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Join us in this episode as we dive into the powerful story of “Max,” a patient who steadfastly refused all vaccines despite his well-controlled HIV infection. Through persistence, respect, and trust, our guest Janet A. Jokela, an internal medicine and infectious disease physician, shares how she gradually guided Max to finally accept vaccination. Janet discusses the strategies she used to build trust, the concept of “vaccine deliberating,” and the importance of patience and respectful communication. We’ll explore how these principles can be applied in today’s climate of vaccine hesitancy, especially in the wake of the COVID-19 pandemic.

Janet A. Jokela is an internal medicine and infectious disease physician.

She discusses the KevinMD article, “Patients and immunizations: It’s a matter of trust.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Janet A. Jokela. She’s an internal medicine and infectious disease physician. She’s the treasurer of the American College of Physicians. Today’s KevinMD article is “Patients and immunizations: It’s a matter of trust.” Janet, welcome to the show.

Janet A. Jokela: Thank you so much, Kevin. Delighted to be here.

Kevin Pho: So we’ll talk about your article in a little bit. First off, let’s briefly share your story and journey.

Janet A. Jokela: Oh, thank you. Thank you so much. I’ve been involved in academic medicine pretty much throughout my whole career. My background’s internal medicine, infectious diseases. I’ve been a residency program director, head of the department of medicine, and then most recently the regional dean of the University of Illinois at Urbana-Champaign medical school campus. Currently I’m the senior associate dean of engagement at the Carle Illinois College of Medicine.

Kevin Pho: Perfect. And tell us about your path in that intersection between what you do clinically and what you do in these physician leadership positions.

Janet A. Jokela: Right, right. In terms of clinically, taking care of patients has always been something that’s been very important to me, as my identity as a physician. Certainly physicians can do a gazillion different things. For me, as a clinical physician, taking care of patients, that’s been really key and has really informed all the other roles and all the other things that I have done. So that’s been huge. That’s really been core.

My responsibilities have changed over recent years with the pandemic, so at any rate it’s all still evolving. But maybe it’s all still evolving for all of us. That said, again, the clinical work that I’ve done has informed everything that I do. I have loved taking care of patients, and I think to be a really good and committed and dedicated clinical educator, patient care has to be part of it. I mean, it gives one credibility and it gives one insights, and you can really help your students and also your students’ future patients. So that’s really key.

So my work at the ACP also has been a really wonderful experience. I’ve been an ACP member since residency, and in many ways the ACP has been my professional home for many, many years, you know, since then. And the educational offerings, the colleagues, I mean it’s just been a fabulous, fabulous professional home for me, and I think for many students and residents that I’ve worked with over the years will say too. The advocacy arm of ACP is second to none. They are phenomenal in terms of the work that they do advocating for patients and internal medicine physicians regularly. So that’s also huge and very inspiring.

Kevin Pho: All right, let’s talk about your KevinMD article. It’s titled “Patients and immunizations: It’s a matter of trust.” For those of you who didn’t get a chance to read your article, tell us what it’s about.

Janet A. Jokela: Sure, sure. I was thinking about immunizations as a topic to write about, particularly because August is National Immunization Month. So at any rate, I was reflecting on that, and a prior patient experience crossed my mind, and I thought it was a really poignant in many ways story to share in the article.

So the time goes back to 2018, when I was meeting with my patient Max, who is someone who I had cared for for many years, and he had been very resistant to vaccines. And he was kind of a very private, quiet guy, and every time I broach the topic, you know, he’d say, I’m not ready. And it’s like, OK. And he wasn’t angry, he wasn’t upset, but he was just kind of firm in his stance. Now granted, he had HIV infection, he was well controlled, but certainly immunizations are a key part of his care with that diagnosis.

So at every visit I continued to broach the topic gently, and when he’d say he wasn’t ready, that’s fine, I kind of backed off, gave him space, and just listened to him. Well, then finally in 2018 he said, you know, Dr. Jokela, I’ve been thinking about what you told me, been reflecting on that, read about it, and I’m ready to get a flu shot. And Kevin, I tell you, I just could not believe my ears. It’s like, are you sure, are you ready? And he said, yeah, I’m ready. And so we did. And you know, I was just thrilled, and yeah, I was just really excited to have that opportunity to help him along his health care journey.

Kevin Pho: Now, during all those times that he saw you and you reminded him about the vaccines and he politely declined, was there something that made him say yes at that particular moment? Was there a singular event, or was this something that built over time? What do you think made him say yes?

Janet A. Jokela: Yeah, that’s a really good question, and I’m not really sure. My sense was there was nothing else going on at that time in terms of, you know, in retrospect, like a looming pandemic or anything like that. That was not the case. It just sounded like he had been thinking about it, and I had been persistent. All right, I was like a dog with a bone. I would not let the issue lie.

But I also was respecting his response, giving him space, and kind of interested to hear what he had to say. When I’d ask him why, he would just say, I’m not ready. And I think the act of asking him why, it demonstrates curiosity, trying to understand his perspective. And I think also that demonstrates, you know, whether I’m asking it or anybody else, it demonstrates that we care. And I think those things were kind of key in building that relationship with him, and also building that trust. I think the trust was really key.

Kevin Pho: And which vaccines in particular would you advocate at every visit? Was it just a flu shot, or was it other vaccines as well?

Janet A. Jokela: Well, particularly in the fall of course I’d be kind of pushing on the flu shot, as that went by. And my recollection is that he had not had a Tdap booster either, and so that was another one that he was due for, so I would also gently push on that. But again, if he said during a visit, like, oh, I’m not ready for any vaccine, it’s like, OK, it’s just my responsibility to share this information with you, that these are indicated for you. Anytime you’re ready to talk about it, just let me know, and we can do that. And that’s pretty much how I left it.

Kevin Pho: With you in your article, you touch upon Dr. Kimberly Manning’s approach of vaccine deliberating. Can you talk a little bit more about that concept?

Janet A. Jokela: Absolutely. And if for any of your viewers or your readers there, if they have not seen this information from Dr. Manning about vaccine deliberating, it’s really wonderful. ACP has a nice link on their website to a short video where she describes it. I highly recommend that for everyone.

Vaccine deliberating refers to the concept that patients perhaps have not fully made up their mind, say in terms of being a firm no or a yes, let’s go ahead, but they’re thinking about it. And unbeknown to me, that’s exactly where my patient was. You know, I had thought he was a firm no, but little did I know that he had been thinking about it. He didn’t tell me he was thinking about it, but he was. And that’s really the vaccine deliberating, trying to decide the pros and the cons and trying to decide whether or not to go forward with a particular vaccine or not.

Dr. Manning describes it really well. You know, I love her approach. I’ve borrowed it many times. It’s so important to be respectful of our patients, to be curious, to try to understand their why. And that’s really what’s involved with this vaccine deliberating position that our patients may take.

Kevin Pho: So as you know, I’m a primary care internal medicine physician myself, and the scenario that you describe comes across very, very frequently. So in my exam room, if I sense that a patient is on the fence about accepting a vaccine or not, tell me what I can do. What kind of tips can you share with me to balance that patient autonomy while also advocating for the benefits of vaccination? What are some phrases I can use, what are some questions I can ask, and take me to that mindset to balance that approach.

Janet A. Jokela: That’s a great question and a really important question. First I’ll say, ACP, the website has some phenomenal recommendations about very specific things in that regard. So one place that I would refer you or anyone else with questions like that is to the ACP’s website addressing these questions.

Things that have worked for me are the phrases like, why, you know, why are you thinking about this, or why are you declining right now, when I’m trying to understand. The other is, if you change your mind, please let me know, I’m happy to talk about it anytime.

I think another piece of this is one’s team. You know, none of us work in silos anymore. We have a team around us, whether it’s colleagues or nurses and others. I think it’s really important for the team to be on the same page. So if I’m giving a certain message to a patient, it’s really important that our nurses for instance are giving the same message and we’re on the same page in that way.

We don’t want to browbeat a patient into doing something they don’t want. That doesn’t work anyway, of course. But at the same time, these, if you want to call them, flowery emotional appeals, that doesn’t work either. You know, I think to be very matter-of-fact, very humble in many ways, listening, being curious, change our advice as new information comes in. I think that’s important. And just demonstrate that we care, we’re doing this from a place of caring and compassion. I think those are all important things.

Kevin Pho: And when you ask patients that question of why, what are a sample of responses that you normally would get back when patients explain why they may be hesitant to receive a vaccine?

Janet A. Jokela: Yeah, you know, that’s a really important question. It could be anything from, like what my patient Max said, which was, I’m just not ready. Other patients may firmly say, you know, I’m not interested, I don’t want it. And then to gently probe. I mean, patients may or may not reveal what they’re thinking, but I think that what we can do to the best of our ability is to try to get at that why and see really what they’re thinking and where they’re coming from. They might have heard about something online or in social media that potentially we could address if we knew what it was.

At the same time, I think it’s also just really important to remain in dialogue with them no matter what they respond, so that we can try to best meet them where they’re at. Now, the issue with Max is that he needed something. In this case he needed a flu vaccine, but he wasn’t in a place where he could receive it yet. And my job was to help get him to that place where he was able to receive it, and eventually he did.

Kevin Pho: Now of course, since that story we’ve had the pandemic obviously, and the situation, to put it lightly, is very dynamic when it comes to the development of vaccines, new technologies, and of course a lot of misinformation about vaccines, specifically the COVID vaccine, that patients are receiving. So tell us what you think about how the pandemic has changed patients’ attitudes towards vaccines. What are you seeing?

Janet A. Jokela: Kevin, I tell you, I’m quite concerned. I’m concerned and I’m saddened. But at the same time, if we don’t continue to share the message that vaccines are important, they’re lifesaving, they’ve been one of the most critical interventions in health throughout the millennia, for hundreds of years, then it will give an opportunity for others who have other opinions about this to step in and share a message that we don’t want.

So at any rate, you see all kinds of information about that, and the data suggests that indeed vaccination rates for just standard vaccines, say especially in children, that that has dropped amongst kids, you know, for some of these standard routine childhood vaccinations. There’s a lot of concern as well earlier this year, certainly with the measles cases that we were seeing, just as evidence that measles vaccination rates have also dropped. Measles is one of the most contagious infections, as we know, completely preventable with the MMR vaccine. And to see those rates drop, it’s just deeply concerning.

So I think it’s critically important that we all remain in that space. There’s been some wonderful people out there and very vocal advocates and scientists who have been pushing back against this kind of movement, if you will. And I think it’s critically important that we remain in this space as well and continue to support our colleagues who are doing this.

Kevin Pho: So what kind of message do you have for practicing physicians, practicing internal medicine physicians, say on an individual basis in the exam room, to regain patients’ trust, especially after the pandemic where that may have led to a dip in vaccination rates? What can individual physicians do in the exam room?

Janet A. Jokela: That’s another great question. I’m glad you asked it. I think it’s critical to remain in dialogue with our patients in whatever way, shape, or form. We don’t want to abandon our patients. To continue to share the message that we care about them, we want what’s best for them, we’re not trying to hurt them, we’re trying to help them in their health journey, whatever that may be. So I think that’s critical.

I think also to be persistent, in the same way that in this case I was persistent with Max. I think that’s critical, to be persistent, to be gentle, OK, as well. I think so often as physicians we forget the impact of our words. You know, we may think that we’re speaking softly or kindly, and what our patients may hear is a megaphone. You know, we forget in some ways how much power we have.

So to be persistent, to be kind, to be respectful, be curious. I think all of those things are really important for building trust and really nurturing trust. Trust can be destroyed so quickly. It’s critical that we nurture it.

Kevin Pho: We’re talking to Janet A. Jokela. She’s an internal medicine and infectious disease physician. She’s also the treasurer of the American College of Physicians. Today’s KevinMD article is “Patients and immunizations: It’s a matter of trust.” Janet, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Janet A. Jokela: Thank you so much, Kevin. I think whether we are in the exam room or in the classroom, in the boardroom or in front of Congress, it’s really important that we continue to advocate for what’s right for our patients, including vaccinations, what’s safe, and how these can help them. So I think that’s critical. So to be persistent, be respectful, be curious, and build trust are critical things for our patients, in whatever place we may find ourselves.

Kevin Pho: Janet, thank you so much again for sharing your perspective and insight, and thanks again for coming on the show.

Janet A. Jokela: Thank you so much, Kevin. Delighted to be here. Thank you.