I agree that science is shrouded in lies, scientists spend all this time coming up with things that save millions of lives and yet they don't admit that they are giving people autism after three uneducated parents have told them that it does!! Gollygee those bunch of vipers!

[aaronjw]

You can't just abandon a kid because they have stupid parents.

 

True, we should be able to eradicate stupid parents lol

[tooty]

You can't just abandon a kid because they have stupid parents.

 

I feel bad for the kid, but there would be too many people on my waitlist for me to ignore.

 

You can argue that treating obese diabetic hypertensive smokers is the same thing. I guess I'm just more sensitive to them.

[thebouque]

Because that begins to sound a lot like China, Germany, USSR, etc

 

If the risk of not vaccinating a child is worth refusing patients then I think it should be made compulsory, just like the treatment of TB. In an emergency situation you do transfuse a child against his parents' will. In a non emergency situation you do get a court order to give chemo to a child. So why not make vaccination compulsory then? Why would you be allowed to get a court order for chemo but not for vaccination? Maybe it's because after all, the risk of not being vaccinated simply isn't worth it. If, you accept that personal liberty > this risk, then pediatricians who refuse patients because they didn't get vaccinated are discriminating and their refusal is absolutely illegal and unacceptable.

[thebouque]

If I were in family or peds, I would 100% discharge children whose parents refuse to vaccinate.

 

If they're not going to listen to my medical advice, they're wasting my time.

 

Just for entertainment, here are some idiotic comments to that article:

 

Great, you've been taught a paternalistic approach to medicine in med school or is it just you? Patient centered care goes down the drain eh

[thebouque]

 

To thebouque: if we force kids to be vaccinated to protect us all from harmful communicable diseases, we should also force people to go to the gym, force the obese to stop eating and have lap bands put in, force smokers to stop and alcoholics into abstinence etc. since not doing this has shown to be deleterious to the health care budget and to population health in general, and by using up the budget on this crap we extend wait times which leads to poorer care, missed diagnoses and improper untimely management.

 

Not to mention forced vaccination would be as paternalistic as anything could get.

 

I totally agree, and my message was ambiguous but I'm against forced vaccination. I was saying that if those physicians think that refusing a child is worth it then they might as well advocate for forced vaccination (since you can get a court order for several other treatments it wouldn't be something new).

[tooty]

I totally agree, and my message was ambiguous but I'm against forced vaccination. I was saying that if those physicians think that refusing a child is worth it then they might as well advocate for forced vaccination.

 

i do

[pheochromocytoma]

At the end of the day I do not believe I would end a doctor-patient relationship because they didn't follow my orders... That sounds like a hissy fit. The doctors job is to make sure that the patients (ad/or their guardian) are properly informed of the benefits an risks of a treatment, and then provide said treatment (assuming the tx they choose is reasonable for their condition (Ie. No beta-blockers to a 22yo with rhinitis bc he heard it helps)). If I have made clear the potential benefits and risks of the treatment I believe pt should take and they choose not to do it, the patient is the one who gets to decide what those benefits and risks really mean to their quality of life. I am not going to end my relationship with them because I disagree with their choice, I am going to continue to provide the best information that I can, and educate them on other ways to modify and improve their situation/outcomes. Wrt vaccines same story, and hope herd immunity is strong enough and universal precautions do the trick in protecting these chillldren nomsayin? I completely agree that children should have vaccines but am I going to stop seeing them if they don't get them? Of course not! They may (or may not) need even more of my help in this situation.

[ellorie]

To me the most reasonable argument is that it is a danger to your other patients. I mean, I totally agree that the doctor's job is to respect their patients' autonomy - but if having that one kid in my practice will endanger my other patients with actual medical contraindications for vaccination - well I can see why physicians don't want to put up with that.

 

Personally I don't think I would discharge them, but the above is one argument for it that I do respect.

[Wayward son]

Nonetheless, I would say to tooty that one would have more justifiable grounds in not accepting to take on hypertensive obese diabetic smokers, since they had made chronic lifestyle choices well known to be deleterious to their health. Kids, on the other hand, have no autonomy and should not be punished for their parents' stupid behavior. This is said, of course, with the caveat that I believe patient abandonment is not a good option and we as physicians should not do it.

 

This would be true depending on the reasons for the physician discharging the patient. In the case of the article the pediatricians were saying they would eventually have to discharge the patient because the philosophy or world view of the patient's family when it comes to medicine is completely at odds with that of modern medicine and the way the physician practices. Therefore the family should (and in most places can) find a practicioner who is more in line with the family's views.

 

In the case of the hypertensive, obese, diabetic smokers they have a high probability of agreeing with the physicians advice and philosophy, but have a hard time putting the recomended lifestyle changes into practices. It is a lack of willpower and something that can be worked on over time. Sure it probably won't succeed, but at least you are on the same page that such measures would improve their health. I would continue to work with those patients.

 

In the case of anti-vaxers, it is not the same. What you understand is good for personal health and public health, they understand as evil. In most cases the more you push the more steadfast they become in their beliefs. I am not talking about the mother who has heard something from someone about vaccines and is understandably worried, I am talking about the parents who through an intense google training regime have a pile of facts (all wrong, out of context, or irrelevant) at their disposal along with an iron will to dismiss science outright, and who scoff at anyone who counters anything they believe as one of the "pro-pharma" shills or sheeple. Education has a good chance of working for the former, but not the latter.

 

However, whether I would discharge such patients would depend on the likelihood of transmission of a vaccine preventable disease to another patient of mine. If I was a pediatrician the possibility of a child too young to be vaccinated contracting whooping cough in my office from the unvaccinated child of irresponsible parents would weigh heavily on my mind. In Australia Dana McCaffery was 4 weeks old when she died of whooping cough. Her parents and two older siblings were fully vaccinated. I am not sure why I should place those patients at risk.

[A-Stark]

I think this is really more of an issue of some physicians simply discharging some particularly "difficult" or - let's face it, noncompliant - parents, who are refusing to follow their advice. I don't think this remotely applies to children with actual health problems, but rather the usual routine well-baby/well-child checks that a pediatrician might undertake. If these parents are refusing immunizations, they probably aren't getting much more out of such routine visits. I find The Star's fixation on this issue typical of media hyperbole - take a limited, very specific situation and blow it up as if it's a great trend to provide some "controversy" and to allow for the writing of a smug, self-satisfied editorial. I think, at a certain point, all physicians need media training to avoid getting sucked into such quagmires, and I don't think the pediatricians quoted in the article were especially savvy about this at all.

[aaronjw]

Paternalism has its place in medicine. Read Atul Gawande's Complications for a poignant example of when paternalism was the correct option.

 

 

Just to poimt out, it's s fantastic book. Hugely enjoyed.

[lostintime]

This would be true depending on the reasons for the physician discharging the patient. In the case of the article the pediatricians were saying they would eventually have to discharge the patient because the philosophy or world view of the patient's family when it comes to medicine is completely at odds with that of modern medicine and the way the physician practices. Therefore the family should (and in most places can) find a practicioner who is more in line with the family's views.

 

In the case of the hypertensive, obese, diabetic smokers they have a high probability of agreeing with the physicians advice and philosophy, but have a hard time putting the recomended lifestyle changes into practices. It is a lack of willpower and something that can be worked on over time. Sure it probably won't succeed, but at least you are on the same page that such measures would improve their health. I would continue to work with those patients.

 

In the case of anti-vaxers, it is not the same. What you understand is good for personal health and public health, they understand as evil. In most cases the more you push the more steadfast they become in their beliefs. I am not talking about the mother who has heard something from someone about vaccines and is understandably worried, I am talking about the parents who through an intense google training regime have a pile of facts (all wrong, out of context, or irrelevant) at their disposal along with an iron will to dismiss science outright, and who scoff at anyone who counters anything they believe as one of the "pro-pharma" shills or sheeple. Education has a good chance of working for the former, but not the latter.

 

However, whether I would discharge such patients would depend on the likelihood of transmission of a vaccine preventable disease to another patient of mine. If I was a pediatrician the possibility of a child too young to be vaccinated contracting whooping cough in my office from the unvaccinated child of irresponsible parents would weigh heavily on my mind. In Australia Dana McCaffery was 4 weeks old when she died of whooping cough. Her parents and two older siblings were fully vaccinated. I am not sure why I should place those patients at risk.

 

Great points, but I guess the issue is that you can't exactly remove this family or kid away from the public and if they don't infect some kid in your waiting room, they'll infect some other baby they sat beside in a bus stop. If they stay with you, they MAY one day vaccinate their kids, i they go away, they're unlikely to ever get vaccinated.

[Wayward son]

Great points, but I guess the issue is that you can't exactly remove this family or kid away from the public and if they don't infect some kid in your waiting room, they'll infect some other baby they sat beside in a bus stop. If they stay with you, they MAY one day vaccinate their kids, i they go away, they're unlikely to ever get vaccinated.

 

I agree with these points completely. I was actually going to write about the possible consequences of letting the patient go and weighing my responsibilities to my other patients vs society as a whole. It is a complex issue and one that I continue to wrestle with.

 

A friend and former co-worker of mine is an anti-vaxer who would under no circumstances allow her children to ever receive any vaccinations. She is smart, very well educated and has spent 15 years working in health care. She is among a group of about 25 sets of parents who home school their children together and are heavily into alternative medicine (and almost every other anti-establishment view, many conspiracy theories etc). The more they isolate themselves (and are isolated by others) from mainstream society the more their world view is solidified. It is internally consistent, but not externally consistent.

 

A parent who has heard that vaccines cause autism from Jenny McCarthy or a friend can be educated in many cases as it only requires the alteration of one view. But a deeply embedded anti-vaxer has likely built up a whole world view that leaves them not only very distrustful of anything that could be construed as mainstream or establishment (and any evidence that goes against your view can be construed as that), but also very trusting of anything that counters the mainstream or establishment (along with tremendous sympathy towards those brave fighters against the establishment).

 

At least that is my own anecdotal view for the major reason why their minds can almost never be changed, as changing their mind about vaccinations also requires major worldview changes, so it is much easier to dismiss any evidence against their position as obviously faulty, paid for by big pharma etc. I used to be a fairly vocal anti-vaxer myself (along with holding most of the same views as my friend above) up until 2006. The change to a strong vaccine proponent was preceded by and followed by fundamental changes in the way I thought about many things like science, skepticism, critical thinking, authority, ethics, politics, and so on.

[North12]

Unfortunately until scientists figure out more about Autism and its true causes we will continue to have the problem of unvaccinated children.

 

Sigh. There is no right answer to how to approach this dilemma.

[HycrestJIT]

It would be interesting to see if these same parents who refuse to vaccinate their children would continue to hold to this stance in the case of congenital asplenia or subsequent to a splenectomy.