IFM | Strengthening vaccine confidence and adult immunization

Welcome to Inside Family Medicine, where you hear from leaders and peers in your specialty while learning about new tools and resources. I’m your host, Emily Holwick, a member of Team AAFP. Today, Dr. James Bigham and Dr. Amra Resic are joining us to talk about vaccines.

Dr. James Bigham is a clinical professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health. He’s a member of the UW Health Immunization Program and Planning Committee and served as a 2022 American Academy of Family Physicians Vaccine Science Fellow. During that time, Dr. Bigham focused on exploring best practices for addressing vaccine hesitancy during clinical encounters. He completed medical school, Master of Public Health, and residency training at the University of Wisconsin School of Medicine and Public Health.

Dr. Amra Resic is a board-certified family physician serving the Palm Harbor, Florida community as an attending physician with BayCare Medical Group. A 2017 American Academy of Family Physicians Vaccine Science fellow, Dr. Resic has a strong interest in preventive medicine and adult immunizations. She provides comprehensive care to patients across the lifespan, with particular focus on evidence-based prevention strategies that reduce morbidity and improve long-term health outcomes.

Through Dr. Resic’s clinical work, she regularly engages patients in thoughtful conversations about vaccine confidence, risk, and shared decision-making, especially in the adult populations where immunization rates often lag. Dr. Resic is passionate about bridging the gap between public health science and everyday primary care practice, empowering patients to make informed decisions that protect both individual and community health.

Dr. Resic and Dr. Bigham, thank you both so much for joining us.

Thank you. Great to be here. Thank you.

You’ve both been AAFP Vaccine Science Fellows, as we’ve mentioned. So can you each tell me a little bit about why you pursued that opportunity and what the experience meant to you? Dr. Resic, I’ll start with you.

So for me, you know, in everyday practice, there’s a big gap in adult immunizations, and it’s more that the patients are not opposed or just unsure or unaware of what they’re due for. And even due to this, the vaccination schedule could be delayed. So I wanted better tools for communication, confidence-building especially, not just the guidelines.

Have it be a real conversation, with my patients so I could use it in daily patient care. So the fellowship really helped translate that evidence into those real conversations. So I pursued this because I was seeing these missed opportunities daily, and I wanted to get better at the conversations, not just the recommendations.

And Dr. Bigham, how about for you?

I pursued the fellowship in the midst of the COVID pandemic. And as many of us experienced, there were a lot of questions about vaccines at that time, and it really felt like I wanted to lean in and try to learn more at that really unique time, especially as we’re seeing a rising tide of people kind of pushing back against some of the data, not being very certain about what they should do for their own personal vaccinations.

And it’s a pretty special thing, once you’re out in practice, to get some protected time to actually dig in and learn new skills. And it was so wonderful to have extra time to just sit back and actually work on quality improvement that actually has paid dividends for my patients and for my practice.

So putting some of this into practice, Dr. Bigham, with your adult patients, how do you begin those conversations about vaccination, especially in an environment of vaccine hesitancy that we continue to see?

Vaccines remain something that are important for us to talk about with patients as part of the care we provide.

And I lead with a presumptive approach. Essentially, if someone’s due for a vaccine, explaining they’re due for the vaccine, and that today’s a good day to provide it. And then I’ll often center on the illness we’re trying to prevent for that individual. And it’s really about leaning into the relationship that I have with that person and helping them understand that as we’re talking about vaccines, we’re actually trying to really promote wellness and prevention.

And I recognize in many ways I’m also leaning into the trust I’ve cultivated through the years with my patients. And if they can see me as a trusted guide in their health and well-being, hopefully they can understand and appreciate that when I’m offering them vaccines, what I’m really trying to do is help them optimize their well-being.

It is all about that relationship. I know that’s so integral to family medicine, really the cornerstone of what family medicine is. Dr. Resic, what are some of the strategies that you use in your conversations with patients?

So for me, it’s part of our routine care for the patient. It’s part of the intake, so it’s not any different from checking the blood pressure or following up on the chronic diseases in their blood work.

So for my practice specifically, on our intake sheet, just like family history and social history, there’s an immunization history. And so we’ve normalized vaccines as part of routine care, and we start with these clear recommendations, and we integrate it to all of the visits, not just physicals.

And how do you explain the importance of protecting not only the individual patient, but also the whole family and community when you have these conversations, Dr.Resic?

So it’s really great because I have a lot of grandparents that are coming in and need to vaccinate because their children are saying they can’t see the grandbaby unless they’re vaccinated against, like, tetanus or measles. So obviously they know it’s not just about them, it’s about the people they see every day, their loved ones.

You know, vaccination is not just individual protection, but it’s also shared protection. I know that there are a lot of reasons that I’m sure both of you hear from your patients about maybe why they don’t want a certain vaccination or why they’re delaying immunization. Dr. Bigham, what would you say are the key factors that contribute to those instances of low immunization uptake among adult patients?

I think if I’m honest, among adults, we’re kind of out of practice. In our pediatric population, it’s sort of routine to have a very set schedule of visits, and it’s sort of expected we’re going to be offering vaccines. And for many adults, especially those who maybe don’t have chronic medical conditions, they may be coming in to see us in a more sporadic way, maybe not annually, for example, and so they may be out of practice with things other than getting a once every 10 years tetanus vaccine.

We know with influenza and COVID vaccines, which are recommended annually for adults, that there’s a very small subset of patients who do get those vaccines. So less than half of patients get those. And, and so in some ways, people maybe just aren’t as aware around the need for vaccines. I will say moving some of our vaccines down to age 50, some of those we used to give at age 65 down to age 50, which is by design to help improve the long-lasting immune response, I’m engaging in more of these conversations with patients.

And as I talk about things like the importance of a pneumococcal vaccine or their shingles vaccine, it’s been really interesting to watch patients begin to appreciate the fact that we want to get the vaccines in at a time when their immune response is going to be strong enough to give them lasting protection.

And so at some level it’s just educating them about the importance of these things that maybe they haven’t been getting with such a routine frequency as when they were younger.

Yeah. That’s great insight. Dr. Resic, from your perspective, what do you think are some factors that influence that lower uptake?

I completely agree with Dr. Bigham. Many adults don’t even know that they need vaccines, that they’re due for vaccines. Again, this is why it’s part of my intake, because if it’s not, then I’m not going to bring it up. So it’s also a reminder for me, preventive care often takes a back seat, and a huge part of family medicine is preventive care.

We want to prevent chronic illness and life-threatening illness. So, if we don’t bring it up, it doesn’t happen. I know time can be limited with patients too, so building it into that intake and just having it as part of your process, I could certainly see how that would be very effective.

Dr. Resic, I’m curious to know what strategies or even possible interventions you’ve implemented in your practice to improve adult vaccination uptake rates, and I know we’ve talked about some of that.

So yeah, part of it, a big part of it is workflow. There’s standing orders that the team member, specifically the MA [medical assistant] during intake, can ask, "Hey, you’re due for your flu shot.

Would you like it today?" So that they can give, before I even walk into the room. There’s a lot of pre-visit planning that goes in the day before or a couple of days before, MAs will look at the patients and see what vaccines they’re due for and kind of notate it, which also helps. And then on top of that we have reminders in the EMR as to what vaccinations are due.

Clearly, a lot of it has to do with team-based care. The MAs, the nurses, they reinforce the message. There’s consistent language across the team. The communication is strong. It’s clear in communication and recommendation. We do try to bundle vaccines when appropriate, and like I said, we use every visit as an opportunity.

The biggest impact comes from making it easy, both for the team and for the patient. We want to make it seamless. It’s not about adding more time but just building into what we already do.

Dr. Bigham, what are your thoughts?

Yeah, I’m going to agree wholeheartedly with you. I think a uniform approach in ensuring that it’s part of what we do as standard of care is really important.

So almost using it like when we’re checking vitals or other rooming sequence elements, checking for care gaps like vaccinations are really important, and then making sure the entire team is all on the same page. And I think that goes from the time of scheduling an appointment all the way through rooming and any of the after-visit elements that happen.

And so making sure we’re all on the same page is really important. And I think having that culture of presuming vaccination, that we’re feeling like today’s going to be a good day and we’re going to take any sort of roadblocks out of the way. And it’s also important to think about the fact that sometimes here in this clinic might not be the exact right setting for the patient, speaking to the convenience for them.

So can we actually broaden the team to maybe include our clinical pharmacist or to include other venues where a vaccine could happen? And so sometimes today isn’t the best day because tomorrow someone has something going on, and so they might not want the side effects from today’s vaccine impacting whatever they’re getting into the next day.

And so making sure that we have a way to really be patient-centered in the way that we schedule and that we provide these, in a way that they feel like they’re empowered as well because I think empowerment is really important for the patients. We know that sometimes hesitancy can be driven when people feel dismissed or like they’re being told they have to do things against their own will, and we never want that to be the case.

We want it to feel like all of our team is leaned in to try to provide the best possible care for that patient.

And we’ve talked about that relationship, the importance of the relationship, and building the trust, and then promoting vaccine confidence.

Dr. Bigham, how do you use clinical shared decision-making to strengthen that collaboration between you and your patients when it comes to these routine adult vaccinations?

Yeah. When we’re doing the shared clinical decision-making, we really are being attuned to the patient as far as their preferences and their values and their specific medical conditions, and then we couple that with our own medical decision-making, our own medical advice. And my hope is it’s really a chance to show the patient very clearly that I am considering them, that I do know them and appreciate them, and as I’m making a recommendation, it’s not just a generic one-size-fits-all recommendation, but really thinking about how to empower them to maintain their well-being.

I, in many ways, feel like if I’m doing this well even with routine vaccines, hopefully it still feels like this. And it’s just so important to make sure that we do take the time, and not a ton of time, but just enough time to make sure the patient feels like we’re seeing them, we’re hearing them, we’re validating them as we’re making the recommendation towards vaccination.

And it’s clear, it’s important that we should make a clear recommendation that is kind of timestamped. Like, today is a good day for this. We should do this today because, to Dr. Resic’s point, convenience matters. When the patient is there and present is the most efficient time to often give the vaccine because it doesn’t require a follow-up visit.

Obviously, not all vaccines require the same depth of discussion, but if the patient sees you taking the time to answer their questions, they know that this is important to you and it’s important for them. So again, good collaborative discussion is important. It’s not just passive. It’s not dismissive, like, “Oh, hey, you just need this vaccine. Do you want it or not?” You know, it’s more of a conversation. And the shared decision-making, it doesn’t mean that it’s neutral. As physicians, we want to give a clear, strong recommendation and guide our patients, but we also want to address their concerns. And it may not happen today, but they may come back.

And then I think, as a physician, we need to recognize that. Like, “Okay, you know, if you don’t want it today, you can schedule a nurse visit later, or you can schedule at the pharmacy, but I really do want you to get it. It is important for your health. My recommendation is that it’s strongly recommended.”

And you talked about the importance of having the care team involved in this process too.

So, Dr. Resic, how does your practice build confidence among its care team while addressing some barriers that might be causing vaccine hesitancy in patients across the lifespan?

So education is really important. We want our team members to be updated, but then also to provide that education and feel comfortable providing the education to our patients.

We have handouts available, you know, for the team members to read and for the patients to read. Again, consistency is very important. We want to give the same message. The team feels empowered. The staff feels comfortable answering basic questions. They feel good when they’re able to also, you know, get the patient vaccinated.

They’ll come in and say, “Dr. Resic,” like, “oh, she agreed to, you know, the shingles vaccine.” And it’s like, okay, like they feel pretty good about being able to do that. And then they know when to involve the physician. Like, “Oh, you know, I talked to her about this. She still has more questions, but, you know, she’s kind of on the fence,” which is good, great teamwork.

And then the culture is that vaccines are standard care. It’s not an optional add-on. It is strongly recommended. And then when patients see this, they, you know, they hear the MA come in, they hear the doctor. Okay, they’re like, “Okay, well maybe this is serious. Maybe I should consider this.” Everybody’s confident and consistent, and the patients like that, and that also helps them to be more confident about receiving the immunization.

Yeah, that makes a lot of sense.

You’ve both shared so much great information with us and our family physician community today. I know everyone has learned a lot, and a lot of things that they can start putting into practice today, right now. But before we go, I want to hear from each of you, what’s something that you each hope other family physicians take away from our conversation today?

Dr. Resic, I’ll start with you.

So adult vaccines are a missed opportunity. Our adult patients need vaccinations too. Our recommendation is powerful. Our patients trust us, and giving a good recommendation is important to them. You know, these small little communication changes in your day-to-day patient visits does create a huge positive impact.

One of the most powerful tools we have as physicians is that recommendations, and you can’t underestimate the impact that has. Again, if we make vaccines part of our routine care and communicate them clearly with the patient, we can significantly improve uptake.

Dr. Bingham, what’s one key takeaway for you?

Yeah, I would really echo the importance of a strong recommendation. I think when we are with our patients and we clearly say, “I strongly recommend this vaccine,” it signals to them the importance of what we’re talking about. And, and I would also just remind all of us that vaccines are not glamorous, but they are lifesaving.

We know that in the 100 years between 1900 and 1999, we added 25 years of life expectancy in the U.S. because of public health interventions. Number one was vaccination. We have made huge gains historically because of vaccines. We need to make sure we maintain those. And so as we approach each patient encounter, I hope that our colleagues recognize that though it’s not glamorous, it seems like maybe it’s one more thing, it really could be that one thing you do that day during that encounter that could significantly impact both the health of that individual as well as their family and our community.

Thank you both so much for joining us and sharing your insight. We are truly so grateful for the time that you devoted to speaking with us today. And to our listeners, if you’d like to learn more about choosing family medicine or you want more information about how to boost vaccine confidence among patients of all ages, you can check out the links in our show notes.

If you enjoyed today’s episode, let us know by dropping a line to aafpnews@aafp.org. And be sure to share the episode with your followers on social media and tag the AAFP.