Dr. Rob Schechter On Vaccines

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Posted on December 1, 2010 by Dorothy

Dr. Rob Schechter is a pediatrician with the California Department of Public Health Immunization Branch.

When Dorothy asked that I blog about vaccines, I thought I would talk about recent headlines that touch on two important aspects about the decision to vaccinate, protecting your child and protecting those around you in the community, including your family and friends.

LONDON CALLING

In January 2010, the General Medical Council (GMC), which regulates English physicians, reported that Dr. Andrew Wakefield, who first suggested a (now disproven) link between the measles, mumps and rubella (MMR) vaccine and autism, had acted “dishonestly and irresponsibly” and with “callous disregard” to children in conducting his research. His actions are itemized over 55 pages of the report from the 2½ year GMC investigation: They include having had developmentally-disabled children receive spinal taps and colonoscopies without any medical need.

In response to the GMC findings, a premier medical journal formally retracted Dr. Wakefield’s original 1998 article that reported the research in question. Ten of Wakefield’s 11 co-authors had issued a partial retraction in 2004.

When speaking with the press at the time of the article’s publication in 1998, Dr. Wakefield advised against giving children the combination MMR vaccine. His ideas received extensive publicity in the British media and public, and in the ensuing fear, the proportion of British children immunized against measles fell to a low of 80% by 2004 (See bars in Table below). As a result, there are now enough people in England who are not immune to measles to permit widespread transmission. The number of people sick from measles, a potentially life-threatening disease, has dramatically increased in the UK (See trend line in Table below). In response to the spread of measles, vaccination rates have increased since 2004 but still have not regained the pre-1998 levels of over 90% that minimized the spread of disease.


2-FOR-1

This episode illustrates that vaccines can provide 2 layers of protection to you or your child. The first layer is to the person getting vaccinated. The second layer is to entire community, but only if enough people are vaccinated to limit the spread of disease to other people.

In England, the level of immunization nationwide against measles has dropped below the level of community protection with dangerous results. The same situation has occurred on a smaller scale close to home. In 2008, outbreaks of pertussis (whooping cough) in our neighbors and of measles in San Diego, resulting in children getting hospitalized, took place occurred in schools and social networks where many parents have declined to immunize their children.

When you decide to vaccinate your child, you are providing immunity to your child and to your child’s community at OFS and beyond. Likewise, high levels of vaccinations of all of those around you help to keep your child healthy. As an old hymn asks (if in a different meaning), “will the circle be unbroken?”

Dr. Robert Schechter, MD


Welcome to our first posting!

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Posted on December 14, 2010 by Dorothy

I chose a discussion of childhood vaccinations for our debut not only because vaccination is a vital contemporary issue worldwide, but because it is a significant one for me personally.

My business, and my life’s work, are based on caring for our community’s babies and small children. Being the owner of three preschools brings with it a tendency toward macro-level concern for public health, and has raised strong feelings in me about vaccination.

As part of my preparation for addressing this topic, I interviewed local pediatricians and read the new book by Michael Specter titled Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives. The author’s premise is that the validity of the scientific method, and decision-making based on its results, is falling out of popular favor, leading larger and larger groups of Americans to make fear-based decisions fueled by anecdotal or emotional input, rather than evidence-based decisions based on statistical probabilities and reliable scientific data.

Specter, a staff writer for The New Yorker, explores in depth three American examples; one of these is the vaccine controversy. He observes with dismay that parents are increasingly swayed more by one compelling individual story linking vaccine to neurological injury, than by a comparison of the likelihood of contracting a vaccine-preventable disease to the likelihood of vaccine injury.

Specter’s point really spoke to me. I have listened carefully to the worries of our parents about the possible vaccine-Autism link, and other concerns that they share about vaccine injury. While I understand these fears, I confess to being mystified at the decision to give less weight to polio, rubella deformity, meningitis, or the horrible death that can be caused by whooping cough, than to the very small and probably disproven possibility that vaccines might cause Autism. Even if a cause-and-effect relationship could be confirmed between the two, the numbers still overwhelmingly favor vaccination.

As a parent myself, I chose and would again to vaccinate on schedule. However, I genuinely support a parent’s right not to. I know that many parents truly agonize over vaccine decisions, and are left with some degree of discomfort regardless of what they choose. We must make the best decisions we can based on what is right for our child and our family. In the end, only each child’s parents can make this call.

However, the discussion becomes even more complex when we factor in the health of our community as a whole. Pediatricians agree that the time of greatest vulnerability to disease for an American child is approximately 9-15 months – after many finish breastfeeding, but before completion of the recommended vaccination schedule. Of course, beginning care at a preschool often also roughly corresponds to the end of breastfeeding, that powerful immune system ally.

Babies in this age-range who enter Old Firehouse School, along with the mothers pregnant with siblings of our children, are the members of our community most vulnerable to the fatal illnesses we have worked so hard to eradicate through vaccination. Preschoolers whose parents have chosen to avoid or delay vaccination are the population most likely to be carriers of these very illnesses.

As the person at whose desk the buck stops, I worry about the dangerous combination I am unwillingly allowing in our preschools. Mixing these populations in close quarters is bad public health policy, yet Old Firehouse School is legally required to do exactly that; if I turn away children whose families have chosen not to vaccinate them, or to delay vaccination, we will lose our childcare license. I can’t help but feel a mixture of worry and a sense of grave responsibility when I think about the unprotected kids we care for, and the little babies so close by.

An extremely troubling illustration is the current epidemic of whooping cough in California; we even had a case of this disease at one of our schools. Writing for The San Diego Union-Tribune, Janet Lavelle states that as of September 22, 2010, “Statewide, there have been 4,017 confirmed cases so far this year, including nine deaths. All of the deaths were infants under 3 months of age…” PKids.org has addressed the epidemic in this video:

Here on our website you’ll find videos of me discussing these issues with several of the most experienced and well-respected pediatricians in our communities. I hope that hearing their thoughts and the information they have to offer on this difficult subject will make these tough choices easier for some of our parents.

Dorothy Stewart, Ed.D.
Executive Director and Founder Old Firehouse School

Finding the Right Pediatrician

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One of the first steps toward caring for the new child we are bringing into the world is choosing our baby’s doctor. These days, this decision can feel a little bit daunting. Whereas best practices were once highly standardized across obstetrics and pediatrics and doctors simply delivered decisions to compliant parents, there is now a great deal of discussion — and disagreement — about birthing practices, sleeping habits, vaccinations, medications, and other controversial topics. It is perhaps both a blessing and a curse that parents now expect themselves to be knowledgeable partners in their children’s care, and to choose practitioners who share their childrearing values.

When I was pregnant, I made appointments for informational visits with two prospective pediatricians. Afterward, I was at a bit of a loss to choose one, because truthfully I found both of them quite intimidating. I ended up choosing the doctor to whom most of my friends were going, although I hadn’t felt much rapport with him.

When my daughter was born, her new pediatrician’s practice sent a doctor over to visit her, but it was not the doctor I had chosen — he was not on call that day.  

We took our daughter home from the hospital and our little darling slept peacefully on and off for three days.  On the fourth day she woke up screaming.  To my new-mom’s ears, no infant had ever screamed with this much urgency. In a panic, I looked up the number for her pediatrician (who had still never met her) and called his practice.

The phone was answered by an icy receptionist to whom I explained that my baby wouldn’t stop screaming. A few moments later, the pediatrician came on the line. Apparently his first order of business was my emotional state.

He chided, “Calm down, calm down! Now what’s the baby’s name?”

I froze. “Wait a minute,” I said, “and I’ll think of it.”

The doctor laughed, “Call me back when you remember who your baby is.” And he meant it, because he then said goodbye and hung up.

In retrospect the anecdote is funny, but our doctor’s condescension was not what I needed at the time. And it proved to be typical of our interactions. Too often, I felt foolish for asking questions or sharing my concerns.  Luckily, our daughter’s health issues were few and far between so that I didn’t need to interact with her doctor very often.

As it turned out, our pediatrician’s bedside manner was none too successful with my daughter, either. Around the time she turned four, she said she didn’t like him and wanted a new doctor.  Specifically, she said she wanted a “girl doctor.” I suspect that preference was simply how she was able to articulate her lack of “connection” to her current pediatrician. Her feelings, combined with mine, finally motivated me to action, and I found a wonderful female doctor whom both my daughter and I could relate to.  

We are fortunate in the Bay Area to have so many wonderful and aware pediatricians to choose from. You, too, will find one who feels like a good fit for you and for your child.

Based on my own experience as a mom and on my professional life working with so many OFS families over the years, I’ve put together a brief guide to choosing your child’s pediatrician. I hope you find it helpful.

We have also included here an interview with Dr. Drew Nash, an East Bay pediatrician who has recently launched a concierge practice for local families. In this interview, he offers some great pointers for finding a pediatrician, and he also discusses how to develop and maintain a good relationship with your children’s doctor.

Ten Steps for Finding a Good Pediatrician

Step One:  Begin early.
A good rule of thumb is to begin your search for a pediatrician in the seventh or eighth month of pregnancy. (If you will be moving and currently have a pediatrician you like, ask him or her for a personal referral, or for any leads about where to start looking in your new community. Also let your current pediatric office know ahead of time that you will be needing to transfer your child’s medical records.)

Step Two:  Check with your insurance company.
Most health insurance companies publish comprehensive lists of “providers” who participate in your particular plan. (You will also want to know which hospitals in your area are plan participants or are covered in case of an emergency, and exactly what services are covered at what cost.)

Step Three:  Ask for referrals.
Ask family and friends about their pediatricians. Listen particularly closely to those who have had to deal with chronic health issues. They will have a good sense of how their pediatricians work with families during trying times. Childcare centers are also good places to ask about local pediatricians; after caring for hundreds of local children, we often know with whom our families are most happy. Your own doctors, particularly your obstetrician, may also be good sources of recommendations.

Cross-reference as many recommendations as possible with the list of covered providers from your insurance company. Identify at least four potential practitioners whom you would like to consider. This is your short list.

Step Four:  Make a telephone inquiry.
Call the offices of the doctors on your short list and ask:

  • How many pediatricians are in this practice?
  • Is (potential doctor) taking new patients?
  • Does (potential doctor) do informational interviews, and if so, what does your practice charge for them?

Step Five: Consider logistics: travel and parking.
On your way to the appointment, note the travel time. Project how commute traffic might affect getting to the office when you’re in a hurry. Is parking easy to find and close to the entrance? Imagine taking a sick child with you on this trip — is it doable?

Step Six: Waiting room reconnaissance.
Notice whether the waiting room is crowded. Try to get a sense of how long the wait is. Is the waiting room clean and cheerful? Does it have interesting things for children to play with?  Is there a separate room for ill children who may be contagious? Strike up conversations with other parents and ask them about the pediatrician you’re interested in.

Step Seven:  The interview.
Make a list of questions to take with you. It's important that you find a doctor whose medical approach is consistent with your own values.

Medical Philosophy
Here are some possible topics you may want to discuss:

  • breast feeding
  • the family bed
  • age of entrance into child care
  • circumcision
  • stem cell collection
  • vaccinations
  • allergies
  • how and when antibiotics should be used
  • philosophy on discipline
  • potty training
  • the doctor’s knowledge of any specific conditions or allergies in your family

Logistical Issues
You may want to ask the pediatrician or office staff about:

  • billing
  • scheduling
  • house calls
  • same-day or drop-in appointments for sick children
  • how sick-child care is handled after hours
  • how insurance co-payments are made
  • when phone calls are returned
  • who will see your child if your pediatrician is not on duty

Step Eight: How is the chemistry?
After your informational interview, take a minute to check in with yourself. How do you feel about this doctor? Listen to your intuition; observe your comfort level. Did you feel that the doctor had time for you or did you feel rushed?  Do you feel that you could communicate well with each other? Did you feel respected, and that your concerns would be taken seriously?

Step Nine: Do a background check.
It’s a good idea to do a basic background check on your prospective pediatricians. First, you will want to make sure that you choose a pediatrician who is board-certified. In addition, if any doctor has had disciplinary action taken against him or her, there will be a report on file with the Federation of State Medical Boards. You can visit the federation’s website at www.docinfo.org or call them at (817) 868-4000 to inquire about the pediatricians you are considering.

Step Ten:  Change if you need to.
Keep in mind that nothing is irreversible. If it turns out later that the pediatrician you picked isn't quite working out, simply find a new one and move on. That's all!


Care to recommend or share some positive information about your pediatrician? No complaints or negative comments, please!