SAN FRANCISCO – Family physicians and pediatricians could polish their communication skills when talking to parents who are reluctant to immunize their children, judging by results of one of the first observational studies of these encounters in private practice.
A pilot study recruited seven pediatricians and two family physicians in Louisville, Ky., for a “field test” of using “standardized patients” in primary care practice settings, Dr. Kristina Bryant said at the annual meeting of the American Academy of Pediatrics. Standardized patients are actors or actresses who are trained to portray patients and are commonly used in medical schools to help teach and test students, explained Dr. Bryant of the University of Louisville (Ky.). Dr. Bryant is associated with several companies that make vaccines. She is on the speakers bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.
In presenting to the physicians, the actresses pretended to be pregnant women looking for a pediatrician. Each woman said that she didn't want to immunize her child because she believed the MMR vaccine causes autism and the varicella vaccine causes neurologic damage. She also said that too many vaccines overload the immune system, that the AAP and the Centers for Disease Control and Prevention are not truthful.
The standardized patients graded physicians after each encounter and four encounters were recorded. Among the four physicians who were recorded, only three discussed the risks and benefits of vaccines, and only two presented evidence to refute the mother's claims that MMR causes autism or that thimerosal is dangerous. Two referred mothers to the AAP and CDC Web sites for more information, and two offered to delay some vaccines–a strategy recommended by the AAP when dealing with reluctant parents. None explored cost as a potential barrier to immunization. Two physicians gave inaccurate information. One said he would have to contact Child Protective Services if the mother refused to vaccinate her child. The other said that the child could not attend public school unless immunized, but Kentucky allows religious exemptions.
“The plus side is that none of these physicians refused to care for this family if the mother refused immunizations, and [all] talked about its being addressed at future visits,” Dr. Bryant said.
To Do List When Shots Are Snubbed
As many as 70% of pediatricians each year may encounter patients who refuse one or more vaccinations for their children, a 2001 survey of pediatric fellows suggested. The AAP recommends the following steps in these encounters (Pediatrics 2005;115:1428-31):
▸ Listen to parents' concerns and try to understand them. Tell them the risks and benefits of immunizations, and correct parents' misconceptions.
▸ Take steps to reduce the pain of injection.
▸ Consider an alternative vaccination schedule that minimizes the number of injections at each visit, if that's a concern of parents.
▸ Explore cost as a barrier.
▸ Document vaccine refusal.
▸ If possible, avoid discharging vaccine refusers from your practice.