Former President Trump ushered in a new era of distrust in evidence, science, and medicine, culminating in a “coronavirus catastrophe,” as editorialized by Nature. Medical mistrust, of course, is not a new concept; patients navigate bias from the health care system daily, and in the context of historical legacies of abuse and unethical practices, such as the Tuskegee Syphilis Study. Accordingly, the resulting adverse impacts on health care outcomes are well-known to disproportionately harm Black, Latinx, LGBTQ, and many other minority groups. The top-down message is critical to restoring trust; however, individual patient-physician interactions also represent fundamental vehicles for change. In fact, the health of society at large depends on it, and currently, our effectiveness at combating the current COVID-19 pandemic.
Can an individual patient-physician interaction transcend institutional legitimization of disinformation, systemic racism, conspiracy theories, fears, anxieties, and historical wrong-doings? I believe yes.
Dr. Jessica Jaiswal, a public health scientist at the University of Alabama, suggests some fundamental places to begin the conversation. When discussing vaccine hesitancy with a patient, understanding their perspective is paramount. Physicians should be cognizant that medical mistrust may be strongly rooted in the context of systemic racism, social and economic inequalities and even, police brutality. Dr. Jaiswal advises avoiding terms like “conspiracy beliefs,” which would be an “ethical mistake,” derailing the conversation from addressing these root causes.
In my practice, it is common for patients to engage me about the COVID-19 vaccination. I find that most often, patients have legitimate concerns, and even the most educated have difficulty navigating the web of conflicting (mis)information. I empathize with them; it is confusing. I favor an approach of motivational interviewing, an evidence-based communication technique ideally situated for guiding patients through ambivalence in a respectful manner. In this technique, information is provided, fears are explored, and the patient’s own productive statements are reaffirmed.
At the end of the day, patients commonly want to know whether I personally received the vaccine or not, similar to how patients commonly query for any number of circumstances, “what would you do if it was your family member?” I’m a neurologist, not an infectious disease doctor or COVID-19 expert, but it doesn’t matter. To them, I’m a trusted voice. Does this work all the time? Of course not. Is this more effective than incentivizing vaccination with beer and doughnuts? I’m not sure, but I like to think so.
Patients will form opinions, adhere to a management plan, and take ownership of their health destiny, all based on trust. Conversely, when trust is not established, or even worse, when patients feel dismissed, they will search elsewhere for answers, sometimes in the form of fraudulent practices or even an armchair expert on TV.
To conclude, I will reiterate one of my favorite tools from the book, Motivational Interviewing in Health Care. When the conversation does not end in resolution, pose, “would it be alright with you if we talk about this again the next time we meet?” This demonstrates respect for the patient, and importantly, leaves the door open for the next visit.
Jonathan H. Smith is a neurologist.
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