Category Archives: physician

Talking to the Opposed About Vaccines

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NaBloPoMo 2018: What I’m Learning

Go figure, I’m having conversations about flu and vaccines every day right now.  Today I described my post from yesterday to a new friend.  He stands firmly in the ‘vaccines are good’ camp.  His sister, however, does not.  Her son has autism.  After hearing about my post, he asked me what I would say to her, if she told me she would not vaccinate her child ever again.  It was a great opportunity to think and practice, and I’m grateful that he asked.  I had already thought earlier today about writing a separate post on communication around vaccines.  So here goes!

First I would tell her that I understand why she would not want to vaccinate, if she blames vaccines for her son’s autism.  I don’t know any kids with autism, but I have friends whose kids are autistic, and I see how stressful and exhausting it can be.  As a mom of kids with anaphylactic food allergies, I also know the feeling of absolute guilt for being the one who gave my kids the things that made them sick.  If I were a mom whose kid was diagnosed with autism after receiving vaccines that I consented to, and I were convinced that the latter caused the former, I would definitely want to protect my kid from anything else that might hurt him, especially anything that I have control over.

Some additional background:  We are a lot better at recognizing and diagnosing autism spectrum conditions now than a few decades ago.  That diagnosis is commonly made in the toddler years, also around the time kids have received a boatload of vaccines.  So it’s easy to see a correlation, but causation cannot be proven.  One could argue that it also cannot be totally disproven, but given the number of children who receive all of their vaccines and the very small proportion of them all who go on to be diagnosed, the evidence definitely leans away from vaccines causing autism.  That is little comfort for a family and a child affected with the disorder, who may always wonder.  As humans, we naturally look to assign blame; vaccines are an easy target.  And why on earth would we repeat actions that have previously caused us trauma, real or perceived?

This year I read an article about a mom of three.   She had vaccinated her two elder children as per guidelines.  After her third was born, however, she started to read lay literature online stoking fear of vaccines.  She had no negative experiences herself, but started to wonder, what was really the best thing to do for her family?  She decided to stop vaccinating when her son was 6 months old.  At 18 months, he got pertussis, or whooping cough.  He almost died.  She posted videos of him coughing and turning blue, captioned with a heartfelt mea culpa, urging other parents to vaccinate:

“This is whooping cough,” she wrote. “This is Brody. An 18-month-old boy. Our third child. Our first son.

“This is a mother that sees ‘anti-vaxx’ all over social media and becomes terrified. Unsure whether or not to give vaccines (even though she did for both of her girls). Terrified to ‘pump her baby with poison’ … so she stops vaccinating after six months.”

“This is pure hell. This is guilt. Guilt of putting not only my son at risk, but my community too …This is embarrassment.”

She wanted to impress the fact that she’s not “bashing” the anti-vaxx community – or blaming or judging anyone.

“The decisions I made were MY decisions. Based purely on my lack of knowledge and fear,” she said.

“This is to show the consequences of not vaccinating my child correctly.”

I wonder about her conversations with her son’s doctors.  Did they try to shame her into vaccinating when she initially expressed a desire to stop?  If so, could this have just made her more resistant?  It could easily look something like a conversation that I would bet happened all over our country today:

Doctor:  Have you gotten your flu vaccine yet?

Patient: I don’t do flu vaccine.

Doctor: Seriously?  Why not?  It’s perfectly safe, you know, and tens of thousands of people die every year from flu.  If you don’t get vaccinated, you could pass it on to everybody you know.  Aren’t your parents elderly?  Don’t your kids have asthma?  You’re putting them at risk for serious illness or death, you know that, right?  And you don’t get flu from the vaccine, that is a total myth.  (Insert list of facts and evidence for benefits of flu vaccine here.)  Really, you should get it (suppressing eye roll).

Patient:  No, no thanks.  Can I go now?

I see and hear my colleagues complain all the time about vaccine-resistant patients.  When they are particularly tired or moody, they can get judgmental and even a little mean.  I understand.  It’s frustrating to watch people we care about making choices we think are against their best interests, especially when it also puts the community at risk.  I fear for my kids if their classmates are not vaccinated—both of my kids have asthma that’s triggered by respiratory infections.  Even if our whole family is vaccinated, they are still exposed to hundreds of snotty, sneezy, coughing faces every day at school.  Flu season is essentially six months long, most of it when we are all stuck inside basically slobbering all over one another.  High. Risk.

But does it really help for me to come at my patients with my ‘advice’ before I understand the origins of their decisions?  What are my assumptions about them when I do that?  Some patients claim science as the basis of their refusal; others admit that it’s totally irrational.  Regardless, how can I best conduct myself?  Here is my current approach:

Cheng: Do you do flu vaccine?

Patient: No, not really.

Cheng: Can we talk about that?

Patient: Do we have to?

Cheng: I would really appreciate it.  I won’t try to pressure you, I just want to understand your rationale.

Patient:  Gives their reasoning.  If it’s like my friend’s sister above, or I otherwise understand that they are resolute in opposition, I thank them for sharing, shift to strategies for illness and transmission prevention (see yesterday’s post), and ask permission to talk again next season.  This happens in a minority of cases, actually.  Most often they say something like, “Well, I just don’t really think about it, I feel like I don’t need it, I think it’s strange that it’s recommended every year, it doesn’t really seem to work from what I hear, and what’s the big deal about flu, anyway? …Do you really think I should get it?”

Cheng: Yes, I really recommend it.  Can I tell you why?

Patient: Okay, sure.

This is when I go through all the evidence that I reviewed yesterday and the rationale above.  If I know something meaningful to them that relates, I make sure to highlight the connection.  At the end I make sure to reiterate that they are free to vaccinate or not; I am honestly unwedded to a particular decision. I invite them to consider and let me know, or just show up to a pharmacy clinic if they decide to get it.  Most people are appreciative of the time spent; many say they learn something they did not previously know.  We end the conversation at least with no hard feelings, and often with positive ones (at least on my end).

It occurred to me this morning, what is my primary objective when I conduct these conversations this way, coming alongside my patients rather than coming at them?  Initially I thought it was to keep people healthy, to prevent death, serious illness, and suffering.  But now I think my primary objective is actually to cultivate our relationship.  I usually have this conversation with new patients, because if I know them already then I know their vaccine patterns and I don’t have to ask, “Do you do flu vaccine?”  If they refused last year I can simply start with, “Can we please talk about flu again?”  When we are new to each other, the way I present sets the tone for our relationship and has an outsize impact on patients’ receptivity to my advice.  The flu vaccine conversation is a prime opportunity to prove that I can listen to, empathize with, respect, and honor their values and autonomy.

On the contrary, when I come at them, bent on convincing them to vaccinate now, what is my primary objective?  Thinking of other times I present this way, if I’m being honest, I’m just trying to prove I’m right and win an argument.  I don’t think that approach has ever really helped anybody.

 

 

Fear, Ego, and Control

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NaBloPoMo 2018:  What I’m Learning

In this post I will attempt to describe some exciting connections between readings from the Harvard Business Review, Dr. Anthony Suchman and colleagues, and Carol Dweck.

An HBR article landed in my inbox this week, catching my inner Imposter’s attention.  The title, “Ego is the Enemy of Good Leadership,” triggered my ‘Is that me?’ reflex.  Because much of the time, I think I’m a pretty good leader (“I’m awesome”).  But I’m forever fearful that my ego will get the best of me and make me exactly the kind of leader I loathe (“I suck”).  I saved the article to read later.

Meanwhile, I continued to Chapter 3 of Leading Change in Healthcare: Authentic, Affirmative, and Courageous Presence.  Basically this chapter deals with earning and building trust.  Chapter subsections include self-awareness, reflection, emotional self-management, clarifying one’s core beliefs, and accepting oneself and others.  In the part on core beliefs, the authors reference Dr. Suchman’s 2006 paper, “Control and relation: two foundational values and their consequences.”  In it, he differentiates between these two ‘foundational world views’:

Control

The beliefs, thoughts and behaviors of the control paradigm are organized around a single core value: that the ultimate state to which one can aspire is one of perfect willfulness and predictability. What one desires happens, with no surprises; all outcomes are intended. For the clinician, the control paradigm is expressed in the questions, ‘‘What do I want to happen here?’’ and ‘‘What’s wrong and how do I fix it?’’  Personal success or failure is judged by the clinical outcome, the extent to which one’s intended outcome was realized.

Relation

In the relation paradigm, the most valued state to which one aspires is one of connection and belonging. In this state, one has a feeling of being part of a larger whole – a team, a learning group, a dance troupe, a community, even the world itself. One’s individual actions seem spontaneously integrated with those of others to a remarkable degree, contributing to the evolution of a higher order process, i.e. one at a higher system level than that of the individuals of which it is comprised…  One asks the question, ‘‘What’s trying to happen here?’’ and, according to one’s best approximation of an answer, seeks to shape others and the world while also remaining open to being shaped oneself. This balance between control and receptivity puts one in the best possible position to recognize and make use of serendipitous events.

In Leading Change the authors write about control, “…This is a fear-based paradigm in which one trusts oneself more than others and holds tightly to power…  It predisposes leaders toward dominance, distracts them from cultivating relationships and leads them to set unrealistic expectations of control.”  And about relation, “This is a trust-based paradigm, anchored in the belief that the sources of order, goodness and meaning lie beyond one’s own creation…  It predisposes leaders to do their best in partnership with others, to attend to the process of relating and to personal experience (their own and others’) and to remain open to possibility.”

When I finally read the HBR article, the message about ego reflected the control paradigm:

Because our ego craves positive attention… when we’re a victim of our own need to be seen as great, we end up being led into making decisions that may be detrimental to ourselves, our people, and our organization.

When we believe we’re the sole architects of our success, we tend to be ruder, more selfish, and more likely to interrupt others. This is especially true in the face of setbacks and criticism. In this way, an inflated ego prevents us from learning from our mistakes and creates a defensive wall that makes it difficult to appreciate the rich lessons we glean from failure.

The ego always looks for information that confirms what it wants to believe [confirmation bias].  Because of this, we lose perspective and end up in a leadership bubble where we only see and hear what we want to. As a result, we lose touch with the people we lead, the culture we are a part of, and ultimately our clients and stakeholders.

Going to bed last night, I wondered, “Is Fear actually driving when we see Ego in charge?”  I think the answer is undoubtedly yes, but it’s more complex than that.  It’s not a fear that we feel consciously, or that we are even aware of.  It’s not sweaty palm, palpitative, panic attack fear.  Rather it’s a deep, visceral, existential fear—of being found out, of not being enough—akin to imposter syndrome, if not exactly that.  Control, Fear, Ego—they all seem lump-able with/in the Fixed mindset, as described by Carol Dweck.  The simplest example of this mindset is when we tell kids how smart they are, they then develop a need to appear smart, lest they lose their identifying label.  So they stop taking risks, trying new things, risking failure.  Their experiences narrow as they, often inadvertently, learn that control of outcome and outward appearance of competence is the primary objective of any endeavor.

Back in August I listened to Dweck’s book, having heard about it and already embraced its theory in the last few years.  I had already started making the connection between fear and fixed mindset, but this day I saw a sudden, reciprocal relationship between fixed mindset, confirmation bias, and imposter syndrome.  I love when these lightning bolt moments happen—I was in my car on the way to work, and this triad came to me.  As soon as I parked and turned off the engine I tore into my bag for the journal I carry with me everywhere and scrawled the diagram as fast as I could, as if the idea would evaporate if I didn’t get it down in ink.  Later I added the comparison to Growth mindset—holding space for learning, integration, and possibility.  I held it in mind for a while, and then forgot it (which is okay—that’s why I wrote it down!).  Then today, putting together this post in my head, I remembered it with excitement.

8-31 triad update

The point of it all is that we are at our best, both individually and as groups, when we are in right relationship with ourselves and one another.  It all starts with relationship with self.  If I live in fear of being found out as flawed or imperfect, then I project that fear onto others.  I act out in an effort to control how others perceive me—when in reality I have no control over that whatsoever.  The negative perception of my ‘Ego’ by others then provokes myriad responses including fear, insecurity, false deference, resentment, disloyalty, and subversion, and the team falls into disarray.  If, on the other hand, I cultivate self-love and connection with others, I never feel that I am going it alone.  I am an integral member of a high-functioning, mutually respectful team, one in which I can admit my weaknesses and maximize my strengths.  We all feel confident that we can handle whatever adversity comes our way, and we rise to each and every occasion–together.

I’m still putting it all together, working out how it translates into daily behaviors, actions, and decisions.  For now I’m definitely paying closer attention to my feelings, especially in conflict, and taking a lot more deep breaths before speaking or replying to triggering emails.  I ask a lot more clarifying questions.  I try to make the most generous assumptions about people’s intentions, and remember always that we are on the same team—Team Humanity.

More learning happening around the clock, I say!  Hoping to articulate better in the sharing hereafter…

What do you think about all of this, does it make any sense at all??

Hope You’re Safe in Chicago

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NaBloPoMo 2018:  What I’m Learning

My friend texted me these words at 4:01pm Central Standard Time today.

Tamara O’Neal, an emergency medicine physician just one year out of training, was shot to death by her ex-fiancé.  He then went on to kill two others, and he himself died, though it remains unclear if he shot himself or died from a police officer’s bullet.  She was on her way to work, saving lives for a living, many of them probably victims of gun violence.

Samuel Jimenez, a 28 year-old police officer, also only beginning his career, was killed.  He leaves behind a wife and three young children.  He was doing his job, protecting innocent lives from deadly violence.

Dayna Less, a 25 year-old pharmacy resident, was also killed.  She was still in training, planning to go home to Indiana tomorrow to celebrate Thanksgiving with her family, and planning a wedding next year.

It could have been my hospital, or my husband’s hospital.  Or one of the hospitals where my sister or my friends or my mom work.  It could have been my children’s school.  An elementary school a few blocks away was locked down until 5pm.  What must that have been like for the kids and their parents?

I was safe in Chicago—today.  But none of us are actually safe, as long as we collectively continue to do nothing about the public health crisis of gun violence that grips and gags us.  And make no mistake it is a public health issue before it is a political issue.  That said, we in healthcare must continue rise up and call for action in policy.  We must demand more of our elected officials.  They must represent us and our collective public interest first and foremost.  A majority of the American public supports common sense gun laws like background checks, licenses for gun dealers, and restricting gun ownership by known domestic abusers.  This should be reflected in our laws and law enforcement.

Please read about the victims of today’s shooting.  Remember them before you read about tomorrow’s victims.  Look up the people who died in Parkland and Pittsburgh.  Put yourself in their shoes, as events unfolded on what started as just another day in their lives.  Imagine what must have flown through their minds—thoughts of children, parents, spouses, regrets, things they wish they had done, things they had looked forward to.  Imagine the terror, the disbelief, the pain, the utter loneliness, the longing for the comfort of loved ones, the wish for another day to be with them, to say goodbye.

Imagine being their family members now, trudging on each day without them, senselessly, with no justice, no closure.  Imagine caring for patients and their families in the emergency department, the intensive care unit, the neurological rehab hospital.  Imagine looking into the eyes of these people, the remaining years and decades of their lives irrevocably altered for the worse by events that unfolded over a few minutes.  And then imagine, as you continue to gaze into their eyes, telling them sorry, there’s nothing we can do about it, this is just the way it is.

The only way enough of us will be moved to take action is if enough of us can truly relate to the experiences of the victims and their families.  Nobody needs to actually live through such horror to be able to empathize.  The human brain is wired for empathy and connection.  At the same time that we cannot imagine what it must be like, we can absolutely imagine.  But we choose to separate, to disconnect, when things are too uncomfortable, to protect ourselves.  This is how tragedies like Columbine continue to happen, every week, every year, for decades.  Not. Acceptable.

Read the American College of Physicians position paper on reducing firearm injuries and deaths.  Apply a critical and objective eye and mind.  Try to understand its reasoning and look up the citations.  Read the appendix, the expanded background and rationale.

Do you want fewer people to die from gun violence in the United States?

What will you do to help reduce the harm?  Because we all need to help.