Professionalism, fidelity and relationship-preservation

Abstract

In February 2012, The Wall Street Journal summarized cases and research documenting growth in the numbers of physicians who ask families to leave their practices due to parental refusal of vaccines for pediatric patients.¹ Some physicians ask families to leave because they feel that they have a professional obligation to maintain a standard of care that is unattainable when parents refuse vaccines for their children. Others struggle with how to maintain a therapeutic relationship with a child whose parents’ health beliefs conflict with vaccine schedule recommendations. Additionally, one social and cultural trend that seems to influence physician-family relationships in these cases is "anti-intellectualism." I consider some important challenges these issues pose for professionalism in the physician-family relationship, and consider a few values helpful in configuring responses to those challenges.

Keywords: :

• clinical
• communication
• ethics
• fidelity
• pediatrics
• physician-family relationship
• physician-parent relationship
• professionalism
• vaccinology

Anti-Intellectualism in Clinical Encounters

Anti-intellectualism is one cultural trend recently noted as a prominent feature of contemporary American life.^2-4 Characterized, among other things, by mistrust of expertise and suspicion about the worth of professional training, this trend offers some insight into the dynamics of physician-family conflict in vaccine refusal cases. Mistrust of physicians’ expertise is one species of anti-intellectualism that affects physician-family relationships in vaccine cases. This mistrust can be expressed through some parents’ preference for making health decisions based upon information they find themselves through popular media (including the internet) rather than information they get from physicians during clinical encounters. Multiple factors drive the rise of anti-intellectualism, but one particularly relevant to the case of vaccine refusals could be concerns about the integrity and effectiveness of scientific peer review.^5,6

Publication of an article by Andrew Wakefield and colleagues⁷ fueled widespread skepticism about vaccine safety. This article undermined public trust in scientific literature by drawing attention to conflicting conclusions in that literature and by publishing data gathered through scientific misconduct. The article offered scientific support for the view that some vaccines cause autism and fueled campaigns for that message led by celebrities and a devoted, well-organized, well-funded media savvy group of committed anti-vaccine activists. The retraction of that article (and the 12 year wait for its publication)⁸ seemed to create suspicion about why experts do not agree about vaccine safety. It also generated confusion, not only among parents skeptical of the vaccine skeptics, but even among members the earnestly intellectually-curious public just interested in understanding the facts.

Another feature of anti-intellectualism seems to be the apparent democratization of specialized knowledge, such as vaccinology. A merit of such democratization is that important information can be easily and quickly disseminated. A drawback, however, is that ease of access to information is not always accompanied by the levels of media literacy (and health literacy, in the case of vaccines) required to actually make knowledge out of information. Information on some websites and in some other media sources is not always monitored uniformly and can, thus, be inaccurate. For vaccine researchers and clinicians, it seems fair to suggest that parents who enter the clinical encounter questioning vaccination based upon information obtained from popular media present significant challenges related to professionalism because they can be a source of significant frustration.

Challenges for Professionalism in the Physician-Family Relationship

One conception of professionalism in the context of healthcare has to do with whether and how clinicians orient themselves to patients, patients’ loved ones, and colleagues; clinicians must, for example, balance technical competence with empathy. Clinical comportment—one important dimension of which is how clinicians manage frustration caused by disagreement during clinical encounters—is an important feature of professionalism at play in cases involving vaccine refusals, particularly when dismissing families from a practice is a consequence of or response to frustration in clinical encounters.

Families who disagree with clinicians about vaccines can be labeled “difficult” not only for refusing vaccines, but for trying to negotiate alternative vaccine schedules, or for questioning physicians about other matters, such as the value of bicycle helmets or seatbelts.⁹ These families can be a source of frustration for clinicians when responding to their questions, concerns, and health beliefs is seen as taking up disproportionate amounts of valuable clinical time. Families of an unvaccinated child can also be a source of frustration for physicians because their presence in the clinic and community can put other children at risk of vaccine-preventable illnesses.

Some clinicians might be frustrated simply because they feel patients questioned their expertise. While this seems easy to dismiss for those prone to the stereotype of physicians as having big egos, such easy dismissals of this frustration should be resisted. There are complex moral psychology issues at play when clinicians experience frustration as a byproduct of what is widely referred to in the healthcare professionalism literature as "moral distress." Moral distress happens to a clinician when she is motivated by good reasons to do some action, but barred (by parental refusal in the case of vaccines) from acting as she is motivated to act.¹⁰

All of these sources of frustration are worth canvassing, but we must also consider that physicians’ responses to frustration, whatever the sources, are probably just as influential during clinical encounters as families’ anti-intellectual mistrust, ill-founded or unusual beliefs, or unreasonable behaviors. Even when families’ concerns are ill-informed, they should be recognized by clinicians as important when they come from parents’ impulses to protect their child. If physicians’ affective responses to and demeanors toward families are dismissive, contemptuous, angry, or spiteful, the physician will likely be ineffective at cultivating a relationship with the parents that will be helpful or therapeutic to the child.

The combination of families’ beliefs, behaviors, mistrust of medical and scientific expertise, and physicians’ frustration with families seeking media based resources for vaccine information can become vitriolic and unproductive if the clinical encounter degenerates into a battle over who’s right. It’s hard to be humble when you’re right: both physicians and parents see the other as recalcitrant, susceptible to ill-informed groupthink, and dangerously self-righteous.

Common Ground Communication

A common value, despite disagreement in some of these cases, can be found when both parties see themselves as advocates for the best interests of the child: fidelity to the child. This value can be useful as a starting point for considering physicians’ responses to frustration when encountering vaccine refusers. A key challenge for physicians and parents in some of these cases will be to stop thinking about who’s right and start thinking about how to draw upon the common ground—care for the child’s welfare—to keep conversation open, despite disagreement.

Another significant challenge for some physicians could be not to assume that their patients or their parents see them as trustworthy. To address this, physicians must make their roles as doctors a priority in clinical encounters. The word 'doctor' means “teacher,” and teachers in an era of anti-intellectualism must recognize that a student’s trust in you doesn’t come with your title. This applies directly to the physician-family relationship. Trust is earned through investing in relationships with folks, despite that they might not think like you. It is earned through fidelity to the person, not to the desired outcome.

From a pediatric and public health perspective, the desired outcome in these cases is meeting standard of care, getting children vaccinated. This is a worthy outcome and a collective professional goal worth preserving as a major tenet of pediatric care. An important challenge in professionalism for pediatricians in cases involving vaccine-hesitant or vaccine-refusing families means meeting the obigation to provide standard of care when possible and meeting the obligation to maintain relationships with families even when, and especially when, they are barred from providing standard of care in a particular clinical encounter. Concisely, “firing” or dismissing families from a practice probably constitutes overzealous pursuit of that goal of vaccination, since it ends the physician-family relationship.

Though some clinicians might argue that dismissing families from a practice reinforces the importance of vaccination and allows clinicians to uphold standard of care and protect patients in that practice, it’s important to recognize how dismissal expresses disregard for the value of fidelity, which can negatively affect the child in the family being dismissed. Dismissal can also sour a family’s experience of clinical encounters generally, perhaps permanently, and perhaps to the further detriment of the child. Dismissal nullifies any chance that the family would see the physician as a resource for later transformative re-thinking about vaccines or other important health-related matters.

Justifications of dismissals based on “sending a message” to vaccine-hesitant familes seems flawed in other ways, too. If we conceive dismissing “difficult” families as a form of "cherry-picking," important professionalism concerns other than those already mentioned arise. Cherry-picking is a metaphor often used in the healthcare context to describe the practice of keeping the easier-to-manage cases for oneself and leaving the harder-to-manage cases to one’s colleagues (or to no one). This practice violates collegiality, another important part of professionalism. Cherry-picking also violates the spirit of cooperation necessary to making the clinician-family relationship work. Dismissal expresses the sentiment "It’s my way or the highway," and this isn’t an approach nourishing to relationships over the long-term. Dismissal can be seen as an unprofessional response to frustration arising from patients’ families not seeing it your way. This is because dismissal can express something important about the clinician’s character: that she values ease in physician-parent relationship more than she values fidelity to the child. Patients or parents who make decisions with which physicians do not agree based on misinformation or different beliefs are frustrating, but still deserving of compassion and caring responses. Patients are not generally expected to respond to frustration in clinical encounters carefully and compassionately, but healthcare professionals certainly are.

What Makes a Physician a Good Teacher?

Consider an analogy to universal healthcare coverage. Like vaccine administration, the case for universal healthcare coverage draws upon arguments motivating values such as "health promotion" and "common good" and upon innumerable data sets revealing effectiveness in public health. Also like vaccine administration, despite scientific and long-term economic arguments and data sets that endorse it, many do not believe in or support universal healthcare coverage. Just as professors of health policy and ethics must prioritize commitment to the student’s learning about the importance and complexity of health policy generally over recruiting subscribers to one’s own point of view about universal healthcare coverage specifically, physicians must prioritize fidelity to the children they serve and a commitment to working with parents over achievement of a particular outcome.

While it’s true that some parents are hard to work with, it’s important to consider whether and when physicians can be hard to work with, too. It takes humility and courage to navigate (rather than avoid through dismissal) disagreement in the classroom or clinical encounter and it also requires good communication skills. It’s likely that children are safer when their parents feel they can consult a physician as a health resource over time, even when parents are not completely adherent to that physician’s advice in individual cases. This suggests that nurturing the physician-parent relationship through open communication should probably be a clinical priority.

Emphasis upon common interest both parties have in advocacy for the best interests of the child might be expressed best in the form of a concrete statement, such as, “I care about your child’s health and I know you do too. It’s important to me that you see me as a resource you can draw upon over time, that we can continue this important dialogue over time, and that we can be partners in nurturing your child’s health. You and I both have the same interest in making this relationship work.”

For physicians maintaining too strong an emphasis on the outcome of vaccine administration during the clinical encounter, agreeing to disagree for the purpose of preserving the relationship might be unsatisfying. What I’ve suggested here, however, is that investing in the relationship over time combined with good communication, humility, a willingness to navigate disagreement, and a willingness to developing strategies for productively managing frustration might generate that desired outcome later. Parting on good terms with the parent embraces points about professionalism made here and might be the best achievable outcome for a particular clinical encounter. A physician can’t do much good for a child whose parents don’t see the physician as someone to whom they’d return when they need a resource.

If common ground of fidelity to the child and commitment to the child’s well-being is solidly established in a particular case, then later some of the most important ideas to talk about when parents disagree with physicians about vaccinating a child might be about health literacy and media literacy. If physicians can open a dialog with vaccine refusers about how information does not necessarily equal knowledge without insulting or demeaning them, this can be a good advancement upon the common ground. Subsequent discussion might also seek to explain the importance of herd immunity, and how other parents’ babies (too young to be vaccinated yet) can be vulnerable to vaccine-preventable disease when this breaks down. One might emphasize, perhaps, that the parents’ child probably benefited from herd immunity when the child was an infant; the idea that a parent refuses something from which his or her child has already benefitted because of others’ consent and participation could be mind-changing for some.

Generally, physicians can focus on communicating the benefits of community-based thinking and the risks of individual-based thinking related to vaccines. Physicians might share a case from their own background they feel passionately about: “I’ve seen children die of vaccine-preventable illnesses. I don’t want to see that happen to your child.” It probably won’t derive the outcome of vaccinating the child if parents feel the physician is trying to manipulate them through fear, but it might derive that outcome later if they feel her motivation comes from fidelity to the child, commitment to maintaining common ground, careful and compassionate communication, and dedication to good teaching.

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.