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Does Immunization Refusal Warrant Discontinuing a Physician-Patient Relationship?

Does Immunization Refusal Warrant Discontinuing a Physician-Patient Relationship? Elsewhere in this issue, Flanagan-Klygis and colleagues1 report on a survey of pediatrician attitudes about terminating the physician-patient relationship when families refuse some or all immunizations for their child. The results are interesting if not surprising. Thirty-nine percent of pediatricians said they would dismiss families who refused all vaccines; 28% would dismiss families who refused select vaccines or delayed vaccine administration. There was no difference between pediatricians who elected to end a relationship with the patient (dismissers) vs continuing care (nondismissers) based on physician age, sex, or number of years in practice. How representative are these findings? Although the survey was mailed to 1004 randomly selected members of the American Academy of Pediatrics (Elk Grove Village, Ill), the eligible responders (those who administered vaccines) numbered only 302. No mention is made of the geographic distribution of respondents or any statistical differences based on the family’s insurance or socioeconomic status. In the introduction, the authors do not appear to be neutral about this issue. Emotional energy is conveyed by using such words and phrases as “parents now aggressively question . . . ,” “scrutiny,” “tension,” and “ . . . may view parental challenges as threats to their integrity.” One introductory comment was especially interesting. “In our experience, when a parent refuses 1, some, or all vaccines, the relationship between that pediatrician and parent weakens.” The authors outlined several objectives with this survey. First, they wanted to “characterize pediatrician attitudes toward dismissing vaccine-refusing families.” Fifty-four percent of questioned physicians had encountered a parent who refused some or all vaccines during the past 12 months. As mentioned in their discussion, the survey didn’t ask if those families were dismissed from the practice, only whether the physician would dismiss “If after numerous attempts at vaccine counseling and education a parent continues to refuse. . . . ” A perception of finality in the hypothetical scenario might have biased the physician toward choosing the item indicating dismissal. Moreover, the common reasons in decision for dismissal, “lack of shared goals” and “lack of trust,” may have been more important than the simple refusal of some or all vaccines. Unfortunately, this survey lumped partial refusers with those who would simply delay 1 or some vaccines. My experience suggests a difference between parents who refuse a vaccine and those who want to delay administration. This pairing could explain the difference between the total and partial “refuser” dismissal rate. In regard to objective 2, the lack of difference between sex, age, and years in practice seems logical. Collectively, more than 95% of surveyed pediatricians in this study rated immunizations as extremely or somewhat important.1 The value of preventive care through immunizations is stressed throughout a pediatrician’s training and career. Studies support the importance of physician/practice attitudes on immunization rates.2 The American Academy of Pediatrics and others support immunization educational programs including “refusal to consent” forms. Immunization rates and timeliness of administration are often measured and referred to as a marker for high-quality pediatric care. These issues affect all pediatricians regardless of age and sex. Another question is alluded to in this survey. Does vaccine refusal represent a refusal to accept a treatment or procedure recommended by the physician when that recommendation is evidence based and considered to be high-quality care? How can one rank vaccine refusal in regard to often mentioned “reasons for dismissal”? Is this as important as repeatedly missing scheduled appointments or failure to pay for services? Is it less important than a refusal to take a prescribed medicine? Does repeated discussion require a disproportionate amount of the physician/office resources that may affect the care of other patients? Is it better to “agree to disagree” and mutually part company or run the risk of alienating the patient/family with repeated “discussion” causing them to fire the physician?3 Dismissing a patient is a rare occurrence for most physicians. I have found a vaccine refusal form to be helpful in continuing a relationship with a family who refuses some or all vaccines. The form doesn’t (and can’t) address issues like “mutual trust” or “lack of shared goals for the child.” Although subjective, these 2 factors often weigh heavier than a simple refusal of recommended care. I feel a straightforward immunization refusal does not by itself damage trust, breach shared goals, or necessarily lead to a “my way or the highway” confrontation. This is supported by a recent clinical report from the American Academy of Pediatrics Committee on Bioethics.4 A future survey to tease out these issues would be helpful. Correspondence: Dr Hendricks, Pediatric and Adolescent Care, LLP, 2000 S Wheeling Ave, Suite 300, Tulsa, OK 74105 (jwh@pac.pcc.com). References 1. Flanagan-Klygis EASharp LFrader J Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Arch Pediatr Adolesc Med 2005;159929- 934Google ScholarCrossref 2. Taylor JADarden PMBrooks DAHendricks JWBaker AEWasserman RC Practitioner policies and beliefs and practice immunization rates: a study from Pediatric Research in Office Settings and the National Medical Association Pediatrics 2002;109294- 300PubMedGoogle ScholarCrossref 3. Tetrault JRoediger J How to dismiss problem patients: balance their demands with your rights. Physicians Practice 2005;1573- 75.Available at:http://shands.org/professional/ppd/practice_article.asp?ID=145Google Scholar 4. Diekema DSAmerican Academy of Pediatrics Committee on Bioethics, Responding to parental refusals of immunization of children. Pediatrics 2005;1151428- 1431PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Does Immunization Refusal Warrant Discontinuing a Physician-Patient Relationship?

Does Immunization Refusal Warrant Discontinuing a Physician-Patient Relationship?

Abstract

Elsewhere in this issue, Flanagan-Klygis and colleagues1 report on a survey of pediatrician attitudes about terminating the physician-patient relationship when families refuse some or all immunizations for their child. The results are interesting if not surprising. Thirty-nine percent of pediatricians said they would dismiss families who refused all vaccines; 28% would dismiss families who refused select vaccines or delayed vaccine administration. There was no difference between pediatricians...
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Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpedi.159.10.994
Publisher site
See Article on Publisher Site

Abstract

Elsewhere in this issue, Flanagan-Klygis and colleagues1 report on a survey of pediatrician attitudes about terminating the physician-patient relationship when families refuse some or all immunizations for their child. The results are interesting if not surprising. Thirty-nine percent of pediatricians said they would dismiss families who refused all vaccines; 28% would dismiss families who refused select vaccines or delayed vaccine administration. There was no difference between pediatricians who elected to end a relationship with the patient (dismissers) vs continuing care (nondismissers) based on physician age, sex, or number of years in practice. How representative are these findings? Although the survey was mailed to 1004 randomly selected members of the American Academy of Pediatrics (Elk Grove Village, Ill), the eligible responders (those who administered vaccines) numbered only 302. No mention is made of the geographic distribution of respondents or any statistical differences based on the family’s insurance or socioeconomic status. In the introduction, the authors do not appear to be neutral about this issue. Emotional energy is conveyed by using such words and phrases as “parents now aggressively question . . . ,” “scrutiny,” “tension,” and “ . . . may view parental challenges as threats to their integrity.” One introductory comment was especially interesting. “In our experience, when a parent refuses 1, some, or all vaccines, the relationship between that pediatrician and parent weakens.” The authors outlined several objectives with this survey. First, they wanted to “characterize pediatrician attitudes toward dismissing vaccine-refusing families.” Fifty-four percent of questioned physicians had encountered a parent who refused some or all vaccines during the past 12 months. As mentioned in their discussion, the survey didn’t ask if those families were dismissed from the practice, only whether the physician would dismiss “If after numerous attempts at vaccine counseling and education a parent continues to refuse. . . . ” A perception of finality in the hypothetical scenario might have biased the physician toward choosing the item indicating dismissal. Moreover, the common reasons in decision for dismissal, “lack of shared goals” and “lack of trust,” may have been more important than the simple refusal of some or all vaccines. Unfortunately, this survey lumped partial refusers with those who would simply delay 1 or some vaccines. My experience suggests a difference between parents who refuse a vaccine and those who want to delay administration. This pairing could explain the difference between the total and partial “refuser” dismissal rate. In regard to objective 2, the lack of difference between sex, age, and years in practice seems logical. Collectively, more than 95% of surveyed pediatricians in this study rated immunizations as extremely or somewhat important.1 The value of preventive care through immunizations is stressed throughout a pediatrician’s training and career. Studies support the importance of physician/practice attitudes on immunization rates.2 The American Academy of Pediatrics and others support immunization educational programs including “refusal to consent” forms. Immunization rates and timeliness of administration are often measured and referred to as a marker for high-quality pediatric care. These issues affect all pediatricians regardless of age and sex. Another question is alluded to in this survey. Does vaccine refusal represent a refusal to accept a treatment or procedure recommended by the physician when that recommendation is evidence based and considered to be high-quality care? How can one rank vaccine refusal in regard to often mentioned “reasons for dismissal”? Is this as important as repeatedly missing scheduled appointments or failure to pay for services? Is it less important than a refusal to take a prescribed medicine? Does repeated discussion require a disproportionate amount of the physician/office resources that may affect the care of other patients? Is it better to “agree to disagree” and mutually part company or run the risk of alienating the patient/family with repeated “discussion” causing them to fire the physician?3 Dismissing a patient is a rare occurrence for most physicians. I have found a vaccine refusal form to be helpful in continuing a relationship with a family who refuses some or all vaccines. The form doesn’t (and can’t) address issues like “mutual trust” or “lack of shared goals for the child.” Although subjective, these 2 factors often weigh heavier than a simple refusal of recommended care. I feel a straightforward immunization refusal does not by itself damage trust, breach shared goals, or necessarily lead to a “my way or the highway” confrontation. This is supported by a recent clinical report from the American Academy of Pediatrics Committee on Bioethics.4 A future survey to tease out these issues would be helpful. Correspondence: Dr Hendricks, Pediatric and Adolescent Care, LLP, 2000 S Wheeling Ave, Suite 300, Tulsa, OK 74105 (jwh@pac.pcc.com). References 1. Flanagan-Klygis EASharp LFrader J Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Arch Pediatr Adolesc Med 2005;159929- 934Google ScholarCrossref 2. Taylor JADarden PMBrooks DAHendricks JWBaker AEWasserman RC Practitioner policies and beliefs and practice immunization rates: a study from Pediatric Research in Office Settings and the National Medical Association Pediatrics 2002;109294- 300PubMedGoogle ScholarCrossref 3. Tetrault JRoediger J How to dismiss problem patients: balance their demands with your rights. Physicians Practice 2005;1573- 75.Available at:http://shands.org/professional/ppd/practice_article.asp?ID=145Google Scholar 4. Diekema DSAmerican Academy of Pediatrics Committee on Bioethics, Responding to parental refusals of immunization of children. Pediatrics 2005;1151428- 1431PubMedGoogle ScholarCrossref

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Oct 1, 2005

Keywords: physician-patient relations

References