Should pediatricians “fire” families if they refuse one or more childhood vaccinations?

Well over a third of pediatricians — 39 percent — say they would "dismiss" families that refuse all vaccinations, a new study suggests. That's surprising, says study leader Erin A. Flanagan-Klygis, MD, assistant professor of pediatrics at Chicago's Rush Medical College.

But another finding surprises Flanagan-Klygis even more. More than one in four pediatricians — 28 percent — say they would fire families that agreed to some vaccinations but refused one or more other vaccinations.

"We were really taken by the number of doctors who would dismiss patients who were partially accepting of vaccinations," Flanagan-Klygis tells WebMD. "We did not expect this high a number."

The study is based on questionnaires filled out by 302 randomly selected members of the American Academy of Pediatrics who provide routine childhood vaccinations. It appears in the October issue of Archives of Pediatrics and Adolescent Medicine.

Doctors aren't taking a my-way-or-the-highway attitude, Flanagan-Klygis says. It's all about trust.

"Their answers really spoke to how important the relationship between parent and pediatrician is," she says. "They did not think they would be able to forge a relationship with a family like that. They felt they would not have the trust they needed to have to move forward."

Media’s Influence on Vaccination Attitudes

The problem, in a nutshell, is that fewer and fewer parents remember how awful vaccine-preventable childhood diseases can be. But media reports of rare-but-terrible vaccine side effects — magnified and multiplied by anti-vaccination web sites — catch parents' attention.

Pediatricians, on the other hand, have learned to have a healthy respect for vaccine-preventable diseases. Trained in public health, they believe that the benefit of preventing these diseases and their complications outweigh the risk of rare vaccine side effects.

"It is extremely frustrating for pediatricians that the accurate information parents need isn't what gets on the news," Flanagan-Klygis says. "Parents come to us with fears that are unfounded yet hard to overcome in the span of a short visit. This is one way pediatricians express their frustration with that situation."

Neither Flanagan-Klygis nor J.W. Hendricks, MD, clinical professor of pediatrics at the University of Oklahoma, Tulsa school of medicine, think frustration alone is a good enough reason for a doctor to fire a family. What's important, Hendricks says, is for the parent and pediatrician to share the same overall goals for a child.

"If you have exhausted all opportunities to discuss immunization and the parent still refuses, there may be a lack of shared goals," Hendricks tells WebMD. "Then the doctor may feel it is best for someone to seek care where they can find a doctor most compatible with their goals."

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The Fired Family — A Missed Opportunity?

Hendricks notes that the study asked doctors whether they would fire a family over vaccine refusal — not whether they actually have done so. WebMD asked both Flanagan-Klygis and Hendricks whether they'd ever done so. Both said no.

"When the patient is gone, they are gone. The opportunity for righting misinformation is missed — perhaps forever," Flanagan-Klygis says. "Is it helping to ask them to leave rather than work with them any way you can? I think if a family feels they can't be in a good relationship with a doctor, then most families will leave. But that is their choice. It should be their decision."

Flanagan-Kylgis tells families that refuse vaccination that she will continue to raise the issue. If families are willing to engage in this give-and-take, she has no qualm about continuing to treat them regardless of their vaccination preference.

Hendricks is reluctant to make families feel badgered. He asks families to sign a consent form listing vaccinations they accept and don't accept.

"The relationship parents have with their child's physician is much more important than minor yeses and noes," he says. "If they can develop a give-and-take relationship, they are going to be happy and their child's doctor is going to be happy. We are all interested in the health of that child. … I would not ever want a family to be fearful that if they ask about a treatment plan or a specific immunization, that their doc is going to say, 'This is it, I can't take any more.'"

Flanagan-Kylgis says this kind of give-and-take may mean extra effort for parents.

"I hope that families will approach the issue of vaccination with an open mind and be willing to have guidance from their pediatrician about credible sources of information," she says. "I hope families will be willing to have a dialog with their doctor if they have questions about a vaccine. If it can't happen in the context of a health maintenance visit, they should schedule time to talk about these issues with their pediatrician. Then they can make the best possible decision for their family."

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By Daniel J. DeNoon, reviewed by Louise Chang, MD

SOURCES: Flanagan-Klygis, E.A. Archives of Pediatrics and Adolescent Medicine, October 2005; vol 159: pp 929-934. Hendricks, J.W. Archives of Pediatrics and Adolescent Medicine,October 2005; vol 159: pp 994. Erin A. Flanagan-Klygis, MD, assistant professor of pediatrics, Rush Medical College, Chicago. J.W. Hendricks, MD, clinical professor of pediatrics, University of Oklahoma, Tulsa; and vice president, Oklahoma Academy of Pediatrics.