Pediatric Annals

5 Questions 

A Conversation with Mark H. Sawyer, MD

Stanford T. Shulman, MD; Mark H. Sawyer, MD

Abstract

Dr. Shulman: Tell me more about your idea of office practitioners keeping track of how many of their own patients are actually immunized.

Dr. Sawyer: I was thinking about how we could improve immunization rates in general, not just for any specific vaccine. I would say the most important thing that a general pediatrician can do is to figure out what their own rates are, and that’s where the missed opportunity assessment comes in; not just for their practice as a whole, but for them individually.The problem with practice-based rates is the tendency to blame your partner. “Oh, my partner saw the kid that day and didn’t immunize him. I would have normally immunized him.” What I am recommending is simple to do. You basically take a series of patients you’ve seen, maybe 20 or 25, and just review their immunization history at the time you saw them and determine whether you gave all the vaccines that you should have given that day. I think most physicians would be surprised that they don’t do as well as they think they do.

Dr. Shulman: Just like dieting. You think you’re doing great and then you start counting your calories.

Dr. Sawyer: Exactly. You do your vaccination count and you learn that you aren’t really doing as well as you thought. This has actually been done on a big scale formally by the CDC and other public health groups where they’ve gone out to private practices and assessed their rates. That’s where I learned this lesson that there is a lot of “It wasn’t me” when the rates are low. But if you do a “missed opportunity rate” for yourself, then it is you. It was your visit, you were the doctor seeing the patient that day. There’s no question about who did or didn’t immunize. It’s one thing for a managed care company to tell you that you need to do better, but if you assess your own rates, most doctors are competitive and this will motivate them to do a better job.

Dr. Shulman: So you’re asking these doctors to be accountable to themselves, compete with their partner, and at the same time improve the health of their community. What about the fact that the adult immunization rates are much worse than pediatric rates?

Dr. Sawyer: I think the pediatricians have a central role in getting adults immunized, if for no other reason than it helps the health of the children that they’re caring for. Pertussis is one of the reasons. We need adults to be immunized, especially when there’s a new baby in the house. I do acknowledge that the reimbursement part of adults being immunized in the pediatrician’s office can be a problem, but at the very least, pediatricians can make sure that the adult family members, and older siblings for that matter, at least know that they need to get immunized, even if the pediatrician doesn’t do it.

Dr. Shulman: How did you end up a pediatric infectious disease specialist?

Dr. Sawyer: I was always interested in bacteria; my undergraduate degree was in bacteriology. When it came time to figure out what I was going to do for a living I was deciding between graduate school in microbiology and medical school, and I decided that medical school had the most opportunities. That naturally led me to infectious disease as a subspecialty within medicine. The reason I went into pediatrics is that sick adults are obnoxious.

Dr. Shulman: So what do you do with your free time?

Dr. Sawyer: I play the cello in a community orchestra. I…

Dr. Shulman: Tell me more about your idea of office practitioners keeping track of how many of their own patients are actually immunized.

Dr. Sawyer: I was thinking about how we could improve immunization rates in general, not just for any specific vaccine. I would say the most important thing that a general pediatrician can do is to figure out what their own rates are, and that’s where the missed opportunity assessment comes in; not just for their practice as a whole, but for them individually.The problem with practice-based rates is the tendency to blame your partner. “Oh, my partner saw the kid that day and didn’t immunize him. I would have normally immunized him.” What I am recommending is simple to do. You basically take a series of patients you’ve seen, maybe 20 or 25, and just review their immunization history at the time you saw them and determine whether you gave all the vaccines that you should have given that day. I think most physicians would be surprised that they don’t do as well as they think they do.

Dr. Shulman: Just like dieting. You think you’re doing great and then you start counting your calories.

Dr. Sawyer: Exactly. You do your vaccination count and you learn that you aren’t really doing as well as you thought. This has actually been done on a big scale formally by the CDC and other public health groups where they’ve gone out to private practices and assessed their rates. That’s where I learned this lesson that there is a lot of “It wasn’t me” when the rates are low. But if you do a “missed opportunity rate” for yourself, then it is you. It was your visit, you were the doctor seeing the patient that day. There’s no question about who did or didn’t immunize. It’s one thing for a managed care company to tell you that you need to do better, but if you assess your own rates, most doctors are competitive and this will motivate them to do a better job.

Dr. Shulman: So you’re asking these doctors to be accountable to themselves, compete with their partner, and at the same time improve the health of their community. What about the fact that the adult immunization rates are much worse than pediatric rates?

Dr. Sawyer: I think the pediatricians have a central role in getting adults immunized, if for no other reason than it helps the health of the children that they’re caring for. Pertussis is one of the reasons. We need adults to be immunized, especially when there’s a new baby in the house. I do acknowledge that the reimbursement part of adults being immunized in the pediatrician’s office can be a problem, but at the very least, pediatricians can make sure that the adult family members, and older siblings for that matter, at least know that they need to get immunized, even if the pediatrician doesn’t do it.

Dr. Shulman: How did you end up a pediatric infectious disease specialist?

Dr. Sawyer: I was always interested in bacteria; my undergraduate degree was in bacteriology. When it came time to figure out what I was going to do for a living I was deciding between graduate school in microbiology and medical school, and I decided that medical school had the most opportunities. That naturally led me to infectious disease as a subspecialty within medicine. The reason I went into pediatrics is that sick adults are obnoxious.

Dr. Shulman: So what do you do with your free time?

Dr. Sawyer: I play the cello in a community orchestra. I was never a professional, but I play in a bunch of chamber groups. And just to show how long you can stay in music, in one of my quartets, I’m 58 and am the youngest by 25 years. We get together in the afternoon because the other three can’t stay up too late at night. So I have to sneak out of work to go play with that particular group. It’s just a delightful thing that you can do forever.

Dr. Shulman: If you had not gone down the path that you chose what else might you have done?

Dr. Sawyer: I would have been in music. In high school, I thought about a career in music, but I realized that I wasn’t quite good enough.

Authors

Mark H. Sawyer, MD, is a Professor of Clinical Pediatrics and a pediatric infectious disease specialist at the University of California, San Diego School of Medicine and Rady Children’s Hospital. He is also the medical director of the San Diego Immunization Partnership, a partnership between the University of California, San Diego and the San Diego County Agency for Health and Human Services to improve immunization delivery in San Diego. He is an active and strong voice for pro-immunization policies and is always on the lookout for cost-effective ways to improve public health, particularly herd immunity. I had a chance to speak with him about his recent project — getting office practitioners to track their own practice’s immunization rates.

10.3928/00904481-20130222-13

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