Pediatricians versus the Dunning-Kruger effect on vaccines

I don’t know if I could be a pediatrician right now.

True, I probably don’t have the personality to be a pediatrician, at least not a primary care pediatrician on the front lines. After all, if I did, I probably wouldn’t have become a surgeon, much less a hyperspecialized cancer surgeon. One reason (among many, of course) is that I don’t have the patience to deal with non-vaccinating parents, particularly parents with massive cases of Dunning-Kruger disease. The same goes for being a pediatric nurse practitioner or nurse, who are also on the front lines in dealing with the antivaccine movement. In any case, you remember the D-K phenomenon, don’t you? It’s the phenomenon whereby people who are unknowledgeable or incompetent about a topic have a falsely elevated estimate of their own knowledge base. In the antivaccine movement, the D-K phenomenon tends to take the form of parents who think that their University of Google knowledge trumps the knowledge of physicians and scientists who have dedicated large swaths of their lives to the rigorous study of conditions such as autism and the question of how vaccines work.

Nowhere is the D-K effect more intense and painful to behold than at blog with a name so arrogantly misplaced that it lights up the planet with its waves of burning stupid. I’m referring, of course, to The Thinking Moms’ Revolution (TMR), where the denizens think so highly of themselves that they refer to themselves as “Thinkers” (yes, capitalized) and dismissively attack (using arguments of pure pseudoscience and nonsense) the medical profession, scientists, and those who follow the science to realize that, no, vaccines don’t cause autism, and, yes, vaccines are effective and far safer than letting children suffer “naturally” from the diseases that vaccines are designed to prevent. The mothers who blog there also give themselves annoying pseudonyms like DragonSlayer, Goddess, Mountain Mama, Sugah, and Professor. So, naturally, the TMR bloggers are the most insufferable non-vaccinating parents you will ever see, and they like to brag about it. I just saw an example of this the other day that caught my attention and made me contemplate at how difficult it must be to be a pediatrician now. Not only is pediatrics one of the worst-reimbursed specialties, but pediatricians have to put up with moms like The Rev (those ‘nyms again!), describing incidents like this description of one of the “Thinkers” telling her fellows about being fired by her pediatrician for not being willing to vaccinate:

Let me set the scene for you.

A bitter cold Friday night in Chicago. Some Thinking moms decide to get together to break up the monotony of a seemingly endless winter. Several bottles of yummy wine lay interspersed among their mostly green, mostly raw, mostly organic food fest. They laugh and talk and enjoy one another’s company. The topic turns to pediatricians.

“I got fired from Dr. * this week.” Says, the youngest one of the bunch. This Thinker has a remarkably healthy child who eats well and is developing normally with no learning disabilities or developmental delays.

“Whaaaaaat did you just say?” We all rubbernecked, saucer-eyed and slack jawed in her direction; our delicate sips turning into large lapping gulps.

“Yep, he sent one letter certified and one to my house . . . Not sure what the point in that was.”

The funny thing is, I totally pictured many of the “Thinking Moms” to be just like this, a crunchy, woo-infused crowd hanging around with each other and getting drunk while they bask in each other’s self- and group-perceived awesomeness and commiserate with each other over glasses of wine, tales “biomedical” quackery to treat autism, and stories of mean and nasty doctors who have the temerity to insist on treating their patients according to the standard of care on vaccines to protect their patients. I realize that this is a controversial issue among pediatricians, and I can see both sides of the argument. Some pediatricians, noting that vaccines are critical to preventing serious childhood diseases and that nonvaccinating parents take up a lot of their time (which is not billable beyond a certain point) and potentially endanger patients in the waiting room, particularly if there are immunocompromised patients there, decide not to deal with the hassle anymore. There’s also an issue of conflict and trust, wherein nonvaccinating parents don’t trust the doctor who is simply trying to do his best for their child, and the doctor doesn’t trust the nonvaccinating parent to do what he recommends. Such doctors might reasonably conclude that it would be better for all concerned if the parents found a different doctor for their child. As one pediatrician put it:

If a family refuses to vaccinate after a discussion of the issue, he tells them “there are so many things we’re not going to see eye-to-eye on.”

On the other hand, some pediatricians, seeing their duty to their patients and feeling very reluctant even to be perceived as abandoning their patients, much less actually “abandoning” them. In any case, contrary to the conspiratorial twaddle peddled by “Thinkers” like The Rev, pediatricians are under an extreme ethical dilemma when confronted with nonvaccinating parents. Evidence-based medicine tells them that it is very important for the child’s health that he receive his vaccines on time. When the parents prevent this (or prevent any vaccination of their child at all), they prevent the doctor from providing what he knows to be the best care for the child. Faced with such compromised care, the ethical dilemma often leads to a choice between keeping the patient and continuing to try to bring the parents around or setting them free to prevent the disruption of his practice and the potential endangerment of his other patients. There’s a third choice that some pediatricians no doubt make, and that’s to give up in weariness and stop mentioning it. Morally, a lot of pediatricians can’t make that choice, and more power to them. Perhaps that’s why there appears to be a trend among pediatricians to “fire” patients, as this young “Thinker” was fired from her pediatrician. One notes that it’s still clearly a minority of pediatricians.

In fact, this young “Thinker” described by The Rev has exactly that issue. She goes on and on, asking what will she do if her child gets sick and she doesn’t have a doctor who knows her child and whom she trusts. (Why she trusts a doctor who wants her to vaccinate her child when she doesn’t, who knows?) Leave it to the “Thinkers” to claim that it’s all about the money:

“Well, first off . . .” said my tipsy brilliant Thinker-friend, “There is no way to code ‘baby got weighed and measured, is well fed and perfectly healthy.’ You are taking up their billable time with your healthy baby! Vaccines are what make the ‘well baby’ visit a ‘well baby’ visit. You have every right to challenge your dismissal from their practice.”

This mother is just plain ignorant. First off, the young mother can’t challenge the dismissal of her child from the pediatrician’s practices, at least not if the pediatrician followed the laws of the state in which he practices. She (and the other “Thinkers” who chimed in) also don’t know much about medical billing, either. All it would take would be a look at the list of billing codes to know that well baby visits are indeed billable as routine infant or child health checks, complete with CPT and ICD-9 codes. For those codes, it doesn’t matter if the child gets an immunization or not. My guess is that this young mother probably had an insurance plan for her child that covered well baby visits 100% but required a copay for vaccines, which is likely why she didn’t get a bill for those visits in which her child didn’t get a vaccine, not because the pediatrician didn’t bill for them.

In fact, depending on the practice, vaccines can be money losers for pediatricians. Indeed, a study from three years ago by athenahealth found that in almost half the cases, payments for vaccines weren’t enough to cover the cost of storing and administering them. A study in Pediatrics from 2009 concluded that for privately insured patients pediatricians vaccines produce little or no profit and that when losses from vaccinating publicly insured children (i.e., receiving Medicaid) most pediatrics practices lose money from vaccines. Indeed, a recent news report indicates that it’s gotten so bad that pediatricians have become very dissatisfied with insurance and government reimbursement for vaccines to the point that 10% of pediatrics practices admit to considering not offering vaccines anymore, instead referring their patients elsewhere for them.

Another rather hilarious claim is that “nurses can’t harass” you about vaccines. “Harassment.” You keep using that word. I do not think it means what you think it means. Of course, what these “Thinkers” refer to as “harassment” is no doubt nothing more than the nurse doing her medical duty according to the standard of care to ask the parents which vaccinations the children have had and to suggest trying to get their vaccines up to date. It’s part of the frikkin’ pediatric history and physical, fer cryin’ out loud! That’s why it’s no surprise that nurses, at every visit, will ask the parents about vaccines and suggest to nonvaccinating parents that they start getting their child caught up on recommended vaccines. It’s their job!

What’s really depressing is what The Rev recommends to maintain the health of her children:

It is in our child’s best interest to build a team of healthcare professionals. After all, we all share a common goal: the health of all our child, right? A couple pediatricians, a chiropractor, a whole foods nutritionist (who understands grains and the gut), homeopath, naturopath, and homotoxicologist are all good team members. The pediatricians and healthcare professionals are covered by insurance so you can have as many of these on staff as you want! I enjoy having a few doctors because then I can weigh what one says against the other and decide for myself what the best course of action is for my child. For instance, my daughter had bronchitis three weeks ago. I tried my best to tackle it with essential oils and homeopathy, two methods of preventative and responsive medicine that are often quite effective for my family. They’ve helped assuage eye twitches, nausea, ear infections, minor allergic reactions, bruises, eczema and a myriad of other ailments. But, this bronchitis was nagging despite the fact that she did not have a fever and was still very active. She needed an antibiotic, so I took her to a pediatrician who prescribed one. My children do not get them very often, so I was willing to take the risk, off set them with probiotics, and make some dietary changes for the duration of their use. Days after she got the clean bill of health, she came down with an ear infection. Some Galilean olive oil with a dab of Thieves and she was good to go. Sometimes allopathic medicine is an option. Sometimes, simply educating ourselves about proper nutrition and preventative care is an option, too.

Yes, The Rev recommends trying quackery first, and when that fails acquiescing to those nasty, reductionist pediatricians and their big pharma-produced toxic chemicals. Just hope that the disease isn’t serious enough that, by the time The Rev abandons quackery and chooses real medicine, it’s not too late for her child.

Maybe that’s why she concludes her nauseatingly self-congratulatory post by congratulating mothers who have gotten letters firing them from their pediatricians’ practices because they are now “Thinkers”:

If and when that letter from your pediatrician arrives? Consider it a victory. You are now a Thinker, and you have been invited to take an active role in guiding healthcare policy in this country. May I gleefully suggest there are several medical, chiropractic, whole-health physician practices in your urban/suburban areas that will be more than happy to care for your child? Investigative physicians that treat the individual child are out there.

Sorry, Rev. None of what you’ve written above sounds even remotely like thinking, much less “Thinking,” to me.