Anger toward the unvaccinated will only cause more harm [PODCAST]

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“The unvaccinated patient is the addicted person, the overweight patient, the smoker in the waiting room. Our antipathy toward them endangers their health, maybe their lives. The unvaccinated will not be convinced with stigma. They will be convinced with integrity, sincerity, and love.

Stigmatization has never been an effective health intervention. And that’s exactly what these reflexive responses to the unvaccinated are. It’s not righteousness, as if righteousness ever helped in an examining room. These days, maintaining grace and an open heart to the unvaccinated is the most ethical practice a physician can undertake.”

Stephanie Sun is an internal medicine physician.

She shares her story and discusses her KevinMD article, “Anger toward the unvaccinated will only cause more harm.”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Stephanie Sun. She is an internal medicine physician, and she wrote the KevinMD article “Anger toward the unvaccinated will only cause more harm.” Stephanie, welcome to the show.

Stephanie Sun: Thanks for having me.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Stephanie Sun: Yes, thanks for having me, Kevin. A little bit about myself: I was born in Canada, in a small town called Trenton in Ontario, just about 2 hours outside Toronto. My parents were family doctors in this small town. I think, like the children of a lot of doctors, I went through some phases where I did not want to go into medicine at all, and then thought maybe this might be something for me after all.

I went to undergrad and grad school at McMaster University in Hamilton, Ontario, initially thinking I would do something like basic sciences research in evolutionary biology. I really enjoyed working on my master’s there, but, like I mentioned before, I got drawn back into medicine and that chance to work one-on-one with folks. To be honest, I really wanted to go into medicine because I thought there was a lot more work in community-level work and working in public health. Maybe I was off target a little bit, but I really enjoyed med school and learning how to take care of people on an individual level.

I went on to do med school at St. George’s University in Grenada. I was part of the global scholars program, where we spent our first year in Newcastle, England, and our second year in Grenada. Then third and fourth year were in New York City, which was a great place to train. I went into internal medicine at Yale Waterbury in Connecticut, and finally made my way to Boston, where I am now, through this Mass General fellowship in rural health leadership. This program focuses on rural health, and our main clinical partner is the Rosebud Sioux Tribe and the Rosebud Indian Health Service in South Dakota. I’ve stayed on since fellowship as faculty, and I just started as the fellowship director not too long ago.

Through a lot of this work, obviously COVID has been a huge, huge game changer across the world, but especially seeing how it has played out in these rural communities has had me thinking a lot about the response to COVID, my own personal response, and what I see in my colleagues, how it’s been to live through this. So that’s kind of what led me to writing this article.

Kevin Pho: So, with your experience in rural medicine, I’m interested in hearing about what you’re seeing in terms of how COVID is affecting the rural community.

Stephanie Sun: Yeah, it’s pretty incredible. So obviously, on the one hand, in these rural communities, at least the one that I’ve been really involved in, the health infrastructure has been struggling for quite some time. I work as a partner in this very rural, remote community where the next closest hospital is about 50 miles away, but the next closest tertiary center is about a 3- to 4-hour drive away. So they have some chronic issues, not surprisingly, of transportation and access to specialty care, and staff turnover can be very tricky. The wonderful thing about working in these communities is that the people who work there are so dedicated to the communities that they’re working in, but there are these challenges that COVID has really exacerbated.

So, on the one hand, it’s been very difficult. On the other hand, it’s been incredibly inspiring to see how these communities, and the community I work with, have responded. With COVID, obviously, we’re trying to stay distant from each other and trying to limit as much unnecessary in-person contact as possible. It’s been a great chance for communities to get support to try innovations that really probably would have helped them a long time ago. You can imagine, when you’re dealing with long distances and patients having difficulty making it in person to a clinic visit somewhere, that the advent and rollout of more telemedicine has been so helpful. Of course, there are limitations to telemedicine, and things are getting worked out, but that has been incredibly helpful for these communities, COVID aside.

One other thing that has been really amazing, especially in American Indian communities like the one that I’ve been working in, is to see how the tribe, the tribal health administration, and the tribal government themselves have been coming together with the government-run Indian Health Service. Anyone can see, with a quick Google search, some of the long difficulties and difficult relationships and whatnot between these two entities. But to see these parties come together in a way to roll out vaccines and testing, it’s really great. It’s amazing to see some of these communities have among the highest vaccination rates in the country. I think that just goes to show what’s possible when you have leadership from different parties that have the community’s best interests at heart, and when these parties get some additional help.

I could go on forever. I won’t. But there are issues of chronic underfunding and different infrastructure problems that these communities have been trying to work with for a while. So COVID, long story short, has been devastating, as it has been everywhere, and a lot of knowledge and culture has been lost, but it’s also very inspiring to see what these communities have been able to do.

Kevin Pho: You mentioned that your experiences in a rural setting led you to writing this article on KevinMD titled “Anger toward the unvaccinated will only cause more harm.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Stephanie Sun: Yeah, of course. This article started brewing in my mind I don’t know how long ago, maybe at least a year or longer. I’m not sure. As for anyone working in health care now, it’s been a roller coaster of emotions, a lot of them, to be frank, quite negative at times. I think especially for folks, well, probably for everyone, but just speaking as someone who works quite a bit in primary care, trying to have conversations with people, meet them where they’re at, and understand where they’re coming from when there’s so much disinformation and misinformation out there, it’s hard. It’s hard to keep your morale up. On top of that, you’re seeing these conversations play out among family and friends. What I’m getting at is questions about everything around COVID and the measures that people have been trying to take to address it. It’s tough for everyone.

In rural communities, the issue of trust, and who is a trustable authority, where do you get your information from, and what do you do with that, I think it’s pretty unique. Folks in rural areas, in my experience, have needed to survive and be resilient on their own for so long, and just not depend on waiting for resources from other places. People can be very pragmatic and trust their own senses and what they’ve seen. For someone like me, who is not based in the rural area, I travel out there a quarter of the year. Building up that relationship and that trust with folks is really important, and you just see these relationships really strain during COVID times.

There are so many factors to it. There’s the lack of information and the quickly changing picture that we see. On top of that, as a clinician, there’s how personally impacted you can be: your personal health, or the health of your family, your friends, and your own life, based on decisions that everyone is making. So I would see these really tough times that my colleagues were going through, and some of my family members, who, as I mentioned, are also in medicine, and see how it affects them.

I would hear some of the things said, or some things I’d see in the news. I cited a few things in my article. There’s a doctor somewhere in Alabama. He was a family doctor and had posted a sign saying he wouldn’t see any unvaccinated people, anyone unvaccinated against COVID, in his practice. On the surface, it sounds like, “Wow, that’s really harsh.” Then there’s another part of me that thinks, “I can see where he’s coming from.” He has a quote saying it’s just too hard to see what ends up happening. Part of me definitely could understand the frustration, the anger. I have felt that too, but another part of me has some concern about where I saw things going.

In my practice in rural medicine, our group also does some office-based treatment for opioid use disorder, namely buprenorphine. It just made me think about how, in medicine, sometimes the way we may feel about certain conditions, or people living with certain conditions, can potentially affect the way that we practice. So I thought more about that. In my article, I explore different areas of stigma from the medical community: on treating opioid use disorder, as an illustration, the slow uptake of prescribing buprenorphine in offices despite very good data, and a few other examples, being obesity biases and lung cancer biases. This article explores some of those issues and the data behind how that can hurt patients.

To be sure, COVID is a little different, in that it impacts us very, very personally, and it’s so widespread, but I think there are a lot of similarities in terms of what we can do about it as doctors. I will be honest, Kevin, I struggled a bit with this article because, like I said, I can really see where this anger comes from. On the other hand, I worry about it getting out of hand. I don’t think doctors can be expected to put away their human emotions and just function without feeling what they’re feeling. I think that’s also dangerous. Even before COVID, there have been issues of doctor burnout, and that comes from, I think, partly, not being as humanized as they could be.

But we have this really privileged place, and this is such a sensitive, tender topic when you’re in that clinic room with someone else, even if you’re coming to this discussion from really different sides. I think it’s kind of beautiful in a way, not to get too cheesy, how this is how being a person with another person can really play out. The biggest takeaway I hope comes from this article is the importance of just continuing to see each other as people and trying to work with each other on that person-to-person level.

Kevin Pho: So tell me some of the techniques, or even a story that you’ve had in the past, where you have successfully convinced someone who was previously against vaccines and brought them over to be vaccinated. Are there any stories or techniques that you could share with my audience that worked?

Stephanie Sun: Yeah, one story comes to mind. But I have to be honest, I’m not completely sure what it was that convinced this person, and that’s often my situation when people do change their minds. I’m not sure exactly what it was that flipped the switch. Sometimes I ask people, “What was it that changed your mind?” and they can’t even point to it exactly, perhaps.

But this one story is that I saw a gentleman in clinic in South Dakota. We were visiting about, I believe it was, him following up after a hospital discharge for a heart issue. So it wasn’t necessarily COVID-related specifically, but I brought up the COVID vaccine and whether he might be interested in it that day. He’s a very reasonable guy. He asked me so many great questions about the new medications he had been started on at the hospital, questions about the side effects and whatnot. Very, very reasonable. When it came to the COVID vaccine, he very politely said, “No, I’m not interested. Thank you. I have a very close family member who got the vaccine, and then the next day had, like, a massive stroke and died,” or something like that. I didn’t have any other information or context about that person’s other health history.

So the way I approached it was this. I’m always very tempted to push back and point out all of the issues in the logic or whatever, to try to learn more, and sometimes that’s appropriate. But in that situation, I had this sense that he wasn’t really ready to talk about it. He had quite a bit of resistance, very polite resistance, up front. When working in primary care, something I remind myself a lot is that you really can’t make someone completely healthy in one visit. It’s about the longitudinal relationship, the multiple visits over time, and just being there with someone.

So I said, “OK, just to let you know, I may bring this up again in the future, but let’s think a little bit more about it, and we can put a pin in it for now. If you ever want to talk more about it, I’m more than happy to.” I was trying to approach it in a nonjudgmental way, just really appreciating that he was even talking to me about it and sharing some of his concerns.

I didn’t see him again for a little bit of time. In my mind, I really was thinking this person is probably never going to get vaccinated. He just seemed very strongly against it and had this very personal and emotional reason not to. He had access to a lot of good information, but I think this story that he had, or this experience he had, was really overriding it all.

I saw him again weeks, months later, and noticed in the chart that he actually had already gotten his first vaccine a couple of weeks before. I felt really happy about that. I was really glad, and I let him know. I said, “First of all, I’m really glad that you took the step. I know that you were kind of hesitant at first, and I’m glad that you kept thinking about it.” I asked him what it was that made him change his mind, and he couldn’t really say. I don’t know if he felt 100 percent comfortable that he had gotten it, and he definitely didn’t seem like someone who’s going to go out there waving the vaccine flag. But he just said, “I’ve been seeing things happen in the community.”

What I took from it was that he was feeling more comfortable with the idea, though he still felt that there were some serious risks. But after having some time to see the impact in the community, and asking about his family and friends, and, hopefully, seeing that many people were actually doing fine post-vaccine, most people were, the vast majority, he just felt like, “OK, let me do this.” In the meantime, there had been a lot of education and communication campaigns in the community about getting vaccinated, and tying that to the importance of the safety of the tribe and protecting elders, and these values that are really important in the community.

I think it’s very clear that it wasn’t necessarily anything that I did that made him take that step, but I think it definitely helped that I didn’t push with too much judgment and just left it as a conversation that’s open, where he’s there as a partner. I worry about setting people up for more resistance based on our responses, but I do think that that’s probably one of the things that helped a lot. It’s like, “OK, we’re still here for you. Let’s meet you where you’re at when you’re ready. We’ll continue the conversation. You’re part of this team too. Your health and the health of everyone is what we care about the most. But of course, your concerns, we have to consider them. They’re really important.” That’s, I think, the key.

Kevin Pho: We’re talking to Stephanie Sun. She’s an internal medicine physician, and she wrote the KevinMD article “Anger toward the unvaccinated will only cause more harm.” Stephanie, what are some of the take-home messages that you want to leave with the KevinMD audience?

Stephanie Sun: Oh, man, I think the biggest take-home message to the audience is that we’re all in this together. We all have come from different experiences. We’re all dealing with different things. But at the end of the day, we’re really all just trying to get through this in one piece, and we’ll be able to do that if we just all stick together.

Kevin Pho: Stephanie, thank you so much for joining me and sharing your time and insight, and thanks again for being on the show.

Stephanie Sun: Thank you so much, Kevin.

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