Quality of Physician Communication about HPV Vaccine – Reply

The role of provider communication style in promoting HPV vaccination raises provocative questions for cancer prevention research [1]. Like Kulczycki and Shewchuk, some assert that an informed decision making approach will improve our nation’s persistently dismal HPV vaccination rates. However, at present, evidence does not support this claim. Indeed, the small body of empirical work on this topic suggests that broaching vaccination with parents in an open-ended fashion may breed more doubt than confidence in the routine immunization schedule [2]. Given that our field is still struggling to reach consensus on what informed decision making looks like in the context of strongly recommended preventive services, the question of whether such an approach can be effective in increasing HPV vaccine uptake is far from settled. We simply don’t know [3].

What we do know is that a provider’s recommendation is a strong predictor of HPV vaccination. To better understand providers’ influence, we developed an evidence-based framework for assessing HPV vaccine recommendation quality in terms of timeliness, consistency, urgency, and strength of endorsement [1]. Our finding that relatively few physicians delivered high-quality recommendations is concerning given that higher-quality recommendations were more strongly associated with HPV vaccination behavior than lower-quality ones [1,4].

Our recommendation quality framework is intentionally agnostic as to communication style. What we define as a high-quality recommendation may be delivered using a directive style or an informed decision making style. As we note in our paper, we hope to expand our framework in the future to include other best practices, including those related to communication style [1]. However, to do so at present, in the absence of data, would be premature.

We consider ourselves strong proponents of what Kulczycki and Shewchuk call the “prevailing zeitgeist” of patient centeredness, going even so far as to publish an edited volume on this topic [5]. We would argue that informed decision making is not always a patient-centered approach; its potential benefits are attended by costs, including time and decisional burden, and it may or may not be the communication style preferred by parents considering HPV vaccination. For this reason, we caution against jumping on the informed decision making bandwagon. Instead, let’s work to operationalize informed decision making in a meaningful way, using empirical evidence to weigh its merits for raising HPV vaccination rates. Will we run afoul of fashion? Perhaps. But, as scientists, surely we’re used to that.