You are supervising resident continuity clinic when Dr. Gabriel, PGY-2, presents a 45-year-old woman seen for follow-up. At the end of his presentation, Dr. Gabriel says, “We discussed the COVID-19 vaccine, and she’s completely against it. She read online about the vaccine causing side effects and altering her DNA. I told her that the vaccine is safe, but she doesn’t believe me and won’t get it even though one of her kids is immunocompromised.” You notice that Dr. Gabriel is visibly upset. After probing further, you learn that they just completed an ICU rotation and took care of many young patients with COVID-19 who had poor outcomes. They ask you, “What is even the point of me talking to patients about vaccination?”
The COVID-19 pandemic has led to an exponential increase in the quantity and speed of misinformation spread and unprecedented distrust of public health systems. Internists in primary care and hospital settings have been uniquely affected by these trends, having provided direct care to patients suffering from COVID-19 complications, pandemic-related mental health challenges, and grief related to loss of loved ones to COVID-19. At the same time, internists have used considerable emotional reserve and time to help patients navigate pandemic-related misinformation and counsel on vaccination benefits. Internal medicine residents experience these complex roles even more acutely as many have been deployed to COVID-19 units and have reckoned with the oversized impact of the pandemic on their training and personal lives. In this article we focus on how clinician educators can prepare and support trainees in addressing misinformation, particularly surrounding COVID-19 vaccination.
Acknowledge the Emotions
Although vaccine hesitancy isn’t a new phenomenon, the circumstances surrounding COVID-19 vaccine uptake are unique. After months of tirelessly caring for patients who previously declined COVID-19 vaccines, our learners are understandably weary and frustrated. This may translate into an emotional response while addressing vaccine misinformation. Educators should be prepared to acknowledge and debrief the emotions experienced by learners during such discussions. Naming the observed emotional response (“It seems like that was an upsetting conversation.”) can be a first step in exploring and unpacking the emotional impact of the conversation, and can open opportunities for sharing, learning, and feedback. Educators can even perform a pair-share with their learners, each sharing feelings related to vaccine hesitancy. This conversation then serves to teach reflective listening. Beyond debriefing these experiences, educators can recommend that learners prepare for these challenging discussions by first attending to their own state of mind. Helping our learners practice mindfulness will put them in a position to engage in shared decision making more effectively with patients.1
The pandemic is not the first time that learners have interacted with patients of differing views or beliefs, and it will undoubtedly not be the last. During discussions surrounding COVID-19 vaccines and misinformation, learners need tools to help them respond with empathy. One such resource, “The Humanism Pocket Tool,” helps clinicians remember that each of their patients is a unique individual with their own story.2 This could promote learners’ curiosity about each patient, reducing the act of simply placing patients in the category of “anti-vaccine”. While listening to the patient’s story, there is value in paying close attention to the words and body language used by patients as they serve as clues to uncovering their agenda and feelings. Direct observation of learners during these conversations can help educators commend learners that recognize emotions in others and provide specific guidance when they struggle with this skill.
Provide Communication Frameworks
Beyond addressing emotions and encouraging mindfulness and connection, learners can be taught the use of expert-recommended and evidence-based tools to construct more effective conversations about COVID-19 vaccines and misinformation. For instance, experts caution physicians against focusing exclusively on sharing data to dispute misconceptions about vaccines and their adverse effects.3, 4 This strategy can backfire, leaving patients more convinced that the misinformation they believe is fact. When confronted with an inaccuracy about the COVID-19 vaccine it is best to identify it as such and then offer a brief alternative explanation. Overall, it is more impactful to focus on the risks associated with the disease itself, the real risk of contracting the illness, and most importantly the power of the patient to take control over these risks by getting vaccinated.4
While frustrating, it is understandable that patients may be hesitant to try a “new” vaccine. With frequently changing recommendations and misinformation that has been rapidly transmitted throughout this pandemic, the already tenuous trust many patients have for experts and the medical field has been eroded. When trust has been lost, it is best to start with listening instead of talking. In these situations, employing tenants of motivational interviewing (MI) can be helpful. Take the time to elicit a patient’s concerns, ask permission, and then provide information in a non-judgmental way, and then again elicit how the patient responds to that information. Understanding and appealing to patients’ values and emotions is crucial to conversations surrounding vaccine acceptance.
One large safety net hospital has integrated these tools of MI into a method for providing vaccine information that they call the “No Judgment Zone.”5 Their approach starts and ends with expressing gratitude for the patient taking the time to talk about the vaccine. From this vantage point, residents and faculty gauge the patient’s interest in vaccination, elicit their concerns, provide brief facts when needed, affirm the emotions surrounding this decision, and then offer patients the opportunity to get vaccinated that day if interested. Addressing misinformation and vaccine myths with compassion and empathy is foundational to engender trust and necessary to guide patients toward health decisions that align with their values.
With information readily available with the click of a button, learners must be comfortable navigating the information cycle and responding appropriately as information moves through each step of the cycle and changes over time. Evidence based medicine (EBM) provides a framework for addressing misinformation by asking relevant clinical questions, identifying and appraising information sources, and applying best available evidence. This process has historically occurred in the silo of the clinician’s mind, without much patient involvement. Recognizing the need to increase patient engagement in the decision-making process, Hoffmann and colleagues described the interdependence of EBM, shared decision making (SDM) and patient-centered communication (PCC) to provide optimal patient care.5 Therefore, increased attention should be given to SDM and PCC in EBM curricula. With an appreciation for the learners’ level, clinician educators must intentionally introduce and reinforce these skills in didactic and clinical settings, including through use of patient experience panels, role play activities, and in-clinic, real-time teaching related to using SDM and PCC when making evidence-based recommendations. In addition, we must teach our learners to empower patients to be informed consumers of information. Learners and patients should have a shared vocabulary when coming together to make clinical decisions. For example, asking the 5W questions (who, what, when, where, and why) may be a useful place to start when patients and clinicians are discussing sources with information that will influence medical care (see Table).6
Through their roles in hospitals and clinics, IM learners are on the frontlines of addressing vaccine and COVID-19 related misinformation. Clinician educators should support learners in these discussions by naming and debriefing the strong emotions these conversations may evoke, emphasizing connection with patients, providing frameworks for effective communication, and addressing misinformation using principles of EBM.
- Randall S, Leask J, Robinson P, et al. Underpinning of the sharing knowledge about immunization (SKAI) communication approach: A qualitative study using recorded observations. Patient Educ Couns. 2020;103(6):1118-1124.
- Soh M, Shaner A, Gelberg L, et al. Using the Humanism Pocket Tool for patients with challenging behaviors. Ann Fam Med. 2018;16(5):467.
- Omer SB, Amin AB, Limaye RJ. Communicating about vaccines in a fact-resistant world. JAMA Pediatrics. 2017;171(10):929-930.
- Manning KD, Isaacsohn M, Agrawal S, et al. The no judgement zone: Building trust through trustworthiness. J Hosp Medicine. 2022;1-4.
- Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA. 2014;312(13):1295-1296.
- University of Washington Libraries. Savvy info consumers. https://guides.lib.uw.edu/research/evaluate/5ws. Updated October 5, 2020. Accessed April 15, 2022.
Clinical Practice, COVID-19, Medical Education, Medical Ethics, SGIM, Social Determinants of Health
Dr. Rimler (firstname.lastname@example.org) is associate professor of medicine at Emory University and assistant program director for the Primary Care residency track. Dr. Sottile (Elisa.Sottile@jax.ufl.edu) is assistant professor of medicine at the University of Florida Jacksonville and associate program director for the IM residency program. Dr. James (email@example.com) is assistant professor of Internal Medicine and Pediatrics at the University of Michigan Medical School. Dr. Nikiforova (firstname.lastname@example.org) is assistant professor of medicine at the University of Pittsburgh and associate program director for ambulatory education.