November 29, 2018
by Amy Givler, MD
My patients have learned over the years that I will enthusiastically suggest they get a flu shot every fall. I’d say half of them are equally enthusiastic to receive it, and another 30 percent agree to get it only after a discussion (every year) on why it is a good idea. That leaves 20 percent who flatly refuse, even after hearing my erudite arguments. One day last week, every patient I saw seemed to be a member of that 20 percent contingent. By the end of the day, I found myself taking it personally, thinking I was an ineffective physician. Intellectually I realized I was being ridiculous, so I gave myself a talking to: “Whether someone gets a flu shot doesn’t define your quality as a physician, Amy.” After all, they weren’t rejecting everything I was prescribing.
It got me thinking about vaccines in general, and why some people reject them. I am definitely in the “pro-vaccine” camp. Worldwide, only clean water has saved more lives than vaccines. Wild smallpox has been eliminated, and polio nearly so. Twelve other major diseases that were the scourge of mankind have been controlled, at least in much of the world: diphtheria, tetanus, pertussis, Haemophilus influenza type b disease, measles, mumps, rubella, typhoid, yellow fever, rabies, rotavirus and hepatitis B.
So why would anyone not want to control disease? What’s not to love about keeping healthy people healthy? One problem is that you are introducing something into the body of someone who is not ill and who may never get the disease in question. Not everyone gets every disease. Another problem is the impressive success of vaccines means we no longer see the ravages of the diseases they prevent, so we’re not as motivated to keep preventing them. My mother trained as a pediatric nurse in the early 1950s and remembered seeing children in iron lungs, paralyzed from polio. Fear of the disease was everywhere, so when the polio vaccines were introduced they were widely accepted.
But I was thinking, as I said, about why people reject vaccines. Or more specifically, why some folks become fanatical anti-vaccinators. I am speaking of those who not only don’t vaccinate themselves or their children, but don’t want anyone else to be vaccinated either.
At the Centers for Disease Control and Prevention’s (CDC) most recent Advisory Committee on Immunization Practices (ACIP), several people used the public comment time to “spew accusations” at the committee members, questioning their motives and their concern over the welfare of U.S. children, in an “aggressive and threatening” manner. I know that this is typical for how controversial issues are handled these days. Instead of polite interchanges, using reasoned arguments, disagreements become shouting matches, with name-calling and character attacks. But rudeness doesn’t have to be responded to with rudeness, and it sounds like the ACIP members responded graciously.
So I am aware that speaking out positively about vaccines can be hazardous to your mental health. Yet understanding the anti-vaccine mindset is necessary if you want to be effective.
As a general rule, whenever something new is introduced, some people will oppose it as a matter of course. This is probably rooted in personality. The opposition is automatic, and the arguments follow only later. Let’s say this is approximately 20 percent of the population. Similarly, some people embrace new things quickly—perhaps another 20 percent. So that leaves 60 percent of people who could go either way—it all depends on how the new thing is presented and what the arguments are. I spend most of my energy talking about vaccines to that 60 percent.
A fascinating study in Pediatrics surveyed 1,759 parents (who had children under 17 living at home) on their attitudes toward the MMR vaccine and their intention to vaccinate. The parents ran the spectrum of opinions about vaccination, from least positive to most positive. They were randomized into receiving one of five information sheets to read:
- A statement by the CDC explaining the lack of evidence that MMR causes autism (“Autism Correction”).
- Information on the dangers of the measles, mumps and rubella diseases (“Disease Risks”).
- Graphic images of children who have measles, mumps, or rubella (“Disease Images”).
- A dramatic narrative by a mother about her child who almost died from measles (“Disease Narrative”).
- A control group who read about bird feeding.
Depressingly, none of these interventions increased the parents’ intention to vaccinate. The parents who were given the Disease Images and Disease Narrative sheets actually increased their beliefs both that vaccines cause side effects and that there is a vaccine-autism link. These interventions could be considered “fear tactics,” which are clearly an ineffective way to change beliefs and attitudes.
Furthermore, for the subset of parents who were least positive about vaccination to begin with, if they were given the Autism Correction sheet, their intention to vaccinate dropped even further. Since opposition to vaccination is generally not scientifically based, using science alone to debunk those beliefs is seldom successful.
When I started practicing family medicine 30 years ago, I was the only source of medical facts for most of my patients. Now I assume that all patients are exposed to medical information on their computers and their smartphones. I’m glad my patients care about their health, and I want them to seek out knowledge, but the internet contains an unfortunate amount of unverified and anecdotal medical information that is misleading and just plain wrong.
So how should we talk to our patients about vaccines? First of all, we should talk to our patients about vaccines.
“Hey, wait a minute,” I hear you say, “that study in Pediatrics showed that none of those ways of learning about vaccines increased parents’ intent to vaccinate.” That is true, in the context of reading an information sheet. But in the context of a trusting relationship with a healthcare professional, the results are different. A European review article showed that the knowledge and attitude of the healthcare professional makes a positive impact on whether vaccines are accepted. Specifically, if health professionals are ambivalent about vaccination themselves, or if they are unable or unwilling to answer parents’ questions, or if they lack empathy with parents’ concerns, then their patients are less likely to be vaccinated.
This came home to me recently. A young friend of mine has a 1-year-old who is possibly developmentally delayed. This concern prompted my friend and her husband to ask their friends for advice and search the internet for help. And thus she stumbled upon the vocal and aggressive anti-vaccine movement. When it was time for the MMR vaccine, she brought several concerns to her pediatrician. Specifically, she asked if the vaccines could be spread out on an elongated schedule.
Her pediatrician said, “The best answer I can give you is that I gave my son all of his vaccines, on time, and he is fine.”
Even though she seemed to be in a hurry, my friend persisted. “But my daughter seems to be developmentally behind. So isn’t she different than your son?”
The doctor seemed visibly frustrated. She then flatly said, “If you decide to not give your daughter all of her vaccines, on time, then you’ll need to find another pediatrician.” And she told my friend she had one month to decide what she was going to do.
When my young friend told me about this interchange, she said she had never felt close to the pediatrician. She never felt a connection to her or support from her. I’m glad she had both my daughter, who is a family medicine resident and her good friend, and myself, to answer her questions and make a case for getting the MMR. She has decided to go ahead with vaccines, on schedule, and she is also changing pediatricians. I am glad on both counts.
In today’s world of 15-minute appointment slots, it’s no wonder our patients or their parents are not getting their questions answered, and aren’t feeling supported. It behooves us as medical professionals to buck that trend, and to work to develop a therapeutic relationship with our patients.
As Dr. Francis Peabody so famously said nearly 100 years ago, “The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”