Physician Self-Disclosure and Vaccine-Critical Parents' Trust: Preparing Medical Students for Parents' Difficult Questions

"Given that so many current encounters between physicians and vaccine-critical parents are counterproductive, it seems urgent to explore the parents' concerns and ways of responding to them in medical education settings."

The arts-based project on vaccine hesitancy described in this article and at Related Summaries, below, emerges from the observation that medical students are not typically exposed to vaccine-critical parents' concerns and expectations, leaving the students unprepared for questions that parents may pose in a face-to-face encounter. This paper argues that, to close dysfunctional gaps in communication with vaccine-critical parents, medical educators should consider appropriate forms of self-disclosure in order to be present as trustworthy, "whole person" physicians who are also familiar with studies for and against immunisation recommendations.

This multi-year arts-based study involves interventions designed to expand the students' awareness of the various voices and viewpoints that construct medical dialogues, allowing them to recognise and question their own hidden values. It explores vaccine hesitancy by: (i) mapping vaccine-critical parents' health beliefs, and (ii) simulating an encounter between a vaccine-critical parent and a medical student. During open-ended interviews in the Netherlands and Finland, 9 vaccine-hesitant parents were invited to ask questions of 9 third-year medical students. The interview data were categorised by themes and visualised in diagrammatic representations, then reflected upon through a collaborative meaning-making dialogue with a vaccine scientist. The parents' selected viewpoints and home video footage, as well as a scientist's reflections, were employed in an educational video scenario.

The intervention began with viewing the film Conversations with vaccine-critical parents, and it was followed by a semi-structured group discussion. Subsequently, the students were given a written homework assignment inviting them to answer the parents' 7 selected questions (e.g., How does "natural" relate to vaccination?). The writing exercise views doctor-patient interactions as "polyphonic", or diffused with the voices of all who are related to them. The students' written answers were coded through a qualitative text analysis according to their level of engagement with the parents' questions.

According to the researchers, "The use of self-disclosure in students' answers was considered the most engaged mode of interaction, and a way to expand the voice of medicine into a whole person physician." Physician self-disclosure invited by the parents in this study did not concern vaccinations - in fact, self-disclosures such as "I vaccinate my children, and they're fine" are not necessarily experienced as trust-increasing and can come across as patronising. Instead, the self-disclosure involved moral choices in practicing medicine or raising children. Several of the parents' questions and concerns in this study invited the physician to self-disclose in order to demonstrate that he or she was an independent "whole person" instead of a "sterile automaton". When asked what they would like to know about the future physicians, several parents invited the students to expand on their professional motivations and beliefs - inquiring, in a way, into their professional moral compass. Two of the 9 students (both male) included self-disclosure in their answers, in that they described a personal life experience or a philosophical anecdote as part of their responses. Both these students referred to an inspiring senior mentor or thinker whose words they strive to manifest as a practitioner. (The rest of the students refrained from disclosing any personal narratives and talked about the goals of medical practice in a distant manner.)

For example, in the film and writing exercise, a Dutch father asked: "What is it about in the end? Is it about becoming as old as possible, or is it about the journey, the time that you have here, using it as meaningfully as possible?" The student replied: "It is true that evolving medicine can give the impression that doctors just fight against nature. However, the purpose of medicine is to let people live the most meaningful life throughout their life cycle.... Johan Wolfgang von Goethe has said, 'Every day, a man should listen to at least one small tune, read a good poem, see a fine painting and, if possible, say a few rational words.' I think the most important thing a doctor can do is to enable this kind of functional capacity for the patient." According to the researchers, this student engaged in a "whole person" approach, demonstrating that he not only acknowledged the perceived contrast between medicine and the parents' beliefs, but also considered himself to be a whole person who is confident with - and open to sharing - his underlying beliefs.

Relatedly, parents don't want their physicians to be mere advocates of governmental guidelines but, rather, to explain their personal connection to the advice they are giving. The researchers contend that, as the parents consider themselves individual decision-makers, a healthcare professional who demonstrates individual thinking generates more respect from them. In fact, in a relationship with a radically vaccine-critical parent, the parent may expect that providers have done "research" on vaccines - meaning that they are familiar with pro and con vaccine studies and that they have engaged in discussions with other parents and healthcare providers who have a range of views on immunisation. When invited to give advice to the medical students, one mother said: "Inform yourself; don't just take on what the manufacturers give you. Of course, they want you to give it because they want to make money. Inform yourself, and don't believe everything you are told in school; start doing your own research."

In the researchers' estimation, this study suggests a need to train students in considering appropriate self-disclosure as part of their patient interactions. "In fact, instead of mechanically aiming to increase parents' uncritical trust (were this even possible), medical education should, perhaps, explore the reasons for perceptions of how trustworthy or untrustworthy a student appears as an individual provider and as a representative of the medical system.....In addition to students' refraining from displaying frustration, the more confidence they have to express what their medical practice is motivated by, as well as to critically reflect upon their immunization recommendations, the more authentically and symmetrically they will be able to interact with vaccine-critical parents."