Vaccine Safety Curriculum for Medical Residents - American Academy of Pediatrics - Page 7

[purslaine]

Originally Posted by AbbyGrant 

I don't really want to get into a debate about semantics. Of course doctors should treat people with respect and not shove things down their throats and ultimately medical decisions are not up to doctors. But they have an obligation to make sure people are making fully informed choices. I think that training guide offers some good insight for doctors on how to have respectful conversations about the issue rather than just dismissing concerns out of hand.  As a matter of fact, it stated specifically not to just dismiss concerns. While of course it's biased, it seems like step in the right direction. Better than just telling people this is the way it is, just deal. It opens a dialogue.

I agree with the bolded.

If the talking points can be used in a respectful discussion, it's a good thing. It would be better if people could have more natural conversation, but still, it is better than nothing.

I am less thrilled with the idea of them using it to convince patients to do something they do not want to do.  It is too patronizing for my taste.  

[purslaine]

Originally Posted by AbbyGrant 

      Quote:

I totally agree. I have refused medical treatment for myself before, and while it would have been nice for me if the doctors had just shut up and gone with it since I had done my research (and had a strong gut feeling I was right ), I knew they had an obligation to make sure I understood what I was doing and what all the risks were and that I was going against their recommendation.  They would have had to deal with the consequences too if I had been wrong. 

Maybe it comes down to degrees….I do think doctors have an obligation to make sure I know the options and risks….

I think my issue with the link in the Op is that the intent seems to be to convince people who do not want to do something to do it.

Would you have been OK if your doctor tried to convince you to undertake the medical treatment, even after  s/he had ascertained that you had done the  research and knew the risks and consequences?  

[AbbyGrant]

I thought this bit was interesting:

Practicing Pediatricians

1.Nearly all have learned to “negotiate” vaccines, use alternate schedules as part of routine practice today.

2.Many parents feel it is now “due diligence” to question one or more vaccines, even if they will readily accept them.

3.MD must deal with own anger/rejection at not being trusted over vaccines.

For me, there was a noticeable change from my oldest child's two month appointment to my youngest child's two month appointment.  For the oldest, it was just assumed that we were going to do all the standard two month vaccines.  For my youngest, the doctor just asked something like "so what do y'all want to do as far as vaccines today?" without us having given any indication prior to that that we wanted to go with an alternative schedule. 

[Turquesa]

From AbbyGrant's link:

Those data showed that the top reasons residents and practicing physicians were given by parents reluctant to immunize their children were

• vaccines may cause autism or other developmental disabilities (72.9 percent),
• a vaccine is "too new" or has not been tested enough to ensure its safety (61.5 percent), and
• too many vaccines are given during a single doctor's visit or during the child's first 2 years (59.7 percent).

"Residents are not really trained to deal with that kind of pseudoscience," Luther told AAFP News Now. "So we developed a program that will teach residents to counsel these parents and patients in order to improve vaccination rates.
 

As Kathy suggested, autism isn't even an issue for some vaccine skeptics.  We selectively vax, with MMR included in the mix, and consider autism to be a red herring.  In fact, it drives me batty when doctors--rather than asking me or bothering to listen--just jump right in with, "You know, that whole autism thing was debunked, right?"  (Ummmm, doc?  You're the only one in this exam room who's mentioned autism...)  It's like they've turned their memorized talking points onto Auto-Pilot Mode.  Sorry.  Digressing. 

The other two bullet points, however, are interesting.  Begging your pardon, but how is it is "pseudoscience" to demand more rigorous science?    

Anyway, I would honestly challenge the underlying assumptions in both AbbyGrant's and the OP's link---namely, that a doctor can and should say "just the right thing" during a well child check to convince you to comply with CDC vax recommendations.

Conventional wisdom holds that pediatric visits last an average of 15 minutes, (no links on this, sorry.  I've timed mine to be about 10 minutes), and there is a LOT of ground to cover in that time--developmental milestones, physical check-ups, breastfeeding and nutrition-related advice, an entire hit-list of things that the doctor is supposed to tell you, (keep the hot water heater at 120, here's how to childproof your house, etc.)...not to mention addressing a whole slew of (non-vax-related!) questions that parents bring to the exam table. 

So it takes a certain degree of naivete among these pediatricians in question to believe that a 30-60 second elevator speech on the virtues of vaccines will some how have the power to sway parents.  Maybe it does in some instances, but speaking for just myself, on an issue this complex, I need much much more than that to make my decisions.  I have poured hours over the CDC Pink Book, The Vaccine Book, Cochrane Review, scholar.google.com, and various pro-v-con websites.  For me, the issue continues to be an evolving one. 

Unless I'm the only parents out there who takes this approach, maybe pediatricians shouldn't put so much pressure on themselves to say The Right Thing.  

[Taximom5]

  Begging your pardon, but how is it is "pseudoscience" to demand more rigorous science?    

Turquesa's entire post is great, but I thought this in particular is absolutely brilliant.

[purslaine]

Here are few lines from the link in the OP that I think would be counterproductive.  

Challenge them by saying, “Do you really think I would recommend something that I didn’t think was best for your child?”

Aggressive - how is one supposed to answer that question without complying or getting into an argument?

Challenge them by saying, “Do you really think all the pediatricians in the country are conspiring to promote a schedule that we don’t think is safe and the best for children?”

Aggressive - same as above

Ask them why they are taking medical advice from an celebrity, friend, relative, magazine instead of from their child’s doctor

Aggresive - same as above - and a little patronising.  Why assume I am getting information from a celebrity, etc? 

There is no obvious conflict of interest (e.g. selling a book)

HA!  I am sure most non-vaxxer or vax questionners know there is a huge conflict of interest within the vaccine community (specifically pharm companies sitting on policy making health advisory committees (shudder))

Following a delayed vaccine schedule does just that - it delays protection. Challenge the parent by saying, “You don’t delay putting your baby in a car seat, why do you want to delay protection from vaccines?”

Some parents might be Ok with this one.  Some parents who know the actual chances of their child catching some VPD's (like Diptheria and Polio) is virtually zero might think they are comparing apples to oranges.  

Missed opportunities to immunize often stay missed and these children never get fully immunized.

a person who says "no" to their doctor over vaccines does not care about this.  Indeed, it is what they are hoping. 

Point out that HPV infection usually occurs within a few years of sexual debut. Challenge the parents by asking “Did your parents know when you started being sexually active?”

This could be interpetted as aggressive.  Moreover, yes my mom did know when I became sexually active.  

[slmommy]

Originally Posted by kathymuggle 

Following a delayed vaccine schedule does just that - it delays protection. Challenge the parent by saying, “You don’t delay putting your baby in a car seat, why do you want to delay protection from vaccines?”

Some parents might be Ok with this one.  Some parents who know the actual chances of their child catching some VPD's (like Diptheria and Polio) is virtually zero might think they are comparing apples to oranges.  

I wanna point out that by this logic, ACIP has kids "riding around in cars w/o carseats" for at least the first 2-12 months of life.  (and before anyone brings up herd immunity, if vax didn't fail so much maybe herd immunity would work better. Pertussis.)

The "challenge parents" lines are straight out manipulation tactics. 

Yes, I do think you are recommending something that is not best for my child - something tells me that would get me fired pretty quick from some US pedis.

[Rrrrrachel]

Herd immunity for pertussis still works in most areas. It does require a higher than usual level of vaccination due to the lower than normal effectiveness. Current suspicions of a mutation aside pertussis is 80% effective. Most vaccines are much better than that, 98-99%.

[Taximom5]

kathymuggle and slmommy, I think you have both put your finger on what's wrong with the whole approach of "challenging" parents.

It is blatant manipulation.  

"Challenge them by saying, “Do you really think I would recommend something that I didn’t think was best for your child?”:"

There are people who have studied their religion for many years; they believe that my children and I are going straight to hell because we don't belong to their particular church.  They certainly know more about their religion than I do. That doesn't mean that they are correct in their beliefs, nor that they know what's best for my children.  But that doesn't stop them from trying to manipulate us every time they see us.

"Following a delayed vaccine schedule does just that - it delays protection. Challenge the parent by saying, 'You don’t delay putting your baby in a car seat, why do you want to delay protection from vaccines?' "

This is a clear attempt to make a parent feel guilty for delaying vaccines.

If putting babies in car seats resulted in 2000 cases of admitted and compensated cases of car seat-induced brain damage, we wouldn't be using car seats.  In fact, many baby safety items, such as cribs, have been recalled and redesigned when fewer than 10 babies die.

Car seats do not cause brain damage, nor do they cause seizures, asthma, diabetes, lupus, MS, rheumatoid arthritis, food allergies, bowel disorders, or any other autoimmune illnesses.

Vaccines HAVE caused all of the above.

Car seats have also been shown to have an enormous effectiveness at protecting a child in all but the worst of crashes.

With vaccines, we are seeing more and more reports that they are not as effective as originally marketed (MMR--we were initially told by that one shot conferred lifetime immunity for 95%), flu shot (as effective as...a placebo), pertussis (again, was supposed to confer lifetime immunity after initial series), Gardasil (immunity wanes after 4-6 years, necessitating 8 boosters before the age of 50).

Comparing vaccines to car seats is therefore totally inappropriate--vaccines offer neither the effectiveness nor the lack of harm demonstrated by car seats.  And it's absolutely disgusting that doctors would be taught to use such a comparison; it's tantamount to lying. And it's inexcusable that doctors would be encouraged to shame, guilt-trip, or discomfit a parent into compliance with an invasive procedure.

[Rrrrrachel]

Is it manipulative for a doctor to point out second hand smoke causes SIDS in order to get a mom to quit?

[Taximom5]

Originally Posted by Rrrrrachel 

Is it manipulative for a doctor to point out second hand smoke causes SIDS in order to get a mom to quit?

Sure it is--even if it's true, it's manipulative.  But that is also not a relevant comparison, because you're talking about an addiction (where manipulation is not very effective anyway).

Last I checked, avoiding an invasive procedure involving risks to me and profit to someone else is not an addiction.

Now, I have no doubt that second hand smoke does indeed contribute or even directly cause SIDS.

But in looking up second hand smoke and SIDS, I find it fascinating that the CDC posts:
"SECOND HAND SMOKE CAUSES SIDS."  http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/

They base this off a study that shows increased incidence of SIDS with exposure to second-hand smoke.

There it is.  A causes B because we see increased incidence.  That proves causation for second hand smoke and SIDS.

Yet we have a study showing that infant boys are 3 times as likely to develop autism if they receive hep B in infancy.

But we are told that correlation does not equal causation.  And the CDC is very careful not to mention that study; it certainly is not dicussed in the Vaccine "Safety" Curriculum.

[slmommy]

Can anyone point me in direction of complete and widely accepted definition of "informed consent" in this type of medical situation?

Wouldn't coercion need to be absent? (ie. emotional manipulation, lying about exemptions, threat of termination of care)

Quote:

Except for during clinical trials, there is no Federal requirement in the United States for providing informed consent regarding the administration of vaccines. [1]

http://en.wikipedia.org/wiki/Informed_consent#Vaccines

Also, if all information comes from industry, and the industry is not obligated to give the patient any information...... 

Quote:

No vaccine manufacturer shall be liable in a civil action for damages arising from a vaccine-related injury or death associated with the administration of a vaccine after October 1, 1988, solely due to the manufacturer’s failure to provide direct warnings to the injured party (or the injured party’s legal representative) of the potential dangers resulting from the administration of the vaccine manufactured by the manufacturer.

http://www.law.cornell.edu/uscode/text/42/300aa-22

[slmommy]

Originally Posted by Taximom5 

Yet we have a study showing that infant boys are 3 times as likely to develop autism if they receive hep B in infancy.

For anyone who wants it:

"Findings suggest that U.S. male neonates vaccinated with the hepatitis B vaccine prior to 1999 (from vaccination record) had a threefold higher risk for parental report of autism diagnosis compared to boys not vaccinated as neonates during that same time period."

http://www.ncbi.nlm.nih.gov/pubmed/21058170

http://www.huffingtonpost.com/david-kirby/new-study-hepatitis-b-vac_b_289288.html

Quote:

To begin with, it is unscientific and perilously misleading for anyone to assert that "vaccines and autism" have been studied and that no link has been found. That's because the 16 or so studies constantly cited by critics of the hypothesis have examined just one vaccine and one vaccine ingredient.

...

It is illogical to exonerate all vaccines, all vaccine ingredients, and the total US vaccine program as a whole, based solely on a handful of epidemiological studies of just one vaccine and one vaccine ingredient. It is akin to claiming that every form of animal protein is beneficial to people, when all you have studied is fish.

[slmommy]

Back to original topic...

Quote:

Do all states allow exemptions from school entry requirements?

Answer: Some states only allow medical exemptions. A minority allow exemption based on personal belief.

I find this one to be really bad. This to me, is akin to lying, although nothing is untrue, it is really leaving out a lot of information with a clear agenda.

Mississippi and West Virginia are the only two states that ONLY allow medical exemption.

All other states have religious exemption. I don't know current number for philosophical exemption but here is a map (although some legislation has been changing recently)

http://www.nvic.org/vaccine-laws/state-vaccine-requirements.aspx

Anyone can get religious exemption. 

[Rrrrrachel]

By lying.

[Rrrrrachel]

From 2005:

http://www.ncbi.nlm.nih.gov/pubmed/16282928

In the years following the hepatitis B vaccination/multiple sclerosis controversy, a number of new issues regarding vaccine safety have been raised, in some cases leading to more debate and confusion. Against this background, an international group of experts was convened to review the current points of view concerning the use of thimerosal as a preservative and its potential risks; the suggested link between thimerosal-containing vaccines and acute lymphoblastic leukemia; the alleged association between aluminum-containing vaccines/macrophagic myofasciitis and general systemic complaints; a possible link between vaccination and autoimmune pathology; and a hypothetical link between measles-mumps-rubella vaccination and autism. At present, there are no data to conclude that childhood vaccines, and in particular hepatitis B vaccine, pose a serious health risk or justify a change in current immunization practice.

[Rrrrrachel]

From the hep b study (which I didn't realize was from 2010, sorry) at the end, after they get done listing all the limitations, sources of bias, and saying this can't be used to conclude causation:

Our findings do not suggest that the risks of autism outweigh the benefits of vacci- nation; however, future research into hepatitis B vaccination scheduling is warranted.

It was an interesting study though, thanks.

[slmommy]

Originally Posted by Rrrrrachel 

From 2005:
http://www.ncbi.nlm.nih.gov/pubmed/16282928
At present, there are no data to conclude that childhood vaccines, and in particular hepatitis B vaccine, pose a serious health risk or justify a change in current immunization practice.

This was published 2010 http://www.ncbi.nlm.nih.gov/pubmed/21058170 (hep B vax and austism)

From 2005 too http://www.ncbi.nlm.nih.gov/pubmed/15722255?dopt=Abstract

"This paper points out that information on the safety of hepatitis B vaccine (HBV) is biased as compared to classical requirements of evidence-based medicine (EBM), as exemplified by a documented selectivity in the presentation or even publication of available clinical or epidemiological data.Then, a review is made of data suggesting that HBV is remarkable by the frequency, the severity and the variety of its complications, some of them probably related to a mechanism of molecular mimicry leading to demyelinating diseases, and the others reproducing the spectrum of non-hepatic manifestations of natural hepatitis B. To be explained, this unusual spectrum of toxicity requires additional investigations based upon complete release of available data."

[purslaine]

Originally Posted by Rrrrrachel 

Is it manipulative for a doctor to point out second hand smoke causes SIDS in order to get a mom to quit?

I think it is acceptable for a doctor to point out that smoking might increase the chances of SIDS.

I think it is acceptable to point out that vaccines might prevent many childhood disease, some of which are not fun. 

I do not think it is acceptable to argue with patients. Give them the information, recommendations, referrals and support - but don't argue, and do let them decide.  Let them decide even if you think they are wrong.  It is their children.  Moreover, by arguing with a patient who has clearly given off "no" signals, you risk jeopardising the relationship.  How is that good in the long run?

I do think smoking and vaccines are apples to oranges (very much so).  We know a parent smoking in the home might very well cause health issues of all sorts.  An unvaxxed child does not have more health issues than a vaxxed child - except they might be more likely to catch a VPD.  Their chance of catching diptheria, for example, might be 0.000005 percent while a vaxxed child may have a 0.000001 (made up numbers, but you get my point).  I do know some disease have a higher chance of occuring - doctors can be clear on that as well - as well as the known/accpeted side effects of vaccines.

[purslaine]

Originally Posted by Rrrrrachel 

From the hep b study (which I didn't realize was from 2010, sorry) at the end, after they get done listing all the limitations, sources of bias, and saying this can't be used to conclude causation:
Our finding's do not suggest that the risks of autism outweigh the benefits of vacci- nation; however, future research into hepatitis B vaccination scheduling is warranted.
It was an interesting study though, thanks.

That is their conclusion.

I may think a three-fold risk of autism does outweigh the benefit on that particular immunisation. 

In general, I do not put much value in anyones conclusions - I like to look at the raw data and decide.

I have seen too many things where I question their conclusions, while still finding the data, study design, etc usefull.

Edited by purslaine - 5/5/12 at 11:38am