It’s an eye-opening survey, to say the least, and its findings are clear: Nearly all — 93% — primary care doctors and pediatricians surveyed say that in a typical month, parents ask them to deviate from the recommended childhood immunization schedule and instead give the shots over a longer period of time, according to a report published Monday in the journal Pediatrics. And while nearly 90% thought that such spacing out of the immunizations would put the children, and the community at risk of spreading infectious diseases like measles, 37% said they agreed to do so often or always. That was a 131% increase since the last survey, conducted in 2009, when only 16% said they agreed to changing the recommended vaccine schedule.
“Doctors are feeling really conflicted because they overwhelmingly think this is the wrong thing to do, and is putting children at risk, but at the same time, they want to build trust with their patients and meet people halfway,” says Dr. Allison Kempe, professor of pediatrics at University of Colorado and Children’s Hospital Colorado, who is the lead author of the study.
Even more concerning, she says, is the fact that 40% of the physicians said that the vaccine issue was the source of their job dissatisfaction. The survey also asked them about different strategies the doctors employed with parents to discuss the importance of following the existing vaccination schedule, but the doctors revealed very little confidence in those methods. In fact, the strategy they believed worked most often only garnered a 20% effectiveness rating, and that was telling parents that the doctors immunized their own children according to the recommended schedule.
“It’s a terrible conflict when I have to make a decision when I’m doing my vaccine orders for a particular child and decide if it’s going to be the pertussis vaccine for that infant or the Hib or the pneumococcal,” says Dr. Julie Boom, director of the immunization project at Texas Children’s Hospital and associate professor of pediatrics at Baylor College of Medicine, of the decision she has to make when parents insist on giving their babies only one immunization during a visit. While Boom makes every effort to discuss with parents the importance of sticking with the recommended immunization schedule, she says “I will offer the vaccine at that visit and explain the risks and benefits of the decision that parent is making and try to get them to come back as quickly as possible to take the next vaccine so the baby will be fully vaccinated as on time as possible.”
But she does that knowing that the baby leaves her office at higher risk of potentially getting sick since he is not fully immunized. “The baby leaving my office is at risk of getting the illnesses for which he’s not vaccinated,” she says. “To know I’m going to pick one [vaccine] and leave the other behind, despite all the time I spend explaining the risks and benefits to the parents—it’s very difficult for me.”
And it’s increasingly a problem for her colleagues as well. While parents who refused to vaccinate their children gained the most media attention in recent years and likely contributed to pertussis and measles outbreaks, even more parents – about 13% — used an alternative vaccine schedule that included delaying some of the shots. These parents often express concern about “overloading” their babies’ immune systems with too many shots in one visit (the most that infants generally get are five, at the year-old visit). In the survey, 35% of doctors said they realized that allowing parents to delay shots sent mixed messages; parents could interpret the action as proof that the existing schedule wasn’t so important after all if doctors ended up changing it.
Part of the conflict may come from the advice from organizations to which these physicians turn for help. As some frustrated doctors began to “fire” their patients and refuse to see them if they declined to vaccinate their children or asked for alternative immunization schedules, in 2005, the American Academy of Pediatrics advised its members to not dismiss those parents and urged them to discuss and educate them instead about the importance of vaccinations and of getting them on time. That may explain why 82% of doctors in the current survey said they felt agreeing to delaying some vaccines would build trust with their patients; 80% said that if they refused to accommodate the parents wishes, these parents would leave to find some doctors who would.
“Nobody is in favor of dismissing patients, but I think we need to get a little bit straighter about communicating to these parents about how strongly we feel about vaccinations, and how detrimental spacing them out is for their child,” says Kempe.
Among the most commonly used strategies to convince parents, doctors cited their comfort with vaccinating their own children according to the schedule, stressing that spacing out vaccines puts their children at risk of getting sick, reminding them of recent outbreaks of vaccine-preventable diseases, and explaining that alternative schedule haven’t been studied for their safety. Doctors have even informed parents that bringing their child back for multiple visits to get jabbed with a shot can be more painful for the baby. None were rated by the physicians as being more than 20% effective, leaving doctors at a loss.
That’s why professional organizations should take a stronger role in providing doctors with more guidance about what may work and what doesn’t. Conducting more studies on different methods of educating and addressing parents concerns could arm doctors with more data and scientific evidence to back up their belief in the established immunization schedule, for example. Kempe also notes that starting to educate parents earlier, such as during pregnancy, may help to reinforce their comfort with vaccines and what they can do to protect their baby once he is born. And reaching parents and parents-to-be on a more consistent basis may also be key to alleviating their concerns about vaccines. “We as doctors have not exploited mass media or the kinds of media that the anti-vaccine movement has,” says Kempe. “We are not doing a great job of countering the misinformation out there, and also not doing a good job of enlisting parents who are pro-vaccine in a proactive way to establish a social norm.”
Part of that has to do with the fact that the time that doctors typically have with parents during well-baby visits is short. Most doctors reported having to spend at least 10 minutes with parents to address their vaccine concerns; that’s about half of the time of an average visit, which also has to cover other important wellness issues such as nutrition, car safety, and more. So Kempe says other strategies, such as group visits or sessions to address vaccine questions specifically, or designated staff at family practices or pediatricians’ offices who are assigned the task of answering questions about vaccines and vaccine safety might be more effective. In Boom’s practice, she often schedules a separate visit for parents to discuss just their vaccine questions, so she doesn’t feel rushed to come to a decision about whether to help the parents space out vaccines or not.
For Boom, the key is understanding where the parents’ concerns come from. “For one parent it may be about long term effects of vaccinations, and for another it may be something else,” she says. “You have to understand where the misinformation is coming from, and then very specifically address each parent’s questions. It does take time.”
Using this strategy, Boom feels she is relatively successful in educating parents about the need to follow the recommended vaccination schedule. But she admits that working in an academic institution, she has the luxury or more time with her patients.
For those that don’t, it’s clear that frustration is reaching a boiling point in doctors’ offices. “I hope this study is a wake-up call, and I hope it’s time to say ‘okay, what we are doing isn’t working,’ and start asking ‘what should we be doing?’” says Kempe.
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