Like many pediatricians, Dr. Dennis Rosen is concerned about the current 20-year high in measles cases. A recent widespread outbreak that began in California in 2014 has generated a lot of opinions about the high rates of non-vaccination among American children, including Jewish day school students. Vaccination refusal by parents in the US has steadily risen in recent decades, and now stands at 13 percent according to one study.
However, Rosen is more interested in what is not being said about the matter. In particular, he focuses on conversations about the importance of vaccination between doctors and parents, and wonders if they are not effective — or not taking place at all.
As pro- and anti-vaxxers continue to wage war in the press and on social media, parents and others would do well to read Rosen’s new book, “Vital Conversations.” This engaging read explores about how better physician-patient communication can lead to better care, as well as to less expensive care. Cutting costs is a major issue in the US, where total health expenditure is almost 18 percent of GDP (in Israel it is little less than eight percent of GDP).
For Rosen, an Israeli-American pediatric pulmonologist and sleep specialist at Boston Children’s Hospital and an assistant professor of pediatrics at Harvard Medical School, the vaccination rate crisis is merely one failing of the healthcare delivery system in the United States that can be attributed, at least in part, to poor communication between doctors and their patients.
Vaccination refusal by parents in the US has steadily risen in recent decades, and now stands at 13 percent, according to one study
In Jerusalem recently to attend and present at a conference, Rosen explains in an interview with The Times of Israel that good communication depends on there being sufficient time for the doctor and patient to have effective conversations. Of course, time to speak with patients is something that doctors have less and less of under the current efficiency-driven medical system.
“As more constraints are placed on the time doctors have to address the health concerns of their patients, the less likely it is that real — and effective — conversations, certainly about a topic as weighted as vaccinations, can take place,” Rosen says.
“Unless I, as a pediatrician, can really understand what the parents’ concerns about vaccines are, where they arise, and how they might best be mollified and ultimately overcome, it is very unlikely that I’ll be able to change that person’s mind. Simply throwing numbers and statistics at them just isn’t going to do it.”
Rosen believes that in having lived in several different countries he is more closely attuned to the need for good communication, and especially for understanding the cultural and socio-economic factors that influence conversations between people.
At age 15, he immigrated to Israel from Toronto, Canada with his family. After attending high school in Jerusalem, he served in the IDF in the Nahal Brigade. Following his military service, Rosen studied medicine at Hebrew University, doing his residency in pediatrics at Kaplan Medical Center in Rehovot. He has been in Boston since 2001, when he moved there for a pediatric pulmonology fellowship at Boston Children’s Hospital. Now 47, Rosen lives in the Boston suburb of Newton with his Israeli-born wife and their three children.
Although Rosen wrote “Vital Conversations” with both doctors and patients in mind, his narrative style favors general, lay readers. In addition to arguing, with the support of personal anecdotes and many research examples, that better communication improves healthcare delivery on a systemic level, he provides patients tools they can use to improve dialogue with their doctors and, ultimately, improve their ultimate medical outcomes.
Rosen simply emphasizes the numbers in explaining how change can happen.
“There are more patients than doctors. Therefore, the patients need to speak up,” he says.
‘As more constraints are placed on the time doctors have to address the health concerns of their patients, the less likely it is that real— and effective —conversations… can take place’
In some cases, what the patients need to say is that they need more time with the doctor. In others, it’s a matter of patients letting their physicians know what is important to them.
In one of the book’s anecdotes, Rosen recalls how, as a resident, he helped stabilized the condition of boy and girl twins born prematurely at just 27 weeks gestation to a young Orthodox Jewish woman. When he went out to tell her family how the babies were doing, he rattled off all the medical procedures and tests that had been done to the babies.
Rosen felt proud of himself, but he was met with silent, unreadable expressions on the faces of the family.
Finally the grandmother spoke up and asked, “But doctor, how much do they weigh?”
“The longer I’ve been in practice and the more time I’ve spent with patients and their families, the more I understand not only about where that question came from but also what it says about much of the ‘dialogue of the deaf’ that all too often passes for communication between physician and patients,” Rosen writes.
“These people weren’t stupid; nor were they by any means disengaged from the modern world which surrounded them. However, they were also in no position to make sense of the myriad data and factoids I had just bombarded them with. The one measure of the newborns’ well-being that they could related to, the single most important piece of information that they needed in order to contextualize the infants’ condition within their personal and collective experiences and that they could share with others, was exactly that which I had neglected to provide them with: the infants’ birth weight. If the babies weighed less than four pounds — and in fact, they weighed less than two pounds each — the brit mila would need to be postponed.”
Many of the illustrative anecdotes Rosen shares in “Vital Conversations” are from his experiences as he trained as a young doctor in Israel. In conversation with The Times of Israel, he emphasizes the importance of physicians learning strong communication skills at the beginning of their careers.
“Doctors get their education cerebrally when they start off, and then they get caught up in the workload,” Rosen says.
“With hospital shifts [for doctors in training] now limited to 16 hours, they need to get the same amount of work done in a shorter time. Something has to give, and that usually is communication.”
To combat this phenomenon, Rosen has been providing simulation training for pediatric pulmonary fellows. In what Rosen calls a “boot camp” whereby actors play the roles of patients and their parents, the young physicians receive training that is split evenly between the medical and the interpersonal.
No one-size-fits-all in medicine, or communication
A recent study by the Center for Disease Control and Prevention cited by Rosen indicated that more than 18 percent of parents surveyed discounted their pediatricians’ recommendations about vaccinations for their children. Rosen believes this shows a serious communication gap between parents and their children’s doctors.
There are various reasons why parents look elsewhere for answers to their questions about vaccinations. Rosen argues that, as with most problems with the delivery of healthcare, this can be remedied by doctors’ taking the time to communicate effectively with patients. In the case of vaccinations, this often involves listening to, understanding and discussing with parents their particular causes for concern about vaccinations.
“The mother of a child with a congenital metabolic disorder is likely to have entirely different concerns about vaccinating her child than the mother of an otherwise healthy child who wishes to provide as ‘natural’ an environment for her child as possible, for example,” Rosen says.
Pediatricians may want children to be uniformly vaccinated, said Rosen, but getting to that point means they can’t take a one-size-fits-all approach.