How to manage vaccine hesitancy

"Over the last few months, my personal barometer of success as a physician seems to be directly related to my patients' acceptance--or refusal--of the COVID-19 vaccine," writes Rebekah Bernard, MD.

COVID-19 vaccine refusal feels more personal, somehow, as if patients are not only rejecting my medical advice but rejecting me.

Over the last few months, my personal barometer of success as a physician seems to be directly related to my patients’ acceptance—or refusal—of the COVID-19 vaccine. On a good day, I leave work feeling a sense of joy and perhaps a bit of pride from convincing a vaccine-hesitant patient to take the shot. Other days, I head home filled with sadness and disappointment, sometimes directed at my patients, but other times at my own inability to react dispassionately to anti-vaccine rhetoric.

I ask myself why I take this rejection of my medical advice so hard. Is it that different from patients declining to take the statin I prescribed or failing to schedule the mammogram I urged? After all, as a trainee in the era of shared decision-making, patient self-efficacy has been ingrained into my practice. Up to this point, this philosophy has worked rather well in the usual primary care areas. I take patients through my blood pressure, diabetes, or colon cancer screening spiels, explaining the risks, benefits, and alternatives. I give them a chance to ask questions. If a patient declines my recommendations, I carefully document their decision, and I move on.

But COVID-19 vaccine hesitancy is a whole different ballgame. Maybe it’s because my usual persuasion techniques—scientific explanations and motivational interviewing—are being met with flat resistance. Instead, I’ve turned to begging, pleading, and personal anecdotes from friends and colleagues in full COVID-19 hospital wards. Even sharing my own story of getting vaccinated (“after all, I love myself more than anyone,” I joke, “why would I do something to cause myself harm?”) fails to make an impact, leaving me to ponder in frustration why patients even bother seeking my advice for any medical problem. COVID-19 vaccine refusal feels more personal, somehow, as if patients are not only rejecting my medical advice but rejecting me.

This calls for a session of personal cognitive-behavioral therapy. Fortunately, I’ve spent enough time under the tutelage of psychologist Steven Cohen to know the steps to follow.

Step one: Identify negative emotions and feelings

Ever since the COVID-19 pandemic, my emotions are all over the place, and seem to vary on a day-to-day basis. Maybe today I’m feeling sad, angry, and frustrated. But the overriding and most painful emotion is the feeling of rejection.Not just a rejection of science, but a rejection of me.If I let myself go down that rabbit hole, I’ll find my anger rising as I think of the years of self-sacrifice, the nights on call, the lack of sleep, the hours of study—what was it all for? Anger then turns to self-pity: No one cares what I did to learn medicine, and no one cares what I say, so I may as well just give up. You can see how these negative thought processes can begin to spiral into dark and dangerous territory.

So, I don’t allow myself to indulge in this type of thinking. Instead, I identify and label my emotions, and then I move to step two: determining whether my thoughts are logical or irrational.

Step two: Identify cognitive distortions

Cognitive distortions are automatic, illogical, unrealistic thinking patterns. They tend to be intrusive and include repetitive thoughts that push to the forefront of our minds and may distract us from other activities.

In my case, I’ve identified feelings of rejection and I find myself engaging in negative self-talk: Patients won’t take my advice, I can’t seem to convince them to take the vaccine, therefore they will die of COVID-19, and it will be all my fault.

Whoa. Now that right there is the cognitive distortion is called personalization, a sort of God-complex in which we develop an excessive sense of self-importance and feeling of control over what happens to other people. This is not an uncommon thought pattern for physicians. After all, we do play an important role in our patients’ lives—but we must remember that role is just one small part of a vast array of experiences that affect a person’s life.

Another way to identify distorted thinking is to listen for extremes in your thought patterns: ‘all or none’ or ‘always or never.’In my case, I may find myself thinking: No one ever listens to my advice, and I’ll never make a difference no matter how hard I try.

Step three: Challenge distorted thoughts and feelings

Distorted thinking is automatic but can be overcome by challenging our thoughts logically and systematically. Once I’ve identified the illogical and inflated sense of self-importance in my thinking—My patients won’t take my advice; therefore, they don’t trust or believe in me, and patients are going to die because I’m not a good enough doctor—I must now ask myself three questions:

  • Is there any proof that these thoughts are valid?
  • Is this belief based on reality or facts?
  • What evidence do I have to support this belief?

I stop and think about how my clinic day went, challenging the thought: No one ever listens to my advice. Was that true today? While a few patients did decline the COVID-19 vaccine, rejecting all my counterpoints to their arguments, the rest of my patients had already received their vaccine months ago based on my recommendations. I consider the thought: I’ll never make a difference no matter how hard I try.I suddenly remember an email this morning from a vaccine-hesitant patient who decided to take the shot, thanking me for taking the time to talk with her. Oh, I had forgotten about that.

Now I start feeling a little better. I keep challenging my thoughts, asking myself, Do I have proof that my patients will die without the vaccine? While it’s possible they could die, it’s more likely that they won’t.After all, in the last few weeks, I’ve treated multiple non-vaccinated patients with COVID-19, arranging monoclonal antibodies and coaching them through symptom management. Some of them have been quite ill, even ending up in the hospital, but no one has died yet, and all of them have promised to get vaccinated as soon as they are well. I guess I’m not that bad of a doctor after all.

Step four: Practice cognitive reframing

My final step is to continue repeating this process any time I have a negative thought or feeling, considering alternate explanations, and choosing to think in a more positive way. The best way to do this is for me to ask myself one very important question: How do I want to feel?And one step further: What do I need to do to feel the way I want to feel?

My answer: I want to feel that I’m making a positive impact on my patients’ lives.To accomplish that, I know what I need to do. I must continue to show up at the office, listen to my patients with empathy, and never give up on them. Even if I don’t convert every single vaccine-hesitant patient, I know that I am making a difference. And so are you.

Rebekah Bernard MD is a family physician in Fort Myers, FL and the co-author of Physician Wellness: The Rock Star Doctor’s Guide.

This article was originally published on Medical Economics®.