Author Archives: RMoore

Improving Diagnostic Judgment: A Behavioral Economic Approach (Part IV in series on Diagnostic Accuracy)

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“We’re blind to our blindness. We have very little idea of how little we know. We’re not designed to know how little we know.”

-Daniel Kahneman, Nobel Laureate in Economics

Regular readers of this newsletter will recall a series of lead articles on improving diagnostic accuracy (Parts I, II, and III found on our phcprimarycare.org blog). Medical schools, residencies and continuing medical education programs have recently adopted some formal training in critical thinking, including how to understand how cognitive biases can lead to mistaken diagnoses. This takes the principles of behavioral economics, based on the pioneering work of Psychologist Daniel Kahneman (summarized for a general audience in his most famous book, Thinking Fast and Slow), and helps us understand how physicians think and make mistakes.

In the January 25, 2022 JAMA, Dr. Pat Croskerry provided a succinct summary of recommendations for overcoming these biases to become a “rational diagnostician.”

  1. Establish Awareness of How Cognition Works. Understand the most common cognitive biases and the difference between type 1 (intuitive/fast) and type 2 (analytical/slow) processing.
  2. Teach and Coach Critical Thinking. Excellent coaching promotes deep learning, allowing 10-fold faster development of expertise. Understanding the mechanism of deep learning can help those of us without ready coaches to improve our mastery of complex areas of expertise. The book The Talent Code, provides the best overview of this topic.
  3. Make the Work Environment More Conducive to Sound Thinking. Three main conditions that interfere with analytical thinking include:
    1. Psychological stress leading to anxiety and dysphoria,
    2. Sleep deprivation causing chronic fatigue, and
    3. Excessive cognitive loading (responding to a barrage of emails and tasks without time to pause and reflect).
  4. Circumvent Type 1 Distortion. Setting up mental steps and processes to allow “executive override” to pause and reflect on the possibility that our intuitive initial impression is incorrect, and evaluating possible alternative explanations or decisions. For example, when a patient’s clinical presentation has some findings that are not explained by our initial, presumptive diagnosis, we pause to consider what else might explain this. For example: “Is this recurrent pharyngitis a sign of an underlying immune compromise?”
  5. Expand Individual Expertise. While routine expertise is developed with training and practice, adaptive expertise encourages flexibility and innovation in problem-solving. Adaptive expertise is fueled by curiosity; it develops when exploring the possibilities raised with type 2 thinking, and also by regularly reading journal articles or exploring topics that are unrelated to any particular patient.
  6. Promote Team Cognition. Regular conferring with colleagues on challenging diagnostic or therapeutic situations brings a collective expertise to bear, which can produce better outcomes for your patients. While synchronous consultation (for example “curbside consultation”) allows some back and forth, and is quicker, asynchronous consultation (for example using eConsult or secure email) allows time for more nuance and detail to be included and more analytic thinking and background research to be done.
  7. Mitigate Judgment and Decision-making Fatigue. Dr. Croskerry suggests the use of “cognitive forcing strategies,” like adopting clinical maxims such as “rule out worst-case scenario,” practices such as routinely documenting a differential diagnosis, or always using a pre-operative checklist.

The common feature of these approaches is that they will require an intentionality derived from a sense of professionalism. It is essential for clinical leaders to find ways nurture these habits for those on our teams.

Principles of Improving Diagnostic Accuracy (Part II of Diagnostic Accuracy Series)

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“There are three constants in life: change, choice and principles.” –Steven Covey

Steven Covey notes that actions and intent flow from principles; they are the foundation used to choose between different courses of action and to decide where to invest energy in self-improvement. The importance of principles extends to specific fields as well, including medicine.

In Part I of this series, we reviewed the extent of diagnostic inaccuracy in medicine, ranging from an error rate of 5% to 50%, depending on the nature of the patient/problem. A key contributor to this inaccuracy is our way of thinking about uncertainty: we are trained to be overconfident in the accuracy of our decisions.

Unfortunately, the other extreme, excessive concern about diagnostic uncertainty, leads less confident clinicians to order excessive laboratory and radiological tests. The Choosing Wisely campaign begins to shine a light on the scenarios where such tests are unequivocally useless but does not provide a framework for unnecessary testing when there is even slight uncertainty.

Last year, the American College of Physicians convened a group of experienced clinicians, teachers, and communications experts to address this challenge of diagnostic uncertainty. The product of this effort is called, “Ten Principles for More Conservative, Care-full Diagnosis.” Here is a brief summary of the first five principles:

  1. Promoting Enhanced Care and Listening. Perform an appropriate and thoughtful history and physical exam. When the diagnosis is unclear, continue collecting the history and evaluating changes in the physical exam at subsequent visits to determine how the patient’s clinical course is unfolding.
  2. Understand Uncertainty. Become comfortable with it, learn how to respond to it, and how to convey it to patients.
  3. Respond Carefully to Symptoms. Balance the natural history of common symptoms (75% – 80% of self, resolve within 4 to 12 weeks) with a consideration of potential psychological causes of symptoms (2/3 of patients with anxiety, depression, or somatoform disorders are undiagnosed), considering both the Social Influencers of Health and the long-term effects of Adverse Childhood Events, which also cause or accentuate symptoms.
  4. Maximize Continuity and Trust. Continuity of care by a primary care clinician is not only the single best predictor of patient satisfaction but also generates the trust needed to address the psychosocial issues mentioned above and to have patients trust the strategy of “watchful waiting” to observe the natural history of symptoms.
  5. Taming the Time Pressures around Patient Visits. Ensure the clinician has adequate time to listen, observe, discuss, and think. Adjust the system and the environment of care, as needed, to support this.

The derivation of these principles, which perhaps seems self-evident, required thought and effort of experts; trying to improve without guiding principles to guide us is disjointed at best. Like moral philosophy, it is the application of principles which is more challenging. Some approaches include taking time to think about how to apply these principles, finding small self-improvements or system changes to move towards achieving them, and telling stories to help reinforce how we approach gaps.

You, as clinical leaders in your settings, have an especially important role to play in helping your clinicians learn and apply these principles. On behalf of your patients, thanks for addressing these challenges in your setting.

Diagnostic Accuracy (Part I in a series)

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm, which defined 6 realms of quality:

  • Safe
  • Effective
  • Patient Centered
  • Timely
  • Efficient
  • Equitable

Most quality improvement and quality assurance activities related to health care address one or more of these realms.  However there is one critical area that is missing from both the IOM realms and most QI plans.  This missing realm is at the heart of what it means to be a clinician, is infrequently measured and is uncomfortable to verbalize.

This realm is Accuracy, in particular the diagnostic accuracy of clinicians.

Diagnostic Inaccuracy:  Studies show that between 5 and 50% of diagnoses are erroneous, depending on the type of patient/problem.  The low range applies to a population of patients where most are normal; the high range applies to a population where all patients have complex abnormalities.  Autopsy studies and studies with “secret shopper” patients show rates of inaccuracy of between 10 to 20%.  (Mark Graber:  “The Incidence of Diagnostic Error in Medicine”, BMJ October 2013)

What is the source of this diagnostic inaccuracy?

At the core is an insufficient appreciation of uncertainty.  Put another way, clinicians and scientists are often overconfident in the accuracy of their decisions.  This psychological trait develops when we are trainees, as it makes us appear confident in the eyes of our patients, and helps prevent us from being paralyzed by indecision.  Fortunately, many medical conditions in primary care resolve on their own, so neither the clinician nor the patient ever become aware of the inaccuracy.

We can reduce diagnostic inaccuracy by changing the way that we think.

Daniel Kahneman (winner of the 2002 Nobel Prize in Economics) describes two ways of thinking:

  1. Fast thinking (also known as intuitive thinking or system I thinking)
  2. Slow thinking (also known as rational thinking or system II thinking)

Fast, intuitive thinking tends to be automatic, with input from emotions.  In his book, Thinking Fast and Slow, Dr. Kahneman notes 12 different classes of bias and 5 heuristics which can lead to irrational decisions, when we think intuitively.

Slow, rational thinking is more deliberative, systematic, and logical, with an evaluation of consequences of a decision.

As we go through our everyday lives and routine practice of medicine, we use fast thinking for most decisions, so we can get through our days without being paralyzed by indecision over minor decisions.  When the stakes are high, or when we notice a diagnostic pattern that doesn’t quite fit, we need to transition to slow, rational thinking.  For a clinician to be efficient and accurate, we need to know when to toggle back and forth between slow and fast thinking.

When slow thinking is associated with a retrospective analysis of a serious diagnostic error, as happens in morbidity and mortality rounds, or when a clinician becomes aware of a diagnostic error that occurred, it is good to explicitly think about which biases or heuristics contributed to the error, to help prompt us to move to slow thinking when needed.

This process is sometimes called “cognitive debiasing,” which is a fancy way of saying “learning from our mistakes”.

2022: Endemic COVID-19 and Preparing for COVID-2x

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The value of experience is not in seeing much, but in seeing wisely.”

-William Olser

What does our future look like with COVID-19 becoming endemic? While vaccines and “natural” infections give some temporary immune protection from infection and re-infection, our collective immune system memories may render these infections less severe as time goes on, but this protection will be less for those who are older or immune compromised. Like influenza, regular COVID vaccine (possibly annual) will be recommended to slow spread of the infection (for healthier people), and make infections less deadly (for those with medical conditions rendering them more susceptible).

This has happened before. Paleo epidemiologists suspect that the “Russian flu” pandemic of 1889 to 1891 was actually caused by a coronavirus, possibly the grandfather of one of the subtypes that currently causes seasonal cold symptoms. Because modern DNA sequencing did not exist in the 19th century, we cannot be sure.

For this current Omicron outbreak, our system is strained, so there is a risk that too many people will let down their guards prematurely, increasing hospitalizations to a degree that forces dangerous staffing patterns, and before new powerful treatments like Paxlovid can become more widely available.

COVID-19 will become endemic, which will not make it benign. Omicron is more infectious than influenza and cold viruses, and immunity to coronaviruses if proving very transient. In the H1N1 outbreak of 2009 killed over 12,000 Americans, the majority under age 65. Hospitals were very full, but not as strained as by COVID in 2021. A massive immunization campaign resulted in just 20% of the population being vaccinated, enough vaccination with natural immunity to keep H1N1 at lower levels in subsequent years. However, the R0 of H1N1 was just 1.5, compared to about 4 for Omicron in the UK where vaccination was relatively high. Seasonal vaccination rates in the United States will not be enough to prevent annual waves of seasonally mutated COVID-19 in the years to come. We may get more used to them, but they will be worse than annual influenza seasons, at least for 2022, and maybe for years to come.

In the end, our annual winter “flu” season, which is actually caused by a collection of flu-like respiratory viruses, will be a more severe each winter, as COVID-19 joins influenza, RSV, parainfluenza, rhinovirus, the other four coronaviruses that cause milder respiratory infections, and others in causing illness and hospitalization each winter. The summer waves we saw the last two years are likely to continue, to some degree, as well.

Quarantines for COVID-19 will be phased out, but some amount of voluntary isolation of those that are ill will persist, and there will be a high usage of masks to prevent spread of respiratory pathogens in the next several years.  Virtual visits will continue to be a significant part of our health care delivery.

There will be other new coronavirus infections in the future. Now is a good time to prepare for the next coronavirus that jumps species.

In the 21st century, COVID-19 is the third coronavirus to appear that causes severe respiratory symptoms (after SARS-1 and MERS). Given the huge reservoir of viruses in other species, we are quite likely to have a Coronavirus infection caused by a different strain sometime in the next decade, a COVID-2x epidemic that could lead to another pandemic. Looking at the shortages we had early in this pandemic, we can prepare for COVID-2x, as well as more severe influenza outbreaks. There are lessons for industry, government, public health authorities, and the general public. Here are some that might be most helpful for clinical leaders in primary care:

  • Ensure local community stockpiles of highly effective masks such as N-95s are ready –enough to last for a couple of months. Encourage patients to keep some on hand as well, for future winter “flu” seasons and future pandemics. Don’t let them all expire at once, set up a system for regular purchase and replenishment.
  • Gather together and organize policies, procedures and leadership lessons, and find a way to go through these systematically each year, so the knowledge is refreshed as staff change. Include not just best practices, but also any mistakes made and options for responding to the most challenging parts of a pandemic.

Transition community connections that were forged in the COVID-19 pandemic to work on other important health issues. Set up regular meetings with your local health officer to work together on shared priorities. Relationships will be key to rapidly and effectively responding to future public health needs.

 

Not all Charity is Equal

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“No one has ever become poor by giving.”

-Anne Frank

Twenty years ago when I was the Medical Director of Community Health Clinic Ole in Napa, someone I still don’t know placed one hundred $50 gift cards to a grocery store in my home mailbox, with a note, saying that I should distribute them to needy patients of our Health Center. Our outreach team mobilized and distributed them to 50 particularly needy individual patients and families. The same thing happened the following year. The anonymous donor trusted me to make sure that their charity would go to a person who needed it; that person would never know who gave this gift, because even I did not know who it was. The charity was given without the desire or expectation of being recognized publicly, or even privately.

Eight years ago, a retired businessman –who came to the United States from India to build a business selling medical supplies—lent a 17 year old young man from his hometown in India the money to be able to attend UC Davis where he was accepted as an undergraduate aerospace engineering student. The young man’s family was of modest means; they could not afford to send him abroad to be educated. The retired businessman was not related to the family, but he made this high-risk personal loan to help him achieve his dream to be a high-tech engineer, and to support his family in the process. This young man met my daughter and is now my son-in-law.

Around this time of year, many people call local homeless shelters offering to help. Thanksgiving dinner at the Napa homeless shelter was purchased, cooked, and served by the local painters union. They called and volunteered to do this, without being asked.
All of these are examples of the highest level of charity. About 950 years ago, a physician-philosopher named Maimonides identified eight levels of charity. Paraphrasing them in order from highest to lowest:

  1. The greatest level: Support a member of your community with a gift, a loan, or helping find employment to strengthen his hand so that he will not need to be dependent on others. This is the charity provided by the Indian businessman.
  2. Give to the poor without knowing to whom one gives, and without the recipient knowing from whom he received it. It is given in secret to a trustworthy intermediary. This is the charity of my unknown neighbor, who provided the gift cards for my patients. Leaving a generous tip for the low-income housekeeping staff at a hotel could fit in this category, as well.
  3. Give to someone that is known to the donor, but the recipient does not know who gave the gift.
  4. Provide a donation when the donor does not know who they are helping, but the recipient does know.
  5. Give directly to someone, with both the donor and recipient knowing each other, but the gift is given without being asked. The painters who prepared and served Thanksgiving dinner to the homeless of Napa would fit in one of these three levels (3, 4, or 5); although the donor and recipient could see each other, they did not know each other’s names.
  6. Giving to a poor person after being asked.
  7. Giving inadequately, but gladly and with a smile.
  8. The lowest level of charity is to give unwillingly.

In the progressively lower levels of charity, much of the purpose of the charity is to be seen by others as being charitable (called virtue signaling by psychologists). This charity is still very important, as many U.S. charitable organizations rely on these lower levels to gather donations. In the higher levels, the charity is not intended to improve one’s social capital but rather aims to increase the opportunities of others and positively impact communities.

Here are three takeaways for each of us:

  1. Contemplate these eight levels of charity; talk them over with your family and friends.
  2. This holiday season think about ways you can give at one of the higher levels.
  3. Let humility guide your giving practices. Celebrate those who quietly, give without expecting recognition.

 

Back to the Future: Refocusing on Prevention and Chronic Disease Care

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only way you can stay on top is to remember to touch bottom and get back to basics.”

-Shane Black (Director, Screenwriter, Actor)

The COVID pandemic has had a number of ripple effects on the health of your patients, beyond the consequences of infection and stress-induced exacerbation of mental health status. Many clinical quality metrics saw plummeting performances in the past two years. For example, the proportion of those with a diagnosis of hypertension whose blood pressure is controlled dropped by over 10%. A major driver is decreased in-office visits where blood pressure is checked, with a relatively small proportion of patients using home BP monitors to follow their own blood pressure. Drops in well-child visits, breast, and cervical cancer screening are other examples.

The summer wave of the delta variant of COVID-19 led to increased infection rates, staffing disruptions, and new vaccination recommendations. It is becoming clear that COVID is so infectious and the level of protection from infection conferred by the initial vaccination series and prior infection is transient, so it will not be disappearing but rather become an endemic disease for the foreseeable future.

With this in mind, it is a good time to remind ourselves of other health issues facing the patients we serve, issues that were often deferred by patients and clinicians in the midst of the waves of pandemic cases. They include core preventive activities, like screening for breast and cervical cancer, use of nicotine products, and misuse of alcohol and other drugs. They include control of chronic conditions like hypertension, diabetes, asthma, and COPD.

In the next couple of months, we encourage you to pause, take a breath, and start to think about how you will re-engage your organization with these important core preventive and chronic disease activities!

Tips from the Field: Leveraging Scribes to Improve Quality

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If you have knowledge, let others light their candles in it.”

-Margaret Fuller,
American Journalist and Women’s Right Advocate

Most organizations that implemented Electronic Medical Record (EMR) systems in the last two decades found that this implementation led to increased clerical workload of clinicians, leading to increased burnout and job dissatisfaction. Additionally, overuse and misuse of templates led to longer but less accurate and less useful clinical notes.

Several primary care organizations in our region added a new position to address these issues like medical scribes, who perform real-time electronic health record documentation, in the exam room (or video call) with the clinician.

A survey of the published literature on medical scribes have shown increased efficiency, clinician productivity and provider experience, while patient experience with scribes is mixed.

Shasta Community Health Center (SCHC) reports that the increased efficiency of scribes leads clinicians to finish their work earlier at the end of the day, with administrative tasks completed which allows them to go home to their families on time. Since first implementing a scribe program over a decade ago, SCHC has refined their model to increase the quality of documentation in the medical record and to drive quality performance in the Primary Care Providers Quality Incentive Program (PCP QIP) measures.

  1. Training: SCHC has developed a training curriculum to train promising candidates in medical language, standards of documentation, etc., which is now being adapted to be offered in community college courses.
  2. Continuity: a clinician-scribe diad often develops short cuts and non-verbal communication methods to work rapidly as a team to support the patient. This may include sending instant messages to the clinician during the visit, such as ordering preventive screenings.
  3. Quality focus: Assigning the scribe responsibility for measures amenable to their intervention, like ordering labs that are due or scheduling well child visits.
  4. Incentives: A pilot showed that a small incentive for scribes linked to a single measure worked well, but Shasta CHC is cautious about unintended negative consequences, such as removing intrinsic motivation for improving quality.

This “tip from the field,” was collected by Partnership HealthPlan of California’s (PHC’s) Medical Directors, Dr. Robert Moore and Dr. Jeff Ribordy, at our first trip to Redding in many months. We will be working our way out to visit other counties and providers in the months to come.

Many Ways of Promoting Lung Health

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Ancient medicine had once had a name for this something present in the living body but missing from the corpse. Spiritus was the breath, the regular, rhythmic breathing of the live body that is so shockingly absent from the dead.”

-Dr. Victoria Sweet, Author and Medical Historian

October is National Lung Health Month, sponsored by the American Lung Association. Why October? Possibly to coincide with the prime season for influenza vaccination.
Here are few ways (besides flu vaccination) primary care clinicians can support our patient’s lungs.

  1. Asthma Treatment: Use combination formoterol-corticosteroid inhalers (such as Symbicort or Dulera) instead of albuterol or levalbuterol for short-acting relief of mild to moderate asthma. International and national guidelines and a strong evidence base support this approach.
  2. Asthma Misdiagnosis: Be on the lookout for the 10% of patients with a diagnosis of asthma who have other conditions. Order spirometry or pulmonary function tests if the diagnosis is unclear, especially if not responding as expected to usual asthma treatment.
  3. COVID: About 20% of patients hospitalized with COVID develop long-term lung damage, causing dyspnea and decreased exercise tolerance. Prevent permanent lung damage caused by COVID by encouraging all eligible patients to be vaccinated, especially pregnant women and teens. Consider use of monoclonal antibodies to treat early COVID infection to prevent it from becoming severe.
  4. COPD: Ensure that patients discharged from emergency departments and hospitals for COPD exacerbations receive prescriptions for tapering oral corticosteroids and combination bronchodilators (long acting beta agonists and long acting muscarinic agonists).
  5. Action Plans: Ensure that patients with COPD and Asthma have action plans to allow them to self-manage exacerbations.
  6. Pneumococcal Vaccination: When giving annual influenza vaccine, co-administer pneumococcal vaccine for those who have not been previously vaccinated. Who are eligible? Adults over age 65, those with immuno-compromising conditions, chronic CSF leak, and those with cochlear implants.
  7. Smoking cessation: ask about smoking status, provide counselling to those using tobacco products, and prescribe smoking cessation medications when appropriate.

Although these are core primary care activities, we sometimes are distracted by other clinical issues that come up in our visits. Please pass this along to your clinicians to remind them to think about more than just flu vaccine, this month.

Yours, Mine or Ours?

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Work is hard. Distractions are plentiful. And time is short.”

-Adam Hochschild (Writer, historian)

The approval of COVID boosters this week, and the expected expansion of vaccination to school aged children in the next 2 months, will lead to a surge in demand for vaccination. Counties, pharmacies, hospitals, and medical providers are planning on how to respond to this demand, which could distract us from something all public health experts agree on: most hospitalizations and deaths are occurring in the unvaccinated. The unvaccinated deserve continued focus and attention.

Additionally, the energy and resources to provide boosters and pediatric vaccinations this fall will distract from other important healthcare needs of the populations we serve: increased levels of depression, substance use and obesity are combined with worsening control of hypertension and diabetes. Children are falling behind on well-child visits and routine childhood vaccinations.

What should be the role of Primary Care Providers (PCPs) in providing boosters and pediatric vaccines, during the fall of 2021? Planning with county stakeholders is key, with each stakeholder asking themselves, “What are YOU best equipped to do, what is MY responsibility, what do we need to do TOGETHER to be successful? What is yours, what is mine, what is ours?”

Yours. Consider directing motivated patients to register for vaccinations at community pharmacies, which are currently providing about 2/3 of vaccinations in the state.

Mine. How can we integrate COVID vaccination in our practices as efficiently as possible to avoid negatively impacting other preventive activities, including efforts to vaccinate those without prior doses of vaccine? Can we vaccinate our patients during regular hours and use the leftover doses at the end of the day to provide non-urgent boosters to those previously vaccinated?

Ours. Work with counties to develop a plan to vaccinate school-aged children rapidly, ideally in the school setting. How can we mobilize volunteers to take the pressure off practicing clinicians?

The work remains hard. The new vaccine policy distractions are plentiful. Although the fall Delta wave is subsiding, time is short before a winter wave begins. Nonetheless, it is worth the time to plan now.

A way for the Vaccine Hesitant to Save Face

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By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Difficulties mastered are opportunities won.“

-Winston Churchill

While we like to believe that we generally weigh different sides of a controversy before coming to an objective conclusion, the reality is that this is very rare. Studies show that humans generally decide first what they believe to be true and then search for supporting evidence and ignore evidence that casts doubt on their beliefs. Behavioral economists call this confirmation bias.

In a fascinating exercise, economist Angela Duckworth and author Steven Dubner (co-author of Freakonomics) debated if they would take a vaccine that prevented them from having any confirmation bias. One conclusion: the result of widespread use of such a vaccine would be economic paralysis. For everyday life to proceed efficiently, we rely on the confirmation bias. However, innovation, justice, and good policy depend on having at least a few individuals who are able, at least some of the time, to more carefully weigh different options before drawing a final conclusion. The most flexible will be willing to change their initial views in the face of evidence to the contrary.

Many individuals who are still refusing COVID vaccination initially felt that they did not want to be vaccinated, but those views solidified under the effect of confirmation bias: they latched onto any concerns, no matter how far-fetched, and actively wrote off evidence of the benefits of vaccination as tainted by a profit motive or a government drive to control citizens. These individuals need a way to allow them to change their view without feeling like they are “selling out” in some way. They need a way to save face.

One option may be to promote the coming Novavax COVID vaccine, likely to be approved for Emergency Use in adults in the next two months. Here is the narrative:

  • This two-dose series uses tried and true purified protein technology, used for decades in Hepatitis B and Tdap vaccines.
  • No fetal cell lines were used in any stage of its research or production.
  • The vaccine uses completely different adjuvants, so there is not a risk of cross-anaphylaxis.
  • The early reports of effectiveness show it comparable to the Pfizer and Moderna vaccines, but with less fatigue and local side effects.

This will not resonate with everyone opposed to COVID vaccination, but it does address several common stated concerns around current vaccine options. It may allow them to change their mind and accept COVID vaccination, in a way that is congruent with their earlier negative views.

A key is for early impressions of the Novavax vaccine to be positive, in your conversations with patients and your social media, leveraging the confirmation bias to increase support of vaccination.