CMDA's The Point

Trusting Vaccines

November 29, 2018
11292018POINTBLOG2

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:

  1. A statement by the CDC explaining the lack of evidence that MMR causes autism (“Autism Correction”).
  2. Information on the dangers of the measles, mumps and rubella diseases (“Disease Risks”).
  3. Graphic images of children who have measles, mumps, or rubella (“Disease Images”).
  4. A dramatic narrative by a mother about her child who almost died from measles (“Disease Narrative”).
  5. 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.”

Amy Givler, MD

About Amy Givler, MD

Amy Givler is a family physician in Monroe, Louisiana. She and her husband Don met in 1980 at a CMDA student event her first year of medical school, and they have both been active members of CMDA ever since. Amy graduated from Wellesley College and Georgetown University School of Medicine, and she then completed her family medicine residency at the same indigent-care hospital where she now works part time. She also works at an urgent-care clinic and is the medical director for a Shots for Tots clinic. Amy loves to write and has written many articles and one book, Hope in the Face of Cancer: A Survival Guide for the Journey You Did Not Choose. She and Don have a heart for missions, and hope to do more short-term trips now that their three children have launched from the nest.

12 Comments

  1. Victoria Macki, MD on November 29, 2018 at 1:24 pm

    I am a family physician in Amy’s generation (graduated 1983), and have the same mindset–that a personal connection with the patient is THE greatest therapeutic tool that a doctor has–and it has rapidly become the most scorned and demeaned one. The “powers that be”, i.e., insurance companies and medical management bureaucrats are unable to quantify this, and therefore dismiss the efforts expended on forming and nurturing this relationship. This is primarily because it is bought with a very rare and precious coin —
    time.
    Throughout my recently ended career (I retired 2 months ago), I have been continually chided for “wasting my time” talking with the patients. I am unrepentant. The patients, actually, were grateful to have (finally) a doctor who would listen to them, and explain things in terms they could understand. I was constantly reminded of my “unproductively”, but I could sleep at night.
    I would like to see the pendulum swing back, so that doctors who spend time with their patients get the respect, credit, and yes, money, that their efforts deserve. In the long run, I believe it would save both time and money, and create a happier, more trusting patient base.
    A recent case in point:
    My 32 year old niece spent 8 months and over $5,000 last year, and saw at least 3 doctors, trying to chase down the cause and treatment for persistent diarrhea. It turns out that it was caused by a course of Augmentin treatment. At no point did a doctor advise her of the propensity of the medication to cause diarrhea, and, since it occurred at the end of her treatment, she subsequently (honestly) answered that she was not taking any medications when she saw multiple physicians regarding the diarrhea. Only after a colonoscopy, was she evaluated for C. difficile. When she told me her story, I was heartsick and appalled, but not surprised. I have heard similar stories over and over.
    Doctors in big hurries to meet a patient-number quota, DON’T have time to counsel their patients. They DO however, rapidly refer for expensive (and often unnecessary) specialty evaluations and testing. And so often, all this could be avoided if physicians got to know their patients, and had the time to talk with them.
    Will it ever change? Probably not in my lifetime.
    Were I to begin again, I would still choose family medicine as a specialty, but I would practice in a “concierge” practice, with costs for my services clearly set forth, and without insurance company constraints.

    • Amy Givler on December 3, 2018 at 4:27 pm

      Victoria,
      Thank you for this well-stated support for the importance of taking time to really know our patients. I am an unrepentant “time spender” also. Even though you have “retired”, I hope you continue to keep your toe in medicine. There are patients out there who need your wisdom.

  2. David Campbell, DDS on November 29, 2018 at 2:42 pm

    I’d like to leave a comment as a professional who doesn’t get flu vaccinations. I’m a maverick in many ways. I happen to be a dentist, so I don’t have pressures to approve and I’m not rated by my patient compliance. I just get the flu from flu shots. Not immediately, but during that season I get it. It’s been uncanny. I don’t visit doctors at all, for years at a time. But when I joined an FQHC, I became required to get the flu vaccines. Suddenly, I started getting the flu. I had never had a flu comparable to the flu I got those years. I was down for a week, in bed, suffering horribly. It happened three years in row. When I started refusing, three years in a row, now, I haven’t had a flu. Actually, I get some flu symptoms, like before. It last a few hours, usually an overnight disorientation with some gastric distress, but relatively minor and insignificant. Just my experience. You can put my in a box of nuts, but some of us nuts have some very valid stories. Blessings to all.

    • Amy Givler on December 3, 2018 at 4:31 pm

      David,
      What you are describing is your anecdotal story. I, too, have an anecdotal story. The one year I didn’t get the flu shot (we were overseas when it was available), I had the worst case of flu that I can imagine — nearly two weeks in bed, the first of which I thought I was going to die. The trouble with anecdotal (N=1) stories is that they can’t be extrapolated to see the big picture. When researchers study the big picture, flu shots decrease the incidence of the flu, and save lives.

  3. JoAnn Alexanian MD on November 29, 2018 at 7:31 pm

    I am a recently retired physician who never had time to research and question controversial issues. Thank you for starting this discussion on vaccines. I have found no good forum to bring up my concerns. Who can explain to me why the vaccine schedule can’t be more flexible especially for infants and toddlers? I am concerned with the tripled quantity of vaccines given to babies and also the additives that are well above the toxic range- esp the aluminum. Can someone explain why we should not be concerned with all the additives? Even I held the Hep B vaccine for my children until they were older because I saw no risk to them as babies. I wish that parents could spread the vaccines out at the very least and I am embarrassed for our profession that we can’t answer these questions without judgment. I appreciate all the physicians who do take the time to explain!
    Thank you for allowing me to ask these questions.

    • Amy Givler on December 3, 2018 at 4:37 pm

      JoAnn,
      I appreciate Patti Francis mentioning the CHOP website. I get the Immunization Action Coalition email and have learned a lot from it – I commend it to you. I am sure that you can get the answers that you seek from one of those places.

  4. Patti Francis on November 30, 2018 at 1:29 am

    I have found the Children’s Hospital of Philadelphia (CHOP/vaccines) a very helpful reference for patients who need more information than I can give them. If they have already made their mind up about vaccines, when I ask them what they thought at the next visit, they haven’t made it to the website yet. I ask them to show me what they are reading as well. I recently read an article in one of my journals about a lawsuit made against a doctor who didn’t state that their child could DIE from the flu and so recommended that they give their child the flu vaccine. She sued the doctor because her child did die, and she won. That has opened another can of worms: how much do we legally need to tell our families about what could happen if their child doesn’t get any vaccine?

    • Amy Givler on December 3, 2018 at 4:42 pm

      Patti,
      Thanks for mentioning the CHOP/vaccines website. It is packed with information and a great resource. That is a sobering story about needing to actually state the risk: “You could die from the flu.” I try not to use scare techniques, generally, and I’m not quite sure how to explain that death is a possibility without it being considered a scare technique. But the flu can be so serious — especially for the very young and the very old. Knowing you, I am sure that you have a “therapeutic relationship” with your patients and their parents.

  5. Kerri on November 30, 2018 at 9:02 am

    Specifically in regard to the flu shot, I think it’s important to be sure that patients understand the purpose of the flu vaccine. It’s not to prevent the flu. It’s to prevent death from the flu. So, even if I still get the flu after receiving the vaccine, I’m far less likely to die from it. Anecdotally, I found this to be true for myself last year — I got the flu, but it was short-lived and characterized by mild symptoms. I make sure that my pregnant patients understand this distinction, and that they also understand their higher risk of pneumonia, ICU admission, and death from influenza compared to the general population.

    Additionally, health care providers need to understand that their flu shots are less about their own personal protection and more about saving patients’ lives. As believers, we have a call to look out for others more than ourselves.

    There’s a lot more to it than what meets the eye!

    • Amy Givler on December 3, 2018 at 4:44 pm

      Dear Kerri,
      You make an excellent point. The flu shot could attenuate the symptoms, and what we are trying to avoid is death from the flu. Thank you for sharing.

  6. John Givler on November 30, 2018 at 9:04 pm

    I’m only a medical student but this encapsulates my views on the antivaxx movement quite well. I truly believe that the best way to reach our patients is by partnering with them for their health. While I am vehemently opposed to the antivaxx movement, I try to remember that most of those who deny are doing so out of fear and a desire to protect the ones they love. That I can get behind. I love the emphasis that this post puts on the doctor/patient relationship as the solution to this issue.

    • Amy Givler on December 3, 2018 at 4:49 pm

      Thank you, John.
      I appreciate your sensitivity to the spirit behind the movement to avoid vaccines. These are not bad people who want others to die! Excellent point. I have interacted with many of them in the past, though, and I am always saddened by how quickly the conversation deteriorates to name-calling and character-attacks. Debating like that just makes people dig in their heels and continue to defend their position.

Leave a Comment