Docs Seek New Ways to Tell Parents Just How Safe It Is to Vaccinate
Casey Hallstrom is unapologetically in the pocket of big pharma: It pays her salary. Yet even though the pharmaceutical sales rep sells drugs for a living, she feels uncertain about vaccinating her three children. In the six years since her oldest child was born, she has challenged their pediatrician: Are all these vaccines really necessary?
How the doctor, Natasha Burgert in Kansas City, Missouri, has responded has made all the difference in convincing a vaccine skeptic to nevertheless make sure her kids get all their shots on time. Burgert has presented vaccination as the default option but has answered Hallstrom’s questions with empathy and authority.
That’s the strategy that research published in the journal Pediatrics in 2013 indicates has been most successful in getting parents with concerns about vaccines’ safety to immunize their children. With 149 confirmed cases of measles in the current outbreak, epidemiologists and public health experts say it’s critical that everyone follow the course recommended by the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the Institute of Medicine, the American Medical Association, and at least a dozen other organizations of medical professionals and get their children immunized.
Immunization succeeds at protecting public health only if the vast majority of people are immunized. At least 92 percent of people need to be vaccinated for a population to achieve what’s called “herd immunity”—the ability of the group to protect the individual. As recently as 2000, measles was considered eliminated in the U.S. But last year, the U.S. counted 644 cases of measles, the most in two decades.
Vaccination rates vary widely according to geography, with the western part of the country holding multiple pockets of vaccine resistance. In Ashland, Oregon, 25 percent of kindergarteners aren’t vaccinated. In 14 California counties, up to 20 percent of kindergarteners have “personal belief exemptions” from public school immunization requirements. The carve-out was originally intended to serve small religious sects that don't believe in medical intervention, but as misinformation about vaccine safety has spread, non-religious families are taking advantage of the exemption as well.
The approach outlined in Pediatrics might be described as “Don’t ask, but tell”—and do so with respect and in an open-ended way that allows parents to express their concerns. The approach has been successful, according to research, and it worked with Hallstrom: Despite her initial misgivings, she has decided to vaccinate each of her daughters, ages six, four, and five months, on time.
“At an appointment, Dr. Natasha will go through behavior, eating, sleeping, milestones. Then she’ll say [my daughter] looks great and remind me that we have these vaccines to do today. She doesn’t offer a choice,” says Hallstrom, who is 32 and lives in Overland Park, Kansas. “I have pushed back a little bit. I’ll say, ‘Maybe she’s getting too many shots at one time.’ And she’ll say, ‘This is how much of this ingredient is in here, and this is how much you’re exposed to on a daily basis.’ ”
Perhaps because the safety and efficacy of vaccines have until recently been widely accepted, there is no template for how physicians should address the issue of immunization. The AAP, which strongly endorses childhood vaccination, has no such guidelines. As a result, approaches vary widely, from insisting parents vaccinate—some pediatricians have gone so far as to “fire” families who choose not to vaccinate—to taking a laissez-faire approach and not challenging parents who express reservations.
Doug Opel, the lead author of the Pediatrics study, is a pediatrician and bioethicist at Seattle Children’s Research Institute. He and his colleagues analyzed videotapes of parents interacting with pediatricians at kids’ check-ups to see how the vaccine conversation unfolded. After reviewing the tapes, they found that doctors’ methods of broaching vaccination can be broadly placed in one of two categories.
Vaccination is one of the few cases where we shouldn’t give patients and parents control in decision making, because there really isn’t a choice here.
Doug Opel, pediatrician and bioethicist, Seattle Children’s Research Institute
Some physicians, in the belief that they’re fostering a collaborative parent-provider relationship, ask parents for their thoughts: “What do you want to do about vaccines today?” Others are more direct and flip the question into a declarative: “These are the vaccines we’re going to do today. Do you have any questions?”
Simply changing the format from an open-ended query to a statement is influential, according to a commentary Opel and Saad Omer of Emory University published in February in JAMA Pediatrics. The rationale can be traced to “choice architecture,” according to Opel and Omer, a concept explored in the fields of behavioral economics and social psychology that “leverages the propensity humans have to stick with a decision that is already made, especially among decisions perceived to be complex.” Basically, parents are looking to pediatricians to convey knowledge and perspective when it comes to vaccination, which has become an emotionally fraught decision for many in light of Internet rumors (unsubstantiated by science) that vaccines pose health risks greater than those of the diseases they prevent. “It is often easier in these situations to simply accept what is recommended, especially when that recommendation is made by someone as influential and trusted as their child’s pediatrician or family practitioner,” write the authors.
By presenting vaccines as the default option, doctors are essentially making vaccination opt-out rather than opt-in, which is exactly how it should be positioned, Opel said in an interview. It’s like your 401(k): If an employer makes contributing a portion of one’s salary the default, studies show, employees are much more likely to save for retirement than if they must take an action to contribute.
Opel has done much of the research on how doctors communicate with parents about vaccines and notes that immunization occupies a unique niche in pediatric practice.
In this age of patient-empowered care, pediatricians regularly engage in shared decision making. Patients today are known for breezing into a doctor’s office wielding a sheath of printouts of the latest studies regarding their condition. But the conversation about vaccines is a particular challenge, because the concerns parents bring to it are often unfounded.
In pediatrics, doctors are seeing more parents taking ownership of their children's health care. “When there is true choice, that is the way to go—to give them control and agency in decision making,” Opel says. “But vaccination is one of the few cases where we shouldn’t do that, because there really isn’t a choice here. From a medical standpoint, there isn’t a medically acceptable alternative to vaccines.”
Mobeen Rathore, chief of pediatric infectious diseases and immunology at Wolfson Children's Hospital in Jacksonville, Florida, says the daily headlines about new measles cases have sparked conversations with his colleagues about whether they should shift to informing parents about vaccines rather than asking for their input. Florida’s AAP chapter has also held discussions along these lines.
“This is the direction in which we’re heading,” says Rathore, who is also a member of the AAP’s committee on infectious diseases. “The chatter on that has gone up exponentially since the measles outbreak.”
Opel’s research shows that Burgert’s approach—assume the parents are on board but follow up by inviting questions—is more successful. In his Pediatrics study, when doctors simply started the vaccine discussion with a statement that presumed parents would vaccinate their children, only 30 percent of vaccine-hesitant parents resisted, compared with the 89 percent who resisted when doctors began the discussion by asking the parents what they’d like to do about vaccines. When worried parents raised objections and doctors didn’t shy away from continuing the conversation but responded to their concerns, half the parents agreed to vaccinate.
“Parents come to us because they want us to reassure them,” says Opel. “If we do that well and empathetically, my study shows that parents will change their minds.”
Hallstrom is proof. Despite her daily interactions with doctors, she has had a tough time stifling her uneasiness over vaccines. She attributes her uncertainty to the power of social media and social networks that disseminate anti-vaccine information. “Social media has gotten parents to question if vaccines are good or bad,” says Hallstrom.
She wonders if the measles-mumps-rubella vaccine could have caused actor Jenny McCarthy’s son’s autism, even though the vaccines-cause-autism link has been thoroughly debunked. She read The Vaccine Book: Making the Right Decision for Your Child, by Robert Sears, which outlines a delayed vaccination schedule. The Santa Monica, California, pediatrician beloved by advocates of “attachment parenting” has advised pregnant women and new mothers that they can blow off vaccines because everybody else doesn’t.
Raising an unvaccinated child, Sears said in 2014, “may not be good for the public health. But…for your individual child, I think it is a safe enough choice.” Since the outbreak, Sears has changed his tune slightly: “My precautions about spreading out vaccines [are based on] a theoretical benefit to kids, and it’s a choice I think might actually bring more parents to vaccinate if they can spread the shots out,” he told MSNBC’s Chris Hayes on Feb. 12.
Even Hallstrom’s husband was baffled by her behavior. “He’s like, ‘Casey, you know all the advances science has made when it comes to vaccines.’ But I’m speaking as a mother, disregarding my background as a pharmaceutical rep,” says Hallstrom. “I want to do the best for my children, and when I hear other moms saying, ‘I think mercury in these vaccines may have caused my child to have autism when they were born normal,’ it makes you start questioning.”
Burgert, Hallstrom says, has done an excellent job of allaying her fears, simply by acknowledging them and offering evidence-based explanations. It helps that at the start of each well check, Hallstrom receives a handout with the vaccines her daughter is due to receive at that visit as well as the next visit. “I know what to expect,” she says.
Burgert says her No. 1 goal is to build trust with parents, though how exactly to do that may vary by family. She almost always starts a vaccine conversation with a statement, but she says a one-size-fits-all approach doesn’t work for all her patients. “The challenge is, there’s no magic bullet. I ask, ‘Why? What are you reading? What are you scared of?’ It’s all about relationships,” she says. “A lot of this vaccine hesitancy is a psychological problem, not necessarily a science problem.”