My Patients Used to Be Enthusiastic About the Covid Vaccine. What Changed?

By Danielle Ofri

Dr.Ofri is a primary care doctor in New York and this article is from NY Times Opinion Guest Essay Jan 27 2024

The response has been almost like clockwork, at nearly every medical visit in the past few weeks. “It’s time for the flu shot,” I’ll say to my patients, “plus the updated Covid vaccine.” And that’s when the groans start.

In the past, the flu shot elicited the most resistance. The patients at my New York City practice would take their other vaccinations without a second thought but balk at the flu shot — because their sister is allergic to eggs or because they’re sure that the flu shot always gives them the flu or because they just don’t do flu shots. Now, though, a majority of my patients respond along the lines of, “Fine to do the flu shot” — sheepishly pause, then say — “but not the Covid.”

When I ask my patients if they have any concerns or questions about the Covid vaccine, hardly any do. Practically no one asks me about safety data or how effective it is at preventing viral transmission, hospitalization and death. Almost no one asks me about current case counts or masking or Paxlovid. There’s just a vague hedge or an abashed, “I don’t know, I just don’t.” As I try to suss out what’s on my patients’ minds, I can feel their slight sense of surprise that there is no specific issue causing their discomfort about getting the updated Covid vaccine. It’s as though they have a communal case of the heebie-jeebies.

Health professionals everywhere are hearing this kind of hesitance among patients as Covid cases and hospitalizations have continued to rise during the winter. As of early January, the average number of Americans dying weekly from Covid was over 1,700. And yet the Jan. 19 Centers for Disease Control and Prevention report indicated that only 21.8 percent of adults 18 and older have received the latest Covid vaccine — less than half of the percentage of those who have gotten the flu vaccine.

Improving this situation isn’t easy, and it will require health care providers wading into awkward conversations that are less about facts and more about emotions. But if we don’t, we will be tolerating a level of preventable death that we’d find unacceptable in any other realm of health care.

It is possible to acknowledge pandemic fatigue without throwing in the towel. Our community’s long-term health and lives depend on it.

When my patients express their hesitance to get the updated vaccine, I’ll explain how the Covid virus has mutated, so that’s why we’ve altered the vaccine, just as we do for the flu shot every year. I’ll point out that in the first two years of Covid vaccination, an estimated three million lives in the United States have been saved and an estimated 18 million hospitalizations prevented. These facts rarely have much effect. There are, of course, practical barriers to the vaccine — cost, access, feeling crummy the next day — but that’s not what most of my patients are bringing up.

Their hesitation is all the more distressing, because, as New Yorkers, they had front-row seats to the vicious first wave of the Covid-19 pandemic, losing family members and friends. The line of refrigerated morgue trucks parked behind my hospital is a sight not easily forgotten. Moreover, these patients are not anti-vaxxers; they take their shingles vaccines and tetanus shots with hardly a shrug. Nearly all received the initial Covid vaccine series and fully remember the urgency of getting those hard-to-find vaccination slots in the early days. Nor do they seem to be science deniers; they embrace standard medical treatments for most of their other health conditions.

Each time I’m faced with a patient hedging on the Covid shot, I have to decide whether to put aside the many other pressing medical issues competing for our limited time to go down the vaccine-hesitancy road. These discussions are notoriously messy and lengthy and rarely change minds. Part of me just wants to move on, as my patients — and indeed the entire country — seem to want to do. Pandemic fatigue has even emerged as its own field of study.

But something in me doesn’t feel ready to let it go. The specificity of their Covid refusal — especially compared with flu refusal — piques my curiosity and consternation. So many of my patients have medical problems that put them at high risk for complications of Covid, such as hypertension, diabetes, heart disease, obesity, kidney disease, asthma. Yet here they are, one after another, rejecting a medical intervention that most have safely received before and substantially improves outcomes. And they can’t really articulate a specific reason, even to themselves. Shrugging this off seems wrong.

So I clear the deck, push myself away from the computer, make full eye contact and begin again. I might start with, “Tell me what’s on your mind” or “What makes you feel differently about the Covid vaccine versus the flu shot?” I try to step into the gray zone of their responses and explore those awkward feelings.

When they say, “I’ve had enough Covid vaccinations already,” I’ll probe where the sense of “enough” comes from. I might ask, “Do you ever feel this way about your diabetes medicines or your mammograms?” We’ll explore how they come to conclusions about which treatments they accept and try to separate vague discomfort from specific concerns.

A review of the facts is less about starting a lecture and more about examining emotional responses. We talk openly about what they are hearing in their communities — that the pandemic is over, that the new boosters are more experimental than the old ones, that some number of vaccinations is too many.

It can be a revelation to some patients when they realize that they may be reacting to a sense of the waters being muddied rather than specific information or misinformation.

I do want my patients to maintain a healthy skepticism about any proposed intervention to the body, whether it comes from their doctor or from social media. I’ll happily pull up information from medical reference sites like UpToDate to review the pros and cons of a treatment with them. I’ll always respect their choice to disagree with my recommendations, but I do want to understand why.

We in medicine are fairly good at responding to specific concerns; we easily marshal facts and numbers because this is the arena in which we are most comfortable. It’s tempting to shy away from the queasier realm of free-floating discomfort, but we can’t. The good news is that this can be a constructive and collaborative moment in the relationship between patients and medical professionals. In my experience, when we talk directly about the awkward gray zone that seems to suffuse vaccine hesitancy, there’s a certain shared humbling. We are all profoundly disconcerted by states of ambiguity.

In deconstructing these uncertainties, I get a sense of many patients feeling a stronger sense of control. They don’t immediately yank up their sleeves for the jab, but there’s a clear shift in attitude. They are much more willing to engage in a conversation about the realities of the Covid vaccine and how it compares with the flu vaccine or getting the Covid infection.

To me, that’s progress. Some do go on to get vaccinated; many don’t. But at least we are able to consider the Covid vaccination the way we’d consider any other medical intervention.

As time-consuming and exhausting as these conversations can be, we have a communal duty to try to unmuddy the waters — all of us. If you’ve been hesitating about getting your updated Covid vaccination, you might want to put your heebie-jeebies front and center on the exam table at your next medical visit. They’re due for a checkup.