About 27% of US adults haven’t been vaccinated for COVID-19 because they have some combination of mistrust of healthcare/large organizations and a strong belief in their personal autonomy. That is why clinicians need to talk “with” their patients about vaccines rather than “to” them.
Although polls and surveys consistently show that doctors are the most trusted source of information about vaccines (about 80%, according to the Kaiser Family Foundation in June 2021), the percentages were lower among unvaccinated people.
Clinicians are an important community-level part of “retail messaging” about vaccines to complement the wholesale messaging that was used early in the pandemic to inform the general population about COVID and vaccines. However, for the vaccine-hesitant, -questioning, or -resistant patient, a clinician being authoritative and “talking to” an unvaccinated patient — with lots of fact-filled information — would be counterproductive because it could challenge their autonomy and reinforce their mistrust of authority figures and experts.
Since April 2020, I’ve been working with organizations and individuals to help them understand COVID and vaccine issues, including misinformation and reasons people might be hesitant to get vaccinated.
I’ve learned that there are many reasons why patients have some mistrust of healthcare providers and the healthcare “system.” Those reasons range from historical mistreatment of demographic groups passed down from generation to generation (eg, the non-treatment of Black Americans with syphilis in Tuskegee), to first-hand or family experiences. This can also be compounded by perceptions of profit motives from pharmaceutical companies, healthcare providers, or institutions, and mistrust of government agencies or politicians.
For clinicians, while it is useful to understand that there are a range of reasons for people’s mistrust, it is important to appreciate that every individual patient who is vaccine-hesitant, -questioning, or -resistant derives their mistrust for very specific reasons. In addition, patients may have strong personal beliefs in autonomy that predispose them to not wanting to get vaccinated, or make them more susceptible to false information about vaccines — which in many cases is being spread by people with financial or other self-interested motives.
Clinicians who are trying to get all their eligible patients vaccinated need to recognize that because of mistrust and autonomy issues, that talking “to” such patients will be counterproductive, but talking “with” them may be much more productive. That is, clinicians should engage them in a conversation that does not directly challenge them — or their sources of false information — but rather helps guide them toward a path to learn more and question some of their assumptions and beliefs in false information.
This is the approach I’ve recommended that organizations, family, and friends use with unvaccinated people who have been co-opted by misinformation or have other reasons for vaccine hesitancy. It was developed based upon my reviewing recommendations from many different groups about how to communicate confidence in vaccines, as well as unique qualitative research I helped conduct in early 2021 about how to combat vaccine misinformation being spread on social media.
For clinicians with “yet-to-be-vaccinated” patients, the goal of individualized conversations should be to extend dialogues about vaccines with the hope that all patients will eventually get vaccinated for COVID-19, as well as other recommended immunizations.
This is the same goal as motivational interviewing, which is a recommended process for engaging vaccine-hesitant patients. Basically, in order to not strengthen a patient’s mistrust, nor challenge their autonomy, clinicians need to enter into a dialogue where the patient is at least an equal partner — and I would argue that even letting them assume a position of authority can be productive in the long term.
For example, if a patient adamantly states their refusal to even discuss vaccinations (ie, they are very resistant), then you might reply with something like what I suggested to my own primary care clinician who was confounded by such a patient:
It’s fine that you don’t want to talk about getting vaccinated. But can you help me for when I talk with other patients who may have similar feelings as yours, by telling me a bit about what you’re thinking or feeling about COVID and vaccines?
Such a response would not be expected to get them to want to be vaccinated at that moment, but it does create the opportunity for ongoing discussions about vaccines by putting them into the position of providing their perspective, while the clinician is the one receiving information. The outcome here is that the patient did not completely shut the door and preclude any further discussions.
This might be similar to a situation with a patient with poorly controlled type 2 diabetes who refuses to discuss the possibility of using insulin or any injectable treatments. While such therapies might be a recommended standard of care, if the patient refuses to even discuss it, their clinicians shouldn’t (and likely wouldn’t) permit that to be the end of the discussion forever. The goal is to keep the conversation going so that the patient-clinician relationship is not sullied, and as more information becomes available to both you and the patient, hopefully the possibility increases that the patient will agree to your recommended course of treatment.
For patients resistant to COVID-19 vaccines, this progression could move them off of their misinformation about vaccines or COVID-19 itself and seek to strengthen their trust in you as a source of information (and your recommendations), so that eventually the balance swings in favor of them getting vaccinated. And, of course, as part of that ongoing dialogue, clinicians can help guide patients to reliable sources of information while helping them question sources that may be misleading or false.
For clinicians looking for additional short resources about how to talk with patients about COVID vaccines, I recommend Ariadne Labs’ Vaccine Confidence Toolkit for clinicians, which I provided a bit of help in developing. Ariadne Labs also has a 1-page handout for patients that some clinicians may find useful, particularly for patients who mistrust authority since it is not coming from a government agency or your local healthcare system. (Similar resources compiled by Ariadne Labs are here.)
Overall, the key to successfully engaging with vaccine-resistant patients, whether it is about COVID-19 vaccines or other immunizations, is to remember that challenging their mistrust or trying to counter their autonomy will likely lead to both hardening their resistance to vaccines and undermining the ongoing patient-clinician relationship. Conversely, engaging vaccine-reluctant patients in dialogue that respects their autonomy and considers their mistrust factors may eventually lead to vaccinations occurring and a stronger clinician-patient relationship.
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About Dr Michael D. Miller
For more than 30 years, Michael D. Miller, MD has been working with large and small companies, government organizations, and patient advocates to improve access and affordability for treatments and innovations. His work has spanned many clinical, scientific, and policy areas, including autoimmune diseases, behavioral health, cancer, cell/gene therapies, diabetes, patents, reimbursements, and vaccines. He graduated from Williams College and Yale Medical School, has served on several nonprofit boards, and has spoken across the country on critical healthcare issues.
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