One rural doctor’s battle to vaccinate patients against COVID-19

Shawn Purifoy, MD, is director of a family medicine clinic in rural Malvern, Ark., population 11,000. Arkansas is among the 10 lowest states in vaccination rates, with 43% of its residents fully vaccinated, so the state’s physicians face an uphill battle in persuading patients to get vaccinated against COVID-19.

Purifoy’s clinic is part of a state-wide ACO that produced and aired a public service announcement urging Arkansans to get vaccinated. He spoke recently with Medical Economics about the reasons behind the PSA and other ways he tries to overcome doubts about COVID vaccinations. The interview has been edited for length and clarity.

Medical Economics: What’s the situation you’re seeing in your community and clinic in regard to COVID-19?

Shawn Purifoy, MD: We’re currently seeing a high rate of positivity in the community and our clinic as far as this most recent COVID surge is concerned. Our daily volume is way up. Our county is one of the leading counties in the state in terms of active cases.As you mentioned we have a low statewide vaccination rate, so all our hospitals are full and our ICUs are full of COVID patients. We’re really just topped out in terms of our capacity and what we’re seeing on a daily basis.

ME: Give me some background about the public service announcement you made.

SP: All these practices that joined in our effort are part of an accountable care organization that works with a company called Aledade. Aledade works with independents like myself and help us in the Medicare Shared Savings Program. So we already had this network of practices across the entire state who typically wouldn’t have known each other. Several of us were brainstorming one day about, “Gosh, what could we do about this low vaccination rate and this surge to get out in front of this?” Because as primary care providers we feel like we’re in the best position for a lot of these patients who are doubtful about the vaccine. And we thought it would be great if we could sort of announce that we’re out here and we’re in favor of the vaccine and we’re not some kind of big group or the media or what have you. We’re just your family doctor.

So one of the doctors in our group said it would be great if we could just make a commercial. I reached out to Aledade and they said this isn’t something they normally do, but this would be a service to our doctors and their patients so they agreed to help us with this. They reached out to a local TV station and we made our video.

We’ve been real happy with the results we’ve gotten. All of us are getting feedback from our patients that they’ve seen us on television. And Aledade’s been happy with it and wants to try it in other markets.

From early on we didn’t think that primary care was involved to the level that it should be when it came to vaccination efforts. And we really felt like if we’d had it early on we would’ve made an effort to reach out to our patients. And we’re still doing that, but because we already felt like we’re behind the eight-ball in this situation, we thought putting ourselves out there would be a good idea.

ME: How many members are in this ACO?

SP: We have multiple practices across the state and over 10 community health centers, and many of them have over 10 sites. So when we start looking at the actual number of sites on the ground we’re at about 150 or more across the state.

ME: That’s pretty good for a state the size of Arkansas.

SP: Yeah, even though we’re an organization formed to be in the Medicare Shared Savings Program, we also have contracts with Blue Cross/Blue Shield, we deal with Medicare Advantage, with Medicaid. So when you start looking all payer lives, we’re going to be bumping next year 300,000. That’s getting close to 10% of our state’s population.

ME: Do people say they saw the PSA?

SP: Yeah, and because they put me in it my patients are kidding me asking if I’m moving to Hollywood. I tell ‘em if this pandemic keeps going I’m looking for any off ramp I can find.

But we do get a lot of people commenting. And we chose to run this in the news spot hour of the central Arkansas TV station because again, we’re looking for that group of people we think are still on the fence. We know the people who look to see what the weather’s going to be every day, or what the local news is, those are the people that we feel we have the greatest chance of touching and encouraging to do the right thing.

So yeah, we’re getting feedback and it’s been congratulatory that we’re actually saying something. That’s the thing I think has surprised me the most, is how many people have said they’re proud of me and our group for taking a stand. Because at the end of the day, I think if patients won’t agree to get the vaccine, well OK. But they can’t disagree with being able to say that we’re doing what we think is right.

People respect that, even if they don’t agree with it. And mutual respect between doctor and patient is very important in the doctor-patient relationship, and we don’t think we’ve done anything to infringe on that. We’re trying to take a stand and say we think this is something that’s important for you; we have your best interests at heart. No one is incentivizing us to do this, this is just us speaking as a group, and I think people get that.

ME: About what percent of your patients, or your clinic’s patients, have gotten at least one COVID vaccination?

SP: I don’t know, and part of the reason is patients are getting those in so many different places. I think we as a group of clinics do better than others. Whenever patients come in we talk to them, to catch them at their wellness visit or when they come in for something else. Every one of them is getting the blitz of, “Let’s talk about this vaccine.” We try not to push in terms of being judgmental or too heavy-handed, but at the same time we don’t want there to be any mistake as to how we feel about it. And when we have a one-on-one conversation with a patient that makes a difference.

By and large patients, if they get a primary care doctor or nurse practitioner who they’ve been going to see for some time, then a trust gets built. And even if patients have questions and reservations, they value the opinion of someone they know in the field. So if I tell somebody, “Nobody’s going to be able to guarantee you that nothing will happen if you take this vaccine, all I can tell you is that I gave it to my children,” that might be the one thing that makes enough difference that they decide to go ahead and do it.

ME: What reasons, or questions, do people give, or do you hear for not getting vaccinated?

SP: The reasons run the gauntlet, from “I don’t let anyone tell me what to do” to “I don’t trust the government“ to, “I’m worried what the vaccine might do to me some day.” People don’t necessarily have questions that they’re ready with, but when you start having a discussion then they’ll start to ask some questions. For instance, we’ve tried to visit with patients about how these vaccines were developed so quickly and dispel some of the myths about corners being cut or they didn’t do all the testing they normally would.

Then we get a lot of, “I’m afraid if I give it to my daughter she’ll be infertile.” So we tell them the American College of Obstetrics and Gynecology recommends your daughter get it, and by the way, at UAMS [University of Arkansas for Medical Sciences] in Little Rock, last month 20% of their admissions for COVID were pregnant or immediately post-partum women. Or I’ve told them I have a couple of pregnant employees, and they both have gotten the vaccine.

So saying those things, or telling them I gave it to my 24-year-old daughter sometimes allows them to go “OK.” I use the example all the time that I could do all the research in the world to figure out how to redo the plumbing in my house, but at the end of the day I’m probably going to ask a plumber I know what he would do. And that’s the way we try to approach this as well.

ME: Do you find people are getting wrong information from social media? Where besides yourself are they getting their information?

SP: I do find that, but I try my best to steer away from the rabbit hole conversation of “what’s your source?” I had a patient in last week who told me they didn’t want to get the vaccine because they didn’t trust the government for anything. And I said, do you buy eggs and meat and milk at the grocery store? You know the government inspects all those things. You trust the government to make sure those things are safe for you. You trust the government to make sure your car is inspected so you don’t die on the interstate. You do trust the government, you’ve just forgotten the government plays a role in those things.

So when I can have that conversation with a patient, and say “What’s really bothering you is this is something new, and you’re getting a lot of different information from a lot of different sources.” And any time that happens, people will start to say—and I hear this all the time—I don’t know who to trust, you can’t trust anybody.

And I just remind them that’s not really true. If you trust me to know what we should do if we find cancer in you, or what you should do if we discover you’ve developed diabetes, then you probably need to trust me to help you decide what to do about a disease that’s killing Americans every day. Not just in places you don’t know, but in your church or at your work.

We’ve lost several patients in my practice during the pandemic, and once that information gets in the newspaper as an obituary then I can talk to other patients about it because it’s no longer a HIPAA violation. And once you can talk to them they may say “Yeah, I knew him, he worked with my brother” or whatever. And when you explain to a patient, “No one can tell you for sure what’s going to happen with this vaccine 10 years down the road, but I can tell you for sure what’s going to happen if you get the COVID virus because I’ve seen it and so have you,” that’s pretty powerful for a lot of patients.

I think we have a pretty good number of patients that are convincible, as long as you respect their questions and take some time to talk them through it then they can make, in my opinion, a good, informed decision. And that’s what we’re seeking.

There’s also a group that it wouldn’t matter what you did, they’re never going to take this vaccine and it’s not too difficult to figure out who those are within five minutes of starting a conversation. And we don’t keep banging on that door. We say, “if you change your mind, we’re here, we’d love to give you the vaccine when you’re ready.”

ME: Do a lot of your patients have comorbidities, making them more vulnerable to this

disease?

SP: Oh, yes. We’ve got a lot of high blood pressure and obesity and heart disease. So that’s just sort of a given. We’ve got a lot of patients with diabetes and hypertension, we’ve got a lot of heart disease here. We also see a lot of children on Medicaid.

At Arkansas Children’s Hospital they’ve been maxxed out, I’ve sent kids up there who couldn’t get a bed yet because it’s just been so busy. And the other side of that is we can’t get patients admitted to the hospital for normal problems. I tell patients, now’s not the time to clean your gutters on the ladder, or to break your hip, because there’s no place to go. People just don’t think about that.

But the biggest seller for us isn’t even the comorbidities, because you can tell those patients over and over they’re at high risk and it won’t matter. The biggest seller for me is telling them you can give this to your family and friends, people at church and work before you ever know you’ve had it. You may not care what it does to you, but would you care if you gave it to a friend who gave it to their mama, and she died? And when you have that conversation, you can see the look on people’s faces like “that’s not something I was thinking about.” Then sometimes you can gain some ground.

ME: Do you require your employees to be masked?

SP: Yes, absolutely, and everyone is vaccinated 100%. We had a little while in the late spring and early summer we weren’t having any positive cases and we let our employees start going without a mask when patients weren’t in the building. Then we started seeing the Delta surge we started wearing masks again and we’ve already had one of our employees get COVID. So we’re going to continue wearing masks until we see a pretty significant decline or we’re all able to get our booster.

ME: Do you require your patients be masked?

SP: Yes, and we’ll always have someone who gets angry or says they won’t come in. One of the benefits of being independent is you can say, “I’m sorry you feel that way but this is my practice and I’m trying to protect my staff and my other patients and it doesn’t matter to me if you like it or not, that’s our rule.”

I had a patient who tried to walk out of our waiting room, someone I’ve known since I was a kid. And he just said, “This is ridiculous, the governor says we don’t have to wear a mask.” And I explained to him if I came to his place of business and he required wearing a mask, whether I agreed or not I’d do it because I respect him. And he settled down and said, “You know, I just didn’t think about it that way, and I apologize.” And he put his mask back on.

So again, trying to be calm with people, and trying to explain your rationale is important. We’re trying not to shame people or tell them they need to do this or they’re dumb if they don’t. Regardless of my personal feelings, when it comes to being a physician and running this practice, we try our best to be as open to everyone as we can, as long as it’s safe for everyone else.

ME: Why do you think the vaccination rate is so low in Arkansas?

SP: I hear this all the time. People say, “I don’t go anywhere, I stay home, I keep my distance, I wear my mask.” And so people search for a rationale not to do whatever it is they don’t want to do, which in this case is getting the vaccine. And that does play some role, because as a rural state people get this feeling that “I’m not in the big city and I’m not around a lot of people and I don’t work in an office, so I should be OK.”

The second thing is there’s probably a lot of social media bias depending on where you get your news. A lot of our patients are pretty conservative, and if you look at the national patterns you see there tends to be less vaccination in highly conservative places than in liberal areas.

The other thing is, people don’t realize we have a hard time every year getting people to take the flu shot. Patients will say, “I never get sick, I don’t need a flu shot.” And you have to have a conversation with them that the reason we give flu shots is not just to protect you, it’s to protect the community. And you can talk about herd immunity all day, but at the end of the day people just discount that.

In a lot of their minds this is just another form of the flu. They’ve been told that on social media, and for the ones who have not had a friend or family member get really sick yet, it’s kind of like when you see something bad on television that’s happening in the Middle East, you shake your head and feel bad but unless you were over there it’s hard for people to have that “this really affects me” kind of feeling.

But more and more, we’re seeing patients saying “Yeah, I had a friend at work who died” and it’s sad that it takes that, but the more it happens, the more people start paying attention. And I think Arkansas wasn’t hit hard by the first round of the pandemic in 2020. That was a blessing but also a curse, because it did not spur a lot of people to get the vaccine.

Then once Delta hit we did see an uptick in vaccinations, but we were nowhere near where we needed to be in getting to that threshold of at least 50% and ideally more like 70% or 80%. And I worry a lot that people who’ve gotten the vaccine are still getting the virus because I’m starting to get that argument from patients: It doesn’t matter if I get the vaccine or not, I could still get infected. Then you have to have another conversation explaining yes, but it’s going to keep you out of the ICU and maybe out of the hospital and for sure keep you from dying. It’s just kind of exhausting after a while having to do that 20 or 30 times every day.

And that was another reason to put that public service announcement out. Last year, when the vaccine was just being released, I put out three little videos on my Facebook page explaining about the virus, how they made the vaccine so quickly and why I thought it was safe. And I did this because I was having to tell this story to literally every patient I saw and I just started saying, “Look at my Facebook page.” And it got 23,000 views. People wanted that information, and they still do. So we feel like the more we can sort of mass communicate, the better off we’ll be.

ME: Are you seeing any patients who’ve tried to take Ivermectin?

SP: Yeah, I have had some patients who’ve told me they’re doing that. Of course I advise them not to, and it can pretty quickly descend into not a good conversation if you’re not careful. So I really just try to keep it above board and say the treatments I’m going to recommend have been studied and endorsed by the vast majority of the medical community, and I’m not going to prescribe medication that’s not indicated.

A lot of times patients will ask why not, if that’s what I want? And I have to explain to them that my job is to first do no harm, and until I feel confident that a science-based endorsement from the FDA has said that’s a treatment we should use, then I’m not going to do it.

In Arkansas we’ve had a huge uptick in calls to poison control from people who’ve gotten sick after taking ivermectin, especially people who are going to the co-op or the tractor supply store and buying their own ivermectin, not even getting it from the doctor. And there’s a lot of danger in that, obviously. If someone does a study that shows ivermectin works then gosh, I’ll be first in line to start prescribing it.

That’s what I try and tell my patients when they say, “The government doesn’t want us to have it” and this, that and the other. Then you have to say, “Do you really think there’s something for me to gain by not giving you something that would help you?” It still comes back to that trust relationship. You trust me, I’m telling you what I think is right, and I’m not going to let any patient bully me into doing something I don’t think is right.

And I think my patients understand that. Do I know that some of them are still going to go out and buy it or get it from another doctor? Sure. I’ve never had an attitude of, “If you don’t do what I say you can’t be my patient.” I respect an adult’s freedom to make whatever decision they want to make. I just may not think it’s the right one. And I always have to put my head on my pillow at the end of the day with a clear conscience about what I’m prescribing and not prescribing, and I couldn’t do that if I was giving ivermectin.

ME: Do you ever find yourself getting frustrated or demoralized, or members of your staff? If so, what do you tell them? And what do you tell yourself?

SP: Frustrated, yes, but not so much demoralized because we still feel like if we can make a difference on a day-to-day basis for one patient then we’re doing some good. Frustrated, though, absolutely. I mean, if I had a nickel for every time I used the phrase “I just don’t understand why people won’t get their shot, why they won’t wear a mask,” I’d be rich. Because we run into that literally every day.

As far as the staff is concerned, we’re a pretty close-knit group and we’ve approached this pandemic from the get-go with the attitude that we have a service to provide to our patients and community by taking care of people. Not just the ones with COVID, but the ones who still have heart disease and diabetes and COPD and other problems that still go on even though there’s a pandemic. And if not us, then who?

So we have been very cautious, I’ve tried to be transparent with my decisions. If you asked my employees, most of them would say they feel safer here at the office than they do at home or out shopping even though we’re seeing COVID patients. Because we are really dotting our i’s and crossing our t’s and making sure we wearing our masks and gloves and doing our cleaning, so there’s a heightened sense of awareness about what we’re doing.

But we also tell our employees we understand that it’s tough. Several of our girls have kids at home, some of them had to take off last year when the schools were closed. We’re running into competition. Hospitals are offering huge signing bonuses and asking nurses to come work for $50 or $60 an hour. And I understand why they’re doing it. But I can’t see the patients that I see without nurses either.

Most of my employees have worked for me for at least 10 years. We don’t have a high turnover rate because we try to create that place where people support each other. And if we hadn’t been that way, if it had been a lot more institutional when all this started, I don’t know if we could’ve stayed in business.

ME: Do you have any advice for other family docs who are trying to persuade their patients to get vaccinated against COVID?

SP: A lot of us, in our minds we think “talk about the science and people will get that.” But in the family practice setting, most patients want to hear you say “this is what I’m doing for me and my family. This is what I would do if I were in your shoes. You have to make your own decision, but this is the reason I’m making my decision.”

I don’t mind talking about the science, but most of the patients who I see have already been all over Google, they’ve read all the stuff. The problem is they don’t have a good way of interpreting that stuff because they don’t live in the world that I live in. So for me to be able to say “there’s a reason why I’m doing it and here’s the reason.” I think that has made more difference than anything.

So I would advise that. Share your own testimonial, but also leave the door open. Avoid the temptation to be frustrated with the patient, because you never know when they might call you and say they’ve changed their mind. Just the other day I got a thank-you card from a patient who has a 20-something son and had been really upset because her son wouldn’t get the vaccine.

And it just so happened that her son came in the next week for something unrelated, and he and I visited. He’s an intelligent young man and we talked for 10 or 15 minutes and I said, “If you change your mind just let me know.” And his mother said in her card “I don’t know what you said to him but he got his vaccine, and thank you for that.” And I know it wasn’t his research, it was our conversation that made the difference. So having that conversation I still think is worthwhile.