SAN FRANCISCO — Communication skills are key when talking to parents who are reluctant to immunize their children, judging by results of one of the first observational studies of these encounters in private practice.
A pilot study recruited seven pediatricians and two family physicians in Louisville, Ky., for a “field test” of using “standardized patients” in primary care practice settings, Dr. Kristina Bryant said at the annual meeting of the American Academy of Pediatrics. Standardized patients are actors or actresses who are trained to portray patients and are commonly used in medical schools to help teach and test students.
The physicians were told that a standardized patient would visit their office within 6 months, but were not told what the standardized patient would do or say, explained Dr. Bryant of the University of Louisville (Ky.). Dr. Bryant is associated with several companies that make vaccines. She is on the speakers' bureaus of Sanofi Pasteur and Abbott Laboratories, and she has received research funds from Merck & Co., MedImmune, Wyeth Pharmaceuticals, and GlaxoSmithKline.
The actresses in the study pretended to be pregnant women who had just moved to the area and were looking for a pediatrician. They portrayed 24- to 30-year-old married women who were “pregnant” for the first time; they simulated pregnancy with a padded belly kit. “We actually had pediatricians patting the mother's tummy,” Dr. Bryant said. “It was very believable.”
The standardized patients presented themselves as upper middle class, college educated, and Internet savvy women. They paid for the visit out of pocket, claiming that their insurance was pending and they didn't have insurance cards yet.
Each woman told the physicians that she didn't want to immunize her child because she believed the MMR vaccine causes autism and the varicella vaccine causes neurologic damage. In addition, she said that too many vaccines overload the immune system, that the AAP and the Centers for Disease Control and Prevention are not truthful, and that she did not believe her child was at risk for getting measles, diphtheria, or other diseases anyway.
The standardized patients graded physicians on a survey after each encounter, and recordings of four encounters were transcribed and analyzed by the investigators.
Physicians scored very well in listening to the mother's concerns about vaccines, maintaining eye contact, spending adequate time with the mother (a median of 19 minutes per visit), using understandable terms, and behaving in a nonpaternalistic manner, reported Dr. Bryant and her associates. They also scored well in eliciting the mother's agenda for the visit, avoiding interrupting, and being warm, compassionate, and nonjudgmental.
Physicians did not score as well on “characteristics that are important not just in vaccination risk/benefit communications, but in communications with families in general,” she said. These included introducing themselves and welcoming the mother, expressing interest in the mother, asking open-ended questions, and encouraging questions from the mother. Scores also were lower in checking for the mother's understanding, validating the importance of her concerns, assessing the mother's knowledge about vaccines, and summarizing at the end of the visit.
Among the four physicians who were recorded, only three discussed the risks and benefits of vaccines, and only two presented scientific evidence to refute the mother's claims that MMR causes autism or that thimerosal is dangerous.
Two referred mothers to the AAP and CDC Web sites for more information, and two offered to delay some vaccines—a strategy recommended by the AAP when dealing with reluctant parents. None explored cost as a potential barrier to immunization.
Two gave the mothers inaccurate information. One said he would have to contact Child Protective Services if the mother refused to vaccinate her child. The other said that the child could not attend public school unless immunized, but Kentucky allows religious exemptions.
“The plus side is that none of these physicians refused to care for this family if the mother refused immunizations, and [all] talked about [vaccine refusal] being addressed at future visits,” Dr. Bryant said.