It is Wednesday afternoon and I have one last annual visit for the day. As I enter the room, a slender 27-year-old woman wearing a white t-shirt and baggy blue jeans sits in the chair across from me. After an introduction, I ask about her recent urinary tract infection for which she was treated two months ago. Her main concern then was a strong odor. “How is the odor now?” I ask. She sheepishly responds, “I don’t know. I lost my sense of smell a month ago.”
I take my eyes off of the computer screen and look straight at her. She knows exactly what I am thinking and tries to reassure me, “I tested negative for COVID.” I continue the interview by asking about other possible COVID-19 symptoms, all of which she declines. Then I ask about her vaccination status, to which she replies that she is not interested in getting vaccinated. “Do you have any concerns or questions about the vaccine?” I ask. “Nobody around me got COVID. I don’t see the point of getting vaccinated,” she states adamantly.
Sensing that she is firm in her beliefs, I tell the patient that getting vaccinated is her choice and I do not push further. As I continue with other routine annual questions, she tells me that she doesn’t sleep well. When I ask why, she replies that she works night shifts, going to sleep at 8 a.m. just to wake up three hours later.
When I ask her where she works, she replies, “In a home health agency, as a home health aide.” I then ask her about the nature of her work, and she tells me that she cares for only one patient. When I clarify that she is unvaccinated, she responds, “The family knows and they are okay with that.”
As we are having this conversation, I remember the many COVID patients I saw sequestered behind the ICU windows in the hospital. Particularly, I think about one young woman in her third trimester — my team performed a tracheostomy on her. The sight of her being ventilated and sedated with a big pregnant belly deeply saddened me. She was also unvaccinated.
After we conclude the discussion, I perform a physical examination and call my attending to join us in the room. As I start presenting to the attending, I promptly provide what I believe is the most worrisome piece of information: this young woman is an unvaccinated health aide. My attending’s expression shifts and she asks the patient about any concerns she might have about the vaccine. When the patient states decisively that she is simply not interested, my attending gently inquires why. “None of my family or friends got COVID,” the patient replies.
“Okay … I see how this might be … not interesting to you,” the attending solemnly says. A long silence fills the room. “I wish I could say the same,” she continues, “so many of my patients have suffered from COVID, and many have died.” She then asks if the patient knows anyone with cervical cancer, which the patient declines. The attending pursues the subject, “but you are vaccinated against HPV, correct?” The patient nods her head. “So you don’t have problems with vaccines?” the physician clarifies. “No, but I heard that you can still get COVID if you are vaccinated,” the patient shrugs, as if she had proven her point.
My attending then tells her that it is true, but the chance of a vaccinated individual transmitting COVID to someone else is lower because of what we call ‘viral load.’ Vaccinated people carry lower viral loads if they do contract the virus, which means that they have fewer viral particles to transmit to others. Vaccinated people are also much less likely to be sick or die from COVID. My attending then shares more alarming data on COVID-19. At one point, she pauses in concern and says that she doesn’t like the way she sounds right now; she doesn’t want the patient to think that we are forcing her to do anything.
Finally, she closes the encounter by saying: “I need you to hear this information … for yourself and for the patient you are caring for. Our society is measured by how it treats its most vulnerable members and right now, we as a country are not doing a good job. I don’t want you to have a death on your conscience.” “Okay … I will definitely consider it,” the patient says, but it is hard to read whether she is truly convinced.
This was an uncomfortable, yet vital conversation. I imagine many similar conversations occur in examination rooms around the country and across the world every day. A caring physician is also an educator, providing patients with meaningful health information. In the midst of a deadly pandemic and dangerous misinformation, this role is more crucial than ever. At the end of the day, the patient has autonomy, but it is our responsibility in the medical community to ensure that both we ourselves and our patients are sufficiently informed to make these significant choices.
Image credit: vaccines (CC BY-NC-ND 2.0) by mattallworth