Can do or will do?

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].

For the last decade or two, a higher percentage of my patients were adequately immunized than were my younger partners’ patients. The gap wasn’t always dramatic, but it was consistent. We all thought this phenomenon was primarily based on a physician selection bias. My age and gender seemed to attract families who tended to be more traditional in their parenting style and predisposed to accepting the party line on immunizations. The families who were more liberal and skeptical about immunization sought out my younger female partners.

Although our suspicions of causation were for the most part correct, an article in the December 2013 issue of Pediatrics (132:1037-46) suggests that how I presented the immunization opportunities may have contributed to my relative success. These investigators observed more than 100 vaccine discussions by 16 providers in nine practices. They categorized the providers’ formats as being presumptive ("Well, we have to do some shots") or participatory ("What do you want to do about shots?").

The researchers found that parents had a "significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive format." We shouldn’t be surprised at this observation. If you present an issue as a "can do" instead of a "will do" situation, hesitant parents are more likely to say, "Won’t do."

However, I am surprised how many providers presented the issue of immunization in what might be called a shared-decision format. But I guess it is just another example of how the role of physicians has changed in the past few generations. For the first half of the last century, most physicians could be characterized as paternalistic. They were accustomed to telling patients what to do. The patient brought the doctor a complaint. The doctor would provide a diagnosis and dictate what the patient should do to get better. End of discussion.

I’m not exactly sure of all the forces that have created the shift, but it became clear that although medical knowledge was expanding exponentially, doctors still didn’t have all the answers. And, in many situations, the outcome was better when the patient participated in the decisions about his or her care.

In pediatrics, the use of a shared-decision, participatory format for managing otitis media has been successful in reducing the amount of antibiotics prescribed. However, this new study makes it clear that welcoming the patient or parents into the decision-making process may not always be the best strategy. My direct, no-nonsense let’s-get-it-done style helped me to achieve a better immunization record than the softer tell-me-what-you-think approach of my partners.

The problem is that one style doesn’t fit every clinical situation. To be a successful physician, one must be able to adjust one’s style to match the diagnosis, personality, and emotional needs of the patient and the myriad of societal and economic features that make up the landscape of the real world. I admit that I haven’t always achieved the perfect match. Although my basic inclination is to use a presumptive approach, I found over the years that I tended to lean more toward a participatory format. It just seemed to work better. But, when it came to immunizations, I wanted to give families the best chance of avoiding a bad decision.

Although most of us would feel uncomfortable with having our clinical encounters videotaped, the results of this study suggest that we should be examining more closely what we say to patients and how we say it. Our success as physicians depends on it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He continues to monitor and comment on anything pediatric. E-mail him at [email protected].