A 57-year-old woman with a history of type 2 diabetes mellitus and asthma comes to the office for a preventive visit during influenza season. The patient belongs to an ethnic minority group and is accompanied by her daughter. The patient's medical conditions are well controlled, and she currently has no symptoms. The provider explains that she is at high risk for complications from seasonal influenza and recommends that she get the seasonal influenza vaccine. The patient says, "I don't trust that vaccine. It's from the government, so I don't think it's safe for people like me." Which of the following actions by the physician is most appropriate?

Question

A 57-year-old woman with a history of type 2 diabetes mellitus and asthma comes to the office for a preventive visit during influenza season.  The patient belongs to an ethnic minority group and is accompanied by her daughter.  The patient's medical conditions are well controlled, and she currently has no symptoms.  The provider explains that she is at high risk for complications from seasonal influenza and recommends that she get the seasonal influenza vaccine.  The patient says, "I don't trust that vaccine.  It's from the government, so I don't think it's safe for people like me."  Which of the following actions by the physician is most appropriate?

Quizplus · Accepted Answer

Trust (eg, belief in the physician's skills, recommendations, and intentions) is central to the patient-provider therapeutic alliance and is associated with improved outcomes (eg, treatment adherence, quality, self-reported health). Among minority patients, distrust of physicians and health care systems may occur due to the following: Historical legacies of experimentation (eg, US Public Health Service Syphilis Study at Tuskegee, which failed to obtain proper informed consent from Black men or provide them with curative and readily available treatment) Personal experience of discrimination, because minority patients are more likely to receive lower-quality health care and to experience suboptimal physician communication Low ethnic diversity in health care (eg, <5% of physicians are Black; <6% are Hispanic) Distrust can decrease vaccine use (eg, <40% of Black adults receive the influenza immunization). Given the patient's high risk for influenza complications (eg, history of asthma, diabetes), the physician should explore the reasons for her concerns and engage her in an open-ended discussion using culturally inclusive health education materials (ie, featuring messages, images, and symbols that carry meaning to a minority community). Discussion should build a partnership and establish alignment of patient and physician goals. Once the patient's concerns and priorities are understood, the physician may be able to provide reassurance through patient-centered education. (Choice A) Although the daughter's encouragement may be helpful, the physician should first attempt to directly engage the patient. (Choice B) Distrust in the medical system should be respectfully explored rather than viewed as delusional, given its legitimate relation to historical events and personal experience. (Choice D) Inquiring about the patient's understanding of federally funded health care systems is less focused and relevant compared to direct discussion, exploration of views, and reassurance regarding the influenza vaccination. (Choice E) Although the patient has the right to ultimately decline vaccination, the physician should first attempt to engage her with open-ended discussion about it. Educational objective: Trust is central to the provider-patient therapeutic alliance and is associated with improved outcomes. Distrust by minority patients may result from numerous factors (eg, historical legacy, experience of discrimination, low cultural inclusivity). Providers can build trust through open-ended discussion and focused reassurance using culturally relevant materials. __________ References: African American adults and seasonal influenza vaccination: Changing our approach can move the needle. (http://www.ncbi.nlm.nih.gov/pubmed/28933619) Trust in the health care system and the use of preventive health services by older black and white adults. (http://www.ncbi.nlm.nih.gov/pubmed/18923129)

A 57-Year-Old Woman with a History of Type 2 Diabetes