Refuse vaccines and risk dismissal by doctor

By Anita Manning, Special for USA TODAY

It's not unusual for a patient to change doctors. Doctors retire, families move, insurance changes.

And sometimes, patients get fired.

"Discharging parents from a practice is never easy," says Thomas Tryon, a pediatrician at Children's Mercy Hospitals and Clinics in Kansas City, Mo. "I never did it without disappointment that I'd somehow failed to communicate enough with the family."

But done it he has, as have other pediatricians.

Missed appointments, rude or threatening behavior and nonpayment of bills are some of the reasons cited — but one that's becoming increasingly common is parents' refusal to allow their children to be vaccinated.

Tryon and colleagues surveyed 900 pediatricians in nine Midwestern states and found that 21% have discharged families for refusing vaccination. About 60% said one in 20 families in their practice refused or requested altered vaccine schedules; 4% said a majority did. Tryon reported findings last month at a meeting of the Infectious Diseases Society of America.

Vaccine safety has been the subject of escalating controversy in recent years as the number of vaccines recommended for children increases and the diseases they prevent fade into the far reaches of memory. Some parents avoid giving their children some or all vaccines because they believe vaccines are linked to rising rates of developmental disorders such as autism or may cause other health problems. But studies have shown that's not true, says the American Academy of Pediatrics. The sheer number of vaccines given to children — 25 shots in the first 15 months of life — has caused some parents to worry that so much stimulation could overwhelm young immune systems, a theory that has no basis in fact, according to the academy. And spreading out shots over a longer period of time leaves kids needlessly vulnerable to infectious diseases such as polio or measles, it says.

Pediatricians spend a lot of time reassuring parents and referring them to information on the safety and value of vaccines, Tryon says, but when parents persist, doctors have to consider the safety of their other patients.

For years, Tryon says, he was flexible with parents concerned about vaccines. What changed his mind was a family that refused to vaccinate their toddler, then had a second baby. Both got pertussis, or whooping cough, which can be prevented by the DTaP (diphtheria-pertussis-tetanus) vaccine.

"In an 18-month-old, pertussis is a bad disease," he says. "In a 6-week-old, it could be fatal."

He was frustrated not only because the illnesses could have been avoided, but also because the family had "exposed everyone in my waiting room."

At that point, he says, "I said I can't take this risk anymore." He instituted a policy that if, after counseling and discussing scientific evidence on vaccine safety and protective benefits, parents still refuse vaccines, they're out. He notifies them by mail and gives them 30 days to find a new pediatrician.

There are situations when it's appropriate for a doctor to dismiss a patient; the American Medical Association has guidelines, says Trisha Torrey, author of You Bet Your Life! The 10 Mistakes Every Patient Makes.

A doctor cannot legally dismiss a patient for race, religion, disability, sexual orientation, HIV status or other category protected under anti-discrimination laws, or in the middle of ongoing care, she says. The doctor must give written notice and continue care for a period, usually 30 days, during which the patient can find a new doctor.

When it comes to medical decisions, "I'm not of the mind-set that the consumer should be in charge," she says. "The doctor and patient relationship should be a partnership. The key is to find a doctor who has the same belief system or is flexible enough to accommodate the patient's point of view," she says.

Many doctors see the issue as a matter of public health and make their policies clear to new patients at the outset.

Three years ago, pediatrician Raymond Cattaneo of Kansas City, Mo., "instituted a strict immunization policy — no refusals and no alternative schedules," he says. Anything else would be "allowing patients to decide something that was not right."

The policy met with some resistance, he says. "A few patients were very upset. … One family called a local news station. But overwhelmingly we were supported."

Unimmunized patients pose a potential risk to doctors, staff and patients, he says. "We have patients who cannot be immunized because of chemotherapy (for cancer treatment). We have chronically ill patients, patients with asthma. And I have patients who have thanked us for our policy," he says.

Patients who disagree often feel demonized, says Barbara Loe Fisher, founder of the National Vaccine Information Center, which supports the right to refuse vaccines. "It's hard to find someone who will talk now. They're vilified and harassed."

On the center's website, there is a "vaccine freedom wall," where parents post stories of "being thrown out of doctor's offices or being harassed for trying to make informed decisions about vaccines," she says. A Facebook page, Proud Parents of Unvaccinated Children, has more than 7,300 fans.

New York City pediatrician Lawrence Pavelsky, who says his practice is mainly consultation and education, works "with families who have a child with chronic illness, and I work to improve their health without pharmaceuticals."

When patients come to him, he says, "we talk about nutrition, sleep, development, vaccines, ways in which kids get sick and why and how to get them well if they are sick" without using vaccines or medication. He believes doctors who vaccinate children are working from information that is simply wrong.

"I did my own research," he says. "Over the last 14 years, I have found that some or even a majority of the information I was taught in medical school was either false, incomplete or had flawed reasoning."

He hopes to encourage more conversation about vaccine safety. "My interest is to create an environment where a dialogue can be had," he says.

But the Midwestern pediatricians in Tryon's survey said they try to talk to parents who mistrust vaccines. After explaining the importance of vaccines over and over, they are "fatiguing on this issue," Tryon says.

"Because these diseases are being prevented by vaccines, people no longer remember how bad they were." When parents refuse vaccines altogether, "they're telling me 'We don't trust your advice.' " ... titialskip