We’re getting into trouble. With headlines like “Why I am angry” and “Burnout rates at an all-time high,” physicians need to take a moment and breath. Unvaccinated people are presenting as very difficult patients that physicians dread.
In his landmark article, “Taking Care of the Hateful Patient,” Dr. James Groves highlighted four distinct patient types that doctors shrink from. Hateful patients are noted to cause negative feelings in the treating physician. He admonished that the physician needs to acknowledge and feel all the negative feelings related to these people. The emotions physicians have in response to hateful patients are viewed as useful clues regarding treatment and referral.
What about our patients who have decided not to get vaccinated against COVID-19 or are hesitant to get vaccinated and then show up in our emergency departments with severe symptoms of COVID-19? How can hard-working and compassionate emergency physicians and nurses wrap their brains around all of this and show up in the way we want to show up for all of our patients? How can we treat these people with concern and empathy like all of our other sick and injured patients?
Physicians and nurses must resist the urge to lecture and talk down to unvaccinated people who will automatically turn away and shut down all communications. The patients can sense the resentment and judgment behind our question, “Why haven’t you been vaccinated?” They hear the silent “dummy” appended to the end of that question. They already think we are arrogant and look down on them. They are not completely wrong about the negative judgments and feelings physicians, and nurses have about them. The first step to changing our thoughts about difficult patients, like the unvaccinated ones, is awareness of what those thoughts are.
I believe that the anti-vaccine group of the unvaccinated people fall into the broad category Dr. Groves called “self-destructive deniers.” He taught that these people unconsciously harm themselves out of deep-seated dependency and actually believe in the denial of the problem (becoming ill from COVID-19) to be a matter of survival. People against the vaccine actually believe that taking the vaccine will harm them in some way. Questions have been raised about actually getting the viral illness from the vaccine, its impact on future fertility, and the intensity of commonly seen vaccine side-effects. In addition, they deny the potential harm (death and disability) that may occur from actually contracting COVID-19. Confronting deniers with mortality statistics or CDC proclamations will be met with denial of bad news or justification of their position from past experiences with vaccinations or prior illnesses.
Faced with unvaccinated patients who present with advanced COVID symptoms will provoke a torrent of negative feelings on the part of health care professionals. We think that this illness was almost entirely preventable. This belief causes disappointment, frustration, and even anger. Feeling anger towards our patients doesn’t help the problem, and it just makes us feel terrible.
The first step to change how we feel about unvaccinated patients is to recognize, without shame or blame, that we disagree and dislike the person’s choice. We have to resist personalizing the choice or outcome of vaccine refusal. Foregoing vaccination does not mean that the patient does not respect the physician or her years of experience. It’s not about you. They are humans motivated by their own thoughts of self-preservation.
What else might be true here? Could this person be making the best decision for themselves with the information that they have? Might the stories of premature deaths and mobile morgue trucks parked outside hospitals escaped their view or attention? Could they be a victim of misinformation or disinformation? Does refusing vaccination make sense to a person who feels like his personal choice or autonomy is being challenged?
What about those people who are on the fence or hesitant about vaccination because of what they have heard or read? How can we approach these people with understanding and compassion so that they will consider accepting vaccination? Adopting a more collaborative approach and listening to their concerns without judgment has to be the start of that conversation.
If we can put aside the anger, we can meet them with curiosity. Acknowledge their concerns and invite them to have a dialog. Perhaps, “I hear that you have objections to the vaccine. I would like to understand what you are thinking.” We cannot address our patient’s specific concerns until we hear what they are. We could respond, “You raise a valid question.” Or we could say, “You’re wondering about this possible side effect. Do I have that right?”
The next step could be to offer some of your own thoughts. “May I share with you some of the current facts, as I understand them?” This conversational approach may be better received than the lecture delivered from on top of the soapbox. Our patients have the autonomy to make their own decisions, and unfortunately, many of them will decide to forego vaccination. Many people decide to continue smoking cigarettes despite all the evidence of the harm it causes.
Accepting the choices, even the terrible ones, that patients make is part of the art of medicine. Sometimes our patients are an inconsistent and irrational hot mess. Sometimes we are that way too. In a fantasy world, all our patients would take our advice, mask, distance, and vaccinate. I call this compliance fantasy. I live in the real world where humans smoke, overdrink, shoot heroin, and forego vaccinations. I accept this. Nothing has gone wrong here.
I would ask my colleagues to hang in there while all the humans keep doing human things. Every day you give your best, and you would fervently wish for all your patients to just do the “right thing.” This is one of the most toxic thoughts you could have. It will never happen, and wishing it were so will only make you suffer.
Try to meet the anti-vaccine and vaccine-reluctant folks right where they are. They believe that they are right and protecting themselves. They may actually be doing the best that they can. They are allowed to disagree and then even request unproven medications or treatments when they present to the emergency department. Gaining the trust or confidence of just one person can make a tremendous difference and even save a life. Give up on the compliance fantasy and accept the unvaccinated as they truly are. They are not difficult patients. They are complicated humans who challenge us in many ways. We can meet that challenge.
Joan Naidorf is an emergency physician.
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