This is the first study to address how parental vaccine refusals impact physicians personally. In Hendricks' editorial about the article by Flanagan-Klygis et al.,19
he takes issue with the authors for assuming that parental vaccine refusals negatively affect the physician-parent relationship.23
The findings from the current study support Flanagan-Klygis and colleagues' assumption that parental vaccine refusals are viewed negatively by pediatricians.19
Physicians who report a negative impact are significantly more likely to self-report working in suburban, solo/group practices with families from higher physician-estimated SES, and to care for larger numbers of families with vaccine concerns and/or refusals. Perhaps most importantly, physicians who report being negatively impacted are significantly more likely to dismiss families who refuse vaccines.
Negative feelings on the part of physicians may interfere with their ability to communicate and form trusting relationships with families who refuse vaccines. Poor communication and dismissal of families limit open discussion with parents and may make it harder to convince hesitant parents to immunize their children.7,24
Several studies have postulated that the number of parental vaccine concerns is likely to have increased since 2000 due to the controversy over thimerosal in vaccines, increased media coverage of unfounded links between vaccines and autism, and the increased number of vaccines being recommended for children.2,10,20
This study suggests that such an increase in parental concerns may be the case, at least in Connecticut, as the great majority of respondents noted an increase in parental vaccine concerns in the last five to 10 years. Similar to national studies, 83% of pediatricians in this study reported parents in their practices who refused some vaccines, and 60% reported families who refused all vaccines.19
The physicians' perspective in this study supports findings from previous studies that children who are undervaccinated due to parental choice tend to be from families with higher SES and have parents with college degrees when compared with children who are fully vaccinated or who are undervaccinated due to other reasons.2,5
Most of these previous studies have addressed this issue by gathering information from parents about their SES and education level. This study supports these findings by examining physician-reported estimates of the SES and education levels of the families in their practices. Suburban respondents serving families with higher physician-estimated SES and education levels report “more or many more” parental vaccine safety concerns and refusals, significantly higher percentages of families with vaccine concerns, and more families delaying and refusing vaccines compared with their urban colleagues who care for poorer families with less educated parents. There are many potential reasons as to why this is the case. Wealthier parents may have better access to the Internet and media sources that discuss potential vaccine safety issues and more time to devote to investigating potential concerns. Also, families who are wealthier and more educated may feel more empowered to question physicians' and governmental recommendations about immunizations.
Only two previous studies have sought to determine how commonly physicians dismiss families who refuse vaccines from their practices. Our finding of more than 30% of respondents reporting having dismissed families for vaccine refusal is much higher when compared with findings from a 2001 survey of AAP fellows in which 5% of pediatricians routinely dismissed families who refused vaccines and 18% sometimes dismissed families, and it is similar to the 39% dismissal rate found when asking physicians what they would hypothetically do if parents refused vaccines.19,25
Physicians who practice in suburban areas and see families with higher physician-estimated SES were more likely to dismiss families who refuse vaccines than were physicians who practice in urban, hospital settings with poorer or working-class families (as estimated by physicians). Physicians who choose to practice in urban areas and hospital settings with poorer populations may inherently have different philosophies about terminating families when compared with their suburban colleagues. This is partly borne out by our study finding that urban physicians are significantly less likely to agree with the practice of dismissing families for refusing some or all vaccines than suburban physicians. However, this finding does not hold true for practice type or for physician-estimated parental SES or education level. Physicians who work in hospital or university settings and care for lower physician-reported SES families do not differ from other physicians in agreeing or disagreeing with the dismissal of families for vaccine refusal. Physicians who work in hospital or university settings may need to comply with institutional guidelines on dismissal of patients and, therefore, may be unable to act on their personal opinions about families who refuse vaccines. Physicians who work in private practices may have more leeway as to when or if they dismiss patients.
That physicians who dismiss families who refuse all vaccines report fewer of these families in their practices may result from both the actual dismissal of families and possible avoidance of these practices by parents who refuse vaccines. When some physicians choose to dismiss these families, the burden of caring for them may be shifted to other physicians in the community.26,27
Practices that do not dismiss vaccine-refusing families may find themselves with a higher proportion of these families whose care may require more physician time, energy, and patience. This hypothesis may be supported by our finding that physicians who report larger numbers of parents with concerns or refusals are significantly more likely to say that these issues have a negative impact on them personally. In addition, higher numbers of undervaccinated patients clustered in certain practices or communities put the whole community at increased risk for vaccine-preventable diseases.4,28
Health maintenance organizations have started to include vaccination rates as part of their pay-for-performance programs that reward physicians financially for meeting certain benchmarks, including childhood immunization rates.29–31
This practice may financially penalize physicians with larger numbers of undervaccinated children and further discourage physicians from caring for these children.32
The AAP, American Medical Association, and Centers for Disease Control and Prevention all recommend against discharging families from a practice based solely on the families' decision not to vaccinate.1,33–35
Physicians who favor dismissing families argue that refusing vaccines can be construed as a form of neglect, that vaccines are important both for the health of individual children and the public's health, and that parental vaccine refusal substantially undermines the physician-family relationship.7,36,37
Those arguing against dismissal question if physicians would terminate their relationship with families because parents smoke around an asthmatic child, allow children to ride in the back of pickup trucks, or contribute to their child's obesity by overfeeding, all actions that put children at risk and go against physician advice.20,36,38
Children whose parents refuse immunizations still deserve quality pediatric care. Dismissed families may seek care from practitioners who further encourage or are more tolerant of their decision not to vaccinate.9,36,39,40
One recent study found a small but significantly increased incidence of vaccine safety concerns among primary care providers who cared for children who were undervaccinated by choice compared with other providers.21
This study was limited by its small sample size, which was chosen based on convenience. The trends in the number of vaccine concerns and/or refusals in the last five and 10 years may be underestimated due to newer physicians who have only recently started in practice being unable to answer these questions. There was a 31.8% total response rate, which leaves the potential for a significant nonresponse bias. It is possible that physicians choosing to respond were more affected by the issues of parental vaccine concerns and refusals. Even if suburban physicians were overrepresented, the findings still support more prevalent vaccine concerns and/or refusals among wealthier, better educated populations. Recall bias or inaccurate estimation by physicians concerning parental SES and education level, percentage of families with vaccine concerns, and those who have delayed or refused vaccines in their practices is possible. Differentiating between delaying and refusing a vaccine may be difficult, as parents may choose to get the vaccine at a later time. Physician estimation of families' SES and education level may be limited or inaccurate. While the estimates given by physicians may not be exact, they do reflect physicians' impressions of the numbers and characteristics of families they see with vaccine concerns and refusals, and this finding deserves further study.
We do not know how well our sample represents the population of primary care pediatricians in Connecticut (regarding years in practice, practice setting, practice type, and physician demographics) and, therefore, cannot presume that our findings are generalizable to all primary care pediatricians in the state. Connecticut has a wealthy, educated population, and physicians and parents may differ from those in other areas of the U.S.41
The rate of vaccine refusal in Connecticut is low compared with other states; however, the rate is increasing, based on its number of non-medical school exemptions.42
Even if generalizable to Connecticut, these findings may not be generalizable to other states.