“Talk to your doctor.”

We hear that advice a lot. But what if you don’t have a doctor to talk to, or the guidance you’ve been given isn’t clear?

Shared clinical decision-making is framed as empowering to patients, but some clinicians argue it assumes access, time, money, and consistent medical advice — conditions that aren’t always met in the real world. 

“It puts the onus on the patient and the family, and it can set them up for failure,” said Zaid Fadul, MD, a pediatrician in Scottsdale, Arizona.

As federal health officials have increasingly leaned on shared clinical decision-making for vaccines — including a recent update to the childhood vaccine schedule that applies the model to shots for COVID, hepatitis A and B, influenza, meningococcal disease, and rotavirus — Fadul and others say the shift could affect vaccine uptake, posing serious public health threats and leaving millions of families at risk.

“Is it malicious? No. I don’t think it’s by design,” Fadul said. “But the net effect is going to be fewer vaccinations, and more kids are probably going to be harmed.” 

Not Everyone Has a Primary Care Physician (PCP)

More than 100 million Americans — nearly one third of the population — face challenges obtaining primary care. Barriers range from lack of insurance to provider shortages to prohibitive costs. 1 in 4 adults and 1 in 10 children in the US do not have a PCP, according to a 2023 report from the American Academy of Family Physicians’ Robert Graham Center.

For families without a PCP, “talk to your doctor” means finding one and making an appointment in a strained system. Most rural counties are considered health professional shortage areas, affecting at least 42.6 million people in 2023, according to the Commonwealth Fund. Almost half (45%) have five or fewer PCPs, and 199 have none. 

“My fear, particularly for rural America, is becoming a two-tier health system based on access and affordability,” Fadul said. “You may not have access to a PCP, which means you may not have a chance to really make an informed decision, and you may get worse quality care.” 

While most vaccinations are done at a doctor’s office, many children also receive shots at a pharmacy, school, or pop-up clinic — settings that may not be designed for in-depth, individualized conversations. 

Medical Advice Isn’t Always Uniform

Even families with access to a PCP must rely on the physician to support their decision to have their child vaccinated. While most pediatricians support the vaccine schedule, a few do not.

Estimates show about 10% of primary care physicians do not agree that vaccines are safe, and 9% do not believe they are effective — raising concerns about how shared clinical decision-making may play out in practice.

“They could try to dissuade people from the recommended schedule in word — or deed, by not vaccinating the child during the visit,” said New York City-based epidemiologist Maureen Miller, PhD.

Individualized Decisions Work Best When Stakes Are Low

The shared decision-making model was intended for situations where outcomes are not serious and primarily affect the individual patient. It “comes into play when you know the population you’re talking to is not at risk,” said Mundeep Kainth, DO, MPH, a pediatric infectious disease specialist in New York.

Introduced in 2019 as a new tier (ranked below routine and above “no recommendation”), the model was first applied to the adult human papillomavirus vaccine because the individual health benefit varies and the population-wide public health impact is low. Another example is the meningococcal B vaccine for those aged 16-23 years: It’s classified under shared clinical decision-making because meningococcal B disease is rare in the US and outbreaks among healthy young adults are uncommon and generally limited to close-contact settings such as college dormitories, Kainth said.

“But if the population is at risk, there should be no question,” said Kainth. “It should be just recommended.” 

Take the flu vaccine. The childhood flu vaccine was reclassified under shared decision-making after the 2024-25 season — the deadliest on record since child deaths were first tracked in 2004. CDC data found that about half of US children were vaccinated in 2024-25, and 289 children died. Critics say the move risks lowering vaccine uptake and weakening population protection when last season’s toll showed how deadly pediatric flu can be. 

“If we do not treat vaccines like a standard part of care that the parent is already consenting to when walking in the door to a visit, then we are undermining our ability to provide confidence in vaccines,” Kainth said.

How to Make Shared Decision-Making Equitable

Expanding the settings where children can receive routine immunizations may help. A 2022 CDC report found that counties with at least one pediatric COVID vaccine provider experienced higher vaccination rates among children ages 5 to 11 than counties with no provider.

Pharmacists can be a valuable resource to help fill access gaps, said Cherokee Layson-Wolf, PharmD, a professor at the University of Maryland, Baltimore. Most Americans, she said, live within 5 miles of a pharmacy and visit on a weekly or monthly basis.

“They’re going to a place where there is a healthcare provider on site,” Layson-Wolf said. “I never really want to say it’s a replacement because we are a healthcare team.”

Community health centers can be another helpful outlet. Many of these centers offer “enabling services” — such as health education, transportation, and translation — which improve patients’ likelihood of getting a flu shot by 16%, according to the National Association of Community Health Centers. 

“It’s ideal, obviously, that patients have a holistic healthcare team,” Layson-Wolf said. 

But barring that ideal, patients may need to find creative ways to “talk to their doctor.”