Health professionals and the vaccine narrative: ‘the power of the personal story’ and the management of medical uncertainty

Health professionals and the vaccine narrative: ‘the power of the personal story’ and the management of medical uncertainty

Terra Manca*

Department of Sociology, University of Alberta, Edmonton, Canada

(Received 16 September 2015; accepted 12 May 2016)

Some vaccine supporters interpret vaccine uncertainties as a form of public ignorance caused by patients’ online research, failed physician–patient relationships, or inade- quate knowledge translation. These interpretations often portray health professionals as homogeneously accepting of all scheduled vaccines for all patients. Nonetheless, health professionals may have limited knowledge about vaccines because the demands of their profession require them to have a broad understanding of a variety of health topics. In this article, I draw on data from interviews with twenty-six physicians and seven nurses in Alberta, Canada between 2013 and 2014, to examine how they used narratives to convey confidence, uncertainty, or doubts in vaccines. All interviewees supported the culturally dominant vaccine narrative that vaccines are essential to population health, yet they also spoke about uncertainties. Interviewees managed their uncertainties through tactics that confirmed accepting vaccination was the most desirable course of action. With each of these tactics, interviewees shared narratives about communicable diseases, vaccine benefits and risks to individual patients, and their reasons for trusting in medical science. When these narratives did not fully resolve medical uncertainties, health professionals often explained that either vaccina- tion was beyond their professional responsibilities or that their uncertainties were irrelevant.

Keywords: public health; risk; risk perception; uncertainty; vaccination

Introduction

In this article, I aim to explore sociological understandings of medical uncertainty and medical progress, and how the creation of an ‘illusion of certainty’ in the health profes- sions relates to the vaccine narrative. Using data from the Canadian province of Alberta, I review how various disease outbreaks in Alberta have been attributed to patients’ vaccine uncertainties. I analyse some of the uncertainties that professionals experienced and the tactics they used to manage uncertainties and knowledge gaps about something they called (in various wordings) as simple as vaccines.

Vaccination, risk, and health professionals

Vaccination rates in some high income countries, such as Canada and the United States, appear to have declined due to vaccination anxiety and ambivalence (Heller, 2008, p. 3; Keane et al., 2005, p. 2486; Public Health, 2006a). In 2013, almost 70% of parents in Canada expressed concerns about potential vaccine side effects. That year, uptake rates for

*Email: tmanca@ualberta.ca

Health, Risk & Society, 2016 Vol. 18, Nos. 3–4, 114–136, http://dx.doi.org/10.1080/13698575.2016.1190319

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individual childhood vaccines were lower than needed to maintain population immunity – rates ranged from 73% (varicella) to 90% (polio [Government of Canada, 2015]). Most young parents and physicians have encountered countless narratives about the risks of vaccine side effects, but they have limited experience with vaccine-preventable diseases (Keane et al., 2005, p. 2486). Vaccine risk narratives are prevalent in the media (Bean, 2011; Hilton, Hunt, Langan, Bedford, & Petticrew, 2010; Kata, 2010). Anti-vaccination campaigns promotion of these narratives has coincided with increasing parental doubts in vaccine safety (Blume, 2006, p. 638; Casiday, 2007). Even so, most parents who refuse vaccines do so because they have unresolved concerns about vaccine safety (Blume, 2006; Poltorak, Leach, Fairhead, & Cassell, 2005, p. 716). Health professionals are expected to address these vaccine concerns, but health professionals belong to social worlds within which rumours and uncertainties around vaccination and medical risks circulate.

Researchers who investigate medical uncertainties have tended to focus on areas where there is no professional consensus about the best course of action, such as hormone replacement therapy or breast cancer screening (see Gerrity, Earp, DeVellis, & Light, 1992; Gigerenzer, 2002; Griffiths, Green, & Bendelow, 2006). By investigating subjective talk about vaccines, it is possible to examine the medical discourse surrounding a widely accepted treatment, vaccination, as a social and cultural phenomenon:

Vaccination anxieties are a lens for understanding how biomedical knowledge is interpreted on the ground. Health risks are constructed not only in biological terms but also as a product of relationships among the state, providers, patients, and international health policy makers. (Bazylevych, 2011, pp. 451–452)

Previous literature about vaccine uncertainties and narrative investigated topics relating to various conceptualisations of vaccine knowledge and risk involving primarily public (and occasionally health professional) uncertainties, non-compliance, and resistance (see Casiday, 2007; Heller, 2008; Hobson-West, 2003, 2007; Kitta, 2012; Leach & Fairhead, 2007; Levi, 2007; Poltorak et al., 2005; Skea, Entwistle, Watt, & Russell, 2008; Streefland, Chowdhury, & Ramos-Jimenez, 1999; Wolfe & Sharp, 2002). Studies that target vaccine uncertainties addressed controversial vaccines such as the human papilloma virus (HPV) (Mamo & Epstein, 2014, p. 160). Most studies have not examined the uncertainty associated with the safety or necessity of more widely accepted vaccines (exceptions include Bazylevych, 2011; Chen, 2005). Some researchers have addressed nurses’ vaccine ambivalence, but research about physician ambivalence is rare (see Bazylevych, 2011 and selected medical research [see Dubé et al., 2011; Loulergue et al., 2009]).

Medical uncertainties and health narratives

Health professions have traditionally practiced as though they are certain of the outcomes from their actions (Atkinson, 1984). Nevertheless, in an early stage of medical training, students learn that uncertainty is common to medical practice. As Knight and Mattick (2006, p. 1085) argued:

The development from lay conceptions of knowledge, where science is considered to be a place of certainty and ‘truths,’ to an understanding of knowledge as being more contextual, contingent and fluid is an important transition for effective medical practice. (see also Gerrity et al., 1992)

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Even treatments that have highly predictable outcomes can involve some uncertainty (Knight & Mattick, 2006). Furthermore, health professionals work with the incomplete information because patients are rarely aware of the full information or the relevance of the information they have. Knight and Mattick (2006) found that medical residents learn to navigate uncertainty surrounding what patients share with them when applying population-based medical research to individual patients (pp. 1085, 1088). Likewise, popular beliefs influence health professionals’ knowledge, uncertainty, and recommenda- tions to patients and families (Bazylevych, 2011; Blume & Zanders, 2006, p. 1833; Chen, 2005, p. 39; Gerrity et al., 1992; Skea et al., 2008). As such, uncertainties about some aspects of medicine are common to daily medical practice and patient encounters, regardless of one’s awareness of them (Gerrity et al., 1992; Griffiths et al., 2006; Fox, 2002; Knight & Mattick, 2006; Schattner, 2009).

I use uncertainty to describe what health professionals placed beyond their own knowledge regardless of expressions of doubt, though doubt may indeed accompany uncertainty and create difficulty deciphering the best course of action.

Fox (1959) used the concept uncertainty, in a similar way, proposing three broad sources of uncertainty: gaps in individuals’ knowledge, limitations of the medical field, and difficulties distinguishing between the two. Fox (2002) expanded upon these cate- gories. First, she divided intellectual or scientific uncertainties between uncertainties that were internal to the professional (that is mastering skills or recognising ignorance) and those that fit within the broader professions of medical knowledge (the gaps and limita- tions of medicine). These uncertainties comprise such issues as: the impossibility of mastering the entirety of medicine’s knowledge and skills; difficulties recognising perso- nal ignorance and ineptitude; gaps and limitations inherent to medical knowledge and effectiveness; recognising gaps in personal knowledge and medical knowledge; the con- fines and inabilities of the medical practice; and the constant changes and updates to medical knowledge (Fox, 2002, pp. 237–238). Fox (2002) also identified existential uncertainties, such as cultural and ethical concerns, pertaining to medicine, which are beyond the scope of this article. These include any uncertainties that accompany human illness, its meanings, and associated human suffering, life, and death (Fox, 2002, p. 238).

Atkinson (1984) criticised Fox’s findings. He argued against aggregating different types of uncertainty, so that they appear to be pervasive in medical practice (p. 951). Atkinson (1984, p. 954) cautioned against the tempting view that:

medical knowledge and practice are inherently ‘uncertain,’ while the ‘certainty’ of dogmatism and personal judgment are responses to that on the part of the clinician.

Instead, he argued medical education involves ‘training for certainty,’ which frees doctors from doubting their actions (Atkinson, 1984, p. 952). Particularly, Atkinson (1984) argued that doctors learn to bracket off any uncertainties that permeate their profession so as to practice with certainty in their judgement.

This bracketing off creates what some scholars have termed ‘an illusion of certainty’ (Gigerenzer, 2002; Sunstein, 2002). As a profession, medicine produces abstract scientific knowledge that appears to resolve various health problems without acknowledging short- comings or uncertainties (Abbott, 1988, p. 55). In textbooks, scientific and professional knowledge can be assembled into full and fully rational systems (Abbott, 1988, pp. 55–56; Kuhn, 1962). Textbooks tend to narrate about rapid transformations in scientific ingenuity as an impossible linear progression towards truth with few errors (Kuhn, 1962, p. 137). They overlook how the role of health profe