The parking lot was full for a Tuesday morning, which Diane took as a good sign. Practices that ran busy tended to run well. She parked in a visitor space near the entrance, checked the time (10:52), and gathered her tote bag and tablet from the passenger seat. A brief drizzle had come through on the drive over. She stepped around a puddle at the curb.
Inside, the waiting room was warm, half-full, mostly mothers with toddlers, one older boy paging through a book on the floor. A cardboard cutout of a giraffe stood by the reception window with a taped sign reading FLU CLINIC SATURDAYS. The front-desk staff knew she was coming. A young woman named Kelsey looked up, smiled, and said, “Ms. Halloran, right? Dr. Marston said to come on back whenever you got here.”
Diane thanked her and followed Kelsey through the side door into the clinical corridor. The practice occupied a single-story building that had been thoughtfully renovated, she noted, with sound-dampening panels on the ceilings and warm wood accents on the exam-room doors. She heard a child’s brief cry from one of the rooms and then a mother’s soothing voice.
Kelsey brought her to a small back office next to what looked like a supply room. “This is ours for however long you need it. Dr. Marston will be with you in a minute; he’s just finishing up with a family. Can I get you coffee?”
“That would be lovely,” Diane said. “Just black, thank you.”
The office was tidy. A round table, four chairs, a whiteboard with staff initials and shift patterns, a small window looking out onto a strip of grass and the neighboring parking lot. Diane took a seat, set down her tote, and pulled out her tablet. She opened the cover, and the lockscreen came up with the photograph she had chosen last month: her two boys in matching red jackets at the pumpkin patch, Ben grinning without his front teeth, Charlie holding up a gourd almost too heavy for him. She looked at it for a beat and then swiped in her passcode.
The IQIP dashboard loaded, and the practice’s data populated across the top of the screen. Coverage assessment complete: 94.1%. Twelve-month change: +2.3 points. Missed opportunities identified: 47 across the review sample. She scrolled through the highlighted charts and read the notes she had prepared last night from her hotel room. The 94.1% put this practice comfortably in the upper quartile for the region. Her target for the twelve-month follow-up was 97%, well within reach.
Dr. Marston came in with two mugs of coffee and set one down in front of her. He was in his early fifties, gray at the temples, a stethoscope slung around his neck over a soft blue cardigan. He shook her hand warmly and sat down across from her.
“Diane, thanks so much for coming out today. We’ve been looking forward to this. I blocked the whole two hours, so we shouldn’t have any interruptions worth speaking of.”
“Thank you for making the time, Dr. Marston. And your numbers look terrific.”
“Peter, please. And thank you. We’ve been working hard on it.” He glanced at the tablet screen. “That two-point-three, I have to say, I’m a little proud of. Last cycle we were flat, and I really wanted to see us move.”
“You should be. Practices at your size usually don’t see that kind of gain without a lot of workflow change.”
“Well,” he said, “we did some things. I want to walk you through them.”
They spent the first forty minutes on his side of the story. He had built a set of prompts into the EMR that flagged any patient coming in for a well-child visit whose immunizations were more than two weeks behind schedule. The prompt fired at the top of the encounter note and again at the discharge screen. Sick visits used to be dead zones for coverage, he told her; his MAs now asked about immunization status at every encounter, and it had picked up a surprising number of catches. The standing orders were rewritten so any nurse could pull and prepare a vaccine without waiting for physician sign-off. That last one had shaved minutes off each encounter and, more importantly, removed a friction point where families sometimes changed their minds.
Diane listened, took notes, asked clarifying questions. Everything he described was exactly what IQIP encouraged. She would be citing this practice in her regional summary as an example of successful strategy adoption.
“Now,” she said, moving into the second phase of the review, “let me walk you through the missed opportunities I flagged from the sample.”
She turned the tablet so he could see, and they went through the charts one by one. A four-month-old whose parents had asked to delay Hep B and never rescheduled. A fifteen-month-old whose MMR had been deferred because of a low-grade fever, with no follow-up call to bring the family back once the fever resolved. A three-year-old who had come in for an ear infection and left without her overdue DTaP catch-up. A ten-year-old who had aged out of the earlier schedule slot without receiving the second varicella dose. An eleven-year-old whose HPV series had been started and then dropped after the first dose because, the note said, “family wants to discuss further.”
Peter nodded through each one, occasionally making a small sound of recognition. “Yeah. Yeah, we saw that pattern too when we went back through internally. The deferrals are the killer. Once they walk out without the dose, the odds of catch-up drop by half.”
“That’s the national data too,” Diane said. “Which is why the scheduling strategy is so important. If you can get them booked for the next visit before they leave the building, you’re not relying on them to call back in six weeks. You’re not relying on your recall system to find them. The appointment is already in the calendar.”
“We’ve been doing that with the well-child schedule for about six months,” Peter said, “but I don’t think we’ve been consistent with the catch-ups. That’s a good catch. Marisol handles most of the front-desk scheduling; I’ll have her build it into the checkout protocol.”
“That’s exactly the kind of change that moves the needle.”
He smiled. “We want to get to 97 next year.”
“You will.”
They worked through a few more charts. Diane pointed out three cases where the EMR prompt had fired but the encounter had ended without the vaccine being given, and Peter said he would review those with the individual providers to see what was happening in the room. She noted his response in her observation field. This was a physician who took ownership of his data, which she would flag in the qualitative section of her report.
Around 12:15, the sounds of the practice shifted. She heard the phone at the front desk ring less often, and the general bustle in the corridor thinned. Peter mentioned that most of the staff took their lunch in shifts starting at noon, and the last morning slot was usually a fifteen- or thirty-minute cushion so that the doctors could catch up on notes.
There was a light knock on the doorframe. A woman in her thirties in dark blue scrubs, a stethoscope around her neck, leaned into the room.
“Sorry, Dr. Marston. Real quick. It’s about the Ellis family.”
“Come on in, Jenna. This is Diane Halloran, she’s with the state, we’re doing our IQIP review. Diane, Jenna is one of our MAs, she’s been here longer than I have.”
Jenna smiled, then turned back to Peter. “So I got Sarah Ellis on the phone this morning about scheduling Nolan’s fifteen-month. He’s due for the next set. And she said she doesn’t want to do it. She said after the last round he wouldn’t stop crying for like two days and she’s just, she doesn’t want to put him through it again. I didn’t push. I told her I’d talk to you and call her back this afternoon.”
Peter nodded slowly, thinking. “Okay. The inconsolable crying thing, that’s actually pretty common, and it’s almost always benign. It’s just the immune response and sometimes the site tenderness. It resolves on its own. But for mom, obviously, it was scary.”
“She was pretty upset about it.”
“Right. So here’s what I’d say to her. Tell her that what she saw is a known and expected reaction, it’s the body doing exactly what we want it to do, and it doesn’t indicate anything is wrong. Then remind her that the fifteen-month is a really important visit because that’s where we get the MMR and the varicella and the Hib booster, and these are the ones that carry the child through the preschool years. If she wants, we can space them out. She doesn’t have to do all of them the same day. But we do want to get him back in.”
Jenna nodded, taking it in. “So offer to split them up.”
“Offer to split them up. And if she’s still hesitant, tell her I’d be happy to hop on a quick call with her, just five minutes, before the appointment. Sometimes hearing it from the doctor helps.”
“Okay. That’s really helpful. Thank you.”
“Anytime, Jenna. And nice work not pushing on the phone. That was the right instinct.”
Jenna smiled and left. Diane heard her footsteps go back down the corridor toward the front.
“That’s such a good example,” Diane said, turning slightly in her chair. “The families that come back with concerns after a reaction, those are the highest-risk drop-offs, and how you handle that first call is everything. Your staff clearly knows what to do.”
“They’re good,” Peter said. “Jenna especially. She’s got a way with parents. She’s been calling back all our hesitancy cases herself for about a year now.”
“Do you have a written script, or is it something you’ve trained her on more informally?”
“More informal, honestly. We’ve talked through the common concerns, and she knows my general approach. I keep thinking I should write it up so the newer MAs have something to work from.”
“That would be a great addition. It’s actually one of the optional strategies in the IQIP framework. If you want, I can send you some template language from other practices in the region that have built out scripts.”
“That would be great. Thank you.”
Diane made a note in the follow-up field. She would email him the scripts and the coverage-comparison data from the peer practices before the end of the week. This was the kind of engaged provider who would actually implement what she sent, which was not always the case.
They worked another twenty minutes, wrapping up the chart review and moving to the summary section. Peter walked her through the practice’s plans for the next quarter, including a Saturday flu clinic he was hoping to expand, and a partnership with the local school district on adolescent catch-up. Diane made encouraging observations and jotted a few final notes. When they had covered everything, she turned back to the tablet and pulled up the site-visit summary form.
She entered the updated coverage data, ticked the boxes for strategies implemented since the last visit, and typed her qualitative notes into the observation field. Strong physician engagement. Effective use of EMR prompts. Front-desk scheduling protocols well established for well-child visits, opportunity for expansion to catch-up visits. Excellent hesitancy management by clinical support staff, potential model for regional dissemination. She reviewed the form, signed the acknowledgment, and submitted it. The screen refreshed and the practice’s file updated in the state system. Twelve-month projection: 96.8%. Well within the target range.
Peter walked her back through the corridor to the front. The waiting room had filled up again with the early-afternoon slots. Kelsey waved from behind the reception window. At the door, Peter shook her hand.
“Really, thank you, Diane. This was useful. We’ll get to 97.”
“I have no doubt. Talk soon.”
She stepped out into the parking lot. The drizzle had cleared, and the sun was breaking through in patches. She walked to her car, set the tablet on the passenger seat, and started the engine. The dashboard clock read 1:14. Her next visit was on the other side of the county, a smaller practice, less prepared, more of a lift. She checked her mirrors and pulled out of the lot.
Inside, at the front desk, Jenna was on the phone with Sarah Ellis, working out a new date for Nolan. The appointment went into the system for a Tuesday morning three weeks out. The reminder call was queued for twenty-four hours before.
The IQIP program depicted in this story is real. Its full name is Immunization Quality Improvement for Providers, and it is administered by the CDC through state health departments. It is described in the CDC's Pink Book (Epidemiology and Prevention of Vaccine-Preventable Diseases).
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Truth Be Told: I’ve Accepted an Invitation to Speak on The Unvaccinated
On September 17th, I’ll be giving a one-hour presentation titled The Unvaccinated as part of a six-hour livestream called Truth Be Told. This is the first time I have accepted an invitation to an event, and I have been honoured with the opening act. The livestream begins at 12pm EST.
Vaccination is the subject closest to my heart, and this is another opportunity to spread the word. The format will preserve the pen name.
Tickets are here.
The code UNBEKOMING is $5 off and applies automatically at that link. Replay available afterwards. Hope you can make it.
In Print
Seven of my books are now available as paperbacks, printed to order through Lulu and shipped worldwide. The Unvaccinated lays out the completely unvaccinated as a comparison group across twenty chapters and five appendices — as far as I know, the only book of its kind. Medicalized Motherhood follows a woman through 123 documented interventions from teenage pill to postpartum discharge. Drilling for Profit argues that cavities, gum disease, and crooked teeth are a dietary problem the dental profession treats surgically. What Your Vet Can’t Tell You applies the same critique to pets — food, vaccines, and a profession trained by the industries whose products cause the harm. Escape from Psychiatry documents the fabrication of the DSM, the collapse of the serotonin hypothesis, and the specific damage done by every major psychiatric drug class.
Two more take up what the first five leave out — the remedies the first five explain why you need. The DMSO Book covers 100,000 studies, zero deaths, and one approval — the suppressed science of medicine’s most versatile compound. Chlorine Dioxide: The Forbidden Remedy collects the interviews, protocols, and evidence from the doctors and researchers they tried to silence.
A physical book reaches the person a Substack post never will — the sceptical relative, the friend who won’t click a link but might open a book, the visitor whose eye lands on a coffee table. Buy one to keep, and one to give away.
I got nauseus while reading this...two devils devising a plan to hurt children.
Beware "standing orders for immunizations." Do Not Consent. Do Not Comply. Notarize it.