Has anyone else noticed the growing presence of ultimatums in medicine today?

The New England Journal of Medicine published a discussion of the ethics of not hiring smokers.  My hospital adopted this policy six months ago, and they are not alone.   There is a tobacco blood test that new employees have to pass.  If they fail, they can look for a job elsewhere.  I do not know the exact details, but I imagine they get a well-worded explanation of why this is legal and a pamphlet on how to quit tobacco.

The policy immediately made me think of pediatric practices that will not see patients whose parents refuse vaccination.  There are a number of big groups in my community that have adopted this policy.

“If you do not do what we think is best, then we will not interact with you.”

The problem with ultimatums is that they do not really work.  Unless the goal is to drive people away.  Then, yes, they work.  If you are trying to encourage people to make positive changes, they are less effective. Ultimatums communicate that the deliverer only cares about those individuals who agree with him.  As health professionals and health advocates, we are supposed to care about everyone.  Even the nicotine addicts and the misinformed non-vaccinators.

Working in emergency medicine, one of the most satisfying aspects of my job is how quickly many remedies take effect.   More frustrating is advocating for less popular and/or more difficult medical truths. Sometimes I feel like a broken record as I go from room to room saying the same things.  Antibiotics do not kill viruses.  You need to take the medicines your pediatrician gave you.  Eat more fiber and drink more water.  Get your flu shot.  Use bug spray.  And, of course, one of the best things you can do for your child’s health now and for the rest of her life is to quit smoking.

People deserve to hear the truth, but telling them once – no matter how carefully worded and compassionately delivered – is unlikely to lead to lasting changes.  Our advocacy is not in a vacuum.  The changes we endorse compete with years of habit, financial limitations, social stressors and conflicting advice dispensed by caring neighbors, grandparents, and the internet.

A few weeks ago, I saw a four-month-old in the emergency department.  His mother was concerned about nasal congestion.  The triage nurse was concerned about the child’s health maintenance. In big letters, she had written, “No vaccines.  Patient has not seen a doctor since birth.”

The baby looked well and well cared for.  I asked why the child had not seen a doctor prior to this. She explained that she had two older children and did not want to vaccinate them. A year ago, her pediatrician informed her that her family could no longer be seen at that practice because of her stance on vaccines. Since she was not going to vaccinate this baby either, she explained; she did not think there was any reason to bring him to the pediatrician.

The message had been misinterpreted. Instead of, “Vaccines are a very important thing that pediatricians care about,” she heard, “Vaccines are the only thing pediatricians care about.”

Because the conversation had been ended, there was no opportunity to correct this misconception.  Additionally, this mother no longer had the opportunity to be reminded that vaccines save lives from a doctor she had known and trusted for years.

Rather than ending the discussion by terminating a chance at employment or a physician-patient relationship, we should strive to keep the dialog open.  Tell me your reasons for not wanting to vaccinate your children, and I will explain my reasons for recommending the CDC vaccine schedule.  Tell me why you think your one-year-old needs a rapid strep swab, and I will explain why the test is useless in children under three years of age.  Just don’t tell me you will find a new doctor if I will not give your child antibiotics for his virus.  Ultimatums do not help anybody.

Katie Noorbakhsh is a pediatric emergency physician who blogs at Dr. Katie.  She can be reached on Twitter @mamakatemd.