In medicine, the relationship between doctor and patient is predicated on that most basic of societal values: trust. The concept of this relationship — and the notion that it is dependent on both parties' participation — dates to the Greek enlightenment, around the 5th century B.C.E. Patients trust that their health care provider will make treatment recommendations based on what is in the best interest of a patient's health, while doctors trust that patients will report symptoms honestly and execute treatment plans faithfully.
As it turns out, trust is in short supply, largely thanks to COVID-19.
I was reminded of this on a recent family visit to my parents-in-law, who live in rural western Pennsylvania. All of us have been fully vaccinated, and to be careful, we all tested ourselves for COVID-19 the night before our arrival, and during our visit. My mother-in-law, who has lupus and is on immunosuppressive therapy, had recently received her 3rd COVID-19 vaccine, following the guidelines provided by the CDC.
This was no small feat. When she first tried to obtain a booster shot from a local CVS pharmacy, she was turned away and erroneously told that the shots were only available to people who had received a kidney transplant.
This is not true. So she went to another pharmacy and was erroneously told she could only receive another vaccine if her doctor's office called and verified that she had a compromised immune system.
This is also not true. Patients should only have to attest, and not prove, that they are immunosuppressed. But her doctor's office did call so she could be properly vaccinated.
This is also not an isolated anecdote. I specialize in leukemia, and have heard similar stories from multiple patients. I have had to call pharmacies near where I practice, in Miami, to verify my own patients' immunocompromised status.
In reality, based on emerging data from Israel and the CDC, immunity appears to wane over time (particularly among older adults), and it may be that the vaccine is not as effective against certain COVID-19 variants. This was the basis for the recommendation for a booster from the Biden administration. Yet until recently, the FDA, in an effort to be either careful and deliberate, or to dig in its heels and demonstrate that it will not be strong-armed by the president, delayed recommending a booster vaccine to a broader population than just those who have compromised immune systems. That added to the mixed messaging — and further eroded public trust in medical institutions.
Based on these data, and the low risk and potential large benefit of getting the jab, my wife, who is an infectious diseases pharmacist, and I felt my healthy 86-year-old father-in-law should receive a third vaccine dose, along with the over 1 million people in the U.S. who have also received an unauthorized booster shot. So did he.
But to do so, at the time, he would have to lie, and claim that he was actually getting his first dose. Sitting in his screened-in porch, we tried to prepare him for his trip to the pharmacy by play-acting the interaction he would have, to ensure he would say the right thing. I pretended to be the pharmacist:
"Good morning sir," I said. "How can I help you today?
"I'm here for my third vaccine dose," he answered quickly.
My wife and mother-in-law shook their heads in dismay.
"No, pappy," my wife said. "You have to say it's your first vaccine dose."
"I don't wanna lie," he answered. "I've never lied to my doctor."
"You have to," she insisted. "Otherwise the pharmacy won't give the vaccine to you." He muttered an "okay" and we started over.
"How can I help you?" I repeated.
"I'm here for a shot," he said.
"What kind of shot?" I asked, knowing that flu shots were also available.
"Oh, I'll have a whiskey!" he joked, to the consternation of my wife and mother-in-law. It was funny but not funny – we were asking him to betray the contract of trust between himself and a healthcare provider, for the good of his own health, and he was consciously or subconsciously rebelling.
Trust in medicine has taken a hit over the past year-and-a-half as we've reacted in real time to what we've defined as truth in a quickly moving pandemic, and in an era in which information is disseminated quickly.
At first, masks were de-emphasized, and cleaning of surfaces was stressed as being more protective of viral transmission, when in fact the opposite was true. The virus was not thought to be aerosolized; now we know that it is. At many hospitals, recommendations for appropriate personal protective equipment (PPE) were minimized –- not based on sound epidemiologic advice or concern for the safety of healthcare workers, but due to lack of supplies, and perhaps even to save PPE for nonessential elective surgeries, which are revenue generators. Thus, despite messaging that coming to hospitals was safe for patients, healthcare workers (many of whom are still not vaccinated) likely did infect patients with COVID-19.
Is it any wonder that some vaccine hesitancy can be attributed to suspicion of information about the safety and efficacy of the vaccines — information provided by the same healthcare authorities who first insisted that masks weren't important?
My wife took my father-in-law to the Rite-Aid near their home, and he did receive his third vaccine dose. And while we all feel comforted knowing he has a bit more protection against COVID-19, I wonder if we've damaged his relationship with his doctor in the future.
As we enter future phases of the pandemic, perhaps finally reaching the point at which enough people have been vaccinated adequately or have developed immunity to protect them from COVID-19, we in healthcare will have yet more work to do.
We need to repair our relationships with our patients, so they will trust us again.
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