Provider dismissal of vaccine-hesitant families

Abstract

Some health care providers have adopted the policy of refusing to accept into their practices families who refuse to vaccinate their children according to the standard vaccine schedule. While the frustration that drives these policies is understandable, the practice of refusing to see these families is misguided. Such a strategy does not benefit the child or the health of the community, and may have a negative impact on both. Physicians represent the best opportunity to influence the vaccine-hesitant parent, but only if physicians are willing to care for these families will that be possible. Maintaining a relationship of open communication and trust remains the best strategy for addressing the problem of parental vaccine hesitancy.

Working with parents who opt not to vaccinate their children can be frustrating for many physicians. Not only does the refusal to vaccinate represent a rejection of one of modern medicine’s most effective tools in protecting the health of children, but the time required for counseling impacts the busy physician’s ability to provide care for other children. As a result, an increasing number of physicians are asking these families to find another health care provider. One recent survey suggested that 25% of pediatricians and 3% of family medicine physicians would always, often, or sometimes dismiss families from their practice if they refused vaccines in the primary series.¹ This can involve asking families who are already part of the practice to find another health care provider or, in more extreme cases, screening families seeking a medical home and refusing to see those who are not willing to fully vaccinate their children.

While frustration over vaccine hesitancy is understandable, the strategy of refusing to allow families into a clinic unless they agree to vaccinate their children is misguided, and the arguments for doing so fail to stand up to close scrutiny. Such a strategy does not benefit the child or the health of the community, and may have a negative impact on both.

The primary ethical purpose of medical practice is to seek the good of the patient.^2,3 Refusing to offer one’s services as a health care provider to a child whose parents have refused some or all vaccinations in no way benefits the child, and in some cases may increase risk to the child. These children have their options for health care limited, and in small communities where most or all clinics follow a policy requiring vaccination of prospective patients, these children may be left with no options other than alternative health care providers or the local emergency department. Furthermore, Buttenheim and colleagues⁴ have demonstrated that these children may face greater risk of contracting vaccine-preventable diseases, because their contact with other under-vaccinated children is likely to increase by virtue of these families clustering into a small number of clinics or even a single emergency department. Finally, the opportunity to educate families and eventually vaccinate children through respectful dialog may be lost when physicians refuse to work with these families.

Clinic policies to restrict access only to children who have been vaccinated also fail to offer a positive contribution to the public health, and may increase the risk of disease spread within the community. When families with under-vaccinated children are forced to cluster in smaller numbers of practices or seek care in the local emergency department, the risk of disease spread increases. The simulation model presented by Buttenheim and colleagues⁴ illustrates how those practices that remain open to seeing patients may become “hotspots” of disease spread in the event of an outbreak. In other words, clinic policies that restrict access to families who will vaccinate their children according to the standard vaccine schedule do nothing to protect the community from disease spread, and more likely, increase the risk.

Defenders of clinic policies to restrict access based on vaccination status argue that they have an obligation to protect their own patients from vaccine-preventable diseases, and that allowing under-vaccinated children in the waiting room poses a risk to their compliant patients. This argument, however, loses force when one considers the actual risks posed by these under-vaccinated children. The risk presented by an unvaccinated child pales in comparison to the risk posed by other children in the clinic waiting room who may harbor respiratory syncytial virus, metapneumovirus, and a host of other infectious diseases that result in far more hospitalizations and deaths each year in the US than do vaccine-preventable diseases. Other clinic policies designed to sequester sick children or limit their time in common areas would likely be far more effective and less contentious than simply refusing to see children who are under-vaccinated.

Finally, some physicians argue that they have the right to choose which patients they will see, that under-vaccinated children pose a liability risk to their practice, and that the time spent trying to educate these families translates into lost revenue. Yet these arguments are not unique to vaccination. Families often refuse the advice of their physicians, some families require far more time than other families with similar problems, and every child who walks in to the clinic with an infectious disease poses a similar (and likely very small) liability risk. Citing these reasons for failing to see families who are reluctant to vaccinate strains the meaning of professionalism in the practice of medicine. It also unfairly shifts the burden to those health care providers who feel a professional obligation to care for these families.

Physicians represent the best opportunity to influence parents who are vaccine-hesitant. Most parents trust their primary care providers and look to them for information and advice. Parents will be most receptive to considering vaccination if they believe their provider is primarily motivated by the welfare of their child. A willingness to listen respectfully, encourage questions, acknowledge parental concerns, and provide accurate information about risks and benefits is essential for developing rapport and trust. Maintaining a relationship with vaccine-hesitant parents allows continued discussion of the risks associated with both remaining unvaccinated and delaying certain vaccines, and the opportunity to remind parents that vaccinations are important in part because effective treatments do not exist for most vaccine-preventable diseases.⁵ “Diagnosing” the parents’ reasons for hesitancy allows for a more targeted discussion and approach.⁵

Even with optimal communication strategies, some parents will remain hesitant to vaccinate their children. A health care provider may understandably suggest or encourage a family to find another provider who might better fit with the family’s needs when a substantial level of distrust develops in the relationship, significant differences in philosophy of care emerge, or the quality of communication is poor. However, when the only source of contention is vaccination, maintaining the patient-provider relationship conveys respect, builds trust, and affords additional opportunities to discuss immunization.⁶ Asking parents who refuse to vaccinate their children to seek medical care elsewhere is counterproductive: it rarely gets a child vaccinated, undermines trust, may increase the risk to others in the community, and eliminates opportunities for continued dialog about vaccination.

10.4161/hv.26284