Dr. Andrew Miller knew something was up. The North Carolina pediatrician saw nearly a dozen new patients at his practice over the span of a couple of weeks last year, all of whom were opting out of their children receiving some or all vaccines.
After the pattern became clear, Miller, a board-certified physician who supports the vaccine schedule, eventually asked a patient how they found his practice. “Well, you know, you’re on that website,” the patient told him.
The website, it turned out, is “Dr. Green Mom,” a blog with an affiliated supplements company run by Ashley Mayer. Mayer is a naturopathic doctor who describes herself as “vaccine-neutral” and who sells her own supplements, including products like “VaxClear” that she claims helps with “toxin elimination” during vaccination. She also maintains a database of doctors in each state who are friendly towards or tolerant of families who forgo some or even all vaccines—and Miller is on that list.
“I agree very little with what is on the Dr. Green Mom site, and I think it mostly operates in a pseudoscience fashion,” Miller told The Dispatch. But he also wants parents turning to sources like Dr. Green Mom to be exposed to sound medical science and understand the safety and necessity of vaccination. Miller welcomes patients who refuse some or even all vaccines into his practice, a position at odds with a growing number of pediatric practices across the country.
Distrust of vaccines and immunization guidance had been on the rise since before the COVID pandemic, and childhood vaccination rates had been slipping for years. But the pandemic worsened these trends. President Donald Trump’s elevation of Robert F. Kennedy Jr. as the health and human services secretary exacerbated existing political polarization around vaccines and emboldened purveyors of false and misleading medical information, fueling an even more chaotic information environment.
For primary care physicians and pediatricians, dealing with parents who don’t believe in most or all childhood vaccines, are skeptical of some immunizations, or are just plain confused has become a much more challenging task.
Some pediatric offices have adopted policies of dropping current patients or not accepting new families if they refuse to vaccinate their children. A 2019 survey of U.S. pediatric offices published in The Journal of American Medicine (JAMA) found that 51 percent of pediatricians reported that their offices had a policy requiring the dismissal of patients refusing vaccines, although only 37 percent of pediatricians reported often or always dropping such patients. Private practices were far more likely to have dismissal policies than hospitals or community health centers.
It’s unclear just how widespread the practice of dropping patients who refuse vaccinations is as well as a dearth of studies on the topic. The 2019 survey is one of just a handful on the subject in the last two decades. Still, the literature shows an increasing trend. A 2012 survey using the same methodology as the 2019 version found only 21 percent of pediatricians dismissed families for vaccine refusal. “I think the prevalence of these policies has gone up, I don’t know by how much, though,” Sean O’Leary—a pediatric-infectious disease doctor and researcher at the University of Colorado who co-authored both surveys—told The Dispatch, noting that the 2019 survey has not been updated.
The proliferation of dismissal policies is one factor driving vaccine skeptical parents to sites like Dr. Green Mom. After Miller found out he was on the site’s list as a doctor willing to treat the children of vaccine-skeptical parents, he decided against trying to have his name removed. Today, the vast majority of his new patients are undervaccinated or nonvaccinated, many of them arriving at his practice by way of the list but also from moms’ Facebook groups and word of mouth. Approximately two dozen of these patients commute more than an hour to Miller’s Durham, North Carolina, practice, he said; some drive up to four hours just to see him.
The pediatric clinic is affiliated with Duke Health, a private, nonprofit health care system that strongly encourages full vaccination but does not allow patient dismissals based on vaccination status. “That physician-patient relationship is an incredibly important one, and while there are things that could terminate that, there very few and far between,” said Miller, who spoke to The Dispatch in his personal capacity, not as a representative of his practice or Duke. “My job is to be there for the patient, even if they don’t really listen to me and do everything that I say.”
The influx has included some of Miller’s new favorite patients. “They’re thoughtful, intelligent people. Many of them actually end up getting vaccines, either some or all, but they’re just looking for someone who is willing to have those conversations and dive in deep with them and treat them as someone capable of handling and thinking through that information,” he said.
When discussing vaccination, Miller said, he sets boundaries with new patients. He tells parents that there are black-and-white situations when a patient’s life could be at extreme risk by refusal of a vaccine, and in those cases, he will insist on certain actions. For example, if a mother has Hepatitis B or is unsure whether she has the disease or is untested, he’s adamant that children receive the Hep B vaccine immediately. But if both parents have been tested, and there’s no additional risk factors like drug use in the home, then for Miller, opting out of the vaccine is within the purview of parental choice. “I feel my job as the clinician is not to coerce, it’s not to belittle or shame,” he said. “My job is to educate and to explain.”
“The number of clinics who are willing to engage and see this population is dwindling. These people are going to end up in these echo-chamber clinics that are telling them what they already want to hear, which I would argue is bad medicine.”
Dr. Andrew Miller
Anna Ruderman, one of Miller’s colleagues who shared her personal views with The Dispatch in, agrees that patients should not be dismissed for vaccine refusals. She believes that parents should be treated with compassion and will discuss with parents the risks of foregoing or spreading out specific vaccines. But she said decisions to depart from the vaccine schedule can be fraught, sometimes leading parents to misevaluate the importance of the guidelines. “It’s so hard because you run into this slippery slope of, ‘Oh, well, they said this one wasn’t important,’ but they’re all important,” she said.
“Vaccines are by far the safest things we do as a pediatrician,” she added. “If we did no other parts of our job and just did the vaccines, that would save more lives than anything else that we do.”
Ruderman has experienced more and more families declining vaccines, many based on false and misleading information. “I spent an extra hour with a patient today in my busy clinic schedule, discussing all of the misinformation and all of the fear that the parent felt, and going through all of the false information like Tylenol or vaccines cause autism,” she said, noting the parent was getting her information from TikTok.
Miller fears the growth of dismissal policies will drive more families toward bad information and medical advice. “The number of clinics who are willing to engage and see this population is dwindling,” he said. “These people are going to end up in these echo-chamber clinics that are telling them what they already want to hear, which I would argue is bad medicine. We really need to keep people within our clinics and keep it so that they can continue to be exposed to the good and healthy ideas, even if that makes it more challenging for us.”
Many pediatricians take a different approach. The reasons for dismissal policies can vary. Some practices worry about the legal liability of not vaccinating children who later contract vaccine-preventable diseases, although many offices require parents to sign a vaccine refusal form designed to mitigate liability risk. Other providers are concerned about the time involved in working with and persuading parents of non-vaccinated patients, reducing available time for others in practices that are often already booked out months in advance for new patients. (Pediatrics is one of the specialties that’s been hit hard by the national shortage of doctors.)
But the primary driver of dismissal policies seems to be a desire to incentivize higher vaccination rates and to protect people in clinics from potential increased risk of exposure to disease. Indeed, outbreaks of vaccine-preventable disease have triggered the adoption of dismissal policies by many medical practices. O’Leary, the pediatrics researcher, said he noticed an uptick after the 2014-15 Disneyland measles outbreak that sickened more than 100 kids in California and even spread to Canada, sparking an outbreak of 150 more cases.
As the Los Angeles Times reported earlier this year, a California pediatric clinic near the epicenter of the outbreak had allowed parents of patients to refuse vaccines. Doctors in the practice felt responsible for the spread of the disease among patients who choose to not receive the measles vaccine, putting at risk not only that cohort but also other patients who were immunocompromised, or too young to be vaccinated. “We had extremely low vaccination rates, and frankly, I think, a lot of our physicians and our patients became complacent; they weren’t seeing these diseases,” said Dr. Eric Ball, a partner at the practice. “And then we started having kids with measles come into our office.”
“We had babies and other people exposed in our waiting room to children who had measles. We had adults contract measles in our office. This was a huge wake-up call for all of us,” he added.
The outbreak resulted in pro-vaccine parents pressuring some pediatricians to put dismissal policies in place. “For some of the practices, they may have been on the fence about whether or not to have a policy like this, but then they started hearing it from parents in their practice, saying, ‘We like you guys and all, but we don’t want to bring our kids where they might pick up measles, so we’re going to go to the practice down the street that doesn’t accept non-vaccinators,’” O’Leary said.
Dropping patients for refusing vaccines used to be a rarity and was actively discouraged by medical groups like the American Academy of Pediatrics (AAP). In 2005, AAP issued guidance that “pediatricians should avoid discharging patients from their practice solely because a parent refuses to immunize his or her child.” In 2013, the guidance was changed from “should avoid discharging” to “should endeavor not to discharge.” But in 2016, the group softly endorsed the practice, writing that “a pediatrician may consider dismissal of families who refuse vaccination as an acceptable option” but emphasizing that such move “is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view.”
Pediatric practices in North Carolina have also tightened their policies in recent years, following outbreaks and increased cases of vaccine-preventable diseases like whooping cough. Several clinics reported the crackdown resulted in more parents choosing to vaccinate. But beyond anecdotes, there’s little evidence on whether dismissal policies result in higher aggregate vaccination rates beyond a particular practice. O’Leary said that pediatricians he talks to often think their practices’ policies result in more vaccination, but “we don’t have data on that.”
He thinks ousting patients for vaccine refusal could, in practice, do more harm than good, citing the unknowns of where such patients will turn to for care next and how dismissal affects families’ trust in the medical system. While vaccination rates are slipping in some areas, they are still high nationally, and O’Leary argued that aside from areas experiencing an active outbreak, there’s no evidence that seeing unvaccinated patients increases the likelihood of the spread of vaccine-preventable diseases within a practice. It’s possible that the proliferation of dismissal policies could actually increase the risk of spreading disease if more non-vaccinated and under-vaccinated patients begin to cluster at a narrowing number of clinics that agree to see them.
As vaccines become a more divisive and politically polarized topic, some pediatricians argue that the specter of dismissal is more likely to drive families away than incentivize them to vaccinate their children. If under-vaccination before the pandemic was more a product of complacency, a new policy could serve as a helpful nudge to parents and signal how important their doctors think immunization should be. But if under-vaccination is now more the result of confusion or fear, dismissal policies can simply seem coercive. “At one point it may have been an incentive, but I don’t know that it still is,” Ruderman said.
At least some local health officials are actively encouraging physicians to turn away from dismissal policies. In Michigan’s Oakland County, the health department had previously encouraged clinics to adopt dismissal policies, but officials changed course after they became concerned the approach was actually harming vaccine uptake. The county has since embraced a “harm reduction” approach designed to help educate clinicians on vaccine hesitancy and strategies to improve vaccine coverage aside from zero-tolerance dismissal policies.
The pressure on pediatricians will continue to increase as misinformation and confusion around immunizations spread and red and blue states pursue diverging vaccine policies. While trust in public health authorities around vaccines has plummeted, pediatricians remain the only source of vaccine information trusted by large majorities across political affiliations: A Washington Post-KFF poll released last week found that 85 percent of all parents trust their pediatricians’ advice on shots, including 93 percent of Democrats and 85 percent of Republicans.
The poll also found that only 12 percent of U.S. parents who trust their pediatrician skipped or delayed a vaccine, other than for COVID or the flu, but that number jumps to 41 percent among parents who distrust their pediatricians.
In March 2024, AAP released additional guidance that O’Leary co-authored on vaccine dismissals. The update still says patient dismissal for refusing vaccines is an acceptable option for medical practitioners, but places even more emphasis on treating dismissal as a last resort “after repeated attempts to help understand and address parental values and vaccine concerns, engender trust, and strengthen the therapeutic alliance” and after “less drastic alternatives” are considered.
For Miller, building trust with patients is incompatible with the pressure of a dismissal policy. “[If] we say, ‘Do this or else,’ maybe they do choose to get one more vaccine that day in that clinical encounter,” Miller said. “But what I’ve done is further undercut the trust and the relationship that I had with them before, and I’m ultimately losing them in the long run, from becoming a part of what I think is the good practice of medicine for vaccinations.”
