The Flu Shot and a Patient’s Right to Choose

Jennifer Anyaegbunam is a Fellow at The American Resident Project. Her post appears on THCB as part of The Health Care Blog’s  partnership with ThinkWellPoint.  Stay tuned for more. Follow the American Resident’s Project on Twitter @Amresproj.

I’ve spent the past four weeks learning about primary care on my Family Medicine rotation. A significant portion of patient care in this setting is focused on “health maintenance” or disease prevention.

Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.

According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.

Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?

I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.

This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.

Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.

“I see you have not received a flu shot this year, Ms. Jade. Would you be interested in receiving this vaccine today?” I asked. As soon as I mentioned the words “flu shot,” she became flustered and stated that she was never going to get it. Given the fact that she had received all of the other recommended vaccinations, I was surprised by her reaction. I proceeded to ask her why she wanted to decline the flu shot.

“Well, I’ve never gotten the flu in my entire life,” she explained. “I never even catch colds.” I told Ms. Jade that most people don’t get the flu, but that if you happen to contract it, especially as an elderly person, it can be quite bad. The flu shot protects you because it helps your body develop antibodies to fight off an infection, if you got one.

Ms. Jade continued to shake her head and said, “My brother got the flu shot and then he got sick and died.” I immediately understood that Ms. Jade was not concerned about her odds of catching the flu. She was afraid of the vaccine itself. In her mind, the vaccine killed her brother.

“Ms. Jade, I respect your right to refuse the vaccine. It is absolutely your choice, but I wouldn’t be doing my job if I allowed you to make decisions without all the facts at hand.” I tried my best to explain to her that correlation does not imply causation –that just because her brother received a flu shot before he died, does not mean that it led to his demise. “The viruses in the flu shot are dead, so you cannot catch the flu from the vaccination,” I said. “At worst, the side effects include soreness or aches at the injection site and a low grade fever.”

I asked her if that sounded reasonable. “Yes,” she replied, “but I still refuse to get the flu shot.”

Patients, are there instances where you feel like your physician is infringing on your right to choose your care? Is there a right way and a wrong way to communicate medical recommendations?

Physicians, did I adequately address my patient’s concerns? Did I fulfill my obligation to provide my patient with all the information she needed to make an informed decision?

Jennifer Anyaegbunam is currently a third year medical student at the University of Virginia School of Medicine and a Fellow of The American Resident Project, where this post originally appeared. You can follow the American Resident  project on Twitter at @Amresproj

12 replies »

  1. Thank you Joe Rickerson for the link. Below is a quote from it:

    “Last month,, in a step tantamount to heresy in the public health world, scientists at the Center for Infectious Disease Research and Policy at the University of Minnesota released a report saying that influenza vaccinations provide only modest protection for healthy young and middle-age adults, and little if any protection for those 65 and older, who are most likely to succumb to the illness or its complications. Moreover, the report’s authors concluded, federal vaccination recommendations, which have expanded in recent years, are based on inadequate evidence and poorly executed studies.

    “We have overpromoted and overhyped this vaccine,” said Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy,
    End of Quote

    It is shocking that so many “expert” medical recommendations are not based on well designed randomized control trials….but are simply the supposedly scientific consensus of the “experts”. I had always assumed that the flu vaccine was well studied…as in this case it is quite simple to conduct a randomized control trial.

  2. I think it’s great that this medical student is focused on listening and understanding how her patients understand health and healthcare.

    That said, since the evidence for the flu shot in older adults is pretty poor, when I was in primary care, I offered per CDC recommendations but I didn’t push it much…there are plenty of clinically more relevant patient concerns to unpack and explore.

    I think it’s more useful for family caregivers, clinicians, and other young/middle-aged people who come into contact with the elderly to get the flu shot.

  3. “This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol.”

    “Ms. Jade was on track with everything from her annual vision screening to her colonoscopy.”

    I wonder how old this “elderly woman” is? Could be she’s being over treated. Has her cholesterol been tested to see what type of LDL it is? If she hasn’t had the flu her entire life I’d say she’s doing just fine without medical intervention.

  4. I won’t get one either even with no frightening correlational anecdotes. They make me sick and usually are limited in the flu antibody types they produce.

  5. Exemplary physician-patient encounters, as yours quite clearly was, do not always result in optimal outcomes for patient or society.

  6. The H1N1 going around this year appears to be targeting children and young/middle aged adults – not the elderly as it would appear that the elderly have had some exposure to the strain in the past.

    An interesting study would be to see how many of those that died had a flu shot versus not given that this year’s vaccine does include H1N1.

    This said if someone has gotten very sick when they’ve had the flu shot and not when they haven’t are they really acting based on misinformation or irrationally?

    At the end of the day, I think a lot of people either think the flu shot is ineffective or they simply mistrust govt. and big pharma. As for mistrusting one needs to ask the question why.

  7. Nicely handled. If only more doctors were that respectful and thorough. Every one, with the exception of my internist, has met my reservations by ignoring them or giving me a good talking-down to. A nonsensical rebuttal of what the doctor thinks is the most common related old wives tale does nothing to help a patient understand the real risks involved with a procedure.

  8. I think you did fine, Jennifer. As mentioned, the evidence is thin, but the scientific rationale is very strong, and if patients believe they are going to be helped by the vaccine then they might ACTUALLY be helped… because of placebo effect. We think this is a real phenomenon owing to cytokines, endorphins, and other molecules put out by a hopeful brain.

    If there were significant side effects from the vaccine then the placebo argument might not be powerful enough.

    You don’t want to urge folks too much to do what you feel is the scientiflcally
    correct thing. They may have some powerful phobia that could cause the exact opposite of a placebo effect and they could release some catecholamines that could cause a fatal arrhythmia or a hypertensive episode. Not good.

  9. You did the best you could Jennifer. Lots of misinformation regarding the flu shot has caused unnecessary fear for many. Sadly this years flu is very strong as my daughter is attending the funeral of a twenty-eight year old friend who passed away from the virus this week. People need to stay home when they are sick and wash their hands MUCH more often.”