Clinical Pearls

A key first step really is to hear — really hear — their concern and be able to say ‘That sounds like a reasonable concern.’ Right? If you can say that, all of a sudden you're allied with the patient. So you ask the open question, then you reflect back and affirm their point of view, telling them, ‘Yeah, that's a reasonable concern.’

A patient might say something that's totally Looney Tunes up front. On the inside you're thinking, ‘Well, that's just completely nuts!’ But if you can't explore it further — listen and affirm that it's coming from a real place in their lives — if you can't do that, then there's no opportunity for a conversation. You've declared you're not their ally.

You never really know anyone else's experiences or traumas. Knowing this, it's best to approach conversations as doors that can be opened or shut. If you say something to shut a door — call people's experiences or perspectives out as uninformed or silly — there's the good chance that the door never opens again. It can be so hard, but affirming experiences and perspectives — even when they conflict with your own — is the way to keep doors open. You might not have a ‘yes’ to vaccination today, but you can't get closer to your patient thinking about it in a positive light if you shut the door.

When you're an ally the conversation becomes about exploring options. You're not trying to win a battle. You're just trying to get them into a more contemplative state where they actually are open to thinking about alternative explanations.

It's better to be honest if you don't know something. In fact, in the Google age, you can turn that into a bonding moment. You can offer to look up whatever they're saying together. Or maybe offer to compare notes at the next appointment if they're prepared to send you the sources they're looking at. ‘We can share in this and look this up!’ By making it a project you're reducing the distance between you, showing you're an ally.

I'll emphasize how the best way forward — the way back to normal — is to protect as many people in our community as possible. Then I'll make an appeal to them. Something like: ‘Someone in a leadership role like yourself or your community leader, can help ensure as many people as possible are protected. You can lead by example and allow us to help your neighbours get their businesses back up and running.’

I try to hone in on someone I know personally, outside of my patient panel. For instance, if someone is worried about the impact on their fitness routines, I talk about my brother. I tell them how he is quite athletic, and only 40, and how when he got COVID it laid him low. I tell them how he's been having chest pain ever since, and how he had to go see a cardiologist. Sure, his heart was fine, but you know, he wasn't really able to get back to sports for weeks and weeks.

We know from the risk communication literature that many people have trouble making statistics apply to their own lives. So, when I talk about blood clots, for example, I talk about how we've learned from some very, very rare events. 1 in 100,000 events. So, one person out of 100,000 gets a blood clot. I compare that to their chances of dying in a traffic accident — which is a chance we take every time we get in a car — that chance is 1 in 20,000. I find grounding it like that helps.

The common theme in all of this is: What's the shared goal? Your goal is to make the vaccination more likely. What's their goal? Their positive goal in a post-COVID-19 world. Let's find it, let's state it, then you know you're on the same team.

I've been trying to move away from talking about what people are afraid of and towards what they're looking forward to. That's a good thing to think about.

If you don't really fully understand where the patient's coming from, there is no opportunity to figure out what they're looking for in life. Patients have very complicated concerns and equally complicated understandings of things. Acknowledging and affirming that is the way to get to a positive goal that you can agree on.

The whole conversation plays out in two phases: desensitize and motivate. Phase 1: You have to help your patient desensitize. They may have a nameless fear of the vaccine, and your job is to help them get less reactive to that fear and so become accustomed to the idea of getting the vaccine. You know it's nameless because every time the conversation comes up the fear is somewhere else. One day it's about the rushed science. The other day it's about gene therapy. The other it's about liberty and government. At root, its nameless and they're afraid. They can desensitize partially by seeing their close friends, their community members, maybe 'the rest of us' but that's a lot less effective. So you want to find out if there's ANYONE close to them who's gotten it, and see if they can use that to desensitize from the fear.

Phase 2: The question then, for these people who have this nameless fear of the vaccine, is 'How do you motivate them to do it?'. You've made it less scary - you've desensitized – but how do you motivate them? Well, YOU don't. THEY do. You just have to work with what makes them tick. Some people are about serving the community; some are about serving themselves. Well, there's their motivations, now help them see a path towards the thing they want that passes through the vaccine. Would they feel like a better member of the community if they got it? Would they feel freer and more like themselves if they got it and could do the things like - travel? Get into a bar? All you're doing is setting up the idea that the vaccine is the key to getting something that they want.

I always have to check myself when patients contradict medical expertise. I always pause and check in with myself because there's a chance of getting really frustrated and angry.

Sometimes you can't de-escalate on the first visit. Maybe that first visit is just a chance for them to go red-hot about their other issues. You ask a neutral question: ‘Have you thought about getting vaccinated?’ And, suddenly, they've gone into the red zone and they're defensive because of the 20 years of history they've had. Clearly it's a protective mechanism. You've got to let that mechanism play out on this visit. No point in getting into the conversation. But you can prime for the next one. Affirm where they're at today, and set for the next conversation.

Anger is a natural human emotion. Especially between people who know one another. It's how you handle it. I don't think you do necessarily permanent damage if you say: ‘I respect you as a person. You've been in my practice a long time. I need to call you back when I'm thinking a little clearer. I will tell you right now, your version of the facts really diverges from my knowledge and training.’ Doing that can de-escalate the conversation. It can make the patient pause and say to themselves ‘Okay, I touched a nerve there.’ And it can give you the space to cool off.

Like so much else in family medicine, its peeling an onion. You've got to gently pull back those layers to get to the real source of the hesitancy. Once the layers are peeled back, and you've got the patient's actual concern, then you can start looking for common ground. Like with everything else, that often doesn't happen in one visit. You need to plan for the long conversation.

My goal for the vaccine can't be getting them to ‘yes’ right away. My goal is to get them to a more open state. A state where they can talk more openly about some of the multiple factors contributing to their hesitancy.

Sometimes it's better to schedule another appointment to discuss the vaccine. The patient can be overwhelmed. Maybe you've just talked about all the other health concerns they have, and their 25 other medications. And suddenly you're saying ‘Okay. What about vaccine now?’ Better to introduce the idea and book a follow up.

Make your case. Let them digest it. Keep the door open. Say, ‘Hey, look, I'm open to talk any time if you decide you want to.’ If you don't see them saying ‘yes’ in the moment, there's no point in pursuing things. Because they need to digest the conversation.