• Fresh Perspectives

    Should We Reject Unvaccinated Patients?

    Potential patients -- usually parents -- occasionally ask me if I am "vaccine-friendly." After having this question posed to me numerous times, I’m prepared for the conversation that follows. I’ve tried to ease into it in various ways, but none has proven universally comfortable.

    The question's phrasing is telling about a person's perspective. It implies that their previous experiences with physicians were perceived as "unfriendly." Also, my defensive side infers it would be unfriendly for me to answer in any way other than a vague affirmative.

    Patients who decline vaccines can be understandably frustrating. Even with our deep knowledge, experience and the best intentions, our pleas often seem ineffective. We are usually at a loss about how to improve our sales pitch when faced with vaccine refusal. As we see vaccination rates declining in some areas, the angst among physicians is understandable.

    Professionally, we must consider our organization's and our own practices' policies on vaccine matters. The AAFP has a policy against immunization exemptions. However, this sort of a physician-oriented policy doesn't have much bearing in states that lack strong school requirements for vaccines and allow general parental belief exemptions.

    Also, increasing numbers of U.S. kids are homeschooled; that number now stands at more than 1.7 million, according to the Department of Education. So ultimately, many patients -- children and adults -- can and will remain unvaccinated. And these unvaccinated families will be seeking primary care.

    Despite an American Academy of Pediatrics policy discouraging practices from discharging patients because of parental refusal to vaccinate, a growing number of pediatric practices are doing just that. I understand why practices create such policies in an effort to protect newborns and kids with weakened immune systems. I support their right to do so, but I fear these policies will only worsen vaccination rates.

    It is our duty to protect our individual patients from unnecessary harm, but how to promote the best public health in our communities is a complex issue. By barring the unvaccinated, we might be able to lower the risk of infections spread by sick patients in our waiting areas and exam rooms, but this practice fosters a false sense of security. Our patients are just as likely to come in contact with unvaccinated sick children at a park, school or library, or, as in the case of last year's measles outbreak, an amusement park. Ultimately, unvaccinated sick kids will seek care somewhere -- walk-in retail clinics, urgent care centers or ERs -- that cannot possibly proactively screen vaccine status or refuse care.

    After a lot of consideration, I have elected to provide care to children and adults who decline my vaccine recommendations. My community, Lawrence, Kan., has higher rates of vaccine refusal than do most in the Midwest. Through the first few years of my practice, I have had lots of opportunities to hone my message when the "vaccine-friendly" question arises.

    "I always try to be friendly," is one common response. "Regarding vaccines, I think it's understandable to be cautious of injecting or ingesting artificial substances into your or your child's body," is another comment that has proven to be disarming.

    The reasons for vaccine refusal are numerous and varied, so I try not to make assumptions about a person's position or concerns. Asking, "What specific concerns do you have about vaccines?" is always a great starting point. The usual litany of disproven vaccine harms are common, but there is a wide spectrum of specificity from "I just don't like unnatural things" to "I am ethically opposed to using fetal tissue in medical treatments."

    Depending on the initial responses and circumstances, I may address those concerns immediately or offer to continue the dialogue at a later time. I've realized a single conversation in the clinic -- or even a few -- is unlikely to change someone's mind on the vaccine issue. I have found an email exchange to be a wonderful method of communication for this and other contentious issues.

    A 2014 article in Family Practice Management is a great guide on understanding the rationale behind vaccine refusals, and it offers tips on how to best respond. Whether in person or by email, I often start with some basic education on how our immune system works and how vaccines work to boost that process. Even a basic understanding of how something works can make it seem less scary.

    The article's final section about trust rings most true to my experience. Although most of my patient encounters will not be specifically about vaccine-related issues, each episode of care allows the patient to see I am caring for them in a rational, thoughtful manner.

    My practice numbers are small, but I estimate that 20 percent to 30 percent of unvaccinated kids who start with me become vaccinated within one year. I'd love to see that number above 50 percent and hope that longer relationships can achieve that. I recognize some people will not vaccinate no matter how much they trust me with their other health issues -- a frustrating paradox, for sure.

    Ultimately, if we deny access, I fear vaccine skeptics' mistrust of mainstream medicine and the percentage of unvaccinated children will only grow. I think the only plausible way to convince a skeptical parent or patient is through a trusting relationship with a primary care physician.

    How do you handle unvaccinated patients in your practice?

    Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.


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