Physicians, public health, and immunizations—are doctors missing the point?

Childhood immunizations are widely acknowledged to be one of the most cost-effective health care measures available.[1] Even in countries with no organized health care system to speak of, vaccination campaigns are seen as a top prior­ity. 

Developed countries have well-established vaccine distribution programs, and coverage rates in those nations are enviably high. Public health programs in BC do a creditable job of ensuring that infants and school-age children are offered their primary series of shots if they do not get them from their family physician.

There are excellent reasons to de­ploy public health resources to ensure vaccine coverage. Scenarios such as patients without access to a GP, re­mote areas without doctors, or situations where physicians do not offer vaccination are all examples that ar­gue in favor of offering immunizations through public health. There is also a view that public health departments can keep better records of who is immunized and who is not and can provide more focus on ensuring that everyone gets all of the necessary shots. 

But childhood vaccination is just one of many preventive health measures that should be offered to our patients. Screening tests for hyper­tension, visual acuity, cervical cancer, depression, tobacco use, and many other conditions are also maneuvers that have great public health significance and are done routinely by family physicians. 

Many of the items on the list are best done in the context of a doctor-patient relationship and others are offered virtually for free in the sense that they are done as an add-on to a visit for another reason. In addition, the “big picture” choice and interpretation of the results of screening tests and preventive care is something that can be best done by someone trained to provide overall patient care—the family doctor. 

It is also fair to ask what cost would be incurred if more of the preventive services listed above were given over to public health departments and new premises, support staff, and public health nurses had to be hired. These services are already performed almost gratis by physicians and often in the context of a doctor visit that would have occurred anyhow (given the regularity with which patients go to their doctors with a list of problems). 

It would be difficult to argue that physicians are an expensive way to deliver preventive care. The new MSP prevention fee (G 14034 Cardio­vascular Risk Assessment Fee: $100, BCMA Fee Guide) applies only to cardiovascular risk assessment, and services such as immunization are compensated at a rate of only $3 per shot. This is hardly an incentive to keep physicians in the business of maintaining a supply of vaccines, needles, and cold storage in their office; it may be time to revisit the value we place on such services.

Sadly doctors seem to be slowly getting out of the business of immunizing their patients. Only in Vancouver, Richmond, and the North Shore are most childhood vaccines still given by GPs. In some rural areas no physicians are immunizing children.

Doctors have always been at the forefront of prevention. From vaccine provision to seatbelt legislation to smoking cessation, physicians in BC have led the way to keep patients from getting sick. There’s no question that we can’t do it all by ourselves, but it’s a mistake for us to let go of our most effective disease-reduction tool. Doctors need to stay firmly in the arena of clinical prevention—no one else can better offer the combination of skills and patient-care settings to both effectively and economically keep our patients well.

—Lloyd Oppel, MD
Chair, Allied Health Committee

References

1. World Health Organization. Fact sheet number 288; March 2005. www.who.int/mediacentre/factsheets/fs288/en/index.html (accessed 7 April 2008).