Earlier this year, my home shop began administering the Johnson & Johnson COVID-19 vaccine to patients in the emergency department (ED). Thirteen years of experience in emergency medicine has afforded me many opportunities to counsel patients on lifestyle modifications, death and dying, tPA administration, and many other complex medical issues. However, I’ve never experienced a more polarizing topic than the COVID-19 vaccination.
My initial attempts were met with a few quick wins. While in fast-track, a middle-aged Hispanic man presented with an injury to his left knee. I suspected a patellar tendon rupture, and while we waited for the orthopedist to evaluate his knee, I offered him the COVID-19 vaccine. He smiled acceptingly and slapped his left shoulder with his right hand, signaling the location he wished to receive his vaccine and said: “Yeah! I’ll take it.”
“I want it too!” His wife exclaimed. Though not yet a patient, she sat patiently at her husband’s bedside, awaiting the orthopedists. She was quickly registered and vaccinated.
Then the “No’s” started to come. An elderly African-American woman with a history of obesity, non-Hodgkin lymphoma, hypertension, and diabetes presented to the ED for medical care. She was the exact person predicted to suffer if afflicted with COVID-19. However, after nearly 15 minutes of explaining the potential risks, benefits, and adverse outcomes of vaccination, she said “No.” She called her son, who was not in the medical field, and he advised her against it. She exclaimed that she was not prepared to make that decision today.
In retrospect, I was unable to convince a single person to be vaccinated. Every person vaccinated that day already made the decision and just needed the opportunity. If I cannot persuade patients to vaccinate in the middle of the worst pandemic in our lifetime, this is a problem that requires immediate remediation.
Birth of a Salesman
- Do you earn a living trying to convince others [or move others toward action]?
- Do you work for yourself or run your own operation?
- Does your work require elastic skills—the ability to cross boundaries and functions, work outside your specialty, and do various things throughout the day?
- Do you work in education or healthcare?
According to Daniel Pink in To Sell is Human, if you answered yes to any of these questions, you are a salesman. Never has this been more evident in the medical field than now. Almost daily, I’m involved in some conversation attempting to persuade patients to vaccinate. However, aside from the pandemic, we often ask patients to lose weight, eat healthy, exercise, quit smoking, give up illicit drugs, practice safe sex, take medicines regularly, etc. Pink refers to influencing, persuading, and moving people to part with something of value, be it effort and attention, as “non-sales selling.”
Information asymmetry
Medical information was once held exclusively in textbooks and medical journals. This knowledge was privy to the select few in the medical community. When we had questions, we read page after page of dense text from a 10 pound Rosen’s or Tintinalli textbook. Knowledge translation was extremely slow. However, the internet created a democratization of medical information, and information is now instantly available to all.
Information asymmetry historically fostered a paternalistic patient-physician relationship, where physicians made the medical decisions for patients. However, with information widely accessible, the relationship is now one of shared-decision making. We accept that patients will attempt to self-diagnose with an internet search before visiting a physician. Expectedly, some patients may need counseling on stump appendicitis or some other rare disease bestowed upon them by diagnosticians at Google. Occasionally, we will order that x-ray the patient requested to help assuage some concerns. Overwhelmingly, this is a good thing; when patients are vested in their health, it becomes easier to move them towards evidence-based recommendations and ultimately better health.
A Pandemic of Misinformation
The internet and social media have become a breeding ground for medical misinformation. Patients searching for medical information can easily be lead astray to a site or social media post containing misinformation. What’s more, content-personalization algorithms and an army of bots increase views, likes, and retweets which can exaggerate the reach of the content creating the false perception that fringe views are more widely excepted.
These algorithms are incredibly successful at manipulating the masses. Ask yourself these question:
- Have you ever purchased a product after checking the reviews?
- Did you watch a video because it had thousands of views and likes?
- Did you read a story because it was retweeted hundreds or thousands of times?
On the contrary…
- How likely are you to purchase a product that had zero reviews?
- Or watch a video with zero likes?
- Or read an article with zero retweets?
A Call To Action
Previously, we in the medical community ignored misinformation. We opined that addressing misinformation would fan its flames, potentially igniting the spread. Thus, we steadfastly ignored the inflammatory rhetoric. However, as death tolls continue to mount during the COVID-19 pandemic, we are witnessing the repercussions of this blissful ignorance.
We must meet people where they are. We cannot bring back the walkman or the VCR, and we cannot escape the boundless reach of social media and its ability to amplify every voice. Patients have questions about masks, hydroxychloroquine, monoclonal antibody therapy, cerebral venous thrombosis, and infertility after vaccination. We must address this misinformation head-on.
The internet and social media have also amplified the voices of the medical community. Physicians are more comfortable than ever using online platforms. What once was anathema to the medical community is now gaining wide acceptance and engagement. As the millennial generation and beyond become a more significant part of the medical workforce, digital platforms will be an even larger bullhorn to amplify our voice. However, having a robust online presence may do nothing to persuade at the bedside.
From Physician to FBI Hostage Negotiator
In this era of shared-decision making and misinformation, some encounters require a higher level of counseling and negotiating skills. Unfortunately, in healthcare, we get very little training in these areas. Our experience with counseling is mostly of trial and error. Additionally, we may also gain some expertise observing our senior medical educators.
According to Bill Gates: “The best way to solve a problem or achieve a goal is to find people who have actually solved that problem or achieved that goal.” Enter Chris Voss—a retired top FBI hostage negotiator with a unique skill set. In Never Split the Difference, Voss concretely describes tools that we can use in any of our high-stakes negotiations.
Mirroring
Mirroring is the imitation of speech patterns, body language, vocabulary, tempo, and tone of voice. It usually acts at the subconscious level and helps to establish rapport by signaling to the other person: “We are alike.” While mirroring involves both non-verbal and verbal communication. The mirroring technique consists of repeating the last three words your counterpart just said.
Voss details how mirroring will trigger your counterpart to elaborate and maintain the connection. With this elaboration, you may uncover some additional helpful information or specific concerns you can address and tailor your counseling.
- Physician: “We are offering the COVID-19 vaccine. Are you interested in being vaccinated today?”
- Patient: “No. But thank you. I’m not interested.”
- Physician: “I’m sorry. You’re not interested?”
- Patient: “No. I’m not interested. I heard that the vaccination costs thousands of dollars, and I can’t afford it right now.”
This dialogue seems silly, but it is an actual conversation I had with a patient. Even my mother did not believe the vaccination was available for free to all.
Voss describes mirroring as a four-step process.
-
- Apologize
- Mirror
- Wait
- Repeat
Apologizing and mirroring soften the question and present it as a request for clarification. Waiting is also a cue for elaboration. During elaboration, you may discover information that can help to remove a barrier. In the case above, the misperception the vaccine cost thousands of dollars was a barrier that we quickly eliminated.
Labeling
Labeling is another tool that we can use to help persuade. It involves naming and thereby acknowledging someone’s emotion. Labeling the emotion strips it of power.
When labeling, avoid using phrases with “I.” It can create the sense that we are more interested in our wishes than the patients. Voss says to begin labels with some variation of:
“It seems like…”
“It sounds like…”
“It looks like…”
- Physician: “We are offering the COVID-19 vaccine. Are you interested in being vaccinated today?”
- Patient: “No. But thank you. I’m not interested.”
- Physician: “I’m sorry. You’re not interested?”
- Patient: “No. I’m not interested. I read on Twitter the vaccination can cause blood clots.”
- Physician: “It looks like you’re concerned about the side effects of the medication.”
With this label, we hope to disarm the patient’s fear about potential side effects. Naming and addressing the patient’s fear creates empathy and allows us to move forward with evidence-based medical advice.
Calibrated Question
Calibrated questions can introduce a potentially confrontational statement but eliminate aggression. Voss recommends avoiding questions that can be answered with a simple “yes” or “no.” The purpose of the question is to engage your counterpart and inspire them to think and expand. Instead, start with “what” and “how.”
Questions I often ask patients are:
- “What is your biggest concern?”
- “What are you worried about?”
- “How can I help you?”
These questions often reveal vital information. For example, if you offer a vaccine and the patient refused due to allergy, it will likely halt the conversation. But, if the patient refuses after reading that Bill Gates is trying to microchip the world through vaccination, there’s a place for patient counseling and education.
Recently a young man presented to the ED with abdominal pain, nausea, vomiting, and diarrhea. Upon questioning, he described his ailment in great detail. Lastly, he added his symptoms resolved the day before arrival at the hospital. I used a label and a calibrated question to initiate elaboration. The patient then provided what Voss describes as a black swan or “pieces of knowledge that sit outside our regular expectations and therefore cannot be predicted.”
“It looks like you’re concerned about your abdominal pain. But your symptoms have already improved. What can I help you with?” I said. The patient reported that he missed two days of work and needed a work note. Can you foresee a scenario where this patient has labs, a CT scan of his abdomen, and stays in the ED for 5-6 hours? I certainly can.
Take-Home Points:
When we look at our profession through an objective lens, we are, in fact, what Daniel Pink refers to as “non-sales” salesmen. Whether it be with our patients, nurses, consultants, students, and medical residents, we ask others to part with effort, time, attention, and much more. The COVID-19 pandemic has highlighted the importance of learning, practicing, and improving these skills. Never Split the Difference provides countless tools that we can use in all aspects of work and life.
- Mirroring helps to quickly generate rapport. Repeat the last 1-3 words in a sentence.
- Labeling emotions can neutralize them.
- Calibrated questioning can help to localize and focus discussion and counseling.
References:
- Pink, D. H. (2013). To sell is human: The surprising truth about moving others. Penguin. [Link is here]
- Voss, C., & Raz, T. (2016). Never split the difference: Negotiating as if your life depended on it. Random House. [Link is here]
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie) and Anand Swaminathan, MD (Twitter: @EMSwami)
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