For Dr. Laura Bianconi, the measles outbreak in Palatine, Ill., earlier this year was the turning point.
The cases spurred Bianconi and other pediatricians at Centegra Physician Care to review their accommodation of families who choose not to vaccinate their children.
They decided to take a hard line and break with the norms of their profession.
The group has a new policy, which went into effect this month, of only treating kids who are adequately immunized. Families that don’t comply will have a month to find a new doctor. The policy only applies in outpatient locations, not emergency rooms.
“We all agreed that we needed to change course for the benefit of the kids in our community,” Bianconi said. “We decided it was more important to protect the health of the kids in our practice who are too young to be vaccinated than it was to let people make individual choices about vaccines.”
A parent’s decision not to have their child immunized stirs up controversy in the public. It’s also a big problem for the medical profession. Almost all physicians encounter parents refusing vaccines, according to a recent study.
The American Academy of Pediatrics strongly endorses universal immunization, but within the field there is not agreement on how to respond to parental refusals.
1 in 5 number of pediatricians who have turned away unvaccinated families from their practices
A small number of pediatricians — about 1 in 5 — have turned away unvaccinated families from their practices, said Dr. Sean O’Leary, an associate professor of pediatrics at Children’s Hospital Colorado and lead author of the study.
The number of pediatricians who reported dismissing families in his 2012 national survey is about the same as in 2009, O’Leary said. But after high-profile measles outbreaks this year, including one at Disneyland in California, O’Leary said he’s hearing anecdotally that more pediatricians are dismissing families in part because parents who vaccinate are putting pressure on doctors to stand up to the anti-vaccine movement.
“The last thing doctors want to do is send kids away,” O’Leary said. “When they take a stance as strong as that, that’s going against their core principles and it sends a strong message about vaccinations.”
Bianconi acknowledged that she has had families leave her practice before the policy change because they didn’t want to expose their children to diseases in doctors’ offices that could be carried by unvaccinated kids. But she said that public health interests were more important than business considerations in making the decision.
It’s not too often that doctors face a choice between serving one patient or another. The decision to dismiss unvaccinated children raises tricky ethical issues. In general, doctors are supposed to do the best they can with the patients they have. There are very few adult patients, for example, who eat right, exercise and don’t smoke, and yet doctors don’t turn them away, bioethicists say.
The American Academy of Pediatrics discourages the practice of discharging patients solely because a parent chooses not to immunize. In its guidance, the academy states: “Families with doubts about immunization should still have access to good medical care, and maintaining the relationship in the face of disagreement conveys respect and at the same time allows the child access to medical care.”
Dr. Soujanya Pulluru, a family physician in Naperville, follows the academy’s recommendation.
These children deserve access to the care we give them. They deserve the right to get medical care irrespective of their parents’ choices.
Dr. Soujanya Pulluru, a family physician in Naperville
“These children deserve access to the care we give them,” she said. “They deserve the right to get medical care irrespective of their parents’ choices.”
Pulluru is the medical director at DuPage Medical Group, one of the Chicago area’s largest independent physician practices. She said the group frequently discusses whether it should continue to serve unvaccinated children. Dealing with families who oppose vaccines is a source of frustration for the staff, she said.
Maintaining the patient relationship allows additional opportunities to educate parents about the benefits of vaccines and disabuse them of fears, Pulluru said. Physicians at DuPage Medical Group follow professional guidelines and document refusals in patients’ medical records.
“The best advice I can give patients is the fact that I vaccinate my three children,” she said.
More than 60 percent of pediatricians reported spending about 10 minutes talking about vaccinations, O’Leary said. The average well-child visit is 18 minutes, leaving little time to discuss other important topics.
The need to constantly talk about vaccines leads to strained patient relationships, said Dr. Peter Liber, founder of west suburban Wheaton Pediatrics.
“If parents don’t believe me when this is a slam dunk that vaccinations are a benefit to each and every child, you wonder if they will trust you on other things,” Liber said.
Starting in 2012, Wheaton Pediatrics stopped accepting new patients who weren’t vaccinated, Liber said. The group also began informing existing families whose children were not up to date on their vaccinations that they would have 18 months to catch up or be asked to leave.
If parents don’t believe me when this is a slam dunk that vaccinations are a benefit to each and every child, you wonder if they will trust you on other things.
Dr. Peter Liber, founder of west suburban Wheaton Pediatrics
About 90 families were asked to leave, Liber said. Some families — Liber did not have an approximate number — changed their minds and agreed to vaccinations.
Liber also views his firm stance on unvaccinated children through the lens of public service. “Frankly we as a profession have not been vocal enough in championing the message of the benefits of full vaccination,” he said.
But Michelle Meyer, director of bioethics policy at Union Graduate College-Icahn School of Medicine at Mount Sinai, said turning away families who refuse to vaccinate is misguided.
“I’m very skeptical that firing patients, which is an extreme and shaming act that amounts to patient abandonment, is going to have a positive impact,” Meyer said.
No published studies have examined the effect that a policy of dismissing families has on uptake of vaccines or on the spread of vaccine-preventable diseases, O’Leary said.
Refusing to treat unvaccinated children could have unintended consequences, Meyer said, like creating more clusters of unvaccinated kids. “I worry about further antagonizing a group that is already very emotional about this topic,” she said.
Meyer and O’Leary agree that because pediatricians still dismiss families despite recommendations to the contrary, the practice should be better explored.
“It’s a difficult decision for pediatricians,” O’Leary said. “I don’t know what the right answer is personally. When I was in practice, we struggled with this.”