20. Mainstreaming COVID-19 Vaccinations and Maintaining Protections

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Santina Wheat MD, MPH, FAAFP (00:00):

Hello, and welcome to today’s episode of Beyond the Needle. Today, we are talking about mainstreaming COVID vaccinations and protections. I am Dr. Santina Wheat. I’m a family physician in Chicago, practicing at a community health center, and a residency director. I’m going to allow my co-presenter to introduce herself.

Marian R. Sassetti, MD, FAAFP (00:20):

I’m Marian Sassetti. I’m a family doc in private practice outside of the West Side of Chicago, in Oak Park. We’re Lake Street Family Physicians. And I’m also an assistant professor at Rush Medical School.

Santina Wheat MD, MPH, FAAFP (00:33):

Today we’re going to talk a little bit, as I said, about mainstreaming COVID vaccines and protections. Let’s start talking first about our new normal in practice. Dr. Sassetti, how do you talk to your patients about what the new normal is going to be?

Marian R. Sassetti, MD, FAAFP (00:49):

I actually use that phrase. I actually say, “We’re in a new normal now. We have to talk about keeping each other, and your family, and our community, safe.” And I usually embed it in the whole… I’m kind of a seasonal, preventive doc. I use the seasons. So right now, way before I use the word COVID, which people are so tired of and fatigued with, I’ll talk about the wintertime season. What are your concerns about what’s out there in this flu and respiratory season? And any questions about keeping yourself or your family safe? Then we’ll talk about getting into here are my ideas about what we can do to help each other and the community, but especially your family and you stay safe.

Santina Wheat MD, MPH, FAAFP (01:33):

That sounds wonderful. And how are your patients responding when you say that to them?

Marian R. Sassetti, MD, FAAFP (01:38):

In general, I think they’re really happy that we aren’t starting off with COVID, but they’re receptive to hearing. I am surprised at the number of people who, this season more than any in my practice, know about RSV, and are talking about RSV. And it brings up the ability for me to talk about masking, and just preventing all of these illnesses. I use the expression that, “This has been your medical home, these are the things we’re going to keep talking about. The flu isn’t going anywhere. I wish we had a vaccine for RSV by the way, but we don’t. So let’s talk about how we keep your kids and you… And did you know that RSV is a big threat to older folks?” And then we can just talk about all the issues, all the threats to health and well-being that are still out there.

Santina Wheat MD, MPH, FAAFP (02:23):

I really like that. I use something similar. I will often share with my patients some of the conversations I’m having with my own family, about how we’ve really enjoyed being able to do things again. My daughters are competitive dancers, and we like to travel as a family. And so talking about how we make certain decisions to help keep us safe so that we can still do those fun things. That if they put their masks on, they’re less likely to get sick, so that they won’t have to miss that competition or miss that practice that they really want to go to. Or get to see their friends who they had not been able to see as much over the past couple of years.

(03:01):

And I sometimes remind them, I’m like, “Do you remember when we used to get sick once a month? Do you remember when you used to get ear infections? Do you remember those things? Isn’t it so much more fun to not be sick? And to be able to really enjoy everything that we’re doing?” And that seems to work sometimes for my patients, but has worked even for my school-aged children, as well.

Marian R. Sassetti, MD, FAAFP (03:21):

I think that’s perfect. I think that’s exactly what our families want to hear from us, with our own nuclear families, and all the families that we take care of, which is, look, we are all tired. We all want to get back to normal life. What are the ways we can do that now? Well, we know masks work. I don’t want to get sick from anything. I don’t want to miss a week of work because of a cold or the flu or RSV or COVID. And now, we know that masks work. I’m out in the community. I like practicing in my shopping. My patients repeatedly have seen me in grocery stores, or other stores, with a mask on. And it’s just a great ambassador role I think, that there I am with my mask on, day in and day out, protecting myself and my loved ones and my community.

(04:06):

I think it speaks volumes. It speaks loudly to our patients who see it. Doesn’t really seem to bother me at all, and I think our patients recognize that. Truth be told, I feel naked without it. There was one day in the office where I was in the hall, and I didn’t have my mask, and I was suddenly, what is wrong here? I couldn’t identify it until I was like, oh yeah, my face is naked, and I’ve got to go back and put on a mask.

(04:29):

So absolutely the new normal in our family. Absolutely what our friends and family are talking about. I was sharing earlier that I have grown children now. We are so scrupulous about mask wearing, we don’t test for COVID anymore. Everybody’s vaxxed, everybody’s boosted. When we gather together, we rely on each other’s ability to be out in the community masking, so we can enjoy each other’s company and not spread anything, whether it’s COVID or the cold or flu or RSV. And we like it that way. Our patients do too. Our patients don’t want to be sick anymore. They’re sick and tired of COVID, but they don’t literally want to be sick.

Santina Wheat MD, MPH, FAAFP (05:05):

I think that’s great. I think that one of the hardest conversations I sometimes have with patients is, “But nobody else is wearing a mask. When I get on that plane, nobody else is wearing a mask.” Or, “When I go to that event, nobody else is wearing their mask, and it feels strange to have a mask on when nobody else is.”

(05:25):

I personally talk to them about the risks that I know that they have in their family. And I talk about how you don’t really know what happened with somebody else. Maybe they had COVID two weeks ago, and so they’re not worried about getting it right now. Or maybe there’s something else going on, but try to have conversations about, are there things that they are looking forward to? I have those conversations with my children, that maybe they want to wear a mask to make sure that they can get to go to. Are there other things that you say?

Marian R. Sassetti, MD, FAAFP (05:57):

No. But I love that language. I think that’s brilliant.

(05:59):

As far as planes, I think most people are aware … If you’re going international, there’s a huge chance you’re going to get COVID and I think everybody knows somebody, or somebody in their family, were on the trip, got COVID. But what I say about masking on the airplane is what happens in the back of the plane is recycled and comes right up to the front of the plane. So yeah, they have good filters, but you’re sitting with everybody in the plane as if you’re sitting next to them.

(06:25):

So I wear a mask. I’m not going to stop wearing a mask for the same reasons we had talked about before, I just don’t want to get sick. When people say, “I was the only one on the airplane not wearing a mask,” I say, “Well, how did that make you feel?” Or I kind of use their emotional response to it, which was, I don’t think anybody’s embarrassed now, but I think people are like, “Wait a minute, did I miss the normal train? Is everybody else on the normal train that I missed?” I actually say, “No, I think this will become the way we keep ourselves safe.”

(06:53):

Again, people missed days of work, people missed fun outings, people missed dinner parties. I don’t think that’s going to happen anymore if we all decide to mask, and it’ll be up to you. But that’s a really well-recognized, well-validated strategy for keeping ourselves safe, is wearing a mask. By the way, Southeast Asia has known that for a very long time. The wearing of mask is just something that’s culturally accepted, and I really do think that’s going to happen too, especially families like yours and mine. Tina, you have little ones, but you’re on an airplane and your little ones are masked up. I’m on an airplane, and we’ve got our gray hair and we’re masked up.

Santina Wheat MD, MPH, FAAFP (07:30):

We’ve talked a little bit about just the general life and we’ve talked a little bit about masks. Let’s talk a little bit about vaccines. How are you talking about vaccines now with your patients?

Marian R. Sassetti, MD, FAAFP (07:41):

I think you’re talking about COVID vaccine in particular, but in general, I have talked on other podcasts, we have the luxury of it is simply being embedded now in our routine. We no longer have COVID clinics. It literally is something that is part of our mainstream day in and day out patient to patient. So if I’m doing any kind of visit, I’ll actually say, “Let’s see what vaccines you might be due for.” Of course, I’m going to bring up COVID. But I couch it that way. Certainly our parents by now are very used to me reviewing vaccine records even if they’re there for a cough or a cold.

(08:14):

My staff is fabulous. I can’t speak highly enough about their commitment to this, but when I walk into a room, I will know what a child especially is due for. And then I’ll just say, whatever the visit was, “Here are the vaccines that your baby needs,” and I’ll just tell them, “A DPT, a MMR and a COVID. That’s just part of what they get when they come to see Dr. Sassetti is that they just get all of the vaccines that they’re due for. That has been much easier than I would’ve thought. It’s just part of the, this is where I take good care of you. This is where I give your baby everything that they need conversations.

(08:50):

By the way, one of the great ways I get buy-in is I will agree not to vaccinate a baby. When I was rounding in the nursery, I would agree to not vaccinate a baby with hepatitis B and I’d get buy-in that way. I’d say, “You know your baby’s not going to get hepatitis B between now and when they see me. So let’s go ahead and wait.” So that they knew I was a doctor who was reasonable and I knew that I wasn’t just going to do a literally check the box. I was going to worry about them and what they were thinking and being concerned about, so I got that.

(09:20):

Then when they come back, I’ll say, they’ll something like, “The hospital doctor,” now that I don’t round the nurseries anymore, they’ll say, “The doctor said that you would be giving my baby hepatitis B.” I say, “You know what? I can wait. Let’s give the baby the hepatitis B.” Especially now with Vaxelis, that vaccine where we can give them everything, I say, “Let’s go ahead and wait. Let’s Wait till we give them everything else.” So I’ve groomed my patients to see me as a doctor who’s reasonable about this, and it’s just part of everything that’s routine. I get to capitalize on being or appearing reasonable at earlier points in raising their kids together, and then I say, this is the time to get the vaccines in them.

Santina Wheat MD, MPH, FAAFP (09:59):

I think that buy-in’s great and I think that’s really important. As long as we’re talking about children and vaccines, I think that that is great just to sort of couch it in with all of the rest. And I think that sometimes I will even find myself not saying it first or last just so that it’s a part of all of them intentionally so that they know that I’m not just focused on the COVID vaccine, that I’m really thinking about prevention as a whole.

(10:26):

I do think this is a great time to remind everyone that just because someone hasn’t received a vaccine doesn’t mean that they’re not interested.

10:34

I was sharing a story earlier about how

10:37

someone I know, their child is about 14 months old and he hasn’t received a COVID vaccine yet. And I was asking about it because the child is around my family a lot and the mom just said, “I haven’t been offered it yet. I have taken my baby to all of the doctor’s appointments. And I forget myself because it’s not as advertised as it used to be. There’s not the same pushes that were happening before, but the doctor also hasn’t offered it to me.”

(11:06):

And I think that the little kids are an interesting group where it may be not quite as easy to get it at the pharmacy for the kids who are under three, but just because they haven’t gotten it doesn’t mean that the parents aren’t willing and interested in having it. And so this is a time that if your office doesn’t have it, potentially knowing what the local resources are so that the children that are coming to your office can get it, and also if your office does have it using what Dr. Sassetti said, as the person that’s rooming your patient, can they make sure that we have it available for them or that it’s on the list of things to talk about?

Marian R. Sassetti, MD, FAAFP (11:41):

I think that is great. Thank you for bringing that up, because I have the luxury of having this embedded in my practice. For our audience members who don’t, Dr. Wheat,

11:52

I think that was great that this is part of it.

11:54 I’m remembering that the single greatest reason that women don’t get mammograms, the answer to this, their doctor didn’t tell them to.

(12:01):

One of the wonderful things about being a trusted caregiver is that if we don’t bring it up doesn’t seem important. So the more we bring it up, the more important it becomes. 12:11

And very often, sometimes frustratingly so, but very often patients will say, “Well, I was waiting for your call.” Or, “I was waiting for your office to call me before I did X, Y, or Z.” 12:22

So we have kind of groomed our patients with that kind of mentality. I can’t say I don’t do the same thing about my dentist, but that kind of look, we are very trusted and they’re waiting for our signals, so let’s go ahead and capitalize that.

(12:33):

And then for our audience members who don’t have the luxury of offering the COVID vaccine in the clinic, making sure that you do know who your partners are in the community and where your patients can get it. And again, I don’t love overburdening our audience members. I think that’s something your staff can do. Have somebody identified who can call the community resources around. What’s the age that a CVS or a Walgreens will go down to and are they comfortable giving that vaccine? Thanks for that reminder.

Santina Wheat MD, MPH, FAAFP (13:03):

And even if they have a handout that you can just have on the counter so you’re your patients can see it.

Marian R. Sassetti, MD, FAAFP (13:09):

Exactly.

Santina Wheat MD, MPH, FAAFP (13:09):

I was talking about kids, how about thinking about, it’s sometimes children but also more adults on the booster end. How is it going for you talking with your patients about the bivalent booster as we’re going through this cold and flu season in particular?

Marian R. Sassetti, MD, FAAFP (13:25):

The patients who really have buy-in and they really just don’t want to get sick for all the reasons that we talked about, it’s been fairly easy to get a great number of them, especially the ones with comorbidities and they self-identify, which is nice, but then I’ll bring it up to especially this kidney disease and hypertension as a reason to get the next booster. For many of us, that means you had five. This last bivalent would’ve been our fifth. However, I do want to address this for our audience members. There is a little bit of pushback now in people I would not have predicted who just kind of shrug and say, “You know what, doc? I think I’m done with COVID boosters. I’ve gotten enough. I think I’m good to go. I’m not going to worry about that last booster.”

(14:08):

And that is when I trot out my tired old, “I really care about you. I really think it is in your best interest. You and I have been a good team. Tell me about this.” And they don’t go a whole lot beyond, “I’m just tired of it. I think my body’s had enough. I’m not worried I’m going to get it. I’m not worried I’m going to die or I’m going to go to the hospital.” And I say, “Well, are you worried you’re going to get sick?” Surprisingly, some will say, “Yeah, if I get COVID, I get COVID.” That’s my time to remind them, especially the ones that I’m pulling out and getting over 50 or ones with comorbidities, “Would you please call me if you do get COVID. I want to make sure you know that there are treatments available.”

(14:45):

But again, just like my smokers, I’ll say, “Okay, can we talk about it at the next visit? Because I really do want you to get that bivalent booster. I really believe it’s going to be helpful. The literature says it’s our best booster to date. I want you to get all the protection my other patients are getting and my family is getting.” I love bringing up my family. “Everybody in my family is getting the booster and I want you to be as healthy as the loved ones in my nuclear family.” Haven’t moved the needle a whole lot in some of those patients, but several of them are coming back, “Yep. I think I’ll get it this time. Yep. Okay.” Get them again, a shrug. I see them in another month follow up then they’ll little shrug and say, “Okay, you brought it up last time, this must be important. Okay, go ahead and give it to me.”

Santina Wheat MD, MPH, FAAFP (15:26):

I think that’s interesting. I think that I have seen a little bit of that as well. I think I was seeing less of it as we initially started giving flu shots out. Some of it was maybe I don’t want them both on the same day, but we’re understanding this idea of we are really going into this time where everybody’s going to be indoors together and so this is a time to get vaccinated. I’m still trying to use that a little bit since we all know that here in Illinois it can stay cold for a while. The favorite story my girls have is of making a snowman in April, so we still have some time where we need to think about being indoors a lot.

(16:04):

I also have been thinking about it with some of the changing pneumonia vaccine guidelines and how sometimes we’re having to reevaluate the pneumonia vaccine for some patients. And so that’s a good time of just, “Oh, I’m just double checking on your vaccine. This is just one of those ones, it’s time to update.” Or maybe they’re also due for that TDAP again and sort of just adding it into the prevention.

Marian R. Sassetti, MD, FAAFP (16:29):

Perfect.

Santina Wheat MD, MPH, FAAFP (16:30):

I’m curious though, have you had the conversation with some of your patients about how it’s not that much different than how we know that the strain of the flu changes every year, and so it might just be that they need to have a vaccine every so often. We don’t quite know what that interval is yet, but that we need to be thinking about it as it changes.

Marian R. Sassetti, MD, FAAFP (16:52):

Sure. Absolutely. Enough of my patients are aware that the FDA did say that we are going to be introducing COVID vaccine at the same time we’re giving the flu. There is argument in the medical and scientific community around that, and that’s a great opportunity for me to say to my patients, “It looks like there’s going to be a COVID vaccine at the same time there’s going to be a flu vaccine, however, there’s a whole lot less certainty around the way COVID behaves versus the way the flu behaves. But here’s what I want you to know. As soon as I have clarity, the same kind of clarity I’ve used my whole time, my whole practice, with you on every vaccine I’ve given you, I’ll let you know. But here’s what my gut is saying. Here’s another vaccine coming and I think it’s a good idea to get it. This virus is doing what it’s supposed to do. It’s mutating, it’s trying its best to find another host. I don’t want that host to be you.” And when I really personalize it as, “Look, this is the virus is doing its job. Let me do my job and keep you from this virus.”

Santina Wheat MD, MPH, FAAFP (17:50):

I really like that. I like that the virus is doing its job. Let me do my job. That really speaks to the reminder that as primary care physicians, we are really there to meet the patient where they are and protect their-

Marian R. Sassetti, MD, FAAFP (18:02):

Exactly.

Santina Wheat MD, MPH, FAAFP (18:02):

…unique situation, which I think is the beauty of our specialty. I have yet to have, and I will say I’m a little bit nervous about having the conversations with people about, well, is the FDA going to do this or not? And I think that that speaks to one of the challenges that we’ve had this entire time throughout the pandemic of how the information is changing so rapidly. And that seems to continue to be a challenge. But I also like how you said that, I’ll let you know as soon as we know, once we have a little bit of clarity, we will share that information so that we’re all on the same page.

Marian R. Sassetti, MD, FAAFP (18:39):

One of the things that I like to remind our patients, but also us, you’ve heard me say if you’ve tuned in before, you’ve heard me say it before, my friends, we were part of history. Nothing like this has ever happened before. I mean, certainly we’ve had pandemics, but we have never… I’ve read that the average time from identifying a disease, a new disease, until to vaccine is 60 years, so we have never seen this before. We get to participate in history. We are partnering with bench working scientists who worked round the clock to get this new vaccine out. And now we have evidence it works. It’s keeping people we love alive and it’s keeping people we love from getting sick. It’s keeping communities healthy. Businesses are staying open, schools are staying open. So yes, there’s uncertainty, but it’s a done deal. This vaccine works.

(19:29):

There isn’t certainty in any part of my life. I don’t go to a single place where there’s perfection. I bring that up to my patients like, “Look, you and I both made history. You got the vaccine and I’m giving you the vaccine. I’ve never had this extraordinary opportunity. So let’s keep our eye on the fact that whatever is happening is working to a great degree. Is it perfect? No, but do I know that in general, this vaccine is working and if you trust me, I’ll keep my eye on the literature the way I have for the last 30 years of practicing, whether it’s talking about your diabetes or hypertension. I’m going to keep reading the same journals and keep trusting the same experts. And when that next COVID vaccine comes around, I’ll let you know. Trust me.” I was joking, but this is what they say, “I trust you but not the pharmacy doc.”

Santina Wheat MD, MPH, FAAFP (20:13):

Fair enough. And I think that’s right. And I think what you were saying before of I’m offering to you what I’m recommending to my family as well. I’m treating you in this as I’m treating my family, because I’m making-

Marian R. Sassetti, MD, FAAFP (20:25):

Exactly.

Santina Wheat MD, MPH, FAAFP (20:26):

… all these same recommendations. It’s so interesting that we’re here several years after this first started as a pandemic that we’re now moving to this, again, as being a new normal and new ways of understanding how much of the virus is in the community. I feel like we’re never going to go away, at least from my perspective, of masking in the hospital and masking in the outpatient office. At least I won’t be. It feels like so many things have changed from just a couple of years ago.

Marian R. Sassetti, MD, FAAFP (20:57):

Exactly. With a lot of good outcome. I mean, one of the things that’s happened is that we turn to each other, and to the experts and say, “Tell me what works.” And we now know it works. Are there other things that will probably work? Sure. Are there things that didn’t work? Sure. It’s [inaudible 00:21:12] and it’s with us. And again, I like that phrase, the virus is doing what it’s supposed to do. The bench work scientists are doing what it’s supposed to do, let me do, supposed to do here for you.

Santina Wheat MD, MPH, FAAFP (21:23):

I really like that. Do you have any last thoughts for our listeners?

Marian R. Sassetti, MD, FAAFP (21:28):

As usual, I always like to thank everybody up and down the state. I am just so grateful. Some of you are taking care of my loved ones, so no matter how rough and tumble it gets and how thankless it might appear, know that we are really grateful. We’re speaking for myself and probably Dr. Wheat. But the Illinois Academy is thankful, is grateful, and I know we’re tired, but this is a time to remind each other you, you’re doing great work and keep it up. For some reason you tuned in, so we’re grateful for that too.

Santina Wheat MD, MPH, FAAFP (21:58):

Thank you for that. And I will add my gratitude as well. And just a reminder that we are continuing to learn and grow in all things about this virus, just like we are in all things about medicine and that this has been an interesting time to, as we started off saying, have our new normal. Have our new plan for how we’re all going to enjoy our lives and be able to travel and enjoy each other and continue to care for our patients the best way we can. So thank you for listening.