It's just how many vaccine-hesitant and antivaccine healthcare professionals there are, if there is one thing that surprised pundits and my colleagues in the medical profession. You would think that an antivax physician or nurse would be very rare, but they are not. I'm not saying that the medical profession is dominated by antivaxxers, as in general vaccine acceptance is higher among physicians and nurses than among the general public. My colleagues would have guessed that there was a lot of physicians and nurses with differing views.
Here is the thing. Contrary to what my colleagues think, a higher than completely rare prevalence of antivax beliefs among physicians is not new. I am pretty sure that antivax views among physicians and nurses have increased since the Pandemic, but that is not new. The vaccine mandates have become politicized. School vaccine mandates used to be one of the most nonpartisan and apolitical polices, but have become increasingly partisan and associated with the right and support for them with the left. The law passed in California in 2015 after the Disneyland measles outbreak that eliminated personal belief exemptions from school vaccine mandates was the catalyst for the politicization of school vaccine mandates. The law was intended to decrease the percentage of unvaccinated California children, but it sparked a huge backlash that laid the groundwork for what we see today. Pundits and my colleagues might be shocked by the increasing association of antivaxxers with the far right, but that started before the pandemic, with antivaxxers marching with far right militias.
Late last week I was made aware of a new survey, because Dr. Peter Hotez had commented on it.
What Proportion of Doctors Are Vaccine Hesitant? | Never thought I would need to call for better STEM education in US medical schools and residency programs… https://t.co/0h1wnsG7qW
— Prof Peter Hotez MD PhD (@PeterHotez) April 14, 2022
My co-author was correct in noting:
My colleague Dr Lavanya Vasudevan (not on Twitter) studies vaccine hesitancy
She has shown that one of the most important drivers of vaccine confidence & uptake is whether trusted primary care doctors themselves support vaccination
This is disturbing https://t.co/7FMrpMBPK9
— Prof. Gavin Yamey MD MPH (@GYamey) April 14, 2022
It is disturbing but not surprising. It wasn't surprising to me, and I suspect that it wasn't surprising to those of us who have been paying attention to the antivaccine movement for a long time. MedPage Today spun the story as shocking.
Levels of vaccine hesitancy among physicians may be higher than expected, with 1 in 10 primary care doctors not believing that vaccines are safe, according to a new survey.
Among 625 physicians, 10.1% did not agree that vaccines were safe; 9.3% did not agree that vaccines were effective; and 8.3% did not agree that they were important, Timothy Callaghan, PhD, of Texas A&M School of Public Health in College Station, and colleagues reported online in Vaccine.
The high proportion of hesitancy among primary care doctors “was certainly a surprise for us,” Callaghan told MedPage Today. “We thought it might be a very small proportion of physicians who hold hesitancy about vaccines given that we have lots of evidence of the safety and effectiveness of vaccines. However, once we dug into the data, we found that concerns about vaccines in general were far more widespread in the physician population than we might have expected.”
I suggest that they give their level of surprise at the findings of the study a chance. He studied vaccine hesitancy. The doctors who embrace the pseudoscience and even conspiracy theories fueling them have been oblivious to the problem of misinformation. We asked what to do about physicians who spread antivaccine conspiracy theories.
Two years ago, the antivaccine group Physicians for Informed Consent sprang into being. It has been around since 2015. The Association of American Physicians and Surgeons (AAPS) was formed in 2020. It was founded in 1943 and has been spreading antivaccine pseudoscience. The AAPS published an article by Andrew Wakefield that claimed that the sixth mass extinction would be caused by the vaccine for measles. I have been antivax for many years.
I think that before the epidemic, colleagues like Dr. Callaghan might have been reassured that their views were fringe, but I think that they are actually antivax.
I'm glad that this incident prodded him to quantify the effect, because I sometimes say "I told you so."
Indeed, the research project was inspired by Callaghan’s own experience with one of his doctors who was not vaccinated and tried to dissuade Callaghan from COVID vaccination.
“It wasn’t my primary care physician, but another one of my doctors realized that I studied issues related to vaccine hesitancy, and over the course of multiple visits, tried to convince me that COVID-19 vaccines weren’t safe and weren’t worth it,” Callaghan said. “It made me question whether this was a one-off, or if we have an actual issue on our hands.”
Ooh! Ooh! I could have told him before the survey.
I'm old enough to use a Welcome Back, Kotter meme featuring Arnold Horshack, which readers under 50 probably won't recognize.
I couldn't resist when my choice of meme revealed the era in which I grew up.
It's not surprising that antivaxxers would be happy about this study.
2/2. continuous jabs? Here in Australia AHPRA threatened doctors if they spoke against the vaccines they would lose their licenses. Does that sound like a smart move? Now it's even weirder with the connection to snakes with this covid Plandemic.
— Mr Noteable (@MrNoteable) April 15, 2022
One time, both sides understand something about a problem. Doctors are considered authorities in medical matters, so what they think about it is important. When physicians doubt vaccine safety, it will have an effect. So when he complains about how many primary care doctors express vaccine hesitancy and antivax views, he's right. That is a big problem. It is important that a high percentage of primary care physicians express antivaccine and vaccine-hesitant views, because it provides them a huge propaganda weapon. They are correct that the observation somehow supports their views.
The study was published in the journal Vaccine. The results of a survey about COVID-19 vaccines are reported in an analysis of vaccine confidence among primary care physicians. One issue with the vaccine may or may not be a problem. The survey was done a year ago when the Pfizer vaccine had just been approved under another EUA for ages 12-15 and the vaccines had been approved under an emergency use authorization for adults. On the other hand, I can see how hesitant the doctors might have been. I don't think antivaccine sentiment has improved since then, and physicians, like it or not, do tend to be affected by what's going on around them. The push to vaccine children has revealed antivax views among physicians who argue against the routine vaccination of children against COVID-19. The results would be worse if the same survey had been administered today.
Only 5.2% of our sample of primary care physicians was unvaccinated as of May 2021, far lower than the vaccine refusal rates for other types of health care workers and the American public. I like to point out that Robert F. Kennedy, Jr. didn't follow the CDC's guidelines when it came to his children receiving vaccines. As soon as the Pfizer vaccine became available in December 2020, the fear of COVID-19 was enough to get us to get the vaccine. I hope the investigators follow up on how many of these physicians accepted boosters.
The authors are aware of this.
Of course, it is critical to recognize that the decision by physicians to vaccinate themselves may be impacted by factors beyond vaccine confidence including their high-risk work environments or the expectations of employers. For that reason, it is also important to analyze general physician confidence in vaccination and confidence in the safety of each COVID-19 vaccine as well.
Let's look at the methods first.
To understand vaccine confidence among primary care physicians, we developed and administered an original national survey to 737 physicians in the United States. The web-based survey was fielded from May 14 to May 25, 2021, using the survey research firm Dynata – a widely respected survey research firm regularly used in social science research [30], [31], [32], [33]. Dynata invited primary care physicians (identified via responses to an initial inventory survey) to participate in our survey from their large, online, opt-in sampling frame of potential survey participants. Of the 737 respondents identified as PCPs by Dynata who began the survey, 625 of also satisfied additional screeners that we imposed as a precondition for qualification in our study; i.e., by self-identifying as a PCP working in family medicine, internal medicine, or general practice. These 625 physicians serve as the sample for our analysis.
We provide a comparison of our sample with primary care physician population benchmarks in the appendix which demonstrates that our sample closely approximates the demographic characteristics of primary care physicians nationwide. Primary care physician population benchmarks from the Association of American Medical Colleges and Medscape suggest that our sample closely resembles the proportion of primary care physicians who are Hispanic or Asian and produces similar salary estimates. Small deviations are seen between our sample and population benchmarks for gender and race, with our sample slightly under-representing women and Black physicians. Critically however, these differences are small in magnitude. Limitations aside, our study provides the only national sample to date capable of analyzing primary care physician vaccine confidence.
To make sure that their survey group matches the demographic of primary care physicians, the authors made an effort.
There are more disturbing findings when you dig into the weeds. The percentage of physicians who agree that vaccines are safe is low compared to the general public.
There were more disturbing results in the weeds.
These are a small group of physicians.
There are more warning signs if you look at the numbers differently.
The authors boiled it down.
Two noteworthy patterns emerge from Table 1. First, as expected, primary care physicians are significantly more likely to agree that vaccines are safe and effective than the general public (significance denoted by the non-overlapping confidence intervals presented in the table, which indicate statistically significant differences between groups at the p < 0.05 level, two-tailed). Second and more importantly, however, there is heterogeneity in physician attitudes towards vaccination that the existing literature and physician-driven vaccination promotion narratives do not account for. 10.1% of physicians do not agree (strongly or somewhat) that vaccines are safe, 9.3% do not agree that they are effective, and 8.3% do not agree that they are important. In addition, to the extent that we might expect more vaccine advocacy amongst physicians who strongly agree that vaccines are safe, effective, and important, it is also valuable to explore the proportion of physicians most likely to believe in vaccines. Our results show that only 67.4% of primary care physicians strongly agree that vaccines are safe, and roughly 75% strongly agree that they are effective (75.5%) and important (76.3%).
What accounts for the results? The authors tried to answer that question with modeling. Political orientation was one factor that strongly influenced vaccine hesitancy.
In Model 1, which focuses on confidence in safety, we find that elevated levels of political conservatism are negatively and significantly associated with agreeing that vaccines are safe. We also find that these effects are substantively large. Holding all other covariates in Model 1 at their sample means, we find that while the predicted probability that extreme liberals strongly agree that vaccines are safe is 78%, the likelihood that extreme conservative PCPs feel the same way is just 59% – a 19% difference across the full range of the ideological spectrum.
And:
A similar pattern holds in Model 2, exploring physician beliefs that vaccines are effective. There, we found that holding all other variables at their means, extreme liberals were predicted to be 18% more likely than extreme conservatives to strongly agree that vaccines are effective. In addition, while the predicted probability that PCPs who had not had COVID-19 would strongly agree that vaccines are effective was 77%, it was only 64% for those who had.
The statement "Vaccines are important" was not affected by political ideology.
It is perhaps less surprising that so many physicians doubt the safety and efficacy of vaccines in general, given the increasing ideological polarization and the observation that physicians tend to lean conservative in their politics compared to the general public.
The result is that people who have contracted COVID-19 are less likely to agree with the statements that vaccines are safe, effective, or important. These are not statements aimed at just COVID-19 vaccines. One has to wonder if this result is explained by physicians who had COVID-19 and were fortunate enough not to have gotten too sick from it, or if they were more of an ideological mindset to doubt vaccines before they got COVID-19. Being antimask, antivax, and anti-COVID-19 interventions tend to cluster.
The authors looked at the attitudes of the PCP towards COVID-19 vaccines. Pfizer, Moderna, and Johnson & Johnson manufactured EUA in the US at the time.
Our analysis in Table 3 revealed that primary care physicians were significantly more confident in the safety of the mRNA vaccines of Moderna and Pfizer than in the Johnson & Johnson COVID-19 vaccine. Specifically, we found that while 68.7% and 72.7% of primary care physicians were very confident in the safety of the Moderna and Pfizer vaccines respectively, only 32.1% of physicians were very confident in the safety of the Johnson & Johnson vaccine as of May 2021. When we include those who were in the ‘confident’ category as well, we found that over 90% of physicians were either ‘very confident’ or ‘confident’ in the mRNA vaccines but only 68.0% of physicians fell into those two categories for the Johnson & Johnson vaccine.
This result is likely to be a product of the time period when the survey was administered, given that there were reports of a rare form of blood clot associated with the Astra-Zeneca vaccine. Has it been that long? If the results were different, I would be shocked.
I was a bit surprised that it was roughly one in ten physicians who did not believe that vaccines were safe and effective. I would have guessed a smaller percentage, maybe as low as 5%, but still far from the majority. The authors note extrapolating.
Combined, our results serve to complicate media narratives and governmental initiatives encouraging primary care physicians to serve as leading vaccine promotors. While a majority of doctors are well positioned to take on this role, a troubling proportion of physicians lack high levels of confidence both in vaccines in general and COVID-19 vaccines in particular. For example, if we take a conservative approach and remove those who ‘somewhat agree’ that vaccines are safe from the proportion of physicians that lack vaccine confidence and use the total number of PCPs from the AMA Masterfile as our baseline for PCPs nationwide, our findings still suggest that almost 25,000 primary care physicians nationwide could disagree with the basic belief that in general, vaccines are safe.
Also:
These findings suggest that we cannot take it for granted that all physicians are well positioned to serve as vaccine promotors and furthermore, that interventions may be needed to increase vaccine confidence among some physicians. This is particularly true because these physicians could have an outsized impact on public health, with a single physician lacking trust in vaccine safety capable of writing large numbers of medical exemptions from non-COVID-19 vaccination, reducing the effectiveness of vaccine mandates [46], [47].
Many physicians were willing to write bogus medical exemptions to school vaccine mandates. As the bill was nearing passage in the California legislature, antivax leaders, such as Sears, jumped on the grift bandwagon. After the passage of the bill, doctors were so prolific in writing exemption letters that the bill was needed to close the loophole. They say that history does rhyme, but it might not repeat itself precisely.
There is a hole in the article that only looks at PCPs. It is true that the influence of the doctor's name on their patients is enormous, but it is also true that the influence of the doctor's name on their society is even greater. Most of the COVID-19 contrarian physicians who have been lambasting for promoting COVID-19 misinformation are not PCPs. Dr. Tracy Beth Heg is a sports medicine doctor, while Dr. Vinay Prasad is an oncologist. A number of them do not even practice medicine, but they are influential in spreading false messages that the vaccines are more dangerous than the disease.
What should we do? The conclusion of the paper suggests:
Identifying appropriate interventions is an important direction for future research and could include improving virology and vaccine biology education in medical school or echoing existing approaches for the general public by identifying trusted individuals in physicians lives to improve their confidence in vaccines.
In MedPage Today, Dr. Callaghan expands on this idea.
While political affiliation did appear to play some role in beliefs, Callaghan noted a wider problem that might be at play. “There’s not that much training on vaccines and vaccinology … in medical school,” he said. “Most medical students aren’t exposed to in-depth discussions of virology to have those strong opinions.”
“And given the clouded information environment that surrounded COVID-19 in particular, and increasingly, vaccines in general, it remains possible that [physicians] are just relying on what they’re hearing in the news and the misinformation that’s out there, as opposed to best scientific evidence,” he said.
And finally:
Callaghan noted that “most physicians are well-positioned to serve as our leading vaccine promoters. … With that said, 10% is a pretty big proportion to be hesitant. It suggests, for that 10%, we need to do some work in terms of education and potentially, intervention, to increase the level of confidence in that population of physicians so that we’re not at 90% in favor of promoting vaccination, but that it’s closer to 100%.”
Unfortunately, as was pointed out.
It’s not the STEM it’s the ideology. You cant educate your way out of a fundamentally irrational world view.
— Mark Hoofnagle (@MarkHoofnagle) April 15, 2022
Thats the thing. They have those. They are just compartmentalizing them when it comes to what is ideologically incongruent. They have no shortage of knowledge, lack of access to info ordata. The simply don’t *want* to believe.
You can’t educate that away. You deprogram it.
— Mark Hoofnagle (@MarkHoofnagle) April 15, 2022
Also:
The medical mind often stands no chance, against religious and political indoctrination!
— SGJ (@sgjdoc) April 15, 2022
We just moved from a rural town in Oklahoma-1 of the OBs touted ivermectin, our pedi refused to get vaccinated and told his patients covid would disappear after the election, an ER NP refused the vaccine too. Political ideology trumping medical knowledge is so sad.
— Claire Cloud (@ClaireCloud_) April 15, 2022
That is the problem. It is an aphorism that has been attributed to various writers over the years.
We are not immune to the effects of ideology, emotion, and belief that doesn't flow from science and reason. We think that we are less susceptible to unreason than anyone else, but that doesn't stop us from thinking that. Because we as a group think of ourselves as less susceptible to conspiracy theories and misinformation than the average person, we tend to fall hard for them. We tend to be very good at motivated reasoning because we are a group that is highly intelligent. We are very skilled at asymmetrically seeking out evidence and arguments that support our beliefs and finding flaws in evidence and arguments that challenge those beliefs, all while reassuring ourselves that our training as physicians means that our beliefs about medicine are all strictly based on science.
It is difficult not to note that physicians have long been willing to accept magical thinking in the form ofcomplementary and alternative medicine, which is now more commonly. The Cleveland Clinic, a major academic medical center, was embarrassed when its director went full-on antivax three years before the swine flu hit.
I am pessimistic about the likelihood of reversing these attitudes because I am in the short term. disproven treatments don't really disappear from medicine until the last physicians who used them retire or die, according to another aphorism. It is likely that the same will happen with vaccines. We can try to educate existing physicians with better science, but it can only go so far. Critical thinking skills and the ability to evaluate science are needed by medical students. Medical students need to be taught to recognize misinformation and conspiracy theories, which is something they aren't taught at all. Neither are most college students, and only if they seek out such learning. The earliest point in physician education that we as a profession control is medical school.
I encourage physicians who were unaware of the problem of pseudoscience, quackery, and the conspiracy theories used to support them to try to do something about it. I understand how you were shocked to learn that about one in ten of your fellow physicians is vaccine-hesitant or even antivax. I won't be able to understand if you don't try to do anything about it.
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