Hylton I Lightman MD DCH(SA) FAAP
The death knell for primary care pediatrics in this country may have been sounded with the Department of Health and Human Services’ (HHS) recent decision to allow pharmacists to administer vaccines to children. This decision is unwise and will no doubt adversely affect children and teenagers and their families.
I am an optimist who chose primary care pediatrics as my life’s passion and work. Building relationships with parents and children to assure the optimal development of each child excites me as I believe each person is created in G-d’s image. Each person comes into this world with his unique tafkid. The digestive issues, bowel movements, sounds, developmental milestones, fluoride varnish, academic performance, strep throats, ear infections, allergies, emotional health, etc., all give clues as to how a child is developing and when and what type of intervention may be warranted. Symptoms should be properly monitored and addressed if necessary. The pediatrician plays a significant role in helping children to achieve their potential.
Further, the pediatrician is uniquely positioned, if he chooses, to see the child’s position within the family milieu. Family psychosocial dynamics are no small determinant of how one develops. If involvement or mediation is deemed necessary, the pediatrician can have a helping hand here as well.
Your children’s primary care office should be your children’s primary medical home.
Many people see vaccines as the center (and sometimes sole) focus of the well visit. While vaccines are important, and my readers know I am pro-vaccines, vaccines are but one part of the well visit. Is the child following the same developmental curve? What does the CBC (complete blood count) reveal? Does the child have a healthy relationship with food? What if the depression survey indicates that the patient may be at risk for depression or is in the throes of depression? And the list goes on.
By no means am I dissing the important role that trusting and trustworthy competent pharmacists play in our lives. As HHS Assistant Secretary of Health Admiral Brett Giroir, MD, says, “Pharmacists have always been a trusted voice in the community.” Yet with all due respect, they are not trained to see the overall picture of a child’s health (a pediatric residency requires a minimum of three years of training before specializing), let alone comprehend what it takes to launch each child into life by assuring a solid physical, mental, emotional and social foundation.
Even when children come to the pediatrician for a vaccine only visit, there is counseling that ensues. We begin the so-called “vaccine only” visit by determining that the child is healthy enough to be vaccinated through a brief physical exam. Mommy and/or Tatty should understand what each vaccine is for and the possible side effects. It’s never as simple as just an injection with a Disney-themed bandaid applied.
I am afraid that if parents bring children to pharmacists for vaccines, many pediatricians will have a harder time than ever getting parents to schedule well visits and then to show up. Primary care pediatrics will fall back rather than progressing forward, G-d forbid. In the words of Gary Leroy MD, president of the American Academy of Family Physicians, vaccines “given outside of the patient’s usual primary care setting could disrupt the doctor-patient relationships that are so critical.”
This is only the first step of my concern about the unsoundness of the HHS ruling.
My fellow pediatricians will corroborate that each pediatric office has its own vaccine protocol. There are a number of pharmaceutical manufacturers with similar products to inoculate against the same disease. Each pediatric office’s Chief Medical Officer will choose which vaccine path to follow. It’s rather like fitting together the pieces of a gigantic jigsaw puzzle: if a piece of a different puzzle ends up in the box, it throws a monkey wrench into the protocol.
Further, how is the pharmacist to know which vaccine a child is to have?
At present, most pediatric offices communicate through their electronic health records (EHR) systems to their City’s Immunization Registry (CIR); some EHRs are set up to simultaneously report vaccine usage to the pediatric office’s statewide immunization registry. I doubt that pharmacies enjoy this setup.
How is the pharmacist reporting which child gets which vaccine? It is a fantasy to think that the pharmacist will check off boxes on a piece of paper that the parent will then ostensibly bring to the pediatrician’s office to enter into the child’s chart.
From experience, I know that it is impossible any physician has 100% control over a patient’s behavior outside the office. Further, I pray that my years of medical training followed by decades of being in the trenches of primary care pediatrics is seen as more than data entry. If the HHS decision is followed by the fast news that a national immunization registry is being introduced, this would be good news for all. But I highly doubt that such a decision is imminent, let alone on the horizon for at least several years.
Since Covid-19 entered our lives nearly six months ago, many pediatric offices have experienced a drop in well visits. This means delays in vaccinations, interruptions inappropriate screenings and referrals, and deferrals in anticipatory guidance to assure optimal health and development. While many offices scrambled to offer telehealth, it is presently, at best, an inadequate substitute for the face-to-face visit and the hands-on exam. The delays in vaccinations could, G-d forbid, result in outbreaks with vaccine-preventable illnesses.
This is the premise underlying the decision of Alex M. Azar, Secretary of Health and Human Services, to use emergency powers by allowing pharmacists to vaccinate.
While well visits rates plummeted in March and April, they began a slow ascent again in May. Most pediatric offices that had closed its doors to in-person visits were fully operational June 1st. A July report from the Centers for Disease Control and Prevention (CDC) noted that New York City saw a rebound in kids getting their vaccines.
I postulate that the uptick of vaccines in June, which I am convinced continued through July and August, is because of the important, central and revered role your pediatrician and his office have in your children’s lives. In the words of the American Academy of Pediatrics President Dr. Sally Goza, “In the middle of a pandemic, what families are looking for is reassurance and clinical guidance from doctors they trust most to care for their children: pediatricians.”
I respectfully suggest that the HHS work with the AAP to assure and restrengthen the pediatrician’s role in delivering excellent health. Delineate a model whereby the HHS helps to provide appropriate personnel to rotate through pediatric offices to help with vaccinating children, particularly with the flu vaccine. Further, the HHS could help by having all city and state immunization registries speak to one another “electronically.” This could possibly reduce gaps in care.
The pediatrician knows his community and his constituency best. Vaccinating through pediatric offices that know their communities can be a double winner — assuring that vaccination rates are maintained at the highest levels possible while providing the best health care.
As always, daven.