Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep114: What we get wrong about vaccine hesitancy, with David Higgins, M.D., M.P.H., M.S.
Transcript
- 0:00 An individual's physician is still the most trusted information source for vaccines and a lot of these questions that we have around our health right now. Welcome to off 0:19 the chart of business of medicine podcast featuring lively and informative conversation. Informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today. In today's episode medical economics, senior editor Richard Pearson speaks with Dr David Higgins, a pediatrician and author who writes about vaccine science and misinformation in their discussion, we'll talk about how misinformation actually spreads online, why vaccine hesitancy is often overstated, and what physicians can do to rebuild trust with families. Dr Higgins also shares communication strategies for addressing vaccine concerns in the exam room, and explains why patients still look to their physicians as their most reliable source of information. Dr Higgins, thank you for joining us, and now let's get into the episode. 1:11 Dr Higgins, thank you for joining us today. 1:14 Thank you so much for having me. It's my pleasure. How would you describe 1:17 the current state of trust in medicine in the United States. Do you feel like medicine and science are under attack? 1:25 Yeah, I don't think you can have the conversation about vaccines in our current moment without talking about the greater conversation and what's going on with medicine and science and health and the loss of trust in institutions. So what I am seeing at the national level, in the general public, and this is reflected in data, this is reflected in polling data that, have you know, that's been done by multiple sources, is this loss in trust in institutions and in quote, unquote experts, and this loss and trust in institutions and experts, makes it more challenging when a lot of our health related information for decades has really been centered around these institutions, whether it's a federal government institution, state institution, or whether it's A nonprofit or professional organization, a lot of what we get, not only as medical providers, but a lot of what the public gets is from these institutions. So as trust erodes from these institutions, trust in the information coming from them is also eroding at the same time 2:37 you are the co author of an article titled The risks of normalizing parental vaccine hesitancy. Why is that potentially harmful to public health in the United States? 2:47 Yeah, so I co authored this article now, several years ago. And in the article, what we argued was that if there's a misperception about how common vaccine hesitancy is that can have detrimental effects at multiple levels. So if lawmakers and policy makers and those involved in vaccine delivery, if they think hesitancy is greater than it actually is, if they think more people are hesitant than they actually are, that can lead to policy decisions, and that can lead to implementation efforts that fail, because there's this assumption that people don't want vaccines. And I know that the conversation right now is really focused on rising rates of hesitancy or concerns and questions about vaccines, but the truth is that still, an overwhelming majority of people and parents for their children want vaccines. The other levels that are affected by a misperception of vaccine hesitancy and how common it is are is at the provider level. So if I as a pediatrician, walk into the room and I'm expecting every family I see is going to be very hesitant to vaccinate their child. I'm going to enter the conversation about vaccines with a lot less confidence. And then I also worry at the level of the general public, there's a it can become a self fulfilling prophecy, right when you are exposed on social media or in the mainstream media to the idea that everyone's questioning vaccines, that the norm is to question and wonder if they're safe and have concerns about them. When you're exposed to that, you start to think, wow, everyone else is questioning vaccines. Maybe I should be questioning them too. Maybe there's something to that I really haven't had doubts about vaccines, but maybe I should think twice. And I'm concerned that that is happening more and more, and unfortunately, people aren't being exposed on a regular basis. To the overwhelming majority who say, hey, vaccines are a good thing, even if I have some questions or concerns, I want to vaccinate my kids. I want to get the vaccines myself, because I want to be protected. And so that article that I wrote, co authored, several years ago, has is never more important than it is today, with our current moment where the conversation is centered around vaccine concerns, 5:27 to sort of flip the script you had mentioned about a possible erosion of you know, doctors own confidence if they if they go in assuming that everyone is hesitant to get a vaccine. On the flip side of that, why is it so important for physicians to remember that anti vaccine feelings really are only in a small minority of people? 5:48 Yeah, so vaccine concerns or vaccine hesitancy is on a spectrum, and it's really important for providers to remember that most of your patients, or parents, if you're taking care of kids, have some ambivalence. They're somewhere in the middle. It is actually very rare to run into a patient or parent who says, I don't see any possible benefit to vaccinating. I want nothing to do about with vaccines, and I don't even want to have a conversation about vaccines, that kind of extreme end of vaccine hesitancy is extremely rare. Right in the one to 2% we have some data that has stayed very consistent showing that children, for instance, roughly 1% of children by the age of two have never received a vaccine, and it's safe to assume that some of those children have never received a vaccine for significant access reasons. So you're talking about a tiny percent, and it's important that providers recognize that when they start having conversations with people, because if you hear a patient or a parent bring up a concern, let's say that they saw something on social media and they bring that up with you. If your immediate assumption is that they are anti vaccine, if you label them as anti vaccine, they want nothing to do with vaccines, then your conversation is not going to go anywhere, and you're going to inappropriately make the assumption that they don't want to vaccinate, when they might be very open to the idea of vaccinating, but they want some of their questions answered. 7:31 If people are left with a choice about getting themselves or their children or other family members vaccinated, there will be some people who very enthusiastically want to do so, and yet, do you think the current policy environment will not just promote the concept of maybe questioning or patient choice, but actually reduce access to shots? Yeah. 7:52 So this is really important, and I'm seeing this change in the conversation over the past year, parents or patients have always had the choice to vaccinate or not vaccinate, and in fact, for a very long time, we have been training providers that that a an important skill in their communication is to acknowledge that autonomy is to say, hey, Ultimately, this is your decision to make, because it is and I am here as your doctor. I am here as your child's pediatrician to partner with you and help you make the best choice you can for their health that is truly informed. Okay, so the conversation has changed recently to one of choice and informed consent, but I think that those terms are not being used in the appropriate way. Okay, so patients and parents have always had a choice. They should continue to have a choice, and us partnering with them and respecting that autonomy actually has been shown to improve uptake, because parents and patients feel heard and understood, and this idea of making an informed choice, well, making an informed choice means that they are given the not only potential risks, but also benefits, and that the risks and benefits aren't presented in a way as if they're equal, because for vaccines, there's very clear evidence for the vaccines that we recommend, that the benefits far outweigh the risks. So the being properly informed about vaccines in order to make the best decision for you or your child is to really understand the benefits and risks and how, how much those benefits far, far, far outweigh the risks that would be making an informed decision if you are misinformed about that, because you have seen falsehoods on social media, because people have played up and over and exaggerated the risks. Because you're not making an informed decision at that point. Okay, you are refusing that. You are making a misinformed refusal about getting vaccinated when all that you understand about them are overblown risks or just simple false claims about vaccines. 10:19 One of your articles was based on measles and rubella. Do you think in coming years it could be possible to eradicate measles and rubella? Yeah. 10:29 So here's the thing with these diseases like measles and this was the case for smallpox, right? This is why we were able to eradicate smallpox. Now eradication means that the disease, the pathogen, is gone from the world. Essentially, there are several diseases where that's not possible with our current technologies and what we have because, let's say there it's in the soil, or there are animals that have this. So even if we were to get rid of it, when humans, they're going to continue to continue to humans are going to continue to be exposed to it if they go outside and touch the soil and and scratch their knee in the soil, those are things like tetanus. But for measles in particular, it is a pathogen that we have the tools and ability to eradicate from the world. We have incredibly effective vaccines, and if we eliminate measles from all humans in the world, from all people, we can actually get rid of the disease. Now, in order to do that, we have some big barriers, right? We have some big barriers to getting to the point where these vaccines are being given and people are accepting them at a high enough rate to get rid of it. And in part, that's because Measles is incredibly contagious, so the fact that we as humans have discovered tools and developed things that we can eradicate incredibly dangerous life threatening diseases like smallpox and measles is one of the greatest achievements in human history. But these achievements are only effective if people accept them. We have a saying in the vaccine delivery world that vaccines alone don't save lives. Vaccination saves lives, and this is an important concept to understand. We can develop the or discover the most incredible vaccines that prevent horrible illnesses, but if all they do is sit in a vial in a refrigerator or freezer somewhere, they don't they are 0% effective. They don't do anything at all. So it is critical that we are continuing to work on improving vaccine confidence and uptake in our patients and in our communities, so that we can see the benefits of these incredible, incredible tools that we have. 13:13 Hey there. Keith Reynolds here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds at mjh life sciences.com, with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute. 14:02 You Kate, how important was the Wakefield study about the MMR vaccine and autism and why do those effects linger? 14:14 Yeah, so vaccine concerns and vaccine hesitancy is as old as vaccines themselves. For over 200 years, there have been people that have had concerns about vaccines. So on one hand, that's not new, and through history, we have seen a pattern of ebbs and flows in different concerns and the degree of hesitancy in the public often, what has happened is that the vaccines themselves have been so effective they're victims of their own success. They've been so effective that people aren't exposed on a regular basis to the effects of these diseases. They don't have a neighbor who's paralyzed from Polish. Anymore. They don't see measles regularly, and so they start to become a little bit complacent about the vaccines, and vaccine concerns and hesitancy tend to take hold in that environment. Now, even though vaccine hesitancy, hesitancy and concerns are as old as vaccines themselves, I think the Andrew Wakefield paper and concerns about the MMR vaccine and autism is a really good example of how a falsehood, and in this case, a fraudulent falsehood, takes hold and perpetuates Now, decades later. So the story with the Andrew Wakefield paper that suggested a link between the MMR vaccine and autism. First, this wasn't a brand new idea. This was already percolating prior to the publication, but he published in a very well respected journal about this association between the Mr. Vaccine and autism. Now, when you actually look at the study from a methodologic standpoint, it had a lot of flaws, or it was not set up in a way to really show causation. It was done with only a handful of patients. It was a case series. Some of those patients actually came from anti vaccine groups, and in some cases, the symptoms of autism started before the children even received the MMR vaccine. But we later learned through some investigative journalism that Andrew Wakefield also had significant financial potential gains in publishing this work. Okay, so when that came out, unfortunately, what we saw was decreased, Mr. Vaccine uptake that hit especially hard the UK and parts of Europe and still to this day, of course, as you and all your listeners are going to know, we see this question and concern about whether the MMR vaccine is associated with autism. Now, there are many different reasons that parents or patients are hesitant about vaccines or have questions, and they differ depending on the vaccine and some of the information that they have been exposed to, but this is still a common concern, despite since that time, doing dozens of studies to answer this question. I mean, I tell people all the time, I say, hey, if the MMR vaccine was really causing autism, of course, as a pediatrician, I would want to know that and pediatricians and researchers around the world want to answer that question, and we have asked that question over and over again for decades and found no evidence, no evidence of this claimed association. So that is the Andrew Wakefield paper. Is a great example of kind of our more modern, contemporary moment with vaccine claims and misinformation. 18:09 That study of memory serves came out in, I think it was in the early 1990s and of course, technology has changed a lot since then. The information environment, so to speak, has changed a lot since then. How would you describe the growth of anti Vax activism online? 18:25 Yeah, so I first want to start and be very clear that anti vaccine activists are a tiny group of people. Okay, when I talk about anti vaccine activists, I'm thinking about someone who is intentionally spreading information that is false or misleading about vaccines with the intent that people are become concerned about vaccines. In reality, a lot of the information that spread is spread by people who are sharing something interesting, something that they, you know, simply hit the like button and the Share button because they find it interesting. The contents that it starts from, is actually from a very small group. And I say this just to say it's important that when providers and health professionals are interacting with people online, they recognize that 99% of those that they're interacting with, and especially people that simply have questions or concerns, they're not anti vaccine activists, and labeling them that way does a disservice to them, and it makes it harder to develop relationships and build some trust. Okay, so that I want to start with, but what we have seen is the way our media algorithms work. They funnel information to us that we want to see they re. Enforce our priors with things like vaccine concerns. And so even if a parent or a patient is not intending to go online or go to social media and ask questions about vaccines, it just comes up as they're scrolling through as they're interacting online, they're exposed over and over again to claims and again. The algorithm tends to send claims and information to people that reinforce Maybe fear or anxiety or questions, and often the people producing misleading claims, they are excellent at communicating those claims in a way that tugs at those strong emotions that We all have right as a parent myself, I want what's best for my child, like every parent does, and that naturally creates some anxiety about decisions that affect their health. Well, it's really easy to prey on those anxieties and fears when you bring up concerns about vaccines. 21:22 You wrote that training healthcare professionals on vaccine communication strategies is critical, but just providing information about vaccines alone is not enough to increase uptake. What strategies do you favor for improving physicians abilities to communicate to patients about vaccines? 21:39 Yeah, so a lot of parents, families or patients, sometimes they do need to have a deeper understanding of something, but providers often enter the conversation assuming that what they need to hear is data. They need more information, and if you simply give them more information and dump the data on them they're going to understand why vaccinating is the best choice. The reality is that's not how any of us make decisions, and often our failure to appreciate that how we communicate is just as important as the facts that we're telling them leads us to miss an opportunity. So I really emphasize the communication skills just as much as the facts and data. Those matter, but the skills matter just as much so. Several of the skills that we emphasize first is really entering the conversation with the assumption that the parent or patient in front of you, of you is open to the idea of vaccinating. Okay, so introducing the vaccine and making an announcement and making sure that it's recommended, what that means is it would sound something like, Hey, before we finish the visit today, Johnny's due for the MMR vaccine, and I think it's really important that he get this for his health. Now, introducing it that way makes it really clear that you, as their trusted healthcare provider, think it's important that their child, or them as a patient, receive the vaccine for their health to keep them healthy and and acknowledges that, again, most parents and patients are interested in vaccinating okay? And then if a parent or patient has concerns or shows hesitancy, there are some really easy skills that you can use to help walk through that conversation. These are motivational interviewing skills, and they are so simple to incorporate. One is simply asking open ended questions to make sure that you really understand their concerns and make sure that they really feel heard with their concerns. Several of the other skills include affirmation and reflection. These are as simple as just affirming that they want what's best for their child or they want to be healthy, because I truly believe we all want to be healthy, and we all want our children to be healthy, reflecting back just simply make sure that you really understand what their concerns are, and that you are on the same page with them about those concerns. Now you can do these things while still recommending that vaccination is the best course of action to keep them healthy. The other thing that's critical is that you are respecting their autonomy, like I said earlier in the conversation, respecting that ultimately, this is their decision to make. And finally, before you share information with them, before you give them some information about why you recommend the vaccines, or about why you can trust in the safety of vaccines. It is really important that you ask permission first. We know from the social science and communication literature that when you ask permission this this is as easy as saying, you know, do you mind if I share. With you. Why I recommend this vaccine to my patients. When you ask that first before sharing information or data, it makes it much more likely that the patient or parent is going to be receptive of what you're telling them. So those simple skills can be incorporated into any vaccine conversation, and can lead to not only a more effective conversation, but also can actually save time in the conversation that you're having, because you will quickly begin to understand whether the patient or parent is in a place where they want to vaccinate or not. 25:33 That day, can you discuss the fact warning fallacy, fact approach in communication? 25:39 Yeah, so this is really important when you are addressing a myth. Sometimes when a parent or patient brings up a myth, it's easy to hyper focus on the myth itself. The best approach to addressing a myth is to first lead with the facts. Lead with the facts of why something is important. Send a quick little warning that there's a myth coming. You can restate the myth, but then end with a fact. I call it the fact or truth sandwich when I train providers on this right? And so this might sound something like, you know, this vaccine is really important, and I recommend it to all my patients for this reason. There is a myth out there that's the warning. There's a myth out there that it causes this that is not true. And here's what is true, this vaccine actually can prevent the thing that you might be concerned about. When you sandwich that myth with truth on either side, the patient or parent walks away from that little conversation that you had with the truth at top of mind, as opposed to the myth being the thing that they kind of focused on. 27:05 What did I not ask about that you would like to emphasize or convey to our audience? 27:10 Well, one of the things that we didn't touch on, that I think is really important to recognize, is even though we've had a erosion in trust of institutions and experts at the top of the trust ladder still is a person or parents, pediatrician or family physician, right? Like a an individual's physician is still the most trusted information source for vaccines and a lot of these questions that we have around our health right now, I actually think that with the explosion of social media information of sometimes conflicting and confusing, sometimes misleading or even false information. I think people are looking for someone to turn to. They're looking for a lighthouse in the storm of information. They're overwhelmed, and the person that is most trusted is still a person's doctor or health professional. So that means it's never been more important that health professionals and providers are learning how to communicate well with families and with patients about vaccines and about other health topics, and making sure that they're out there, out there in the exam room and clinic, but also out there in their communities, saying, hey, I want to partner with you. I want to partner with you to help you understand all of the noise that you're hearing right now from social media, from your you know, neighborhood groups, from wherever you're hearing. I want to help partner with you to make sense of it. And when you do that, people really appreciate that. It takes work. It takes a commitment to being with people, to having these conversations that are sometimes difficult, but it's work that's worth doing. 29:16 I'm Richard payer chin reporting for medical economics. My guest today has been Dr David Higgins, a pediatrician and author who has written about vaccine science. It's been a great conversation, and thank you so much again for joining us. 29:30 Yeah, thank you so much, Richard. It's been a pleasure to be with you 29:41 today. Once again, that was a conversation. Between medical economics senior editor Richard Pearson and Dr David Higgins. My name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies to. And solutions for your practice. You can find us by searching off the chart wherever you get your podcasts. Also, if you'd like the best stories that medical economics and physicist practice published delivered straight to your email six days of the week, subscribe to our newsletters at medical economics.com and physicist practice calm off the chart. A business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Latrell, medical economics and physicians practice are both members of the MGH Life Sciences family. Thank you. Applause.