In DEPTH Perspectives from Our Contributors

To help explain to other clinicians how the circumstances in which they practice medicine affect how they view this topic, with evidence to support their points, Drs. Linda Girgis, Jasminka Criley, Umbereen Nehal, and Alex McDonald offer their perspectives below. We hope these sourced viewpoints both create visibility into how different colleagues interpret and address key issues, as well as serve to expand clinicians’ frame of reference—all to achieve better patient care and enhance physicians’ day-to-day practice of medicine.

Racially Concordant Physicians

There is variability in the uptake of the COVID-19 vaccine based on age, geographic location, politics, and demographics; however, race and ethnicity is one of the largest contributing factors. Vulnerable populations, particularly Black and Latinx, have lower vaccine uptake for a myriad of reasons. This article is spot on in discussing that a “one size does not fit all” approach is critical. However, the clinician who is recommending the vaccine may also impact patient and parents’ decisions, as noted in Nature. We know that longitudinal relationships between primary care physicians and patients is another critical component to building trust in any medical recommendations. As a family physician, I often have patients and families for whom I have cared for years and built significant trust with. We know that minority patients are often more satisfied and feel more connected and more engaged in healthcare decisions if their doctor speaks the same language and shares the same culture, often resulting in higher quality care. Racially concordant physicians are an important piece when discussing sensitive topics, such as vaccines. As a White male physician, I often try my best when discussing these topics with minority patients, but I know I am perhaps not as effective. Nonetheless, effective patient-/family-centered communication can be taught to any clinician. Furthermore, I try to address and acknowledge historic wrongs by the medical community that may lead to greater lack of trust. When it comes to public health messaging, the messenger is often as important—if not more important—for minority communities who may have greater hesitance or questions about vaccines. Local religious leaders, permeators, or respected individuals of the community may in fact be the best messengers. Public health departments and healthcare workers must specifically sit down and partner with these leaders before we can truly reach enough of our most vulnerable populations. If we truly want to address health disparities, we must acknowledge our past and diversify our healthcare workforce.

Community Leaders & Trust

As a medical student when the Wakefield paper was published, I did not realize that selecting pediatrics meant a career combating vaccine misinformation. Distrust in doctors seemed unfathomable; to me, a doctor was my Pakistani surgeon great-aunt who founded a hospital and cared for both elite families and refugees. Antivax appeals to suburbanites who trust the “wellness” industry, while media amplifies alarmist content. Though the pandemic killed ~1 million Americans, disproportionately minorities, the Washington Post ran a narrowly focused health article that doctors’ offices “fat-shame” women by measuring weight. I explained to the reporter that bias is a crosscutting issue that includes Black patients undertreated for pain and fat-phobia. Data are essential to advancing equity. My own late mother was labeled low priority for COVID care in Texas based on her age, ethnicity, chronic illness, and BMI. I was misquoted as I would “not allow” patients to opt out of weights. Authoritarians imposing our will is how doctors and public health are often portrayed. “Antiestablishment advocate” identity, not poor science literacy, drives rejection of public health. Public health does need to regain trust before we can act as one “community.” The eugenics movement subjected African Americans to forcible sterilization. In 2014, public health deans reprimanded the CIA’s misuse of vaccines for espionage. This validated fears that “Western vaccines sterilize Muslims.” Polio eradication stalled as vaccine workers were shot as “spies.” Media also inflames. Recently, “feminist” anthropology professors sought media attention, prior to Institutional Review Board approval of their “vaccine side effect” online poll, with beliefs that the COVID vaccine disrupted menses/fertility. This fertility fear is shared by evangelicals. Yale researchers describe evangelicals as “immune” to vaccine education. This is perplexing when evangelical doctors, Dr. Birx and Dr. Collins, oversaw COVID vaccine development. Why is Black doctors’ pro-vaccine community outreach more effective in driving vaccine uptake? Whether my Pakistani surgeon great-aunt or “abuela” in Encanto, communities trust local leaders.

Private Practice

Since the start of the COVID-19 pandemic, the way we practice medicine has forever changed. While we are continuously changing protocols for how we handle patient flow safely, we still face the practice problems that existed before the pandemic. While many physicians are feeling increasingly burned out, pediatric vaccine hesitancy has caused further burnout rates and higher job dissatisfaction among community physicians, especially pediatricians. In private practice, we are already time crunched in managing medicine while also running a business. COVID-19 has placed increasing burdens on our daily lives in terms of keeping up with the guidelines and trying to answer increased patient fears. Parents have never been afraid of vaccines like they are with COVID-19 vaccines. In the past, it was much easier to address parents’ fears. However, COVID-19 vaccines have become very politicized and the star of the media. People are being bombarded with misinformation, and it is hard for them to know what is true. Addressing vaccine hesitancy is taking a huge amount of
time in already stressed practices. As primary care physicians, it is our responsibility to make sure parents are getting the right information, which often involves combatting the wrong beliefs they accepted about vaccines. While they may accept the risk for themselves, they are not so willing to do so for their children. Although it adds to our stress, we must continue to address pediatric vaccine hesitancy, especially regarding COVID-19. If we don’t, the information parents get will likely be the wrong information. In primary care, we know it is always easier to prevent a disease than to treat one. Our pediatric patients deserve our best efforts to get their parents the information that will help them make the right decisions.

Community Vs Individual

I am principal investigator on an NIH project to improve hand hygiene for children using interactive digital media. I have had many opportunities to discuss vaccine hesitancy from all walks of life. Possible culprits include lack of scientific literacy, trust, or understanding who to trust and pressure from the community. The role of digital misinformation and fear has been huge. Vaccine hesitancy highlights the limits of our present approach to healthcare, in which effective therapy is widely available but human behavior stymies widespread adoption. This role of parents in determining whether to vaccinate their children against COVID-19 is a thorny ethical problem. At conflict are the collective duty we all have to community safety versus individual autonomy: A parent’s right to determine what medical treatment should be administered to a child can conflict with what clinical trial results indicate. Behavior change is not trivial. Messaging is maybe less important than conversing. When educating, it is important to understand where people are coming from and meet them at their level. This means, providing information in the language that makes sense to them, giving time to process it, and respecting their decisions; these are big decisions. Far too often, patients are faced with difficult decisions and confronted with health issues they did not know they had, using confusing terms to those without healthcare background. For preventive medicine, this should not be the case. Patients should have the time to be informed. We should take the time to rebuild the trust that has been eroded. As a society, we need to invest this time, to increase scientific and health literacy from an early age. If we encourage critical thinking, and we build mutual trust, patients will be able to make better decisions to support individual health. As a result, we will all, as a society, benefit.