Flu shots and persuasion


Compliant patients are all alike; every noncompliant patient is obstinate in his or her own way. Because of this, persuading patients to make good choices is rarely easy and never universal.

At Kaiser Permanente, we have begun in earnest providing flu shots. Every department participates (even dermatology) with a goal of vaccinating every eligible patient. Most patients want their shot. When patients decline, it’s game on. A rare few decline for justifiable reasons such as an allergy. Most say “no” for flawed reasons: “I never get the flu,” “The shot always gives me the flu,” and “I don’t believe in vaccines,” are common ones.

a thermometer to measure the way to a goal. jabkitticha/Thinkstock
There is no single way to persuade patients, even when they are wrong. Most of us learn successful techniques only through years of experience. What if there were methods that could help? There are: The field of behavioral economics, made mainstream by people like 2017 Nobel Laureate Richard Thaler, have much to offer us in medicine. We now understand that patients, like all people, don’t always behave rationally. They sometimes make decisions based on misinformation and fall prey to cognitive biases and pitfalls. In particular, patients often fail to weigh future consequences, called present-bias, and choose to continue their past behavior even when detrimental to their health, called status quo bias.

Fortunately, we can help them. Here are techniques I learned while working on my MBA that I’ve found useful in persuading patients to make better choices:

  • The “everyone is doing it” technique. At KP, we’ve put up boards with the iconic goal thermometer showing how many flu shots we need to reach our objective. When patients see we’ve given over 1,000 shots in dermatology in just 2 weeks, this technique helps convince them. Patients prefer to be like others rather than to stand out, particularly when there is uncertainty.
  • The “this is who you are technique.” Patients hate to be seen as inconsistent. In fact, we are all more likely to make a choice seen as consistent with who we are rather than change our mind, even if doing so is a better choice. Highlight how they have previously shown good decision making and healthy behaviors and point out how getting vaccinated is consonant with who they are. For example: “Being a vegan, you are clearly someone who takes care of her health. Getting the vaccine is similar to choosing to eat plants. It’s what healthy people like you do.”
  • The “well, that’s not like you” technique. Here, you point out how their choice is inconsistent with their previous choices. You might say, “Why would you get the hepatitis A vaccine last week and not the flu shot today?” Like the previous technique, this creates cognitive dissonance. You might soften the approach by saying, “You might have thought this,” or “I’m sure you didn’t realize.”
  • The emotional decision approach. Making the risk seem real and imminent can combat future discounting. One example might be: “We have had several people hospitalized and one death from the flu in San Diego already.” Use stories and descriptive language to make the risk salient.
  • The use your authority approach. The long coat does matter. A more modern version of the paternalistic physician is referred to as “asymmetric” or “light paternalism,” and we should recognize that it might be used to save a life. One example is: “I advise you to get the flu shot because I care about you, and I’m worried you might end up in the hospital or worse if you don’t get it.” There’s a reason why tobacco companies once used doctors in white coats to sell cigarettes – we can be quite persuasive.

Dr. Jeffrey Benabio, director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego.

Dr. Jeffrey Benabio

Patients are free to make choices, however good or poor. Persuading them to choose good is our work as doctors. I found these techniques can help patients make any number of good choices and aren’t limited to vaccines. They can be used for smoking cessation, exercise, physical therapy, unhealthy drinking, and medication adherence to name a few. I hope using them makes you a little better at your work, too.

“A great deal of literature has been distributed, casting discredit upon the value of vaccination ... I do not see how any one ... who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value.” – William Osler

Dr. Benabio is director of health care transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at

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