I asked a group of 33 pediatricians what they would say to the question, “Do you believe in vaccines?” while standing in line for coffee. I asked for their help in thinking about an effective, 2 minute answer.
This is part 2 in a series. For detailed information behind the why, read part I (emotional responses) or watch the video explaining how this came to be. As I said, I’m not a believer in scripts. I’m not attempting to suggest there is one, 2 minute segment for every family that will help. Part of the reason I started this blog was that in practice, I realized when I told families what I knew and learned in training, they listened. When I told them what I did for my own children and how I felt, they made decisions. Telling my story seemed essential.
(This is going to sound familiar) I don’t want to increase the divide between those parents who are worried or skeptical of the possible harms of immunization, and those parents, doctors, and experts and who believe in the benefits. Rather, I want to regain our similarities.
Today I’ve included responses from pediatricians that mentioned things that I experienced as “evidenced.” But rather than talk to you about numbers, causality, rates of autism, and the absence of thimerisol in all childhood vaccines (except multi-dose flu shots), these comments focus on the evidence that helps physicians discuss immunizations with families. There was a paucity of numbers in the responses from these physicians.
I’d say how much I wished pediatricians were better ‘rock stars’ with our message of prevention so we could be more effective in the media limelight. I’d speak my own willingness to touch the hearts of the families I care for, to carry the bag of fear and worry for them, perhaps lessening their load a bit.
If you’re interested in reading studies about autism and vaccines, the safety of thimerisol, or neurologic outcomes after immunizations, look at “Examine the Evidence.” I often discuss the last study in this list with families. Lots and lots of evidence. But in my experience in the office, data is ultimately not very helpful for families who are fearful of vaccines. As Dr Arlo Miller suggested in comment #34 to Part I, stating how we feel may be much more valuable than stating what we learned in school.
Dr Ellen Lipstein, a general academic pediatrician at Cincinnati Children’s:
For me, and I hope for my patients, vaccines aren’t about beliefs, but about evidence. In all the decisions we make for the people we love we have to balance the evidence of risks with the evidence of benefits. For me there is no doubt that vaccines are highly beneficial for the person that receives them, their family members and the general community. They are not without risks, but the risks are very small, compared to the risks of not vaccinating.
I concur with the “motivational interviewing” approach for patient counseling. It is NOT one-size-fits-all persuasive discussions. Rather, it moves the patient/family to positive behavior change through a partnership. One of many recent reviews can be found in Archives of Pediatrics
Dr Ellen Lipstein again,
In working with families who are vaccine hesitant, I think a valuable option would be to take a page from the shared decision making literature. Specifically we need better resources that visually depict risks. Traditionally (perhaps not surprisingly, nearly all this work is in adult medicine) tools that help individuals determine their values and risk preferences have been limited to situations where there is nearly absolute clinical equipoise, two equally good (or bad) medical options. Think prostate and breast cancer screening and treatment. However, we know that individuals struggle with decisions that the medical community thinks are relatively straight-forward and not situations of equipoise. Taking the lessons from these other settings may help us design resources that facilitate parent understanding, clinical discussions and choices that everyone can live with.
Dr Doug Opel, a bioethicist and pediatrician:
Given that parents consistently report that their child’s provider is the most important influence in their immunization decision-making, we really should have a good idea of what we should say to parents. For instance, studies of doctor-parent communication since the 1960s have found that parents better adhere to recommended treatments and are more satisfied with their visit if they felt that their concerns were understood. A provider’s interpersonal sensitivity and empathy have also been linked to improved outcomes.
We are currently conducting a study in which we are videotaping well-child visits to do just this. The hope is that by directly observing what providers actually say and how parents respond, and then link these provider communication behaviors over time to the child’s immunization status, we can know which communication techniques are linked with improved immunization. A start, I suppose.
Dr Denise Shushan, a pediatrician working in the ER:
I do spend some time with some families who are concerned about MMR/autism in particular detailing that the research of Dr. Wakefield has been thoroughly and repeatedly discredited, as well as informing families that his original intent was to discredit the existing MMR vaccine because he was hoping to sell his own version of the MMR. Most parents are quite receptive and surprised – I think it reminds those people who are intent on believing the “Big Pharma is fooling everyone just to make billions hawking their dangerous vaccines” meme that the supposed saint whose research linked autism and MMR vaccination was motivated by something far less altruistic than they might otherwise believe.
The percentage of cautious parents have risen and fallen depending on the news cycle. I would say the peak numbers were around 2008 with the Hannah Poling [case]. And, 2009 and 2010 with Omnibus proceedings and Wakefield’s starring role in his own Greek tragedy… has made the percentage of cautious parents drop quite a bit.
So, what do you say to the cautious parents? Much of it is not talking, but listening. Studies have shown in low concern settings, people look to the experts for advice. In high concern settings, people look to the empathetic listener, not the expert.
Dr Doug Diekema, a bioethicist and emergency room pediatrician:
First, I make people aware that they may be putting other children at risk by not vaccinating their own children—that almost every school has someone who has cancer or an immune deficiency and who would be placed at risk if they came in contact with an unvaccinated child who had pertussis or measles or chicken pox.
Second, I think we can recognize parent’s concerns about vaccines and share our own concerns about children who are unvaccinated. In the past 6 months, pertussis has killed two infants in Washington State and more than 10 in California. Those are real children killed by a real disease that can be prevented by vaccines. In just two states, 12 deaths in 6 months. Even the wildest scare tactics of the anti-vaccine crowd can’t match that in terms of devastation.
Dr Kronman, a pediatrician and infectious disease fellow:
Some people cannot be immunized, and immunizing your child will protect them, too. At times children are too young to receive vaccines, and others who have cancer or other immunocompromising conditions cannot be vaccinated. Vaccinating your child will protect her, but it will also protect your aging father on chemo. It is good for your child AND for society.
Life expectancy has risen over the last century by 20 years or more, and much of that is due to NOT CATCHING AND DYING FROM DISEASES PREVENTABLE BY VACCINES.
One study in Pediatrics in 2006 categorized parents into 4 groups. Believers, relaxed, cautious, and unconvinced. The “cautious” group is the key group that we should focus our attention to. Believers and relaxed parents believe in vaccinations and they believe in their health care provider to head them in the right direction… Unconvinced parents will never change their minds about vaccinations no matter how much time and effort you spend talking and educating them.
Do I believe in vaccines? Absolutely. Are they completely risk free? No, but in reality nothing is really risk free. It essentially all comes down to the risk versus benefit ratio. The benefit of vaccines far outweighs any rare or perhaps theoretical risk associated with them. After all, [parents] only want to do what is right by their children and to not cause harm.
Dr Ed Marcuse, a pediatrician and Professor of Pediatrics:
I know full well that while science does not have all the answers, it is the best way to get reliable information. But I know there is good and bad science and can be hard to sort out.
Diseases like whooping cough, mumps and measles are again starting to rear their heads causing children to suffer and die. And although vaccines, like all medicines, can cause side effects, the ones you hear about (like autism, allergies, learning disorders, multiple sclerosis, diabetes among others) aren’t caused by vaccines. So the risks that most people fear aren’t real risks.
Dr Marcuse concludes by saying:
I refer [parents] to unbiased sources of good science-based information. At the top of my list is NNii because I can say it accepts no funds from vaccine manufacturers or the government and its only mission is to provide sound information to help parents make well informed choices.
That’s some evidence.
5 Places to go if you’re looking for more:
- www.healthychildren.org : The AAP website designed for parents. It’s easy to read, has great information and backed by a force of 60,000 pediatricians making up the AAP.
- www.ecbt.org Foundation to help families understand the need for timely (up to date) immunizations. There are videos and resources on getting your child’s shots if you can’t pay for them.
- www.vaccine.chop.edu : Great resource for scientific information about shots.
- Examine the Evidence