Learn how politics impacted public health with Dr. Michelle Fiscus.

Dr. Jen Barna speaks with Dr. Michelle Fiscus to hear a cautionary tale that is very relevant to the times we are living in today about politics and public health.

“You know, the government has told us that we have to put children in car seats, we have to wear seat belts, we can’t drive when we’re drunk. There are lots of ways in which the government has intervened on behalf of public health, and this is really one of the most important ones that we’ve ever had.” Dr. Michelle (Shelley) Fiscus, Chairperson of the Board of Directors of the American Academy of Pediatrics District IV (Tennessee, Kentucky, Virginia, North Carolina and South Carolina), Associate Clinical Professor in the Department of Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt University, former Medical Director of the Tennessee Department of Health’s Vaccine-Preventable Diseases and Immunization Program

In today’s episode, Dr. Jen Barna speaks with Dr. Michelle Fiscus to hear a cautionary tale that is very relevant to the times we are living in today. Dr. Michelle Fiscus is a board-certified pediatrician and public health official who practiced general pediatrics in Franklin, TN for 17 years before serving in public health. She served as the Medical Director of the Tennessee Department of Health’s Vaccine-Preventable Diseases and Immunization Program until she was terminated in July, 2021 for sharing factual information based upon Tennessee law, around the rights of teenagers to make medical choices for themselves, including the right to be vaccinated against COVID-19. On today’s episode, we hear her story and a frank conversation around dealing with rampant misinformation around vaccines. 

Dr. Shelley Fiscus is an Associate Clinical Professor in the Department of Pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt. She is a past-president of the Tennessee Chapter of the American Academy of Pediatrics and now serves on the Board of Directors of the American Academy of Pediatrics as District IV Chairperson, representing Tennessee, Kentucky, Virginia and the Carolinas.

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Please enjoy the full transcript below

Dr. Michelle: The government has told us that we have to put children in car seats, we have to wear seatbelts, we can’t drive when we’re drunk. There are lots of ways in which the government has intervened on behalf of public health, and this is really one of the most important ones that we’ve ever had.

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Jen: Welcome to DocWorking: The Whole Physician Podcast. I’m Dr. Jen Barna, and today I have a guest that I think you’ll find very interesting. I’m so excited to have with me here, Dr. Michelle ‘Shelley’ Fiscus, a pediatrician who has practiced General Pediatrics in Franklin, Tennessee for 17 years prior to going into public health in 2016, and subsequently, as medical director of Tennessee’s Department of Health Vaccine-Preventable Disease and Immunization program. Dr. Fiscus was terminated in July 2021 for sharing information about rights of teenagers to be vaccinated against COVID-19. Dr. Fiscus, thank you so much for coming to be on the podcast with me today and I would love to hear your story, and I’d like to hear your perspective. If you don’t mind, could you please just tell us a little bit about what happened leading up to this situation in July?

Dr. Michelle: Sure. Thank you so much for having me as a guest. My story I guess is a little bit of a cautionary tale. As you mentioned, I was working in Tennessee as the State’s Medical Director of the vaccine program, basically, which meant that in normal times, I was over the State’s Immunization Registry or Immunization Information System, the Vaccines for Children Program, which is an entitlement program for children who are insured by Tennessee Medicaid or who are uninsured so that they can get vaccines. Then, to respond to possible vaccine preventable disease outbreaks across the state, and make sure that we were investigating those, and quarantining and isolating people as they would need to have done if they had a highly infectious disease. 

Then, once COVID came along, I was pulled into that response and then eventually responsible for rolling out the COVID-19 vaccine across the State of Tennessee and really where we began to see some issues in Tennessee was actually several months before we actually had COVID-19 vaccines. When we were urging the Governor of Tennessee to allow us to start doing some pro-active messaging around the importance of COVID-19 vaccines, about how this was what was going to help us end this pandemic, around the safety of these vaccines, because we knew people were going to be concerned about Operation Warp Speed and the perceived rapidity of how these vaccines were investigated. It was really back in the fall of 2020 that we started getting a lot of push back from the administration as far as not being willing to allow us to message about the COVID-19 vaccines. So, that was concerning to say the least and frustrating because we wanted to get out ahead of a lot of the anti-vaccine rhetoric and misinformation that was coming out. 

We continued along trying to rollout the vaccine in Tennessee, and then in May, as we were preparing for the FDA emergency’s authorization for children ages 12 and older, for the Pfizer vaccine, I started to get a lot of messages from medical providers around the state who just weren’t sure what to do if a minor should show up without their parent requesting to be vaccinated. It doesn’t happen often, but it does sometimes happen. So, I reached out to our Office of General Counsel at the Department of Health, and I knew that there was something called the Mature Minor Doctrine in Tennessee, which is Tennessee Supreme Court case law from 1987 I think. That allows what are considered mature-minors. So, 14-, 15-, 16-, 17-year olds.

If their medical provider feels that they’re mature enough to seek their own medical care, then they’re allowed to consent for it without a parent, and that is something that has been in place in the State of Tennessee for 34 years. This is not anything new.  So, I asked our Office of General Counsel to provide me the language for that in a way that I could share it out with other providers. So, I was given that, I was told that it could be shared, and then I sent it out in a memo to the network of providers that we have that were administering COVID-19 vaccines around the state. And what resulted from that was that memo ending up being sent to some legislators who were sympathetic to an organization called Tennessee Stands in Tennessee, which is an anti-mask, anti-public health, anti-kind of everything COVID organization, and that organization got the ear of the few of the legislators. And the next thing we knew they were actually calling for the State Department of Health to be dismantled over this Mature Minor Doctrine, because they felt that this memo that was sent out was meant to undermine parental authority, when what it was meant to communicate the existing law of the land in Tennessee to providers, so that they would know what to do if a 15-year old showed up asking for a vaccine. 

Jen: There are a number of things that you’ve just mentioned that I have questions about, and maybe our listeners would have questions about them, too. So, first of all though just to clarify, you went through all of the steps to get permission really to share this information which is just the legal precedent in Tennessee. It was not anything new. In fact, it was decades old prior to putting out the information, which was simply factual information about what the rule is in Tennessee.

Dr. Michelle: That’s right. Yeah. I was corresponding on a regular basis with the providers that were approved to administer COVID-19 vaccine and sending memos to them about changes in storage or changes in guidelines. And so communicating with them wasn’t anything new, but with this being legal language and I’m not a lawyer, I wanted to make sure that the information that I was sending was correct, and so did go to legal counsel and asked them for the language which I copied and pasted into this memo, and it was actually told, which I did not know that the language had been on the Tennessee Department of Health’s website for actually a very long time. Nobody knew it was there.

Jen: You mentioned also that months prior to that, did I understand you correctly that you were not to share vaccine information?

Dr. Michelle: Right. So, we had been asking before even the vaccine was released to start just building confidence in Tennessee amongst Tennesseans about getting these vaccines. We were not permitted to do that. In fact, the governor’s office controlled all of the communications around anything having to do with COVID, whether that was disease, or cases, or vaccines, or any of that it was all controlled by the governor’s office and not the Department of Health. So, what you have then is communications people who are not necessarily consulting with the physicians and the public health experts in the state, and putting out messages that weren’t always ones that were going to build confidence with the people of Tennessee around these vaccines.

Jen: Essentially, they were blocking the scientific information that physicians use to give advice. There was no limit to the misinformation potential that could be disseminated during that time.

Dr. Michelle: Right. Even now, we see ads going up on Facebook, where you have vaccines being given with an injector gun, or it’s being given an incorrect site, or the syringe is filled with something discolored that isn’t appropriate. So, it’s been very difficult to get messaging out that is both scientifically sound and also addresses the concerns that people might have that would give them pause about going and getting vaccinated.

Jen: I’m sure out of all of the different specialties in medicine, pediatrics is the one that is the most first in dealing with vaccine misinformation. And you especially as past president of the Tennessee Chapter of the American Academy of Pediatrics, and then currently serving on the Board of Directors for the American Academy of Pediatrics for District Four, which includes Tennessee, Kentucky, Virginia, North and South Carolina. I’m sure you are a perfect person to ask, having the experience of dealing with misinformation with vaccines up until the COVID crisis, and now it seems to have just exploded. The level of misinformation has increased so exponentially. Your experience as a pediatrician, how does that inform the way that you are dealing with this current crisis?

Dr. Michelle: I think, you’re right. Pediatricians have been doing this for decades now. I mean, really sends the Andrew Wakefield paper, in The Lancet 1998, pediatricians have been really at the forefront of battling vaccine misinformation and frank disinformation. It’s exhausting. I’ve been very public about the fact that one of the reasons why I left private practice was because my practice was in a very affluent area of Tennessee, a very affluent county even in the country with a higher than what anyone would like, percentage of people who were opting out of getting routine childhood vaccinations and at one point I really had an existential crisis where someone whose daughter was due for HPV vaccine at age 11 said that they weren’t going to get it for them because they had heard it caused infertility. I remember just pausing for a minute and saying, “I have cared for your child since literally the day she was born. I have been there for you, when you’ve had fevers that have scared you, when she’s had ear infections, when you’ve had developmental concerns or school concerns, and do you really think that I would recommend to you so strongly something that would have some significant chance of causing harm to your child, and where does that really put her relationship after more than a decade, if this is really what you think I would do?” It was one of the things that drove me out of practice was just this constant head beating around vaccine misinformation. Just in the five years since I left practice, it has exploded, especially with COVID. 

And COVID has just added fuel to this fire of vaccine hesitancy, downright vaccine refusal. What the anti-vaccine movement has done is they have landed on, “Well, we shouldn’t get vaccinated because it should be our choice, whether or not.” So, this whole idea of medical freedom is now what’s resonating with people especially in states that lean more red, that, “I’m not going to let the government tell me what to do, I’m not going to get a vaccine for my child because it’s what the government wants me to do, and I should be able to make these decisions for myself,” which the government has told us that we have to put children in car seats, we have to wear seatbelts, we can’t drive when we’re drunk. There are lots of ways in which the government has intervened on behalf of public health, and this is really one of the most important ones that we’ve ever had. As exhausting as all of this is, I really feel for the physicians who primarily work with adults, because this is really quite new.

A lot of those practices, at least in my experience in going into see my internist, a nurse might ask me, “Would you like a flu shot?” You answer, yes or no, and then that’s often the end of the discussion. Now, you have a situation where just asking whether you’ve had a COVID-19 vaccine could create somewhat of a hostile reaction and a patient could make a visit very unpleasant and really derail the rest of your conversation for that visit. So many providers are not willing to have the vaccine in their office. Even if you had a conversation and you were somewhat successful in getting an individual to consider getting vaccinated, in a lot of cases, they can’t get the vaccine while they’re there. By the time they get to their car, and think about it again, and now, I have to go to another place and make another appointment, then the motivation is lost. So, it’s all a very complex, very resource intensive situation and it wears everybody down, I think.

Jen: Just in case anyone’s listening and wondering about your Andrew Wakefield reference 1998, the paper in Lancet, that was the paper that was 12 years later retracted that initially associated the MMR vaccine with autism, and to some extent I think is credited with much of the origin of vaccine misinformation and fear of vaccines that has grown over time in the US.

Dr. Michelle: It was really the catalyst for the modern anti-vaccine movement. There’s been anti-vaccine stuff since smallpox in the late 1700s. But Wakefield’s paper was really the catalyst that started this whole modern movement around this anti-vaccine ideas and started with people being concerned about autism and has morphed into so many other issues that are not factual. It’s what kind of brought us Jenny McCarthy a few years later and she was talking about her son that she said had autism from vaccines and came to find out later he probably didn’t have autism, and it has created movies like Vaxxed and Vaxxed II that have really shared stories and anecdata from people who really tell very frightening stories of watching their child regress. 

When you listen to those kinds of stories and you don’t have the ability to really discern the source of some of the information you’re listening to, they can be terrifying. It makes sense that people would start to get concerned about something like giving a child a vaccine. At the end of the day, these are still parents who want to do what’s right for their child. They just unfortunately are becoming victims of misinformation and not thinking about the risk of not vaccinating their children.

Jen: Circling back around to what happened to you, after just sending out that information to the pediatricians in the state who were asking questions about how to deal with the situation that may arise if a teenager requests a vaccination. So, what happened after that?

Dr. Michelle: Well, there were a few members of the legislature that were quite upset by that memo. Then they were also upset that there were some social media messages going out featuring adolescents who had a Band-Aid on their arm because they’d gotten vaccinated. Those messages were just saying, “Hey, you’re eligible now to go get vaccinated.” But they took issue with that and, as I mentioned, actually called for dismantling of the Department of Health, which in the middle of pandemic, it’s just ludicrous that anyone would really suggest such a thing.

But the messaging that was on social media also wasn’t from the Department of Health. It was coming out of the governor’s office once again. So, their anger was very much misplaced in Department of Health. But what happened as a result was this constant pressure from members of the legislature on the Department of Health, on the governor’s office, and what resulted was a couple of weeks after this, I was called in by my superior, who said, “It looks like you’re probably going to be fired.” I said, “What grounds would there be for firing me?” He said, “Well, none as far as I’m concerned, but what we’re told is that the governor’s office is pressuring the Commissioner of Health to get things right with the legislature.” 

The way to do that they think is to fire the person who wrote the memo. So, I sat wondering what to do for about two weeks. It was about two weeks later that they finally did fire me. I was offered a letter to sign rendering my resignation or a letter acknowledging the expiration of my executive service, which is the nice way of saying, you’re fired. Seeing that, I had done nothing wrong. I’d actually been commended for the work that I’d done for the vaccine program over the past two years. There was no reason for me to resign. So, I accepted the expiration of my service and left on July, the 12th, I think, and then figured out what to do next.

Jen: Would you have foreseen that coming in terms of just the politics of how politics had begun to intertwine with the application of medicine and growing disbelief in scientific studies? Is that something that surprised you when it happened or were you already seeing that that was a possibility?

Dr. Michelle: I think most of us that are higher in the department, were walking on eggshells all the time just waiting to be fired. I don’t think any of us would be surprised if we were called in at 3:30 in the afternoon and told that we were terminated. What we saw growing though was really what went from we’re not going to message about vaccines to this response to the legislature of the State and the Department of Health to say, “We’re not going to give vaccines.” 

So, in response to all this sabre-rattling from the legislature, the Department of Health, the Commissioner of Health decided, “We’re going to put a pause on all vaccination efforts for children, whether that’s routine vaccines,” and this was back to school. This was June and July of this year. We were already behind some 30,000 doses of MMR vaccine in last year’s kindergarteners, because they had stayed home during the pandemic. So, this overcorrection of the Department of Health in order to appease these legislators who were really buying into a lot of frank misinformation, Ivermectin is better than vaccination.

Jen: That’s in my dog’s heartworm pills.

Dr. Michelle: Yes, mine too. [laughs] Yeah, we have legislators who believe that.

Jen: I’m just curious if you are aware of how Tennessee is fairing compared to other states where vaccination rates are higher.

Dr. Michelle: Oh, Tennessee is terrible. It is one of the most poorly vaccinated states in the country. It has the highest number of pediatric cases of COVID-19 in the country. 

There have been a couple of times wherein it has had the highest case count of COVID-19 per population in the world. These are not the distinctions that we should be making and it’s very unfortunate because the tactic has been the same through the entire pandemic. “Don’t talk about it, don’t promote public health measures, don’t promote wearing a mask and being distanced and not gathering, don’t promote getting vaccinated and making sure you get your booster. Do allow lots of conspiracy theories to circulate and talk a lot about alternative things that don’t work.” 

The result of that is that people are sick, people are dying, people are hospitalized, and we don’t know what the impact of this has on young children who are growing, who may end up getting infected with this virus one, or two, or five, or 10 times before things are over. What does that do to a child who’s growing over the course of five or 10 years or so. It’s really concerning. At the same time, you have a governor who has told parents that by executive order, they can opt out of any mask mandate that they want to. There is no opportunity for virtual learning for students. So, they have to attend in person or they’ve threatened to cut off funding to school districts if they allow children to learn virtually. There are no mandates to vaccinate teachers, and as a matter of fact, one of the first laws that the legislature passed even before we had vaccines was to outlaw the mandating vaccines for any government entity. Not just for this COVID vaccine, but any future COVID vaccines ever are against the law to mandate in the State of Tennessee. I don’t think the numbers can be ignored as far as what the impact of these policies have had.

Jen: Speaking of impact, the long-term implications of these types of policies and just the whiplash, I guess, of public opinion on people who are in the public health roles, I think if I understand correctly, there were 64 people nationwide in the role that you have in the various states in some metropolitan areas as the Director of Preventable Disease and Immunization programs, and out of those 64 people, a large percentage, I want to say 25 people have resigned, is that correct or they left those positions within the short period of time? 

Dr. Michelle: Right. I was the 25th of those 64 people in that role to leave their position just over the course of the pandemic, whether they resigned, retired, or were terminated. Myself and there are other examples around the state of people who cross the line with their administration. You have an Immunization Program Director, who is following CDC guidance, following what the FDA recommends, trying to put out those messages, and encourage vaccination, and then you have a political body that is for whatever reason, and much of this now is political ideology, unfortunately, not wanting those messages to be put out. So, it’s a very careful line that people in my former position have walked for years trying to push policy in the right direction without getting in trouble for doing it. 

But to have 40% of the people in this role leave over the course of the pandemic, and really not hear a word about it is very concerning. In some of these cases, these are people who were in the role for 30 years. The institutional knowledge that’s there, the growth of these programs, and they leave, and in a lot of cases, people aren’t banging down the doors to come work in public health. They’re underpaid, they’re undervalued, and it may take six months, 12 months, or longer to replace these individuals plus, do what the very steep learning curve of directing a program like this. So, it really puts the people in their state at risk when they have this turnover in a position like this in a pandemic.

Jen: Absolutely, a cautionary tale as you said, how has this decision affected you personally in terms of what you’re choosing to do next, and has it impacted your career in terms of whether you would want to stay in public health or not? Are you choosing to stay in public health?

Dr. Michelle: In a fashion, I love public health, I love health policy. It’s something that I’ve gotten a lot of through my work with the American Academy of Pediatrics, but then also over the past few years in public health. I would really like to stay in that work. I’d like to find ways to move the needle to improve the health and wellbeing of people. Unfortunately, when you’re very vocal about speaking out against the governor and the leadership of the Department of Health, it’s pretty hard to find a paying gig in the state. Really, we had started talking as a family way back in the spring about, “Maybe, it’s time for us to leave Tennessee.” We had been there for 24 years. I’ve lived there longer than any place in my entire life. That was my seventh state. 

We talked with our children who were young adults about– it has changed a lot over the last five or six years. It has very much moved from a tight community where people would do things to help one another to one where it’s moved to this individualism, and I’m going to make my own decisions and I’m not going to listen to experts. I never thought that I would leave a state over politics. But basically, that’s what we decided to do. We made a very difficult decision to put our forever home on the market one that we had built for our retirement. 

Eight years ago, we had handicapped toilets on the first floor, and like, “We weren’t going anywhere.” We listed the house, we told the kids we were moving and because of my role with AP on the board, I have to stay within my district for two more years. So basically, the furthest I can get both geographically and ideologically from Tennessee and remain in my district is Northern Virginia. So, just actually a month ago, today, we moved to Northern Virginia, and are getting accustomed to a new place and making new connections, and our oldest child, our daughter decided to move with us. It’s been fun and exciting, and stressful, and very different. I’m the primary breadwinner in the household, too. So, finding also a place where I can contribute to public policy and still earn a living is pretty important. Right now, I’m doing some public health consulting work and looking for the next right thing. I’m just not sure what that is yet.

Jen: Well. it sounds like Tennessee’s loss and Virginia’s win, and I’m sure that you will ultimately come out ahead. But it’s a huge personal sacrifice that you’ve made just for standing up for what we know through our medical education to be what is scientifically proven to work, and those, of course, are vaccines. Interestingly, the people that are anti-vaxxers are still willing to have our medical care when they become sick with something that they could have prevented with a vaccine ironically.

Dr. Michelle: We had the double whammy in our state, too. My husband was on the Williamson County School Board in Tennessee, and the goal board meeting that became rather infamous back in the summer, when people were screaming at someone in their car and saying, they knew where they lived, and that they’d never be seen in public, again, simply for supporting the use of masks in schools. So, between the two of us, we were pretty big targets in the community. So, he has also resigned his position on the school board.

I will say, oftentimes, better things come from periods of adversity, and we are already feeling the benefits of being on the other side of this and being outside of toxic work environments. It was a hard decision because you want to stay and fight, and if all the good people leave, then who’s going to do that work. But at some point, you also have to say, “We’ve got to do what’s right for our family and for our own mental health, and sometimes cut those ties.” As of now, we’re glad that we did.

Jen: Dr. Michelle ‘Shelley’ Fiscus, thank you so much for coming and talking so honestly with me, and I really appreciate you sharing your story on DocWorking: The Whole Physician Podcast.

Dr. Michelle: Thanks so much for having me. It’s been great.

Jen: As physicians, it’s our job to deal with complex and challenging situations. When we’re taking care of patients, that’s what we do, that’s what we’re good at. But there are situations that occur that are outside of patient care, like being overscheduled or a colleague who’s acting inappropriately, we may feel in the context of a very busy schedule that we don’t have time, or the resources to go to anyone, or to reach out for help in resolving this. But what if you were part of a community of likeminded physicians where you could go confidentially and discuss these issues, and look for solutions and hear about experiences of other physicians and how they’ve solved similar problems facilitated by a group of experienced coaches who specialize in working with physicians, so that you could go back to work, fix these problems with confidence, and get on to enjoy your life again. 

If that sounds appealing to you, our program DocWorking Thrive maybe just for you. Please check us at docworking.com. It’s D-O-C-W-O-R-K-I-N-G dotcom or email me, [email protected]

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Amanda: This is Amanda Taran. I’m the producer of DocWorking: The Whole Physician Podcast. Please don’t forget to like and subscribe, and thank you for listening.

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