Helping families make decisions about their child’s health takes training, expertise, and experience. The training is standardized (medical school, residency, fellowship), and the expertise confirmed by passing board examinations and maintaining yearly CME (continuing med education). But the experience piece is ultimately unique for each physician. With each day in clinical care, patients teach, instruct, and shape how we understand wellness and illness. Through individual experiences with patients, physicians ultimately become who they are in the exam room. In medicine, despite the huge push to standardization everything from centralized phone calls to how much (or little) time we get with patients, individual doctors will fortunately remain unique. As patients, we still get to enjoy our physicians as people helping us through illness and injury.

This week has been intense. Wednesday, I spent the morning as a patient in the care of my incredible doctor. (I’m fine). She’s entirely instructive for me as a patient and as a physician; her bedside manner astounds. I believe she’s just very good at her job, partly because she’s uniquely experienced. I believe her experience being a nurse for many years before becoming a doctor really colors how she provides care–she gets it.

The week has also been intense because of this series. I’ve been thinking about immunizations, reading comments here on the blog, writing, and witnessing my patients’ responses. I’ve received many e-mails. Yesterday, I was at clinic for over 10 hours and like most days, immunizations were a huge part of my day. But I said things I’ve never said before…True synergy between my clinical self (doctor) and my writer self (Mama Doc), this experience is shaping who I am, in and out of the exam room.

Of course, experiences in clinical care (and living on planet earth) shapes how all pediatricians discuss and listen to families when discussing immunizations. Here’s the final segment in my series on asking pediatricians if they “believe” in vaccines. The 20 or so pediatricians who responded, talked about their experiences in representing vaccines. Additional comments are included in part 1 (emotion) and part 2 (evidence).

Experience:

Dr Kronman, a pediatrician and infectious disease fellow:

We don’t see these diseases anymore. I work at a premier tertiary/quarternary care facility for children. I have seen children die of influenza (seasonal, H1N1), pneumococcus, meningococcus, the late sequelae of measles, pertussis; I have seen Hib meningitis, tetanus, severe debilitating outcomes with varicella, cervical cancer caused by HPV, and severe rotavirus. This list goes on. But most people haven’t seen these things anymore. People don’t have to panic about their children in the summer becoming permanently paralyzed from polio, because we don’t see it anymore. And the reason? Vaccines.

Dr Natasha Burgert, a general pediatrician in Missouri said

In other parts of the world where I have briefly practiced medicine, I have seen the faces of grieving families whose children have died from vaccine preventable diseases.  Those families did not have the equal opportunity that you have for your family.

Dr Natalie Vogel, a general pediatrician:

With patients in clinic, and when thinking about immunizations, I come back to thinking about how hesitancy is about a person’s personal perception of risk. Understanding risk is so complicated and personal! It pits fact and epidemiology (“science”) right up against emotion. My sense of risk is very different from the next person’s. Addressing that sense is crucial in a discussion of vaccines with a tentative family.

One comment, from Alison Buttenheim, PhD MBA, a researcher working with Dr Flaura Winston furthers what Dr Vogel mentions. Dr Buttenheim discusses her experience and research focused on improving pediatricians’ skill in discussing immunizations:

These clinical interventions are likely to be marginal. We recently completed 23 in-depth interviews with parents in a high-SES [socio-economic-status] urban neighborhood, most of whom I would classify as hesitant but ultimately adherent (lots of requests for spaced schedules). One clear take away from this qualitative research is that parents know what they want to do long before the first well-child visit. Among the more hesitant parents in our sample, the choice of a pediatric practice was based in part in finding a provider who would accommodate an alternative schedule. I think we need to focus our research on parental decision processes outside of the MD office, and how they are shaped by media, peers, etc. Attention to cognitive heuristics and biases (such as how we interpret risk and look for confirming but not disconfirming evidence) should reveal promising opportunities for communications and policy interventions.

Dr Denise Shushan, a pediatrician in Seattle,

When I’m talking about this with parents in the ER, I always begin by acknowledging the profound mistrust that has developed in the community between vaccine-making companies, physicians and families.  I also acknowledge that, while I think that the vast majority of cases of serious events that occur near vaccine administration times are coincidental, there may be a subset of kids in whom the immune reaction generated by vaccine administration stimulates some pre-existing propensity for medical badness (obviously, I don’t say it that way, but my brain is fried after working all night).  In my opinion, our job is to research this issue to try and determine if there is such a subset of kids, and if so, to figure out how to identify those kids We trust most parents on their gut feelings on so many other occasions.  Yet, as a profession, we are quite dismissive (which seems arrogant to families) of parents who describe a deterioration in their child after immunizations.  I don’t think that helps our cause any.

Dr Kronman, a pediatrician and infectious disease fellow:

I HAVE AND WILL CONTINUE TO PROVIDE ALL OF THESE VACCINES FOR MY OWN CHILDREN. I had to go to health center #2 and stand in line for 4 hours last year to get the H1N1 vaccine because [our pediatrician's office] didn’t have it yet. And standing in that line was certainly a risky proposition in south Philly. But it was the right thing to do. Simply put, immunizing your child protects her.

Dr Doug Opel a bioethicist, pediatrician, and father says

I find myself in your scenario a lot…maybe not with complete strangers but certainly with new-parent family members right before an immunization visit who call me for my ‘opinion’ and from neighbors who stop me walking my dog to ask me where I stand on giving my patients and my own kids the H1N1 vaccine. I usually follow some version of ask-tell-ask.  That is, I don’t give them a one-liner “you should do X or do Y” from the get-go.  Instead, I let them talk first: “well, let me first hear how you are thinking this through? What are fears?  What have you read?  What have others told you?” That kind of thing… It’s easier [for parents] because I think it is far more manageable to correct misinformation in 2 minutes than it is to summarize the breadth of the pros and cons of immunizations.

Dr David Hill, a pediatrician in North Carolina wrote,

I’d like to think it helps that I vaccinate my own three children and myself. Sometimes, when I mention this, it does. But sometimes I just get that look that says, “So you drank the Kook Aid, huh?”. What we’re facing with vaccines I fear is but one symptom of a medical reimbursement system everyone knows is crooked. We pay enormous sums for procedures and a pittance for preventive care, so why should anyone think what we do has value? People read every day about psychiatrists who collect huge sums speaking for PHRMA, orthopedists who implant the hardware they’ve invested in rather than what’s been proven best, about laminectomies, meniscal shaving, and arterial stent insertions doctors perform with no evidence whatsoever they work better than placebo. We sold the public hormone replacement therapy, Cox-2 inhibitors, and Baycol. We know what we’re saying can be trusted, but the public often feels they can’t tell.

Dr Hill also said this, which I think I’ve repeated to about 1/2 dozen people since:

I like the quote from the All Things Considered piece on physicians as PHRMA speakers, noting that not only do we teach doctors to think critically in medical school, we teach them that we’ve taught them to think critically. For this reason doctors assume they are impervious to the non-critical-thinking-based persuasion used by drug reps.

Maybe we really need to step back in pediatrics and re-evaluate how we discuss vaccines. Authority and expertise, per se, may not be the right context in which to discuss this. In my practice I talk about the experiences I’ve had with vaccine preventable illness but also the experience of how it feels being a mom when intervening with shots.

Dr Melissa Arca, a general pediatrician says:

Parents, I believe, just want to know that we [as pediatricians] “get it”, we understand where they are coming from. We do, we are parents too and have made these same decisions.

Dr Gayle Smith, a general pediatrician in Richmond, VA

I’m one of those people who remembers infantile paralysis.  That’s what they called polio when I was a young child.  I do believe in vaccines. I remember my great grandmother saying, “Don’t go play over on Shiloh Street because that’s where the little boy died of polio,” and I grew up in Pittsburgh where the initial polio vaccine trials took place.  Mothers in my neighborhood had the opportunity to be a part of history, to vaccinate their child with something that might save a life.  In the beginning, nobody knew for sure that the vaccine would work without unacceptable side effects.  They only knew that too many children died or were left paralyzed by this horrible virus.  My great grandmother, who wasn’t afraid of anything, embodied the visceral fear that this germ could claim the life of her grandchild.  That memory left its indelible mark.

I do believe in using the body’s natural, God-given ability to save itself from disease.  Vaccines give us a way to make immunity without paying the huge price of illness, maybe even death, to get that protection.  Yes, I believe in vaccines, and I am grateful for them…just like my great grandmother

Continuing this discussion about immunizations is essential. What’s your take? What do you want to hear more about? How can I help?