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the problem is not just hesitancy, it's also access

May 25, 2021 03:22AM

Time for doctors to take center stage in COVID-19 vaccine push


Each morning earlier this year, Atlanta general internist Sandra A. Fryhofer, MD, would rise at 6 a.m. to cruise all the COVID-19 vaccine-appointment websites for openings for her senior patients at mass-vaccination sites, pharmacies, grocery stores, warehouse stores—seemingly everywhere but in her own practice.

Dr. Fryhofer’s internal medicine practice spent several hours of staff time daily on “emails, texts, calls, even scheduling vaccine appointments for patients who are not internet savvy,” she said. “It was a nightmare, but we did it because we knew how important it was for our patients to receive this lifesaving vaccine.”

By the time the state health department finally came calling with an allotment of COVID-19 vaccines for Dr. Fryhofer’s practice, she had already helped secure vaccinations for all but of a handful of her eligible patients. The Georgia Department of Health was able to connect her with a physician practice in an underserved area in need of the doses and that could make better use of the precious commodity.

As trying as those early months when Americans’ demand for vaccines far outstripped the supply were for patients and doctors, AMA members across the country say now is arguably when doctors’ most difficult work will begin.

About 60% of American adults have received at least one COVID-19 vaccine dose, according to the Centers for Disease Control and Prevention (CDC), though there are stark racial and ethnic inequities in rates of vaccination. The supply of vaccine is now outpacing demand in many areas of the U.S., and more physician practices are getting access to vaccine allotments in their offices.

Yet those who remain unvaccinated are more likely to fall into the category of people dubbed vaccine hesitant. They may have lingering concerns about the COVID-19 vaccinations that were developed and shown to be safe and effective with unprecedented speed, or they might have new questions sparked by the extremely rare adverse events linked to the Johnson & Johnson vaccine.

Additionally, those who are vaccine hesitant often face very tangible barriers such as finding the time to get vaccinated, a way to get there, or paid time off work in case they experience the flu-like symptoms that can leave a person bedridden for 24 hours or more.

As of April, 65% of Americans surveyed by the Kaiser Family Foundation (KFF) said they had already gotten vaccinated or would do so ASAP. Another 15% fell into the “wait and see” category, while 13% said they definitely wouldn’t get vaccinated and 6% said they would do so “only if required.” Such resistance could endanger the nation’s bid to vaccinate as many people as possible and bring an end to the pandemic in the U.S.

The AMA COVID-19 vaccines guide for physicians offers evidence-based messaging guidance and best practices for consideration in external communications on COVID-19 vaccine topics.

Call to action

Now the White House is calling on America’s doctors to make use of their unique influence with patients to overcome this vaccine hesitancy and contact them in person, by phone, letter, email or social media with a strong personal recommendation to get vaccinated against COVID-19 ASAP.

The Biden administration believes the supply of vaccines to physician offices will increase and wants physicians to register to become a COVID-19 vaccination provider, and the CDC is urging states to get more COVID-19 vaccine to doctors’ offices.

The AMA has been urging the Biden administration to increase the vaccine distribution to physician offices and this is a good first step. Physicians who are part of a health system should reach out to their health system point of contact about whether the system is already enrolled or would be interested in enrolling. Physicians in independent practice who are interested should contact their state or local immunization program.

“People who wanted the vaccine were clamoring at the door to get it. And now it’s about convincing the movable middle” who are vaccine hesitant, said AMA member Alex M. McDonald, MD (@AlexMMTri), co-founder of the #ThisIsOurShot movement of physicians and health professionals engaging with vaccine misinformation and disinformation on social media.

The effort, led and supported by the California Medical Association, has exceeded 500 million impressions on Facebook, Twitter and Instagram, with more than 25,000 doctors, health professionals and others making use of the #ThisIsOurShot hashtag and promotional materials on a regular basis.

“The hard work is just beginning now, and the last couple of months has been preparing to get to this point,” said Dr. McDonald, a family and sports medicine physician with Kaiser Permanente Southern California.

According to the CDC, “more than 80% of adults have a medical office where they receive health care, and many people may prefer to be vaccinated in their regular doctor’s office.” Studies have found that a doctor’s strong recommendation “is closely correlated with vaccination,” says the agency, which recently introduced new tools that aim to ease the COVID-19 vaccine hunt. A recent Morning Consult poll found that a majority of American adults named “the traditional doctor’s office” as the place they would prefer to go for vaccination.

“Our focus right now has to be on doing catch-up, to encourage the patients who still have questions to get vaccinated,” said Dr. Fryhofer (@DrSandyFryhofer), an AMA trustee who serves as the AMA’s liaison to the CDC Advisory Committee on Immunization Practices (ACIP) and is a member of ACIP’s COVID-19 Vaccine Work Group. “That requires patience and it’s not easy, and it’s answering questions and keeping the door open to answer even more questions. And, hopefully, we’re able to give them the confidence that this is the right thing to do.”

Dr. Fryhofer said it’s unrealistic to expect that most physicians—financially battered by the pandemic and largely left out of the first rounds of vaccine-distribution plans—will be able to go to the lengths that her practice, with a fairly small patient panel, did during the early days of the vaccine rollout. But she said the question of how to aid in this mighty public health effort must be on each physician group’s radar.

“Every practice needs to look at their practice and figure out what they can do to encourage immunization,” she said. “You want to be careful about how many blast emails you send out, because then people don’t pay attention to them. You might text the patients who you’re particularly concerned about, or who need a little bit of a nudge. ... If the vaccine is there in the office, it’s so much easier than having to take these other steps.”

The AMA has developed frequently-asked-questions documents on COVID-19 vaccination covering safety, allocation and distribution, administration and more. There are two FAQs, one designed to answer patients’ questions, and another to address physicians’ COVID-19 vaccine questions.

Going door to door

Phoenix endocrinologist Ricardo Correa, MD, is intimately familiar with the difficulty of pushing ahead with vaccination, especially among younger people at lower risk of serious illness from COVID-19. Dr. Correa, an AMA member, is highly active with the Spanish-language version of #ThisIsOurShot, called #VacunateYa. He has become frustrated with the apparent limits of broad-based appeals on vaccination.

While 64% of Hispanics tell KFF pollsters they’ve been vaccinated or plan do so ASAP, 17% are in wait-and-see mode, 9% say definitely not and 18% say they’ll get the shot only if required.

Dr. Correa (@drricardocorrea) volunteers with the Phoenix Allies for Community Health Clinic (PACH) and each Saturday they take their supply of Moderna vaccines door to door in search of people to immunize against the deadly coronavirus, targeting hard-to-reach people such as those who work in the back of the house at restaurants. While Dr. Correa and his PACH colleagues have vaccinated nearly 500 people so far, he is disappointed by the hit-and-miss process.

“The reception has been like 50% or 60%,” said Dr. Correa, endocrinology fellowship program director and the director for diversity at the University of Arizona College of Medicine in Phoenix and the Phoenix Veterans Affairs Medical Center. Nearly all the PACH Clinic patients—and those Dr. Correa and his colleagues are vaccinating—are living and working in the U.S. illegally.

“The only identification we ask for is an ID card to show that they are older than 18 years old, or a phone number so we can call them for the next follow-up vaccination,” Dr. Correa said. One frequent objection to vaccination, he said, is worry about side effects resulting in losing paid time from work.

Nearly two-thirds of Hispanic adults—and about three-quarters of those who are “potentially undocumented”—are concerned about missing work to get or recover from the COVID-19 vaccine, according to another recent KFF survey. Over half of Black adults also have the same concern, compared with only 41% of white patients.

It’s a concern the recently enacted American Rescue Plan attempts to address, offering employers the opportunity to get reimbursement for lost employee productivity related to vaccination, but it’s unclear how many employers are aware of the provision or know how to take advantage of it.

Going door to door “is the only way that we will be able to vaccinate as many people as we can to get to herd immunity,” Dr. Correa said. “The TV announcements, all of the campaigns—I don’t see that they’re being translated into vaccination.”

That’s part of why he’s gotten involved with #VacunateYa—to reach Spanish-speaking young people where they spend so much time.

Dr. McDonald said relying solely on the one-to-one communication between patient and physician in the exam room will not meet the immensity of the moment.

“We as physicians and health care leaders have a responsibility to speak up and to share good, accurate information—not only within the clinic or hospital but beyond the traditional boundaries of where the doctor has been,” he said. “The average person sees their primary care doctor for 15 minutes, four times a year. So that’s an hour a year, versus the two to three hours they spend per day on social media. Part of our duty as physicians is to speak in these public forums.”

Need to make vaccination easier

The SSM Health system where family physician Joanna T. Bisgrove, MD, works has communicated with every one of its patients regarding vaccination.

“I am reinforcing and giving out information any chance I have,” she said. “We have a flag in Epic that tells us whether the patient has been vaccinated.” As of mid-May, the southern Wisconsin health system had delivered over 230,000 COVID-19 vaccine doses, with nearly 200,000 coming in vaccine clinics at the larger clinics. Over 16,000 were delivered through mobile units, and more than 21,000 went to system employees.

“Everybody who’s eligible has at least had one touch point—by email, by phone call,” said Dr. Bisgrove (@JoTBizMD), an AMA member who serves on the AMA Women Physicians Section governing council. One concern that she’s heard from patients who are hesitant about vaccination involves the time and trouble it takes to do so. The main site with evening and weekend hours is the Alliant Energy Center in Madison, and that’s a drive-up only option.

Other vaccination sites are open typically between 8 a.m. and 5 p.m. “Those are working hours,” Dr. Bisgrove noted. “If you can’t get off work and you don’t have a car, it’s hard to get a shot.”

While SSM Health has had success with system-based vaccination efforts, clinicians such as Dr. Bisgrove haven’t had supply on hand to give to their patients on demand. As she closed her conversation with this writer, Dr. Bisgrove noted that she was about to see a patient whom she knows from previous visits has not gotten vaccinated because the patient cannot get the time off work to do so.

“This is a woman who—if I had the vaccine,” Dr. Bisgrove said, “she’d be vaccinated.”

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