i'm still trying to reconcile this as well. trying to inform parents, and compromising on vaccine schedules and what they get is sometimes a way to get a foot in the door. most often the vaccine refusals i get are parents whose first child is autisic and they then don't want their subsequent children vaccinated. or, they want their MMR delayed. while both may not make medical sense, i can appreciate their viewpoint. and when all i can say is that "there is no documented link between vaccinations and autism, and there have been multiple studies showing no increased risk of autism amongst vaccinated children as well as the fact non-vaccinated children develop autism" doesn't seem to help much. not to mention that the fact thimerisol was removed from vaccines (voluntarily) now makes those parents think that they took it out because people "were on to it". i've only had one parent ask about the atlanta case of the pre-existing mitochondrial disorder that won a claim against the vaccine injury fund-- which was surprising, but it may not have made its way through the internet boards yet.
only once did i have someone not want to vaccinate because "pediatricians are in with the vaccine makers". i told the mother that if we were truly in it for the money we'd recommend *no* vaccinations, as an LP, inpatient abx and hospitalization all make us FAR more money than the little to no money (or loss) civilian pediatricians get for routine childhood vaccinations.
the issue i run into most frequently, and is most likely to cause me to want to fire parents, is the asthmatic with smoking parents. they come in wanting allergy or pulmonology referrals when they're smoking "outside all the time" at home. "always smoking outside" is total BS-- and even after explaining how smoke particulates and other crap can trigger asthma/allergies more than "black mold" they liek to blame everything under the sun on, they roll their eyes and tell me "they've tried, nothing works, blah blah blah". those are the parents i want to fire. i document "secondary inhalation/poisoning toxic fumes" or something like that (it's a diagnosable thing in our EMR called AHLTA) and harp on it each visit.
in the grand scheme of things though, i think it's more important to try to win the overall battle with parents than fire them over littler stuff. no parents are perfect, and i try to emphasize we are a team. as long as what they want to do isn't actively harming their child, i say go for it. and even little stuff that the AAP harps on that aren't EBM, like the dreaded "nipple confusion" or "cereal in the bottle" or "gas drops" i'm not going toe-to-toe with them on- -'cause i really don't think it's a big deal. smoking, vaccinations, yes. but even those things can be worked on. and the reality is, unvaccinated kids are *probably* going to do ok-- and when they're 9 and catch chicken pox you can take some inner enjoyment of "i told you so". or, if something bad happens like HiB meningitis, you can chalk it up to having tried your best but not being able to make everyone do what you want. on the flip side, forcing a parent to vaccinate by threat of firing them (or alluding to it) and if one of those rare complications of encephalitis or something does occur, i'd feel much worse as a pediatrician.
anyway, massive tangent. but i guess my point is i would only fire the patient if the parents are no longer vested in my (our) management. as long as they're listening to something i'm telling them, i'd stick with it. otherwise i could fire them and have a clear conscious-- because there's really nothing else to do-- except hope their kids buck the trend and turn out more rational than their parents.
--your friendly neighborhood do what you can when you can caveman
