The response has been almost like clockwork, at almost every medical visit over the past few weeks. “It’s time to get your flu shot,” I’ll tell my patients, “plus the updated Covid vaccine.” And that’s when the moaning starts.
In the past, the flu vaccine generated the most resistance. Patients in my practice in New York took their other vaccines without hesitation, but balked at the flu shot – because their sister is allergic to eggs or because they are sure the flu shot always gives them the flu or because they just don’t give flu shots. Now, however, the majority of my patients respond along the lines of, “It’s fine to get the flu shot” – pause sheepishly, then say – “but not Covid.”
When I ask my patients if they have any concerns or questions about the Covid vaccine, almost none do. Almost no one asks me about the safety data or how effective it is in preventing viral transmission, hospitalizations and deaths. Almost no one asks me about current case numbers, masking, or Paxlovid. There’s just a vague hedge or “I don’t know, I just don’t know.” » As I try to understand what my patients are concerned about, I can sense their slight sense of surprise that there is not a specific issue causing their discomfort about receiving the updated Covid vaccine. It’s like they have a common case of heebie-jeebies.
Healthcare professionals everywhere are hearing this kind of hesitancy among patients as Covid cases and hospitalizations have continued to rise over the winter. As of early January, the average number of Americans dying each week from Covid exceeded 1,700. And yet the Centers for Disease Control and Prevention’s January 19 report indicates that only 21.8% of adults 18 and older have received the latest Covid vaccine, less than half the percentage of those who received the flu vaccine.
Improving this situation is not easy, and it will require health care providers to engage in uncomfortable conversations that are less about facts and more about emotions. But if we don’t, we will tolerate a level of preventable deaths that we would find unacceptable in any other area of health care.
It’s possible to recognize pandemic fatigue without throwing in the towel. The long-term health and life of our community depends on it.
When my patients express hesitancy about receiving the updated vaccine, I explain to them how the Covid virus has mutated, which is why we changed the vaccine, just like we do every year with the flu vaccine. I will point out that in the first two years of Covid vaccination, about three million lives in the United States were saved and about 18 million hospitalizations avoided. These facts rarely have much effect. There are, of course, practical barriers to the vaccine – cost, access, feeling sore the next day – but that’s not what most of my patients bring up.
Their hesitation is all the more painful because, as New Yorkers, they were on the front lines facing the first brutal wave of the Covid-19 pandemic, losing family members and friends. The line of refrigerated morgue trucks parked behind my hospital is a sight not easy to forget. Furthermore, these patients are not anti-vaccines; they take their shingles and tetanus shots without shrugging their shoulders. Almost all have received the first round of Covid vaccines and vividly remember the urgency of getting those hard-to-find vaccination slots in the beginning. Nor do they appear to be science deniers; they adopt standard medical treatments for most of their other health problems.
Every time I’m faced with a patient hesitant about the Covid vaccine, I have to decide whether to put aside the many other pressing medical issues vying for our limited time to take the route of vaccine hesitancy . These discussions are notoriously complicated and lengthy and rarely change minds. Part of me just wants to move on, as my patients – and indeed the entire country – seems to want to do. Pandemic fatigue has even become a field of study in its own right.
But something inside me doesn’t seem ready to let go. The specificity of their refusal of Covid – especially compared to the refusal of the flu – piques my curiosity and my dismay. Many of my patients have medical conditions that put them at high risk for complications from Covid, such as hypertension, diabetes, heart disease, obesity, kidney disease, asthma. Yet here they are, one after another, rejecting a medical intervention that most have already received safely and dramatically improves outcomes. And they can’t really articulate a specific reason, even to themselves. Ignoring this seems wrong.
So I dump the game, step away from the computer, make full eye contact, and start again. I might start with: “Tell me what you think” or “What makes you feel differently about the Covid vaccine compared to the flu vaccine?” I try to get into the gray area of their responses and explore those awkward feelings.
When they say: “I have already received enough Covid vaccines”, I will try to find out where the feeling of “enough” comes from. I might ask, “Have you ever felt this way about your diabetes medications or your mammograms?” We will explore how they reach conclusions about which treatments they accept and attempt to separate vague discomfort from specific concerns.
A review of facts is less about starting a lesson and more about examining emotional reactions. We speak openly about what they are hearing in their communities: that the pandemic is over, that the new boosters are more experimental than the old ones, that a certain number of vaccinations is too many.
This can be a revelation for some patients when they realize that they may be reacting to a feeling of confusion rather than specific information or misinformation.
I want my patients to maintain a healthy skepticism about any proposed intervention on the body, whether it comes from their doctor or social media. I will be happy to retrieve information from medical reference sites like UpToDate to review the pros and cons of treatment with them. I will always respect their choice to disagree with my recommendations, but I want to understand why.
In medicine, we are quite good at addressing specific concerns; we easily gather facts and figures because that is the area in which we are most comfortable. It’s tempting to avoid the more nauseating realm of floating discomfort, but we can’t. The good news is that this can be a constructive and collaborative moment in the relationship between patients and healthcare professionals. In my experience, when we talk directly about the awkward gray area that seems to permeate vaccine hesitancy, there is a certain shared humility. We are all deeply disconcerted by states of ambiguity.
By deconstructing these uncertainties, I feel that many patients feel a stronger sense of control. They don’t immediately roll up their sleeves for the vaccine, but there is a clear change in attitude. They are much more willing to engage in conversation about the realities of the Covid vaccine and how it compares to the flu vaccine or Covid infection.
For me, this is progress. Some get vaccinated; many don’t. But at least we can approach Covid vaccination in the same way as any other medical intervention.
However long and exhausting these conversations may be, we have a common duty to try to unclog the waters – all of us. If you’ve been on the fence about getting your up-to-date Covid vaccine, you might want to put your heebie-jeebies front and center on the exam table at your next doctor’s visit. They have to take an exam.