One Person - JAMA A Piece of My Mind, by Wendy Stead, MD

_{Photo Credit: iStock/FatCam}

“Have you changed your mind about getting the COVID vaccine yet?” I ask her. 

She has arrived late for the visit. Her blood pressure is too high. She has another appointment in 20 minutes and just surprised me with the news that she was admitted to another hospital last week for uncontrolled diabetes. There is so much ground to cover in so little time that I almost don’t mention the COVID-19 vaccine again. We’ve already had 2 other conversations about vaccination, and I have failed to convince her both times, ending each visit wondering whether I brought her closer to acceptance or just scared her. But as I quickly rifle through the list of the most important interventions I can make today, vaccination against COVID-19 leaps to the top. 

So I jump in. 

“I know you have worries about it, but I’m just wondering if you’ve thought more about getting it since our last visit 6 months ago. A lot more people have been vaccinated since then, and the vaccines are very safe.” Before I even finish my opening remarks, I see her physically withdraw. The space between us widens, and we steel ourselves for another round. 

She says she is already keeping safe. “I don’t go anywhere except the grocery store and church. And my family doesn’t go anywhere either,” though I know both of her daughters work outside the home and neither is vaccinated. I know she lives with one of her daughters and school-aged grandchildren; they often accompany her to these visits, her face shining with pride. I ask if the kids are back in school—already knowing the answer. She answers, “Yes,” and I quickly spring the trap, “You know you’re exposed to every other kid in your granddaughter’s school each day when she comes home.” Her shoulders slump. “And when your daughters come home from work, they bring those contacts with them too.” Another direct hit. She turns further away, and now I am aiming my most convincing material toward her back. 

I pause to catch my breath and look at her—this beautiful, kind, mother, and grandmother, a health care worker herself before the pandemic, who raised 2 amazing daughters on her own. She has been my patient for 20 years—we have navigated advanced HIV disease, diabetes, severe hypertension, and so much more together. She often tells me at the end of our visits that she “loves” me and I don’t hesitate to say the same; knowing that crossing this thorny verbal patient-physician boundary says clearly to her that I care deeply about her as a person, as well as a patient. We have built a long relationship based on this caring, trust, and mutual respect, yet I haven’t been able to convince her to get vaccinated against COVID-19. This same patient who accepts the influenza vaccine annually and every other treatment I’ve ever offered is unwavering in her refusal of the most important life-saving therapy I have to give in this moment. 

I am surprised by how suddenly I feel like I’m going to cry. And I can’t put my finger on exactly why. Are these tears of frustration for the many times I have faced this situation over the last year and walked away unsuccessful? Are these tears of rage for the misinformation she tells me she is hearing and believing? Are these tears of fatigue for the uphill battle I know I am facing when she tells me her entire family doesn’t want the vaccine? Are these tears of self-pity because I feel hopelessly ineffective even with a patient I have known for 20 years? Do my tears come from a place of fear as I think about how bad it will be for her, with all of her risk factors for severe illness, to get COVID-19? Or do they come from sorrow as I flash forward to what it will be like to lose her to something we could have prevented? 

She tells me that she is sure nothing will happen to her or her family because God will protect them. And that’s the final straw for me; watching her faith face-off against the enormous loss of these last 2 years is too much. I am exhausted, my adrenaline spent. I need to stop treating this as a fight and try to convince her we are on the same side of this, that I am here as her physician, her guide, and her friend. I need to keep building this bridge. 

As I speak my voice cracks and my eyes well up and I am glad to partially hide behind the mask and goggles. “I know you believe God will protect you,” I say. “I think God protects us too, but maybe not always in the ways we can understand. And I’ve seen too many people die from COVID already to think that God will protect us from it.” 

She pauses as the back of her head considers this. “But I hear the vaccine doesn’t even work,” she says. “People still get infected. And the people on the news say it’s dangerous.” 

I keep pushing. “Who do you trust to give you medical information? Who do you trust most to take care of you and give you good advice to keep you healthy?” I ask—praying silently that her answer is not “the news.” She finally turns to look me in the eye again. “You,” she says. “I always tell my daughters that I trust my doctor.” 

I feel a slim opening, the cracking of a door that I want to force open, but know I will have to slowly and gingerly squeeze through. “Then please don’t let those other people mislead you. Please believe me when I say the vaccine is safe. It will protect you from getting severe illness, and you are at extremely high risk. We cannot lose you to this virus. Your family can’t lose you, and neither can I.” 

We are silent together for a moment. She wipes at her eyes. “You need to talk to my daughters,” she says. “Will you call them? I want them to understand.” 

“Yes!” I almost jump out of my chair. And I do call her daughters, later that day and the next, and leave voicemails and text messages asking them to call me, to please support their mother in this and to please get vaccinated themselves. 

As our visit comes to a close, I am left wondering what just happened. I allow myself to feel the smallest glimmer of hope that this time I have convinced her. But as I walk from the room wiping my own eyes, another realization lands heavily. 

My tears are also of shame. No matter how much history I share with this patient, I know her experience with medical care all these years has been vastly different from mine. As a White child growing up in a middle-class family in Massachusetts, I have always believed that doctors and hospitals were there to help me—my faith in the medical system was strong long before my medical school training. But as a Haitian immigrant, woman of color, single mother in a low-wage job with a stigmatizing chronic health condition, I know her experience has been vastly different. Physicians and the health care system have certainly not always been there to help her. I have understood this disparity intellectually for years, but only during this pandemic have I felt it as it should be felt; as a gnawing pain in the pit of my stomach that I urgently want to do something to fix. 

So I try to build a bridge over the chasm of misinformation, pulling my patient across, less with science or numbers or threats or fear, and more with the strength of our human bond. I have read too many articles, heard too many experts talk about the crucial role of the primary care physician in convincing patients to get vaccinated, not to feel the full weight of this responsibility. So no matter how much time it takes or how many minutes I will be late for my next patient, I will keep trying to come up with convincing reasons for her to take this vaccine. I want desperately to be the one who can connect her to this live-saving treatment. 

At the time I am writing this, I don’t yet know what her final decision will be. I think we have made progress. We have at least moved from “No” to “Please call my daughters,” and for today maybe that is victory. Maybe the bridge we have built will hold. Maybe I will be the one to convince her. 

When I finally get to my last patient an hour late, I am apologizing profusely as I open the door. “Rough day?” she says and smiles. She is a retired nurse who already got her COVID vaccine booster. 

“It’s been one of those mornings,” I say. “You know how it is.” 

She laughs as she shakes her head and says. “Yup, it only takes one person, right?” 

And I hope, with every ounce of my being, that she’s right. 

Read the full article in JAMA here.  

Full link: https://jamanetwork.com/journals/jama/fullarticle/2790282