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Leveraging the Doctor-Patient Relationship to Increase Vaccinations

Beth Howard
August 10, 2021
A young doctor using a digital tablet during a consultation with a senior woman

In his family medicine practice based in Frederick, Maryland, Julio Menocal, MD, has been administering COVID-19 vaccines since February as part of a state-sponsored program to get shots into arms at physicians’ offices. Although his patients — many of them undocumented immigrants — clamored for the shots in the early days of their availability, he has to work harder now to win over the holdouts. 

Recently an 18-year-old woman, in the office for her four-day-old infant’s first well visit, expressed her concern that the vaccines would implant a microchip into her body. Instead of trying to dispel the disinformation, “‘I told her, ‘You really need to think about if you get COVID and don’t do well. Who’s going to raise your kid?’” Menocal says. The new mom and her 19-year-old sister, who was accompanying her, got their shots that day.

Menocal’s story illustrates the uphill battle health care providers face in reaching patients who have been thus far resistant to getting a COVID-19 vaccine as well as the unique role that a trusted physician can play in converting the holdouts. As more and more providers begin to offer vaccines in their offices, they’re hopeful that they can leverage the doctor-patient relationship to win over vaccine skeptics.

“We’re down to the ground game,” says Howard Haft, MD, director of the Maryland Primary Care program, which provides funding to more than 500 practices in the state and spearheaded the COVID-19 vaccine push. “The challenge is having those crucial conversations with the most hesitant patients. And there’s probably no better place to do that than in primary care.”

In doc we trust

More than half of unvaccinated Americans say they would prefer to get a COVID-19 vaccine from their doctor’s office, according to a survey from The Commonwealth Fund and the African American Research Collaborative. What’s more, 30% of vaccine-hesitant adults say they would be more likely to get the shot if it was offered during a routine medical visit, according to the CDC.

“Some of my patients wouldn’t take it unless I personally put it in their arms,” says Earic Bonner, MD, whose internal medicine practice in rural Eden, North Carolina, has been administering the COVID-19 vaccines for several months. Likewise, family medicine physician Richard Bruno, MD, who mostly treats non-white patients at his practice in downtown Baltimore, says 20% to 50% of his patients insist that he be the one to administer the shot.

Other efforts to get COVID-19 vaccines to local doctors are gaining ground. For instance, through California’s CalVaxGrant program, small physician practices can get up to $55,000 to help store and administer COVID-19 vaccines. A number of individual practices as well as large clinics are starting to take on the challenges of giving COVID-19 vaccines during office visits.

Not all of them are primary care doctors. Kashyap Patel, MD, an oncologist in Rock Hill, South Carolina, started giving COVID-19 vaccines to his patients almost three months ago. “When any provider — including oncologists, nephrologists, cardiologists — see patients on a regular basis, there’s a level of communication that’s been established,” he says. “We’ve been able to vaccinate over 100 patients in the last eight to 10 weeks who would not have taken a vaccine otherwise.”   

Getting shots in arms

How do these doctors convince reluctant patients to roll up their sleeves? It varies. “Every conversation is different because people’s concerns are different, depending on their income level, their education level, their cultural backgrounds, their religion, and their political beliefs,” Bonner says.

His most difficult discussions have been with undocumented patients who fear deportation. “One of them told me, ‘You can’t guarantee me that this won’t become an issue for immigration,’” Bonner says. His only choice was to respect her decision.

Menocal’s practice tries to get around that fear by not requiring an ID or social security number for COVID-19 vaccines. His practice has even dispensed vaccines on Saturday mornings, mostly to Hispanic residents, from the parking lot of the local Home Depot — no questions asked. “Whatever name they give us, we assume is correct,” he says.

But longitudinal relationships with regular patients may offer a better opportunity for improving COVID-19 vaccination rates, the doctors agree. For instance, Bruno can personalize his appeal to those who are on the fence.

“I can’t think of anybody who has been spared from having someone — a friend or family member — affected by COVID,” Bruno says. “I’ll say, ‘Remember when your mom got sick with COVID and went in the hospital? She got better, but I would hate for you to get COVID and give it to your mom again.’ That can have an impact.”

Countering common worries

Bruno also has simple comebacks to common suspicions that patients raise, such as the vaccines are too new or were approved too quickly. “I tell them that the technology is not brand new, that we’ve been working on it for decades,” he says, “and that the FDA usually takes several years to approve a vaccine, but these were allowed to skip the line because we needed them right now.” Eight out of 10 times, he says, he is able to nudge patients over the vaccine finish line.  

Leah Alexander, MD, who practices pediatrics in Fair Lawn, New Jersey, says her track record varies — even within families. “I saw 15-year-old twins for well-care visits,” she says. “One twin agreed to receive the vaccine in our office, but the other refused.”

Alexander carefully explains how the COVID-19 vaccines were developed and how they work when parents are skeptical. But she says, “a mom of an 18-year-old recently questioned each statement from the CDC COVID vaccine information sheet. She wanted me to prove each claim with a scholarly research article, which I could not do during a 15-minute well-care visit.” Still, 70% of her patients ages 15 and older have received the J&J vaccine or at least one dose of an mRNA vaccine, she says.

Joe Weidner, MD, a family medicine specialist in Rising Sun, Maryland, in the rural northeast corner of the state, has had some success in persuading vaccine hardliners by handing them a chart showing the vaccine’s success in his own practice.

“We have data from the first 30 high-risk people who were offered a vaccine here,” Weidner says. “Of those, 24 accepted the vaccine and only one of them ended up in the hospital with COVID. Of the six who refused the vaccine, three of them went to the hospital.” If that information doesn’t create a convert immediately, he says, “it may still fuel a second conversation weeks later.”

Practical issues

The unique characteristics of the COVID-19 vaccines, such as the need to keep some very cold, present novel problems at small practices and clinics. That’s less a problem than it was in the beginning. Doctors in the Maryland program only get the J&J and Moderna vaccines, which have less stringent storage requirements compared with the Pfizer vaccine. 

Most doctors administering vaccines in the office have had to let some doses go to waste after vials are opened. The slower pace of vaccinations at this point in the pandemic means they don’t always have enough people to vaccinate six patients at a time (for the Pfizer vaccines) or 10 patients at a time (the Moderna vials contain 10 doses each).  

“We’ve done that maybe two or three times, where we’ve wasted one or two doses, sometimes more,” says Weidner. On occasion, Bonner has retrieved the last dose of a batch from a doctor in a neighboring suite, instead of having to open a new vial for one patient — and vice versa.

Since they are administering fewer doses now, some doctors now schedule a vaccination day during the week. “Once I open a bottle of Moderna, I need to use the whole bottle within six hours,” says Weidner. “That’s why we have to group people together and schedule them to come back. But it’s a bit of a barrier for people to have to return to the office.”

Administering COVID-19 vaccines inevitably disrupts staffing and office operations. “We always give vaccines in the office,” says Bonner. “But the pandemic has caused us to be so much busier, whether it’s screening at the door, monitoring vaccine patients for 15 minutes after their vaccination, or making sure that people who may have COVID don’t get to the back around other patients. It adds layers of work that someone has to do.”

Whatever the challenges, Patel sees the vaccination effort as part of his responsibility to do right by his patients. “Cancer patients are the most vulnerable in terms of getting COVID-19 and having serious complications,” he says. “When we can sit down one to one to discuss the vaccines, it does have an impact. Even though we don’t get paid for the time that we spend convincing patients, we feel that it’s our duty.”

Bonner agrees. “It’s starting to get exhausting,” he admits. “But I’ll keep trying.”