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You're a physician. Act like it.

A local pediatrician wrote a blog entry this past week where he referred to those that question if our current vaccine schedule is safe for all children as "yapping dogs urinating on the tree of immunization."

Yes, you read that correctly. A physician referred to patients as urinating yapping dogs.

How have we arrived at a place where it is publicly acceptable for physicians to act in this manner? He is not the first physician to have written in such an unprofessional manner on this subject and he is unlikely to be the last. It is excused and even applauded. Why? Because vaccines.

I am not going to discuss the safety of vaccines here, only the manner in which we debate it. Specifically, the way physicians discuss and write about the topic.

Our treatment of the topic begins-where else?- Facebook.

I’ll admit I spend a good amount of time on Facebook. I like to see what political/social justice type things my friends from college are up to. I like to post pictures of my kids for distant friends to see. Sometimes I’ll take one of those quizzes: Which Golden Girl are you? (I got Rose, in case you’re wondering. I was really hoping for Dorothy but I guess I haven’t matured to her level of sass and pith quite yet).

One thing that dominates my feed are posts from my fellow doctors and nurses bashing parents who don’t vaccinate their kids. And yes, I mean bashing. I don’t mean expressing concern for their children. I don’t mean seeking to find ways to turn the tide of increasing numbers of people not vaccinating their kids. I mean, bitching about them and how they’re screwing up herd immunity for the rest of us because they are bad people who ignore science.

I have issues with this.

Ironically, these people of science are not being scientific at all. The whole argument is that these crazed non-vaccinators are ignoring science. They’re irrational. They’re backwards (some even compare them to the Taliban). They’re stupid. They’re ignorant. The problem with this argument is that the accusers here are ignoring the fact that they themselves are not being scientific in the way they engage. Let’s look at the facts:

-By and large, non-vaccinating parents are highly educated with average to above average intelligence. That’s what the research shows us. Most of them have read everything their doctors have read and come to the decision that it’s not compelling evidence to them for one reason or another. So, calling them stupid or irrational simply isn’t accurate.

-Most parents who do not initially vaccinate will vaccinate their children within a few years. The vast majority of patients questioning vaccination cite their doctor as their most trusted source of information. But here’s the rub: the research shows that if their doctor comes at them with the attitude most doctors hold, these parents actually become *more* likely to not vaccinate. What has been shown to work, scientifically, is for physicians to engage in respectful, open minded dialogue with them and not engage in scare tactics or intimidation.

We have an obligation as physicians to pediatric patients of these parents and also to the greater community and society. Those physicians who feel universal vaccination is vital for the health of children thus have an obligation to work to convince non-vaccinating parents of our pediatric patients to change their mind. We’re tossing aside evidence based medicine and compromising our service to our patients and society with our attitudes towards these parents.

Why? Basically because this topic makes most doctors really really mad. And we allow really really mad to get in the way of our obligation to these kids. We find it emotionally comfortable to get angry and make it into a moral failing in these parents. Some of it is righteous anger in defense of community health. Some of it is control issues. We don’t like it when patients don’t do what we say. We got into medicine to help people and now they’re not letting us help them. Maybe it makes us sad to see them hurting themselves. Maybe it angers us off they’re messing up our plan. We are the doctors after all.

I was discussing a law recently with some fellow physicians that I read about going into effect in a southern state. They were starting to arrest mothers who did illegal drugs while pregnant once the babies were born. Two of us thought it was a terrible law because addiction is a disease and criminalizing it really wasn’t the answer. Putting a baby’s mother in jail soon after birth is very obviously not good for a baby. Knowing she’ll go to jail if she delivers her addicted baby in the hospital will inevitably lead to some of these mothers delivering their babies at home and not getting proper medical care. They’re certainly going to be more likely to lie to their physicians about what drugs they’ve been doing. The physician in favor of the law was adament that these women must be punished. They’ve harmed their child and they must be punished. The fact that this law was only going to hurt these babies further was not the issue here. Addiction was not a disease, it was a moral failing. For the sin of harming their baby, we would have to harm their baby further. Makes sense, right?

The truth of it is, it is simply easier and more satisfying to write these non-vaccinating parents off as kooks and lost causes. But if you truly believe not vaccinating their children (your patient) puts them at risk, you have a moral obligation to not write them off as a lost cause. You are that child’s advocate. You are a physician practicing evidence based medicine. So act like it.

Parents who are simply questioning vaccinating may or may not know much about it. So, gauge how much they know and offer them education in a respectful way. Talk when appropriate and listen when appropriate. Don’t engage in scare tactics. Show them some compassion. This will maximize the chances they will vaccinate today or soon thereafter. In case we’re not clear on this: making them sign a release recognizing they’re placing their child’s life at risk by not vaccinating is not productive in this regard.

Some parents are at the point where they are refusing to vaccinate and have probably read up on a lot of what you have to tell them about vaccine safety and efficacy. If you can tell they’re already familiar with the information you have to offer, it’s time for you to sit and listen (you can do this, docs, I swear. You really can). Ask them why they don’t want to vaccinate and listen respectfully and compassionately. If they’re open to your responding, then go ahead and respond. If they’re not, then thank them for sharing with you and let them know you truly believe vaccination is the best thing for their child and that you hope the dialogue can be kept open at future visits.

If the above approach chafes your chaps, if it seems just plain wrong, that’s a perfectly valid feeling you’re having; but it certainly isn’t scientific.

Instead of reading self-congratulatory after self-congratulatory article on how awful these non-vaccinators are, you’d be better served to read up on why parents make that choice. Better yet, try talking to a few of them. As a mom of a child with autism, I can tell you there are plenty of parents in that community who would be more than willing to talk to you about it. Step back from the moralistic thinking and consider all the psychological and social reasons parents might have to make this socially unpopular choice. What life experiences have they had that have led them down this path?

One thing I always tried to stress to my interns in residency was that there’s a place for book knowledge but most of what you need to know about being a good doctor comes from experience. Your experience as you go along and learning from the experiences of the doctors teaching you who’ve been at it so much longer than you. If you’ve seen a child suffering from a vaccine preventable disease, you’re most likely eager to share that with your patients. But, you’re better off trying to find out about your patient's experiences affecting their decision. Scientifically speaking.

One common misconception among the American public that upsets physicians is the idea that vaccines cause autism. How can so many people believe this still?! It’s been scientifically disproven! Heck, it’s even been anecdotally disproven in the case of thimerosol. Let’s get rid of the exclamation points and ask that question for real. Why is it that people still believe all vaccines or MMR or vaccines containing thimerosol cause autism? Is it all due to that villain Dr. Wakefield who published that now discredited study in the Lancet? Has he mesmerized these foolish parents? Or could there be a more logical explanation. Perhaps one explained by medicine?

Let’s set aside the vaccine facts for a minute here and consider some facts that are at the core of every family’s life who has a child on the autism spectrum:

1. Doctors do not know what causes autism 2. They’re pretty sure it’s a genetic predisposition that gets triggered but they don’t know what’s triggering it 3. But they’re pretty sure it must be multiple things because they can’t really find any one thing these kids have in common 4. Doctors have no cure for autism 5. You don’t even have a very good treatment for it 6. Most PCP’s don’t know nearly as much about autism as an informed parent. As PCP’s, we’re generalists and it’s not something stressed in med school. It's barely covered at all. 7. The rate of autism keeps climbing and the truth of it is, you don't know why

Can you honestly tell me a parent in this situation would be irrational to question things that are dogma to modern medicine such as vaccines? Modern medicine has failed them. What they need from you is not a lecture or an anecdote of what can happen to unvaccinated kids. Assurance of the rarity of adverse events from vaccines (and yes, there are rare but quite serious effects at times) will not comfort them. They need their trust in medicine restored. And that begins with you, the PCP.

I say begins because it is a process that can’t be rushed. You have to sit with them, sit with the uncertainty and anger and helplessness that comes with special needs parenting. You need to show them their child is your patient who you care about. That you see the challenges and the joys of their life. To show them that this isn’t about a battle for control. That you want what’s best for their child. And that you’re open to learning from them. That it really is a dialogue and not a lecture.

Only 1% of parents in Pennsylvania choose not to vaccinate their child, but the lessons we can learn from this issue will make us better doctors in a lot of ways. And better people for that matter.

Listen. Empathize. Validate. Assert. Repeat.

I often tell my kids: it’s okay to get angry. It’s not bad to feel angry. But when we get angry, we have to make good choices of what to do with that anger. I think we could all stand to hear that on a regular basis. So, my fellow physicians: it’s okay to get angry about vaccination. It’s not bad to feel angry. But you need to make good choices.

You’re a physician practicing evidence based medicine. So act like it.

You're not a dog, Dr.Donnelly.

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