Shift from universal to optional vaccination risks normalizing preventable disease

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From KevinMD, I'm Dr. Kevin Poe, and this is the podcast by KevinMD.

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Dr. Kevin Poe.

Hi, and welcome to the show, subscribe at KevinMD.com slash podcast.

Today, we welcome Umair Shake.

He's a medical student.

Today's KevinMD article is the impact of the CDC's new childhood immunization guidance.

Umair, welcome to the show.

Thanks for having me.

All right.

So we're talking offline.

I know that you are in between your third and fourth years of medical school.

So what led you to write this article and send it over to KevinMD?

Yeah, absolutely.

So I always love sharing with people that, you know, even though I'm in medical school,

my background is actually in speech and debate.

When I was in college, I was a double major in communications in Spanish.

And I was really inspired to enter into the fields of medicine during the COVID-19 pandemic,

watching figures like Dr. Fauci and other public health officials take the stage.

And I realized the importance and power of communication within medicine.

And that's something I've always sought to bring as a unique lens to medical education.

And now, as a third, you're someone who's in between my third and fourth years of medical

school, I am seeing firsthand the impact that communication and messaging and public health

is having on on the health and well being of our country.

And so with this piece, I was reading the stories about the new changes in the immunization

guidelines that came out in January of last month.

And I was thinking to myself, you know, this, it was a throwback to my pre-clinical days

where we had learned about these diseases that really we had been told, you should know

them for your boards, but you're probably not going to see them.

And so I remember going through the lessons like, oh yeah, like, complex spots, cries,

and conjunctivitis.

That's measles.

And everyone sort of had a, you know, good laugh about it.

They're like, oh yeah, we have to know this for boards, but don't really worry about it.

And I had been reading all these stories about these diseases that had, you know, long been

almost completely eradicated, coming back and being at a higher prevalence than it had

been previously.

And I told myself, I want to take my communications background, my skill in writing and telling

a story and combine it with something that is very pressing public health issue and

see who would be interested in reading it.

And that's, that was the main inspiration behind this article.

And I also wanted to provide a student's perspective.

I feel like I'd seen a lot of things written from attending physicians and which is fantastic,

but I think when you're a student going through this, you see things from a very different

lens.

You're up and coming in the system.

It's new to you.

And so when it changes so much in a small period of time, it's easy to feel confused and

overwhelmed.

And what I also wanted to do is provide a roadmap for my fellow students and saying, Hey, listen,

you have power.

You have the ability to take this into your own hands and really be stewards for the future

of public health.

So for those who aren't familiar with the changes in the vaccine guidelines back in January,

just give us a synopsis of what has changed.

Yes, absolutely.

So there were quite a few changes that were made in terms of recommendations.

And I believe that, you know, it's, it was something that came from the rationale of,

we want to focus on share decision making and individualized risk assessment rather than

these general sort of blanket guidelines.

And the rationale was not all children have exposure risk to certain diseases.

For some vaccinations, the severe outcomes are statistically concentrated in specific

populations.

And so the argument was that universal recommendations may not be necessary when disease burden is

highly stratified by risk.

And there were different arguments on every side.

From the policy makeup perspective, we were saying, you know, as disease prevalence falls,

these mandatory or universal approaches that we have now can be reconsidered.

It was also really important that the language that was used to recommend and advise parents

and their kids has changed.

Namely, the number of conditions for which the vaccines were universally recommended and

shifted to risk risk rate stratification went from 17 to about 11.

There were some vaccines like rotavirus influenza, COVID-19, hepatitis A, B and meningococcus

that were put into share decision making or risk based categories instead of universal

recommendations.

And the other thing as well is the process by which this was done.

So historically vaccine recommendations have been shaped by the ACIP or the advisory committee

on immunization practices, which is an independent panel that review safety and effectiveness.

Those structures were altered under current leadership at the CDC and HHS, which some

people say has by removing these independent experts and replacing them with appointees

that are sort of aligned with changes to vaccine policy.

Groups including the AAP or the American Academy of Pediatrics and other medical organizations

have urged federal judges and courts to block these changes arguing they're not backed

by the same standard of evidence in which they were set in and that they could possibly

endanger public health.

And there are some states and professional groups that have said that are going to continue

to follow the older evidence based schedule rather than the CDC's newly issued guidance.

And so it's important nothing to have an understanding of those the two sides of that

story.

So by reframing what previously was compulsory vaccines under this paradigm of shared decision

making, individual risk stratification, what do you think about that?

How is that going to impact our public health going forward if we shift to this new paradigm

Absolutely, you know, I think that it is going to one way or another have a tremendous

impact on public health.

I think that we are going to unfortunately start to see some of these diseases that previously

we say existed in the footnotes of history or the margins of medicine start to come back

in ways that we really haven't seen in recent history.

And I think when measles is a great example of this is seeing the rise in incidents in

certain areas of the country such as Texas over the past few months, an area that is on

the cusp of losing its immunization status.

I fear that things like that may start to happen for these other diseases that I mentioned

previously.

At the same time, so there's the sort of technical aspect of it and when you look at the statistics.

Beyond that, I want to mention what something very powerful and in what Dr. Fauci refers

to as the normalization of untruths and beyond just the immediate impact of the disease,

seeing people's trust in the public health system, in physicians, continuing to waver

and weaken is something that is particularly concerning to me.

So we in medicine were trained to learn the disease, the biology, the pathophysiology,

all of these different areas, but what we don't learn is how to communicate effectively,

how to tell stories, how to talk to patients, how to interface with public health and systems,

realizing that the health of people, communities, families is seamlessly intertwined with the

health and well-being of our systems.

And so I fear that this sort of normalization and fear that we're seeing in the general

public is going to continue to widen.

And the onus really falls on us as health professionals to prioritize learning how to communicate

with the general public.

Instead of using jargon, these very heavy terms that only we in the medical community

can understand what's focused on telling stories and interfacing with people where they

are so that they can understand that we are really trying to help them and provide guidance

to keep them healthy.

So historically, as you know, the United States has an individualistic streak and runs throughout

our history and that paradigm of individual choice and shared decision making is surely

going to resonate with a vast proportion of our patients.

So how do you square those?

You mentioned the effects of public health, but how do you square that with our culture

of individualism and the fact that that is going to resonate with some patients?

Abside.

I think it's a great question.

And it's something we've been seeing more and more, even in areas outside of medicine.

You know, I think of areas like social media and all of these different areas where consumerism

and individualism is really pushed on us and we're led to believe that it's all about

sort of what you want and what's best for you with very little look towards the side

with the other people that it affects.

You know, I think there are a couple of ways to go about it.

I think the first is reconciling that there are some areas of our life that are individualistic.

And we need to maintain our mental health.

We need to maintain our what's good for us.

But at the same time, there are things that are not individualistic and there are elements

of our society and even just using the word society.

We get to the fact that there are these things that are collective within our country.

And one of those things is health.

And I think it's important to realize that shared decision-making need not necessarily

be, I don't want a vaccine or I don't want to do something.

Shared decision-making can just as easily be empowering and we can have these difficult

conversations with our patients the right way and communicate to them, yes, it is your

decision.

Yes, it's your child, it's your body, it's your immune system.

It's absolutely true.

But what can we expand from that and say, one of the reasons why we have the health that

we do and the eradication of these diseases essentially that we do is because people, when

it comes to health, people understand that everyone needs to take accountability for the

greater good.

And when it is framed from a value-based perspective rather than a paternalistic sort of directive,

like you need to do this because it will protect people and it will protect you.

And instead we shift the tone of that conversation and we say, you know, we recommend you do this

because it is genuinely in your best interest and it's in your best interest for the people

around you.

I think that cognitive reframing and that messaging is incredibly important and if we frame

it like that, people will start to realize, you know, not only is this best for me, but

it's also good for the people around me and I should help do my part.

Another argument I hear in favor of these changes is that the administration wants to

align our vaccine schedules more to those of other countries and I always hear Denmark

and Japan cited most frequent.

So what do you think about that particular argument?

Yeah, no, and that's something I've been seeing as well and I think that's really, really

important.

And I think the policies in those other countries are also very closely tied to the health

infrastructure that they have and if we were to look at parallels between these other

countries that have these sort of vaccination schedules that they do, that perhaps are

not as stringent or rigorous.

But you look at it in the context of their overall health care system and see the infrastructure

they have in place, see how easy it is for people to get medical care and attention

that they need versus the US where we have a system that is dominated by insurance and

dominated by, you know, these, these incredibly long wait times and you need referrals for

specialists and all these different things.

Our health care systems just fundamentally work on a different level and I actually think

that, you know, the policies that we have adapted up until these more recent recommendations

have come out has been a part of the reason why we've remained as healthy as we have and

even then, I mean, if you look at the statistics for sort of like global health or overall

health of the US, it lags rather significantly behind that of other developed nations.

And I just think that sort of tells a huge part of the story is, yeah, if we had easier

access to health care, if we had, you know, if we have better coverage, if we had better

resources available for people, then and we were just talking about individualism versus

collectivism a moment ago, these other societies are very invested, people are very invested

in the health of their community.

And so as long as we continue to have this individualistic culture guiding us in the

US, we would need these strict recommendations to maintain that same level of health.

So I think if we were, if we wanted to adapt what those other nations were doing, we would

need to see a big cultural shift in our mindset in order for that to really keep us at the

same level of our health.

I want to go back to the patient communication piece.

Now clearly, you mentioned that you have that background in speech and debate.

And of course, in our exam rooms, when we talk about health care and vaccines in particular,

there is really nothing more politicized than that.

Chances are 50% of patients, one out of every two will either disagree or agree with what

you recommend in the exam room regarding vaccines.

What are some tips you could share with physicians who may not have that background in debate

to navigate some of those discussions?

Absolutely.

I think this is, thank you for asking that.

I feel like this is such an important thing that as I was saying earlier, in medical

school, we have our oskeys, we have all of these different things.

We have the didactic sessions, but we have very little practical applications at this.

We don't practice it nearly enough.

I think the first thing is coming at it from the point of view of the patient.

What's important to them?

What do they value for their health and the health of their kids and their loved ones?

Too often, I have, in this comes from personal experience, being a kid and my provider coming

into the room and saying, all right, we're going to give you these shots today.

And you feel like, I was like, whoa, what's going on here?

You just told me what I needed to do.

You didn't tell me anything.

They have a chart on the wall.

You have questions.

Look at the chart.

This is what's recommended at this stage.

But in my experience, sitting down with patients and being like, you know, there are a

couple of things we'd like to do at your visit today.

But first, I just want to get a sense of what's important to you.

How do you feel your health is right now?

Are there any changes you'd like to make?

And that, not only sort of like disarms the patient in terms of defensiveness, but

it really makes them feel like that they are being listened to.

That this doctor is wants what's the best for them.

And you might get a myriad of responses from that, like, oh, I think my health is good.

I don't want to do anything or, you know, I feel like I could be better.

Are there any things that I should be doing?

And depending on the avenue the patient gives you, then you could sort of pivot accordingly.

But I would say some baseline communication principles and any of those circumstances would

be to say, you know, we have these recommendations based on your age, based on your pre-existing

conditions.

Here are some things that we'd recommend.

One of those things involves a vaccination.

Here's what the vaccination is.

Here are some of its possible side effects.

But here is why the net benefit would outweigh the long term harm for you.

It's completely your decision.

But we, I want to be in line with your goals that you told me.

And you know, this, this is something that can help you achieve that.

And if you were to frame it from that point of view, even if they disagree with vaccinations

as a principle, they'll see, you know what, this, this doctor really is, is listening

to me and they are hearing what's, what's valuable to me.

And the other thing too is not pressuring them at a certain time.

And this is something I've seen a lot more physicians in corporate recently, which is,

you know, take some time, think about it, doesn't need to be done today.

If you have any questions, I'm available.

Give me a call, give my office a call.

Whatever, whatever I can answer for you, I'm, I'm more than happy to do.

And it, it's just a matter of being open.

And, and instead of coming at it from the perspective of, this is what you need to do.

There's a chart on the wall.

This is what it says.

I need to do this today.

That's when you're going to start to see patients shrink back.

So it's, it's really all about that framing.

Now, as we talked about, you are in between your third and fourth years of medical school.

From what you're seeing, not only in your medical school, but others as well.

How are they teaching students to navigate the increasingly political environment of health

information?

Yeah.

I don't think you were asking that.

I, and I feel like I kind of have a front row seat to this being a medical student in

Washington, DC, who, all of these changes are happening and we, we see it in front of

us every single day.

So I, I would say that there has been more of an emphasis placed on patient-centered communication

than I, I think, previous generations of medical students have had.

You know, I've talked to a lot of my physician mentors and they said, you know, these

oskeys that you have now, these communication sort of things that you, you have going on

are not things that we did.

And so I, I think there is a movement in the right direction to have these difficult

conversations with patients.

That being said, I don't think it's all the way there yet.

I think there are, there are still things that are missing.

And I think one of those big things is policy education.

I did my master's of public health before starting medical school and I sort of entered

into medicine with that policy perspective.

And so now, whenever I learned about something new in the world of medicine, one of my first

thoughts is, well, how does this shake out at the national level, at the health policy

level?

And so I think that is an action step that a lot of medical schools can take.

They're doing the right thing with the guards to communication.

They're slowly getting there.

Let's build health policy into that too.

Let's learn how lobbying works.

Let's learn how legislation works.

Let's learn how these changes that have come so quickly and undone so much work over

the past century have happened, have taken place.

And when we do that, we empower our physicians and our aspiring physicians as well to take

an active role in advocacy.

And there are always, and I'll tell you being in DC, there are always these events happening

at Capitol Hill for one thing or another.

It's all these different groups have their days in Congress where they go and they talk

to representatives and the show, the turnout from physicians needs to be higher.

And not only that, we need to learn how to advocate for ourselves.

One of the things we don't learn also is public speaking and how to communicate easy and

a difficult message, break it down into an easy to understand manner, and then disseminate

that to a large audience.

That's a huge skill that if we were to start building in as physicians, I think we would

see a big shift in public health with regards to how the public sees us.

We're talking about umar shake.

It's a medical student today's Kevin M. DeArticle is the impact of the CDC's new childhood

immunization guidance.

Umar, let's enter some take home messages to the Kevin M. DeArticle.

Absolutely.

A couple take home messages.

The first is for students, you have the power, the future of the healthcare system,

you are the center of it.

And it is so important that you prioritize learning how to communicate, advocate all of these

different things for not only your patients, but for yourself and for your community.

Second take home message to physicians who are currently practicing, help inspire the

next generation of us to really be on the front lines of this advocacy work, show, tell

us in your experience what we need to do and then help us shape our careers accordingly.

At the same time, the way you communicate with your patients, model that for us younger

students, so we can better interface and connect with a growing population of people that

is growing increasingly distrustful of the medical system.

And finally, for patients themselves, you guys, what we do in medicine is for you.

It is to take care of you to help you in any way that we can ask us questions.

Don't be afraid to ask us whatever things you may have.

We're here to help you.

We are here to serve.

And we want to help you take the most control of your health as you can.

And we ultimately want what is best for you.

Mary, thank you so much for sharing your perspective and insight.

Thanks again for coming on the show.

Thank you so much, Dr. Kevin.

I really appreciate it.

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