2. COVID - What Now?? Overcoming Barriers and Frustrations During COVID-19

Join Dr. Timothy Ott, an academic doctor with 30 years of experience and is currently teaching the family medicine residency at Southern Illinois University, as he hosts a round table with Dr. Kristin Davis, Dr. Santina Wheat, and Dr. Chris Smyre to discuss barriers to COVID-19 vaccine implementation including the obstacles they faced at their own practices, what they wished they knew then, and what has changed throughout the course of the pandemic to make things easier. They will also share the new issues that they are encountering and how they are managing them and doing what they can within the constraints each practice has.

We are all facing these challenges. Through this series of podcasts we hope to walk together to face and overcome these barriers and frustrations.

Visit us at illinoisvaccinates.com/podcasts.

Chapters

• 0:00 Introduction
• 1:39 Episode Begins

Transcript

Speaker 1 (00:04):

Welcome to Beyond the Needle, a physician's guide to increasing COVID-19 vaccination rates, brought to you from the Illinois Academy of Family Physicians, through the Illinois Vaccinates, or I-VAC, grant. I am Carl Lambert, family physician and a member of IAFP, and I'm an Assistant Professor of Family Medicine at Rush University Medical College. I-VAC is a joint effort administered by the Illinois chapter of American Academy of Pediatrics, the Extension for Community Health Outcomes, ECHO, Chicago and the IAFP. Funding for this podcast series is provided by the Office of Disease Control, through the Illinois Department of Public Health. Through this podcast series, we'll empower the primary care physician to feel confident in implementing COVID-19 vaccination so that their patients can receive the vaccine at a routine visit.

               Support for providers is available through boot camps, learning collaboratives, do it yourself toolkits and this podcast series. CME credit is available for each podcast through the Illinois Academy of Family Physicians. For more information, visit IllinoisVaccinates.com under podcast. You will hear from a variety of primary care clinicians and staff from across the state who've become experts on COVID-19 vaccine implementation. As primary care clinicians, this is the kind of work we've been doing throughout our careers. For centuries, we've been trusted allies at preventative health for individuals, families and communities. We will share the highs and the lows of our experiences and lessons learned throughout the pandemic. Thank you for joining us as we come together to vaccinate against COVID-19.

Timothy Ott, DO, FAAFP (01:40):

Hello. My name is Dr. Timothy Ott. I'm a family doctor here in Quincy, Illinois. I have over 30 years of experience. I'm currently an academic family doc with SIU-Quincy Family Medicine, but I was in private practice for 20 years before that. Today, I have with me Dr. Santina Wheat, Dr. Kristin Davis and Dr. Chris Smyre. Today, we're going to talk about COVID. What now? Overcoming barriers and frustrations. My first question is addressing barriers, communication, and misinformation. Dr. Smyre?

Christopher Smyre, MD (02:19):

Thanks, Dr. Ott. A little bit about my background. I am in my second year at Southern Illinois University. However, I am located at the clinic site in Springfield, Illinois, and I'm also Director of Equity, Diversity and Inclusion for the entire department. I think when we talk about barriers with regards with communications with patients, that is something that I think is very important. This pandemic has taught us how quickly information can change from being current to no longer relevant, out to date. It's also been very challenging with just sometimes misinformation and misaccurate information being relayed intentionally, and sometimes unintentionally.

               And what I've found is that for me, really engaging my patients to be confident that they have an accurate understanding of why we're offering this, normalizing the confusion of sort of hearing different messaging, just feeling like they're not in congruency, but explaining the science of why we say get vaccinated and continue to wear your mask has been really helpful to make sure that patients understand. And sometimes, that understand leads to them being agreeable to get the vaccine. Other times, they may still not be agreeable, but at the end of the day, I'm very happy with them being informed about the risks, the benefits, so that they are making a choice that aligns with their values.

Timothy Ott, DO, FAAFP (03:38):

Thank you. Dr. Wheat?

Santina Wheat MD, MPH, FAAFP (03:40):

Thank you, Dr. Ott and thanks for sharing that, Dr. Smyre. A little bit about me, I am the Program Director of the Northwestern McGaw Family Medicine Residency Program at Humboldt Park and am a practicing family physician for nine years at Erie Family Health Centers in Chicago. And I would say that share some of Dr. Smyre's experience, but I would also say that it's not always just an explanation that I am trying to give to my patients. I've had so many patients that haven't wanted to get a vaccine until they heard it from me. They were worried that even if they were hearing it from another physician, that it wasn't true. They wanted to hear it from me, their personal physician, that I was in agreement with this and were waiting until they heard from me.

               I've also had experiences where patients have had misinformation, but didn't really want to talk about it. I've actually gone as far as to say, "Oh, this is the misinformation that I've heard," or, "These are the stories that I've heard. Have you heard this one? Are you worried about this one?" And it's actually allowed patients to start saying, "No, I haven't heard that one, but I heard this one," or, "Yeah, I heard that one. What do you think about that?" And it's been a great opportunity to address some of those things that have come out from all of the different sources.

Christopher Smyre, MD (04:52):

I think that's such a great point because doing prenatal care, one of the ways that I sort of bring that up, especially with pregnant, expectant mothers, is saying, "My experience has been the number one value and concern of pregnant mothers is not to threaten this pregnancy. Anything that has a chance of harming the pregnancy, we're not doing. We're not on board." And so they smile and they're like, "Yeah, that's exactly how I feel. I really care about this baby that's growing inside. I want to make sure the baby's safe and protected." And I say, "And usually the number two value is once this baby's born, I want this baby to be safe."

               And sort of it gets them in sort of naming their values and then saying, "This vaccine actually does align with that because it keeps you safe with making sure that you're less likely get severely ill. And also that you get to make these antibodies and passes antibodies on to your baby, so that your baby's protected once they're born." And so I think really being able to normalize and express the concerns as legitimate concerns and still provide information for why even taking those consideration, the vaccine still may be in alignment with their value and their best interests can be really helpful for patients to get what is truly going to allow them to have the best outcome that they're looking for.

Timothy Ott, DO, FAAFP (06:07):

Thank you, Dr. Wheat and Dr. Smyre. Second question is about frustrations. How do we keep up with the ever changing recommendations on the vaccine? To you, Dr. Davis.

Kristin Davis (formerly Drynan), MD, FAAFP (06:18):

Hi there. I'm Kristin Davis and I am on staff at the west region of Advocate Aurora's Health system, so serving in a larger service area capacity. Used to be in private practice seven years ago and celebrating 20 years in practice this year. Also serving as the current Illinois Academy of Family Physicians Foundation board chair. Part of that brings me to the frustrations that we have in a bigger health system, but even with the bigger health systems, staying on top of the recommendations is difficult. I think that it just goes to show you that if you look at some of the resources that come in that we use as physicians day to day, and for instance, I will check my email as I did just before this podcast. And one of those emails comes from the Family Medicine SmartBrief, and it's a great resource for trying to keep up with the current changes on everything.

               But one of those frustrations tends to be that everything changes day to day, like I said. So it gets very, very confusing for patients and for physicians themselves, even if you feel like you're on top of everything. One of the things that I saw the other day was a current CDC recommendation that is about considering waiting eight weeks for ages 12 and up between doses one and two, especially in males between the ages of 12 to 39. And the reason for this was possibly to avoid the already very low risk of myocarditis changes. And that there just changes the conversation again, back to what Dr. Smyre and Wheat were already alluding to trying to reaffirm that these vaccines are good and they're promoting health and they're preventive and they're keeping us out of trouble and the more that we can get with this the better. But then the skeptics step forward and say, "Okay, well now this just proves that you don't know what you're doing," and you sort of have to start from scratch.

               And we, as physicians, know that's not true. We know that as we move forward day to day, studies move forward day to day, and we change our guidelines just as we do for the frequency of mammography or the frequency of Pap smears. Yet we still have patients coming in that want more, instead of less of certain things, even if the guidelines have changed. So part of the frustration, even in a larger system, being given this is how we're going to do things, which is what tends to happen in a larger health system, rather than having some of the control over how you vaccinate in the office. Having those conversations and having the time to go through all of those changes and keep up with them, it's frustrating wherever you practice.

Timothy Ott, DO, FAAFP (09:38):

Thank you, Dr. Davis. Dr. Smyre, do you have something to add?

Christopher Smyre, MD (09:43):

Yeah, I know it's going to be very challenging and frustrating and for me, first year out of residency and in the pandemic, a lot of my mentor advisor, my program director, Dr. Wheat___, he was like, "That first year out is another steep learning curve, that you are going to go through. You're going to learn all this information about how your style is going to develop." And as I'm figuring out my own style, without that safety net in place anymore, all the recommendations are changing. And what I found so helpful was having more senior faculty, more experienced people who were staying up to date, who already had their resources and knew how to quickly search through it, to then send out either morning email saying, "Hey, here are the current guidelines for our clinic. Here's the reasons why, real quickly. Email me and we could talk more if you have questions in understanding that."

               And so it really offloaded some of that expectation and pressure because instead of trying to figure out where to look, is this still accurate, I just knew I could go to the medical site director and say, "All right, what are the rules for today when I see people?" And that just made it such a more simplified process. But then also on the positive side and sort of looking at the cup half full, all the changes led to a lot of opportunity. So where are we looking at? Let me try this time. And give me a lot of practice reps to familiarize myself with the CDC website, which I never really had to get as integrated into my workflows, as far as resources, as I have now, and really starting to build my own comfort with okay, I can go here and I can look.

               This is sort of how I can know if this is still accurate or when this is sort of timestamped to be sort of up to date. And that's something that I think, like any other tool, the more we practice and use it, the more quickly we can navigate it and the more familiar we get with it. The pandemic has given us a lot of opportunities to become familiar with a lot of resources and websites and tools.

Timothy Ott, DO, FAAFP (11:34):

Thank you, Dr. Davis and Dr. Smyre. Our third question is about frustrations and barriers regarding the decision making process and who gets input as clinicians to offer the vaccine and what can you do within the constraints you may have in your practice area. Dr. Wheat, you want to lead us off on this one?

Santina Wheat MD, MPH, FAAFP (11:55):

I would be happy to. I am, as I mentioned at an FQHC and we're a fairly large FQHC and we were fortunate to be amongst the early rollout of vaccines. And so it was a very, very strict rollout and who could be vaccinated, how that could happen, where it was happening, what locations, et cetera. And so at the very beginning, we were just thrilled to have a vaccine, though there didn't feel like there was a whole lot of control over it. What we could control though was we could specifically reach out to patients ourselves and say, "Hey, you're eligible for this. Let me get you scheduled today." And also we could identify people and know that maybe they were closer to this site or that site.

               And I was able to have my team, I work as part of a medical team as caring for patients living with HIV, we were able to specifically pull those patients that were at the highest risk and have straight conversations with them about what they needed and when they should come in and if they should come in person or not, but which site was the safest for them to get their vaccine at. And so a lot of it has been navigating how can I do specific things for my patients and make them feel like they're having the personal touch along the way? Fortunately, some of this has gotten a little bit more flexible. We now have it in my own office and we're able to offer it at the end of an appointment. And so it's been more control of when do we know that the patient has had the vaccine? How can we ask them for it? And thinking about how do we load their vaccine into the system? There's been a lot of frustrations about the system that we have to use, the I-CARE system.

               And we did really learn that we could use some of the experiences that we had had previously with our children who were getting vaccines for children and the problems that we had had with that system before, we were able to use some of those lessons learned to help us to do this so that we didn't feel like we were trying to reinvent the wheel or struggle along the way. And so I guess the things that I could control were how I spoke to my patients and how I'd get them in. And then just sort of rolling along with the process. Like Dr. Smyre said before, everything changes on a daily basis and so just sort of rolling with those processes the best we could.

Timothy Ott, DO, FAAFP (14:18):

Thank you, Dr. Wheat. Dr. Davis?

Kristin Davis (formerly Drynan), MD, FAAFP (14:20):

Yes. I think that as I alluded to in the larger health system, there's a little bit of lack of control as to the information that's being put out, but also the control of how to get the vaccine in your office. So where I work, for instance, it's still not available and I'm at the whim of the system for getting that into my office. But the positive part of that is there is now a little bit more time because I'm not actually providing it to discuss it, which is also part of my day to day with each patient. So if they've had the vaccine, I confirm that that is actually true in Epic.

               That's the system that we are using. If they have had part of the vaccine, which I consider boostered as having had the vaccine, but if they've been, say vaccinated one or one in two, depending on what was required in that booster, then we bring up the topic of why and again, as we talked about before, what their thought process is, and trying to convince them to rethink and why that would be the case. As far as the upside as well for not having that decision, making it also relieves me of that pressure of needing to figure out how to keep up with any changes that would happen with the vaccine itself. But I would much prefer to be able to say, "Okay, since we've talked about it and I think I've got you now, can we just do it now while you're here?" I don't have that at my fingertips, which I really would wish for.

Christopher Smyre, MD (16:12):

Yeah. I really can appreciate that because at our clinic we do have it available and so a lot of times after having that conversation and answering other questions, they're like, "Okay, I'm going to do it. I can do it." "Great. Go right out front. We'll get you added to the schedule today and go ahead and get that done," or, "I just want to think about, I'm not ready today, doctor. I just need a moment to mentally prepare myself before I get it." And I was like, "All right, I'm going to see you back in two weeks anyways. We'll go ahead and get you on the books, so you'll get that. Then you'll see me and I'll be observing you to make sure everything goes smoothly like we anticipate it will go." And sort of having that reassurance that you're there physically with them for any active responding to perceived concerns and answer those questions.

               "I got the shot. How do I feel?" Or, "Doc, I'm feeling this. Is this the shot?" And it's like, "No, it's just a little itchy. It was cold outside today." Can be really helpful for patients in reassuring them and sort of be with them where they are. I know one of the things that I was very appreciative about in our institution was that even our administration were trying to figure out how do we do this? What input, what suggestion does everyone have? This pandemic with just staff hiring and being understaffed sort of causes us to have to rethink at multiple stages. How can we be effective and efficient with who's here? That open dialogue was really important to me because at our institution, our Dean declared in 2019 that we would be anti-racist. And so really thinking about how can we make sure, especially early on when there's a limited supply, that we're administering and offering in an equitable manner?

               And so through conversations, we were talking, like Dr. Wheat had mentioned, to our patients to sort of create our own list of who's agreeable to it per the age restrictions and conditions. But then after we got that, one of the things we realized was that usually those who are most vulnerable aren't really thinking about this vaccine because they're worried about more immediate concerns. And so they may not be calling us to say, "Hey, is that side available now?", because they're worried about what am I going to do tomorrow or eight hours from now. And so with that in mind of the different social challenges that our patients experience, what we did was after we got that general list, we then reranked it, as well as we were very intensive at reaching out to all of our minoritized and marginalized patients to make sure that they were aware of it.

               And then based off of age, race, which was seen as a factor for morbidity mortality, we actually reranked based off of that and then sort of started calling people from the top of that reranked list so that we had a more equitable distribution of the vaccine when they were limited. I'm so happy now that that is no longer stuff that we have to worry about because we have the larger supply. And now it's just a matter about making sure that people understand the importance of it and our agreeable to get it.

Timothy Ott, DO, FAAFP (19:03):

Thank you, all, for that. Our next frustration barrier is that the urgency of the vaccine is decreasing. Dr. Davis, you want to lead off on this issue?

Kristin Davis (formerly Drynan), MD, FAAFP (19:15):

Yes. I think that the perception of patients, and I can speak to just this last week, which has been more than the week previously, which has been more than the month previously, is that the urgency for getting vaccinated is declining. And I think that that's an obvious product of Omicron and it's declining rate, but also that the vaccinated population, as well as some of the unvaccinated population, had a better time with COVID overall, seemingly. And this part of the complacency is part of the frustration in and of itself in now trying to carry the vaccinations forward. So where patients were getting vaccinated more urgently, as vaccines became available and there were lines for it, couldn't find it, et cetera, it's become more lax.

               And so I think that's part of the day to day talking points and trying to encourage people to complete their vaccination process, or again, if they are disinclined to become vaccinated because they had COVID already and "did fine", that's another challenge that I think we all are presented with. Patients are back to thinking too, that infection equals long term protection. And as we all know, that's debatable based on the studies so far. And the current polls are showing declining percentages of people that are feeling that it's important to get their children vaccinated. So even again, just this last week, the rates of vaccinations are starting to go down, especially in kids where they might not get that done at all or get one and stop. The family got COVID at Christmas. I hear this all day long. "Well, we all had it at Christmas," and then we have to start the conversation over again that that's just not enough. So I think that's an important thing to keep addressing and to have where we, as physicians, don't become lax about it as well.

Timothy Ott, DO, FAAFP (21:38):

Thank you.

Christopher Smyre, MD (21:38):

I think that's a really great point.

Timothy Ott, DO, FAAFP (21:39):

Dr. Smyre?

Christopher Smyre, MD (21:42):

I think that's a great point, Dr. Davis, about making sure not only thinking about patients maybe becoming more comfortable, but also providers. We have residents that we work with and I feel like all the residents, at this point, know if I am supervising them for the clinic, that I'm expecting to have asked. And if the answer is, "No, I haven't got the vaccine," to be able to explain their value and their reason and rationale behind it. And so to the point now where sometimes they'll come in, "I'm sorry, Dr. Smyre, I didn't ask them. I'll ask the next one about the COVID vaccine." But just making sure that they understand that we are still in the pandemic still, so it is both an acute concern and also it is preventative once we're done with the pandemic.

               So at every visit, that is a relevant talking point, whether it's a preventative visit or an acute visit. I think the more that they sort of build that into their own habit training, the more they practice and also the quicker they come and they realize that having these conversations doesn't have to take an extended period of time, but that we can sort of practice and refine and become efficient at asking, understanding, clarifying values and moving on to other concerns that the patient or the provider may have.

Timothy Ott, DO, FAAFP (22:56):

Thank you, Dr. Smyre. Dr. Wheat?

Santina Wheat MD, MPH, FAAFP (22:58):

I really appreciate those points. And I will just add that I think that some of our physicians have become a little bit lax about this. I don't think it's just the residents. I think that some people are now assuming that if somebody hasn't gotten a vaccine yet, that they're probably just not going to get it and that's just not true. I think that there's some people that have just been waiting to see how the rest of us did with this vaccine and so there is something to be said for that. We had, earlier this week in clinic, there was like little cheer that went up in our provider room because somebody got their first dose of the vaccine during the day. So this is still a conversation that's worth happening. I will also add to what Dr. Davis said.

               I've had in my personal circle, questions about, "Oh, well, did you see that article in the New York Times about the vaccine and how it's not really helping children?" But I think that it comes back to in part that it's not just that we're saying that people aren't going to get COVID with the vaccine. We're saying that people are not going to be seriously sick. And so I think reshaping that conversation of, "We're not saying you're never going to get it, but we would like to keep you out of the hospital. We would like to keep you as healthy as possible. We would like to make this, if you get affected, to impact your life as little as it can. We still want to protect you." Reshaping that conversation and continuing to have it are those things that we still need to do for our patients who have not yet gotten boosted or have not gotten their first doses yet and that have young children that maybe are just turning five or that haven't yet gotten it and are over five.

Kristin Davis (formerly Drynan), MD, FAAFP (24:37):

I think that its-

Timothy Ott, DO, FAAFP (24:38):

Thank you, Dr. Wheat. So this is the first in a series of podcasts to address issues around the COVID vaccine. I hope you learned today that we all face frustrations and barriers. And to close, would like to address some of the things that we can and can't control. From a perspective of the small, private practice doc, I'd like to say that one of the things I'm hearing from small private practices is that they don't have access to the vaccine, or they can't get small enough quantities of the vaccine. So that's not something you can control, but hopefully there's a larger medical institution nearby, or a health department or an FQHC that you can partner with to get the vaccine for your patients. So we plan on addressing those sort of issues and additional podcasts. Dr. Wheat, any closing comment?

Santina Wheat MD, MPH, FAAFP (25:36):

Yes. Thank you. I would say that one thing that we as physicians can really control is the conversations that we have with our patients. We can always ask our patients if they've been vaccinated and ask them where they are in their thought process. That is something that we can always control. If we don't know that they have it, we can ask them, "Oh, did you get it?" And if it's not showing up in our system, add it in ourselves so that we have that information there. There's nothing like always asking that question and just sort of reminding your patients that you care because maybe one day they'll be ready, like Dr. Smyre was mentioning before.

Timothy Ott, DO, FAAFP (26:12):

Thank you, Dr. Wheat. Dr. Davis, closing comments?

Kristin Davis (formerly Drynan), MD, FAAFP (26:15):

Yes. I think it's all about the conversation as well and somehow fitting that into each visit, whether it is for an acne recheck or for their wellness visit. I think it's important to be tackling this every single time that we have an opportunity and trying to continue to convince patients not only who are relatively well, but for the sake of our immune compromised population and those who are yet to be born, et cetera, that it's important that we all keep in mind, everyone else, as well as themselves and their family in the decisions that we make and answering all of the questions that we can to try and make them feel more comfortable. I also think that it's very important to include yourself as an example. So not just saying, "Hey, I'm vaccinated because I work here or because I was required to be," but saying, "I'm vaccinated because I believe in it and I wanted to be. My son is vaccinated. My daughter's vaccinated," et cetera.

Timothy Ott, DO, FAAFP (27:30):

Thank you, Dr. Davis. Dr. Smyre, closing comments?

Christopher Smyre, MD (27:34):

I think the only thing I would like to add is that this pandemic has been laced with so many challenges and frustrations for people, human beings, in general, and especially for my fellow providers and some other healthcare workers. Appreciating the stress that it may have and not getting bogged down or feeling like you're the only one that's frustrated with some of the inefficiencies or other challenges that you may have within your area of practice. But I hope that hearing from all of us today allows you to know that it is very normal to have these frustrations. And sometimes you just have to laugh at it because it's so frustrating, but it will get better with continued thought. There's been so much progress in our understanding of this virus and creating the vaccine. And with more time, we'll continue to become more efficient in how we administer it.

Timothy Ott, DO, FAAFP (28:31):

Thank you, Dr. Smyre. Thank you everyone for listening and I hope you tune in for future podcasts and I hope that we help you understand the vaccine. Thank you.

Speaker 1 (28:48):

Thank you to our expert faculty and to you, our listener, for tuning into this episode. If you have any comments, questions, or ideas for future topics, please contact us directly at podcast@ilvaccinates.com. For more episodes of Beyond the Needle, please visit IllinoisVaccinates.com/podcasts. You'll find links to resources, transcripts, speaker disclosures, a survey to gather your feedback and instructions to claim CME credit. Subscribe to this podcast series on Healthcare NOW Radio, Spotify, Apple, Google Play, or any of the major podcast platforms. Please follow the Illinois Vaccinate Project on Facebook, Twitter, Instagram, and LinkedIn. Thank you, again. We hope you tune into our next episode.