NaBloPoMo 2018: What I’m Learning

Go figure, I’m having conversations about flu and vaccines every day right now.  Today I described my post from yesterday to a new friend.  He stands firmly in the ‘vaccines are good’ camp.  His sister, however, does not.  Her son has autism.  After hearing about my post, he asked me what I would say to her, if she told me she would not vaccinate her child ever again.  It was a great opportunity to think and practice, and I’m grateful that he asked.  I had already thought earlier today about writing a separate post on communication around vaccines.  So here goes!

First I would tell her that I understand why she would not want to vaccinate, if she blames vaccines for her son’s autism.  I don’t know any kids with autism, but I have friends whose kids are autistic, and I see how stressful and exhausting it can be.  As a mom of kids with anaphylactic food allergies, I also know the feeling of absolute guilt for being the one who gave my kids the things that made them sick.  If I were a mom whose kid was diagnosed with autism after receiving vaccines that I consented to, and I were convinced that the latter caused the former, I would definitely want to protect my kid from anything else that might hurt him, especially anything that I have control over.

Some additional background:  We are a lot better at recognizing and diagnosing autism spectrum conditions now than a few decades ago.  That diagnosis is commonly made in the toddler years, also around the time kids have received a boatload of vaccines.  So it’s easy to see a correlation, but causation cannot be proven.  One could argue that it also cannot be totally disproven, but given the number of children who receive all of their vaccines and the very small proportion of them all who go on to be diagnosed, the evidence definitely leans away from vaccines causing autism.  That is little comfort for a family and a child affected with the disorder, who may always wonder.  As humans, we naturally look to assign blame; vaccines are an easy target.  And why on earth would we repeat actions that have previously caused us trauma, real or perceived?

This year I read an article about a mom of three.   She had vaccinated her two elder children as per guidelines.  After her third was born, however, she started to read lay literature online stoking fear of vaccines.  She had no negative experiences herself, but started to wonder, what was really the best thing to do for her family?  She decided to stop vaccinating when her son was 6 months old.  At 18 months, he got pertussis, or whooping cough.  He almost died.  She posted videos of him coughing and turning blue, captioned with a heartfelt mea culpa, urging other parents to vaccinate:

“This is whooping cough,” she wrote. “This is Brody. An 18-month-old boy. Our third child. Our first son.

“This is a mother that sees ‘anti-vaxx’ all over social media and becomes terrified. Unsure whether or not to give vaccines (even though she did for both of her girls). Terrified to ‘pump her baby with poison’ … so she stops vaccinating after six months.”

“This is pure hell. This is guilt. Guilt of putting not only my son at risk, but my community too …This is embarrassment.”

She wanted to impress the fact that she’s not “bashing” the anti-vaxx community – or blaming or judging anyone.

“The decisions I made were MY decisions. Based purely on my lack of knowledge and fear,” she said.

“This is to show the consequences of not vaccinating my child correctly.”

I wonder about her conversations with her son’s doctors.  Did they try to shame her into vaccinating when she initially expressed a desire to stop?  If so, could this have just made her more resistant?  It could easily look something like a conversation that I would bet happened all over our country today:

Doctor:  Have you gotten your flu vaccine yet?

Patient: I don’t do flu vaccine.

Doctor: Seriously?  Why not?  It’s perfectly safe, you know, and tens of thousands of people die every year from flu.  If you don’t get vaccinated, you could pass it on to everybody you know.  Aren’t your parents elderly?  Don’t your kids have asthma?  You’re putting them at risk for serious illness or death, you know that, right?  And you don’t get flu from the vaccine, that is a total myth.  (Insert list of facts and evidence for benefits of flu vaccine here.)  Really, you should get it (suppressing eye roll).

Patient:  No, no thanks.  Can I go now?

I see and hear my colleagues complain all the time about vaccine-resistant patients.  When they are particularly tired or moody, they can get judgmental and even a little mean.  I understand.  It’s frustrating to watch people we care about making choices we think are against their best interests, especially when it also puts the community at risk.  I fear for my kids if their classmates are not vaccinated—both of my kids have asthma that’s triggered by respiratory infections.  Even if our whole family is vaccinated, they are still exposed to hundreds of snotty, sneezy, coughing faces every day at school.  Flu season is essentially six months long, most of it when we are all stuck inside basically slobbering all over one another.  High. Risk.

But does it really help for me to come at my patients with my ‘advice’ before I understand the origins of their decisions?  What are my assumptions about them when I do that?  Some patients claim science as the basis of their refusal; others admit that it’s totally irrational.  Regardless, how can I best conduct myself?  Here is my current approach:

Cheng: Do you do flu vaccine?

Patient: No, not really.

Cheng: Can we talk about that?

Patient: Do we have to?

Cheng: I would really appreciate it.  I won’t try to pressure you, I just want to understand your rationale.

Patient:  Gives their reasoning.  If it’s like my friend’s sister above, or I otherwise understand that they are resolute in opposition, I thank them for sharing, shift to strategies for illness and transmission prevention (see yesterday’s post), and ask permission to talk again next season.  This happens in a minority of cases, actually.  Most often they say something like, “Well, I just don’t really think about it, I feel like I don’t need it, I think it’s strange that it’s recommended every year, it doesn’t really seem to work from what I hear, and what’s the big deal about flu, anyway? …Do you really think I should get it?”

Cheng: Yes, I really recommend it.  Can I tell you why?

Patient: Okay, sure.

This is when I go through all the evidence that I reviewed yesterday and the rationale above.  If I know something meaningful to them that relates, I make sure to highlight the connection.  At the end I make sure to reiterate that they are free to vaccinate or not; I am honestly unwedded to a particular decision. I invite them to consider and let me know, or just show up to a pharmacy clinic if they decide to get it.  Most people are appreciative of the time spent; many say they learn something they did not previously know.  We end the conversation at least with no hard feelings, and often with positive ones (at least on my end).

It occurred to me this morning, what is my primary objective when I conduct these conversations this way, coming alongside my patients rather than coming at them?  Initially I thought it was to keep people healthy, to prevent death, serious illness, and suffering.  But now I think my primary objective is actually to cultivate our relationship.  I usually have this conversation with new patients, because if I know them already then I know their vaccine patterns and I don’t have to ask, “Do you do flu vaccine?”  If they refused last year I can simply start with, “Can we please talk about flu again?”  When we are new to each other, the way I present sets the tone for our relationship and has an outsize impact on patients’ receptivity to my advice.  The flu vaccine conversation is a prime opportunity to prove that I can listen to, empathize with, respect, and honor their values and autonomy.

On the contrary, when I come at them, bent on convincing them to vaccinate now, what is my primary objective?  Thinking of other times I present this way, if I’m being honest, I’m just trying to prove I’m right and win an argument.  I don’t think that approach has ever really helped anybody.