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What Kind Of Doctor Fires Vaccine-Refusing Patients?

This article is more than 8 years old.

A number of stories published in the midst of the Disneyland measles outbreak last winter looked at the trend of doctors, particularly pediatricians, “firing” families that refused vaccines for their children. The practice remains controversial among pediatricians but relevant enough that a recent session at the American Academy of Pediatrics Annual Conference addressed how pediatricians can legally protect themselves when parents refuse vaccines and the most appropriate way to dismiss a family from the practice, even though the AAP discourages such dismissals.

Now a new study in Pediatrics today takes a closer look at the pediatricians who are more likely to sever the doctor-patient relationship as a result of parental vaccine refusal. In a survey of 534 pediatricians and family physicians (a 66% response rate), a large majority (83%) said they have at least one family refuse at least one vaccine in a typical month, and more than half (63%) said 1% to 4% of parents refused vaccines. More disturbing, one in five said at least 5% of parents refused vaccines.

But there’s a silver lining to those numbers: Only 11% of doctors said the proportion of parents refusing vaccines had gone up since the previous year. Most said it stayed the same and nearly a quarter said it had dropped (23% of all respondents and 28% of pediatricians).

Another interesting finding — particularly in light of the new California vaccination law — is that vaccine refusal was lower and pediatrician dismissal from practices was higher in states with stricter vaccination laws. Twice as many doctors in states without philosophical exemptions to school vaccination requirements said they didn’t have a family refusing vaccines in a typical month. And although one in five pediatricians reported “often or always” dismissing families that refused vaccines, the proportion was almost four times higher in states without philosophical exemption laws (all but 19 states). In those states where philosophical exemptions were allowed, just 9% of pediatricians said they regularly fired vaccine-refusing families, but more than a third (34%) of pediatricians fired vaccine-refusing families in the states without philosophical exemptions.

Even the ease of the exemption process in states that have exemptions to school/daycare vaccine requirements made a difference in pediatrician practices. Whereas 12% of the pediatricians dismissed non-vaccinating families in states with easy exemption processes, the proportion jumped to 22% of pediatricians in states with a moderately difficult exemption process and 28% in states with difficult exemption processes.

But what did pediatricians have in common if they sent their vaccine-refusing families packing? As one might guess, they were more likely to live in states without philosophical exemptions and more likely to be from the South (where more of the states with stricter vaccination laws are). But the biggest factor was being in private practice. Those in private practice had five times greater odds of dismissing families for vaccine refusal than pediatricians in HMO, university or public settings, perhaps at least partly because the latter may not have the option of firing families. But liability and autonomy may play a role as well.

At the time of the Disneyland outbreak, I wrote about two particularly permissive doctors when it came to vaccines (one was particularly vocal about the California law). In reporting that article, I asked some pediatricians whether they accepted non-vaccinating families and why or why not. At the time, Tucson-based pediatrician Chris Hickie discussed the AAP policy and explained his reasoning told me how he made this decision.

“I think the AAP's policy statement asking me not to ‘eject’ vaccine-refusing parents from my practice is valid when your practice area has good vaccination rates — that is, at or above herd immunity levels — and you aren't having vaccine-preventable disease outbreaks,” he said. “I think it becomes a dangerous policy to patients when you live in a practice area where you do not have herd immunity levels of vaccination because then the odds become much greater that a child will come into your office with a vaccine-preventable disease like pertussis, measles or chickenpox and expose a vulnerable patient too young to be vaccinated or with a medical reason for a weakened immune system that either won't respond to vaccines or cannot receive vaccines.”

Hickie made a decision for his own practice when pertussis walked through his office doors during a 2013 outbreak in his area.

“I decided to stop seeing electively non-vaccinating families when an older unvaccinated child came into my waiting room with florid pertussis — coughing paroxysmally to the point of turning blue and retching,” Hickie said. “Thankfully my waiting room was not crowded and no infants were present, but the episode helped me to realize that spread of vaccine-preventable diseases via my waiting room is much more likely to happen if there are electively non-vaccinating families in my practice.”

One of the arguments against this practice, the authors of the Pediatrics study point out, is the hypothesis “that dismissing families could lead to increased clustering of vaccine-refusing families within certain regions, leading to outbreaks of vaccine-preventable diseases.” But they said their results suggest otherwise: “Our finding argues against this hypothesis because lower vaccination rates and higher rates of vaccine-preventable diseases tend to be in states in which physicians are less likely to dismiss families.” Instead, they suggested their findings appear to match up more with the idea that “having a policy for dismissing families may actually increase vaccine uptake, as it provides a strong message to families on the importance of vaccination.”

Yet they acknowledge we just don’t have enough research in this area. In fact, no studies at all have looked at how pediatrics policies of dismissing families affects uptake of vaccines. Given the concerns about pockets of under-immunized children and the recent outbreaks, researchers clearly need to get on the ball.

My book, The Informed Parent, with co-author Emily Willingham, is available for pre-order. Find me on Twitter here.