As the fall immunization season begins, physicians are adopting different approaches to get shots into arms as they cope with disruptions to vaccine supplies, conflicting federal guidance, and ongoing controversies about vaccine safety. 

The FDA approved COVID vaccines only for older and high-risk groups, while the CDC encouraged broader use. Patients have had trouble finding vaccines at retail pharmacies and clinics and faced uncertainty over insurance reimbursement for the shots. Well-publicized comments by President Trump and his Health and Human Services Secretary, Robert F. Kennedy, Jr, about the safety of long-accepted vaccine practices also have added to the confusion.

“The lay leaders of the land are seeding doubt, and it’s making people question everything,” said Eleanor Glass, MD, a family medicine specialist in Cincinnati. “As soon as it hits the media cycle, I get questions the next day.”

Physicians are striking bargains with patients, subtly setting expectations through language, and sharing how they treat their own kids. They’re betting that the forging of trustful doctor-patient relationships will pay off in the long run, such as when teenage children of vaccine-adverse parents start making decisions for themselves.

At the same time, physicians said that patients seem to be relying on them more than ever to help sort out some of the confusion. “We have become people’s trusted navigator to help them separate noise from evidence and trustworthy from not trustworthy,” said Glass, a third-generation doctor in her family. “I don’t think doctors 80 years ago had to do that. It’s a very different role today.”

Physicians Seek Alternatives to Federal Guidance

Amid the uncertainty, medical systems such as Denver Health are charting their own course on vaccine guidance.

Denver Health, a large health system that serves about 25% of that city’s population, in a typical year would provide vaccination information to its physicians each fall based on guidance from the CDC, which has an advisory committee that makes recommendations on vaccines.

This, however, is anything but a typical year.

In June, Kennedy abruptly dismissed the 17 sitting members of that panel — the Advisory Committee on Immunization Practices (ACIP) — and appointed a new panel. In September, the new panel diverged from some previous recommendations regarding the COVID and measles, mumps, rubella, and varicella vaccines. It also punted amid Trump Administration pressure to recommend delaying hepatitis B vaccination in newborns.

At Denver Health, the new ACIP guidance remains part of the health system’s standing orders, but the system also incorporates recommendations from leading professional organizations, such as the American Academy of Family Physicians and American Academy of Pediatrics, said Judith Shlay, MD, a family physician at Denver Health.

Other physicians said in interviews that they consider federal recommendations to be unreliable and are turning to the same three physician organizations. “When I look at the CDC website, where I normally would look, I often can find several different pages that have different information and are out of date,” said Glass.

Pro-Vaccine Parents Fear Losing Access

It’s not just doctors who are grappling with the changing landscape. Families who support vaccination are also trying to figure out what to do this year, and some are pushing for earlier immunization in case vaccines become even harder to get.

Pediatrician Nathan Boonstra, MD, a prominent vaccine supporter in Des Moines, Iowa, and chair of the Iowa Immunizes organization, said some parents are asking that their children be vaccinated earlier than typically recommended. Some are requesting human papillomavirus (HPV) vaccination earlier at the typical age of 11 or 12 years.

“HPV is one of those vaccines that tends to be in the crosshairs,” he said. “I have some concerns that the recommendations could change, so getting immunized at age 9 is not a bad idea.”

Similarly, some families are asking Boonstra about accelerating their children’s measles, mumps, and rubella vaccine schedules by moving the second dose from the typical timing at the age of 4 years to as early as 28 days after the first dose between 12 and 15 months.

“I’m not routinely recommending that for families right now, but some are concerned about that, and we can have that conversation,” he said.

New Guidelines Pose Barriers for the Willing

In Ohio, Glass pointed to a family she treats — a mother and father, an older child, and a newborn. The family wants to protect the baby, who’s too young for a COVID vaccination, against the disease. But no one in the family is older than 65 years or at high risk, which means they aren’t automatically considered by the FDA to be eligible for COVID vaccination.

“Last year, it wouldn’t have even been a question,” Glass said. “This year, I have to have a longer conversation about whether or not they meet criteria.”

The family can afford spending $130 per vaccine if needed, she said, “but not every family can make that choice.”

Public Skepticism Sparks New Concerns

Public statements by President Trump and federal health officials casting a doubt on immunizations such as hepatitis B vaccinations have created new anxieties among parents.

Glass found herself explaining hepatitis B scenarios that many parents haven’t considered — a child hospitalized for an unexpected illness who receives a needle stick or a kid who gets bitten by a child whose parent is infected. “These are now the scenarios I have to describe to my patients that I probably wouldn’t have had to last year.”

Shlay said parents are also asking about thimerosal, a preservative that was largely removed from childhood vaccines years ago. Attention has resurfaced — thanks to a new ban on its use. “People didn’t really have knowledge about thimerosal, so they were confused,” she said.

Building Trust Still Matters

Despite the challenges, physicians emphasize that the doctor-patient relationship remains their most powerful tool.

Glass describes maintaining relationships with vaccine-hesitant families whose teenage children eventually seek catch-up vaccinations independently. “As the kids turn somewhere between 16 and 18, they start requesting updated vaccines,” she said. “Having that trusted relationship over the years — and maintaining it — pays off.”

This approach is controversial among some physicians who decline to treat families who don’t vaccinate on schedule, Glass said, but she defends it: “I’d rather be that kid’s doctor, even if I think the parents are making poor choices for their kids, because I feel I can build that relationship and guide them in the future.”

Corinne McLeod, MD, ob/gyn in Albany, New York, takes a similar stance with her patients. “I must remain a trusted provider, especially for pregnant patients I’ll see in labor. Sometimes you have to pick your battles and drop unsuccessful arguments while maintaining care relationships,” she explained. “Don’t destroy therapeutic relationships over political- or faith-based opposition.”

Boonstra agreed that physicians remain influential despite the noise. “We are still the number one source of information for families. We are very influential in terms of whether or not families decide to immunize,” he said. “Making a good recommendation is actually very important.”

Strategies That Work

Physicians emphasized several effective strategies to boost vaccine use:

‘Presumptive’ language. Shlay advocates for what she calls a “presumptive approach” — stating what vaccines are due rather than asking if parents want them. “‘Today your child is due for 6-month vaccines,’ and we name them off. ‘Any questions?’ If people say no, we give them. If people have questions, then we discuss it.”

Motivational interviewing. When patients are worried, Shlay recommends motivational interviewing — ask about concerns, reflect them back, and offer perspective: “Let me understand. Can I give you some perspective on that?”

Linda Girgis, MD, a family medicine specialist in South River, New Jersey, said her strategy is to “keep reassuring them on the safety data and share relevant links to reputable sources when needed. It is important to hear them out to know where they are getting their information and what they are thinking.”

She added that “it is never helpful to label a patient as ‘anti-vaxxer’ or other names they are being commonly called.”

Prioritization and negotiation. Rather than all-or-nothing approaches, several physicians use strategic prioritization. For a patient with asthma, Shlay might emphasize the pneumococcal vaccine first, then discuss influenza vaccination given the respiratory risks.

McLeod tries a form of negotiation when appropriate. “If patients refuse newer vaccines like respiratory syncytial virus, offer established ones like Tdap. Familiarity reduces fear. Decades-old vaccines like polio or hepatitis seem less scary than newer technologies.”

However, she’s pragmatic about what’s achievable. “If forced to choose, I focus on the intervention preventing the [most imminent] harm — bleeding from lack of clotting factors vs vaccine-preventable diseases,” she said, referring to vitamin K shots vs hepatitis B vaccination in newborns.

Discuss side effects. Santina G. Wheat, MD, MPH, associate professor of family and community medicine at Northwestern University Feinberg School of Medicine, Geneva, Illinois, said she’s seen patients experience unexpected side effects due to vaccination “and then say they would never get that vaccine again.”

Her strategy is to be open about adverse effects such as pain and skin reactions and discuss how to treat them. “When my patients feel prepared, they are more willing to undergo it again.”

Don’t give up on doubters. Wheat said she’s seen many colleagues get frustrated when patients reject their vaccine recommendations.

“It can be helpful to remember that just because a patient chooses not to follow a recommendation at one visit does not mean that they aren’t hearing you or don’t value your opinion,” she said. “Sometimes they need more time to think about it. If we address recommendations at every visit, that will give our patients the opportunity to feel comfortable with them.”

Lead with empathy. Glass emphasized understanding that “most people genuinely just want the best for their family. Nobody wants to create a public health problem.” She recommended responding with open-ended comments — “tell me more about that” — rather than immediately countering patient concerns.

Refer to personal experiences. Glass said her own vaccination decisions resonate with parents. “When the first nurse came at my 2-month-old with four needles, I had a moment of anxiety and fear. But I did not hesitate because it is, by far and away, the safest thing for her long-term health.”

Boonstra disclosed serving as an unpaid principal investigator in a Pfizer trial of a pneumococcal vaccine. The other physicians quoted in this article reported having no disclosures. 

Randy Dotinga is an independent writer and board member of the Association of Health Care Journalists.