Vaccine Conversations: Meeting Patients Where They Are

I had a routine well-child visit with an established patient, MC, and their parent, DC. I finished the examination by saying the nurse would be in to administer the scheduled childhood immunizations, which were part of a vaccine series the child had received in the past. Today, though, DC said, “I don't want any more vaccines for MC.” When asked the reason, DC explained that a middle-aged friend who was previously fit and healthy must now walk with a cane. DC clarified that the friend had experienced several uneventful COVID-19 infections before getting the COVID-19 vaccine and blamed the vaccine for the friend's health decline. I understood that DC was concerned about the adverse effects of vaccines, but having run out of time, I decided to address the issue at the next visit. How can I gain insights about patients' attitudes regarding vaccinations? How do I begin a constructive conversation that leads to shared understanding and shared decision-making?

Vaccine skeptics have long existed, but vaccines are currently the subject of intense rhetoric and dialogue. Most patients and caregivers still opt for many, if not all, available vaccines, but vaccine hesitancy and questioning have been increasing. In 2019, the World Health Organization named vaccine hesitancy as one of its top 10 global health threats.¹ Since 2020, the discourse surrounding vaccination has intensified. Isolating measures during the COVID-19 pandemic moved vaccination from a private office visit with one's personal physician to impersonal parking lots and pharmacies, administered by anonymous people shrouded in personal protective equipment. This physical relocation largely removed the opportunity for decisions and actions to be made in the context of a relationship with one's personal physician.

Patients increasingly arrive in physicians' offices unsure of what—or whom—to trust. In previous decades, the norm in medical practice conventionally regarded the doctor as an expert authority and trusted source of information. However, evolving medical models that emphasize patient autonomy and shared decision-making, along with increasingly available health information online, have changed that dynamic. The science and policy decisions usually discussed in journals and at medical conferences are now handled publicly in ways that undermine trust and foster uncertainty. For many, this development erodes faith in a health care system that they perceive may no longer have their best interests in mind.^2,3 The seeming alignment between respected medical institutions, such as the US Food and Drug Administration, and for-profit interests of pharmaceutical and health insurance industries has sown further doubt.⁴ Increasingly, politicians and influencers exploit the confusion to promote themselves and their ideas.³

As a result of these factors taking place in the broader context of a general distrust of science, vaccine discourse that previously occurred between doctor and patient has escaped the four walls of the examination room. Therefore, our perspectives and approaches when discussing vaccinations with patients should consider the messages patients encounter in the broader context of their sources of information. Some of the assumptions we hold around emotions, values, fairness, fears, and influence may need to accommodate patients' concerns.