business

The Doctor Is Out -- to You

Pediatricians are encountering parents who refuse vaccinations for their children, prompting the doctors to show them the door

Shirley Reese, a mother of six, was thrilled last fall when she learned that her small town of Iron Mountain, Mich., was getting a full-time pediatrician. She quickly made an appointment to bring in her oldest son, nine-year-old Samuel, because of some concerns she had about his performance in school, as well as problems with his tonsils and adenoids.

By the time she left the appointment, she recalls, "I was crying." It had nothing to do with the pediatrician's assessment of Samuel. Rather, it was because Samuel's tenure as the pediatrician's patient had lasted less than an hour.

The pediatrician, Alexis Wolfe, had told Reese she should find another physician for Samuel because she refused to accept the doctor's recommendations to administer several vaccinations for the boy. Reese says she has another son who is autistic, which she thinks may have been brought on by vaccinations. "I'm not going to brain-damage any more of my children by having them vaccinated," she says.

A Matter of Trust?

Reese isn't alone. While no one knows exactly how many doctor-patient relationships are going up in flames, the number appears to be growing, and seems most commonly to be occurring among pediatricians over the issue of vaccination. In a survey of 302 pediatricians published a year-and-a-half ago in Archives of Pediatric & Adolescent Medicine, 28% "said that they would ask the family to seek care elsewhere" for "refusing specific vaccines," and 39% said they would do so for families refusing all vaccines.

They mostly cited as the reason "lack of shared goals" and "lack of trust," while "fear of litigation" was cited by a relatively small number. This wasn't just a random consideration of hypothetical situations, since 85% of the pediatricians sampled reported encountering a parent who refused at least some vaccines during the previous year, and 54% said they had had a patient who refused all vaccines.

Increasingly it seems, the pediatricians are following through on their threats, despite the potential for serious revenue loss. Wolfe of Iron Mountain says she has booted three families out of her practice since last fall, and in five other cases has continued to treat specific chronic conditions, while pushing the families to obtain their children's primary care elsewhere.

Academy Guidelines

Wolfe says she "believes strongly in vaccines," partly because she has a brother who was left blind, deaf, and in a wheelchair after contracting Hib meningitis as an infant—a condition for which a vaccine was developed right around the same time. As a resident, she says, "I watched kids [who weren't properly vaccinated] have non-reversible nerve damage" from various conditions. "I understand people being cautious about vaccines," she says, adding that she's willing to adjust vaccination schedules. But she feels she has no choice but to discharge patients like Reese, who refuse vaccinations completely.

The simmering situation prompted the American Academy of Pediatrics to issue a detailed advisory to its members two years ago about how best to respond to "parental refusals of immunization of children." The advisory suggests that pediatricians try hard to convince patients to go along with vaccinations or, failing that, get patients to sign "a refusal waiver" provided by the academy.

Lisa Fox, the mother of a five-year-old son who has been diagnosed as autistic, last week visited her pediatrician in Crown Point, Ind., and encountered the refusal waiver. She blames vaccinations he has received for her son's condition, and has in recent years gently put off her pediatrician's suggestions that certain vaccines and boosters be administered. (The Centers for Disease Control recommends 10 vaccines, most with multiple administrations, totaling more than 35 vaccinations for children.) "But when we went in this last week, [the pediatrician] said, 'I'll be giving him his vaccination boosters today. We need to get him caught up.' I said, 'We're not going to be doing this.' She asked me to sign a letter."

No Longer Welcome

Fox flinched when she got to this part of the waiver: "I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others that my child might come in contact with." Says Fox, "I really disagree with that statement. There's gathering evidence that giving the vaccine creates more harm than not giving it."

When she returned a few hours later to pick up some documents she had asked the doctor to fill out, says Fox, "The office manager said [the pediatrician] would have no choice but to discharge me." The pediatrician, Lara Azzi, wouldn't comment except to refer me to the Web sites of the American Academy of Pediatrics and the CDC.

Azzi was apparently acting in accordance with the academy's guidelines, which state that "when a substantial level of distrust develops, significant differences in the philosophy of care emerge, or poor quality of communication persists, the pediatrician may encourage the family to find another physician or practice." Fox says she's currently in the process of checking out a pediatrician whom she understands to be more sympathetic to her concerns about vaccination.

Bad Business

And what about the business implications for pediatricians giving the boot to an apparently growing group of parents? Douglas Diekema, a Seattle pediatrician who authored the academy's guidelines on handling anti-vaccination parents, says that so far "The numbers are small enough that it has little impact on physicians."

But longer term, he argues that physicians who refuse to treat objecting patients may actually save money. "These [anti-vaccination] families typically take a lot of time, and that time is not reimbursable. You're spending lots of time trying to convince them [to vaccinate], and you're losing money. You get the same amount of money if you spend 30 minutes as if you spend 10."

While he didn't say it, the situation is actually worse than that for pediatricians, since they not only spend more time with such parents but lose out on the revenues from the vaccines that would have been administered. It sounds like a business owner's worst fears: customers who don't want to buy from one of the owner's core product lines, and then depart in bad spirits.

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