It was 2018. Previously, “Max” had steadfastly refused all vaccines. Despite his HIV infection, which was well controlled, and my pleading with him over multiple years to get a flu shot, he was firmly opposed. He was intelligent and very matter-of-fact, and we had discussed this often. It was obvious that he did not want to be vaccinated, despite the clear recommendations and benefits for a patient with his diagnosis. He often said, “I’m not ready yet.” I was in the trenches with Max.
In our fall visit in 2018, he opened with, “You’ve been talking with me for a long time about vaccines, and I’ve been giving it a lot of thought. I’ve read a little more about the flu shot, and I’ve decided that I’m ready. I’ll take a flu shot today.” I could barely believe my ears, replying, “Are you sure? Are you ready?” to which he smiled and said, “Yes.” At his next appointment, he agreed to a Tdap vaccine (since the flu shot had gone so well and uneventfully). I was thrilled.
How did Max and I get to this point? With persistence, respect, and perhaps most importantly, trust.
During our annual fall visit, I would broach the topic saying “I know we’ve discussed flu shots. If you have changed your mind, please let me know.” And then we moved on to other topics, such as his CD4 count, HIV viral load, and adherence to antivirals. Faithfully, every visit, the vaccine topic was raised, even if only briefly.
My goal was to give him space and keep the door open in case he did change his mind. We discussed the issue forthrightly; frothy emotional appeals were avoided. The decision-making power resided with him, as it should. My job was to build the relationship, seek to understand, provide information including the value of a flu shot, and, when he was ready, proceed.
Our relationship was one based on trust. Max trusted me, and I trusted him to listen to my advice. I respected his decision and autonomy, never giving up hope that one day he might change his mind. My relationship with Max illustrates the importance and power of relationships that internal medicine physicians have with their patients. If Max and I had just ignored this topic or if I had assumed he would never get vaccinated, it is likely that he never would have done so.
Unbeknownst to me, Max had been “vaccine deliberating,” as Kimberly Manning, MD, FACP, has so eloquently described. I have borrowed Dr. Manning’s playbook many times and think it is an incredibly respectful, engaging approach. A sense of curiosity and seeking to understand “the why” helps us better address our patients’ concerns and demonstrates that we care.
August is National Immunization Awareness Month. This is a great month to implement some of Dr. Manning’s approaches. Useful for internal medicine physicians, ACP hosts a wide range of valuable vaccine-related resources on its website.
Since the pandemic, we have witnessed decreased interest, confusion, and in some cases, outright hostility about vaccines, unfortunately. We also know that vaccines are some of the most critical, life-saving preventive measures in the history of mankind. How do we effectively share this information with our patients? ACP’s website and Dr. Manning’s video have some excellent suggestions for how to do this. We, as internal medicine physicians, must continue to speak up and be respectfully persistent because if we do not, others will step into that void, and the message conveyed may not be the one we would choose. We also must take care of each other as we do this, as recent years have not been easy.
On a related note, how do we nurture trust? As we know, trust is foundational to patient relationships and the care we provide. We also know trust must be earned. Growing and nurturing trust will take a village, to be sure. We begin in the trenches with our teams and in our interactions with our patients. We share the most accurate information and change course as new information becomes available. We do so with humility, kindness, and compassion in a spirit of service.
Due to changes in my clinical practice, I was no longer caring for Max during the pandemic, so I do not know if he received a COVID-19 vaccine or not. My hope is that he was open-minded about the vaccine and hopefully received it. Being in the trenches with Max reminded me that how we interact with patients can deeply influence patients’ health behaviors. It is not just what we say but also how we say it. Persistence, respect, and trust can make all the difference.
Janet A. Jokela, MD, MPH, ACP’s Treasurer 2022-2025, served as the Regional Dean of the University of Illinois College of Medicine-Urbana, and currently serves as Professor and Senior Associate Dean of Engagement at the Carle Illinois College of Medicine, Urbana, IL.
The American College of Physicians is the largest medical specialty organization in the United States, boasting members in over 145 countries worldwide. ACP’s membership encompasses 161,000 internal medicine physicians, related subspecialists, and medical students. Internal medicine physicians are specialists who utilize scientific knowledge and clinical expertise for diagnosing, treating, and providing compassionate care to adults, spanning from those in good health to individuals with complex illnesses. Stay connected with ACP on X @ACPIMPhysicians, Facebook, LinkedIn, and Instagram @acpimphysicians.
