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I am William Callahan. I'm with Thomas Jefferson University Health. I'm at their Abington location. And we're gonna talk about the primary care conversation with regard to vaccination of adult patients. These are our objectives. We're really gonna focus on individual and systemic barriers with regard to giving vaccinations to patients and ways that we can address those barriers to encourage our patients to get vaccinated. I have no financial disclosures for this talk. So, when it comes to patient vaccinations, there's particularly adult patient vaccinations, when we look at the multiple factors that are related to this conversation, the number one thing that is going to drive patients to get vaccinated is the conversation they have with their primary care provider. Now, when it comes to that conversation, of course, part of the issue is reminding the provider to have that conversation. So, what is it systemically or systematically that is in place to remind the provider to give the vaccination? Um, particularly looking at the EHR, right? The electronic health record, and then what type of workflow is set in place. So if the primary provider doesn't do it, uh, who else is in place that might be doing it, right? Is a nurse at the practice offering it? Is, uh, is the pharmacist who may be working with that provider doing it? Is someone in the emergency room who may be seeing that patient doing it? But we do know that in primary care, this is a major conversation, right? Because the goal of primary care is primarily primary prevention. So if we can prevent disease, particularly infectious disease, we're really doing our patients a favor. So, we know that that really needs to be a focus in primary care, but there is Issues in primary care, you know, and I know that I am in primary care, so please, you know, don't think I'm picking just on primary care. I'm saying this from experience, right? One of the biggest things is that we have time pressures, right? We have maybe 20 minutes to see a patient for an annual physical or, you know, maybe even less time to do an acute visit, right? And then A visit would be anything that's not an annual physical. So that could be following up things like diabetes, hypertension, hypercholesterolemia, all in one visit, and as well at that same visit as addressing any concerns that the patient may have. So, sometimes when you're doing that, you don't also then feel that you have the time to sit and have a discussion about vaccinations. In addition, we live in a world with a ton of information available at everyone's fingertips. We have modern media, alternative media, social media, we've all these different medias coming together, which, unfortunately or fortunately, gives a lot of information, and I, I say unfortunately because a lot of it is misinformation. And uh we then have to deal with that when our patients bring it up, you know, they will say, well, I've seen this about vaccines, or so and so said this about vaccines, and, you know, we really need to then sit there and take the time to address that. And sometimes we're really not sure what to say, right? Someone may say something, I'm really just not sure what to say next. So there's a lot of pressure on primary care, and as a result, You know, it really does affect our ability to then recommend vaccines. To look at this, we're gonna talk about a patient, Mrs. Williams. She's 55 with a past medical history of type 2 diabetes and hypertension. Uh, she's currently due for her COVID-19 booster, her pneumonia vaccine, and her shingles vaccine. She comes from a low-income neighborhood. She is intermittently insured, and as a result, has not been filing with one provider specifically. She's been seeing multiple different providers at the same clinic. It's a very busy clinic, and she's always seeing someone different. Uh, she does have a history of medical mistrust, and she is regularly engaging with, uh, different websites that are providing online misinformation about, uh, medicine. And she's also received an inconsistent tone from different clinicians. In other words, she sees one, maybe there's some good chemistry there, but she doesn't see that person again. She then sees someone else and maybe doesn't feel the same connection with that person. And maybe part of that is what she is feeling and hearing at that visit. So, we're gonna look at 3 different visits here. We're gonna say that at each visit. She is offered a vaccine and she turns it down. So during the first visit, she gets a very dismissive approach, right? That person says the science is clear, you're overthinking it, and very much just sort of shuts the door on her concerns. Then the 2nd visit, again, the recommended vaccine is brought up, and this person then says, well, it's up to you, we can talk later, very much gives a shoulder shrug to her concerns. In this particular visit, though, the pharmacist later follows up and gives a very, you know, strong recommendation to the vaccines, but this leaves the patient confused, where the patient, looking at the two very different, uh, recommendations, one that is essentially a shoulder shrug, and the other is much stronger, she doesn't know what to believe, what to trust, so this leaves her very confused. And then the third visit is a very empathetic visit, right? She's, she is told this patient, Mrs. Williams, is told, tell me what worries you most about these vaccines, and that person takes the time to sit with her and really listen to her concerns. We have a question now regarding Mrs. Williams. Which factor most contributed to Mrs. Williams' continued vaccine refusal across visits? Is it A, dismissive language in visit one, B, you're overthinking it, damage trust early? Is it B, inconsistent messaging across PCP and pharmacist visits widen the perception perception gap? Is it C, there's no structured immunization check during chronic care visits, which left gaps invisible, or is it D, pre-existing medical mistrust and online misinformation were never directly engaged. So please lock in your responses. OK, great. Uh, now we're going to delve a little deeper into each of these. So, why did this happen? Well, again, we do know that there's an increase in adult vaccine uptake when, 1, recommended by primary care providers, but 2, that there's a bundle bundled workflow change in primary care. Things like reminders, prompts. Um, as well as the, the provider actually giving a recommendation on what to do. Now, those reminders and prompts are more for the provider to remember to do this, because again, we have a very busy schedule, and so having something in our electronic health record reminding us what to do is really helpful. So, again, we have patient factors, we have systemic factors, just looking at a few of these. So, Mrs. Williams' 3 visits really show us how PCP level pressures really do compound patient level barriers. So, Looking at the first visit, that confrontational visit, being curt or dismissive with a patient really doesn't help things, right? That just really sets the patient further in their mistrust, right? And, and can really damage future trust building. And then we have the inconsistent voices. So this would be the 2nd visit, right, where the PCP basically gives what I call the shoulder shrug, right? I mean, they're not physically shrugging their shoulders, they're just really showing indifference, and then the pharmacist is framing it much more strongly, but this leaves the patient confused, right? The patient doesn't know really what to believe because they're hearing two very different opinions on the same topic. Then we have that historical mistrust, right? That mistrust which has developed both historically, but also from what the person is reading online, and it's never been addressed, right? Everyone's just been overlooking this, and then we have those workflow blind spots. So, we do know that the person may or may not be showing up for regular uh annual visits, but they are coming in for chronic care visits, which are dominating what's being discussed. And as a result, there's really little focus on adult immunizations, and what we also need to look at is, is there a reminder to the provider that they should be doing this, because if there is, that's of course going to improve the likelihood that they have this discussion. So, looking a little deeper into these barriers, the dismissive or confrontational default, right? So this is the visit of the science is clear, you're overthinking it, right? That really shuts the door on the patient. The patient says, I don't want to get the vaccine, I'm, I'm concerned. And for someone to tell that patient, you're overthinking it, the science is clear, it really dismisses their concerns, right? It really says that, you know, what you're saying doesn't make sense and we shouldn't discuss.