Names changed and age adjusted for privacy.
Janet looked up at me through tears in her eyes – wondering what I was going to ask next. We had spent the better part of the last hour recalling and documenting the medical history of her eight- year- old, Sam. An hour that was only possible since I was a trainee. Primary care providers are often expected to see patients in less than twenty minutes. Janet and Sam were moving to Pennsylvania from a neighboring state and were new to CHOP, so I had taken a full history and physical – detailed family history and all.
Much of our conversation was medically important but emotionally benign – “Does Sam have any allergies?” “No.” But as I went month by month through their last year of ER trips, hospitalizations, and finally a diagnosis of Type 1 Diabetes, I could tell that she was reliving each moment. Her love and care for Sam was clear. It had taken many sleepless nights full of hourly ketone checks and constant fears of hypoglycemic attacks to reach his present health.
As I made my way through the visit’s checklist, I came to what was always my final question…
“Are you interested in a Flu or COVID vaccine for Sam today?”
My inquisitive posture was met with exasperated, but engaged, silence.
“I am not so sure… he’s just been through so much,” Janet responded. She continued, “I am just not sure what is best anymore with everything I read on the internet.”
By this time in the year, even with just 11 months of clinical experience, I was already developing an inward cynicism around the community’s view on vaccinations. Frankly, I was more surprised when a patient did want the COVID vaccine than when they declined the shot.
Instead of meeting skepticism with skepticism, I asked a question that I had never asked before.
Has anyone ever explained to you how vaccines work?
News about vaccines is not hard to find these days. Outbreaks are occurring on a weekly basis near and far, as political and medical leaders alike ring alarm bells at what these events signal for the future.
Vaccines have heralded in an era of childhood health like no intervention ever seen before. For medical trainees, they have fundamentally changed the diseases we interact with daily in the hospital. Whereas residents of generations past managed dozens of patients with measles over their career, current pediatrics trainees may never see a case of measles.
Yet if we look around, vaccines are increasingly up for debate as if they are novel science not yet understood or validated. The impact of these debates, felt acutely in each examination room as patients and families, weighs heavily on the shoulders of pediatric providers and trainees. The response I far too often adopted while on my clerkship was to accept vaccine hesitancy or misinformation – choosing to move the visit along instead of dig deeper into the importance of vaccines. Asking patients over and over about their vaccine preference felt futile and, with limited time to see each patient, as a waste of time. The attending physicians I learned under similarly moved on quickly from vaccine dismissal. For some, they had known their patients for decades and could already predict the patient’s response; for others, they simply had other more pressing conversations towards which to focus their counseling. And for others, it is just emotionally taxing to be told “no” over and over again throughout a busy clinic day.
Balancing my own learning with advancing care for the patient visits I attended, I fell into the fallacy someone else will take the time to go through vaccine education. It was easier, I often felt, to turn down the emotional valence of the visit and focus on the parts where the patient and I agreed. As just the trainee, I would often comfort myself by hoping that another provider would eventually take the time to thoroughly go through vaccine hesitancy with the patients; yet, who is to say the “other” providers I was thinking of were not hoping the same? If too many providers all fall into this version of the bystander effect, we abdicate our responsibility to educate the public on the importance of vaccines, yielding the floor to online influencers and forums.
But we cannot assume the response of our patients to receiving a vaccine – or any treatment for that matter – before we discuss the pros and the cons. Each new visit presents the opportunity to turn over a stone that had been previously untouched: to teach a caring, driven mother about how a vaccine might complement the hard work she is already doing to keep her child healthy.
As it turned out, no one had ever offered to teach Janet how vaccines worked before. Perhaps she just did not recall when her past pediatrician discussed the difference between live and attenuated vaccines. But even more likely, we – the collective we – as healthcare workers had gotten so used to families denying vaccines that we had stopped trying.
Using straightforward analogies of “memory against infection” and “weakened version of the same virus,” I slowly introduced the mechanism of common vaccines. Janet started to open up and ask questions – such as wondering if there was a risk of spreading infection after receiving a vaccine. Her questions demonstrated both her investment in her child’s health and willingness to approach the complex topics of vaccines and immunology in order to make the best choice for Sam. Like many parents she had heard rumors about the connection of vaccines to neurobehavioral diagnoses. One parent in her community group had shared how pharmaceutical companies had never tested the safety of the individual components of vaccines. These concerns, though not true, were rightfully alarming. Together, we discussed each concern at length, and I was able to validate her concerns while also sharing the safety data and side effects risks that I knew to be true, counseling time only possible thanks to an extended visit period afforded to trainees.
Through this conversation, I was able to praise the hard, important work she was already doing by managing Sam’s blood glucose monitor and insulin pump. She was already working so hard to keep Sam out of the hospital, and as our conversation continued, began to weigh the risks and benefits of vaccinations in a new light. Janet shared that she was still scarred from past interactions with healthcare professionals that made her feel talked down to and disrespected. She highlighted that many in her community had given up on vaccines altogether and that it was hard to remove herself from that influence.
As we went through her questions, I watched her grow in her own knowledge about vaccines and confidence in stepping beyond her the stories she had heard. Janet agreed to give Sam both the influenza and the COVID-19 vaccines that day. Together, we had navigated the tumultuous waters of vaccine hesitancy in America and found our way to shared decision making that put Sam’s health first.
Talking about vaccines with patients is hard, and with recent events it is not getting any easier. Particularly in busy primary care clinics where providers are endlessly pressed for time and compensated for efficiency not thoroughness, taking the time to discuss each concern is not always possible. Further, many PCPs struggle with compassion fatigue and sometimes are just not mentally prepared for the challenge of counseling against vaccine hesitancy. I hope that my story highlights that change is possible. For Janet and Sam, change came on the first visit to a new practice but for another patient change might come on the tenth or twentieth visit. You never know when a patient is going to be ready to make that change, but it is up to us to keep opening the door.
Everyone deserves a chance to learn how vaccines work.
