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COVID CONWAY COMMUNICATIONS REBOOT #2
Q&A NOVEMBER 2021
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Hi Colleagues and Community! I’m Dr. Kate Conway and I have been writing CCC since Summer 2020. I now have a team with me ready and excited to bring you answers to your questions every month. I am a Family Physician specializing in Global Health and Medical Education. I have been working hard during the pandemic to take care of my family, my patients, my coworkers, and my students. I believe in the power of relationships and sharing our stories to empower positive change in this world. I will share my own personal reflections along with introducing our monthly Q&A topics. Stay Well, Stay Safe, Stay Smart!
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Question I am answering: How do you answer all these questions?
In this November edition we will be answering questions on Booster shots, Breakthrough infections, Vaccine approval process, Multisystem Inflammatory Syndrome in Children, and Covid Conversation tips. Each question is first answered with Take Home Points for quick and easy reference. This is followed by More of the Story when our writers have provided a deeper dive on the topic and then Resources Used to Answer this Question with the primary references listed, including links to take you there. We hope to include infographics and other visual aids along the way and will make sure to highlight multi-media resources when we can.
We will always strive to answer the question with the best information available. It is our goal to provide information from trusted sources and balanced perspectives. We will also be honest when a question can’t fully be answered because science is still trying to answer it and may only have partial data available for review and interpretation. I am humbled by how much we have learned in such a short amount of time. Asking questions is one important way we all stay tuned in together. Please continue to submit COVID questions here:
Google Form COVID Q&A. You can also reach me if you have any questions or need clarifications on material published here katharine.conway@wright.edu.
Please share this with others and be on the look out for ways we will continue sharing with you via our social media and website links coming soon.
During this season of light and gratitude, we look forward to share health and hope with you.
~ The BSOM CCC Reboot Team
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Team Member Introduction: Who am I and Why do I COVID Care?
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Hi! My name is Maneesh Chidambaram and I am a first year medical student. I am writing for this publication because in the past year I have witnessed how misinformation has affected our community and the lives of people we care about. I believe the best way to combat this misinformation is through evidence-based information which I hope to share.
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Question I am answering: What are updates on the COVID-19 Booster Shots?
Why do we need booster shots?
Like many things in our lives, nothing lasts forever. Vaccines signal our own immune system to build a defense system against the virus. Part of this self-made defense system is called antibodies. As our own defense system can decline over time, it is important to maintain a high antibody level in the wake of the arising variants that are still evolving. A booster will help build and maintain your self-made immune defense. We don’t yet know how many or how often boosters will be recommended. This will continue to be studied as we live with this version of the SARS-CoV2 virus and learn more of what we need to do to stay healthy against it.
Check out this webpage for FAQs answered: ODH Booster Shots
Can I mix and match my COVID booster shot from my vaccine?
Yes, you may receive your booster from either the same or a different company you received your vaccination from. For Example, if you received a Moderna vaccine, you may receive either a Moderna, Pfizer, or JNJ booster.
Is the booster shot free?
Yes! The booster is free to you when it is available to your age bracket.
Do I need a booster if I already had COVID-19?
It is important to remember that even if you have had COVID-19 infection, Studies show that being fully vaccinated will reduce your chances of hospitalization and death from reinfection. The initial vaccine series (JNJ or Moderna or Pfizer) is the most important one to receive at this time. People who are fully vaccinated and are otherwise healthy still have very good immune defense even without the booster. People who have high risk health conditions and/or high risk exposure in their jobs would benefit most from boosters at this time.
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Resources used to answer this question:
Webpage: Centers for Disease Control and Prevention, COVID-19 Vaccine Booster Shots, Accesses 11/04/21, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html
Article: Centers for Disease Control and Prevention, Comparative Effectiveness of Moderna, Pfizer- BioNTech, and Janssen (Johnson & Johnson) Vaccines in Preventing COVID-19 Hospitalizations Among Adults Without Immunocompromising Conditions — United States, March–August 2021, Wesley H. Self et. al., Accessed 11/04/21, https://www.cdc.gov/mmwr/volumes/70/wr/mm7038e1.htm?s_cid=mm7038e1_w
Website: Ohio Department of Health, Fact Sheet: COVID-19 Vaccine Booster Doses Adults and Adolescents, Accessed 11/06/21, https://coronavirus.ohio.gov/static/vaccine/fact-sheet-covid-19- vaccine-booster-doses.pdf
Website: American Medical Association, COVID-19 vaccine boosters mix and match: What the evidence shows, Accesses 11/06/21, AMA article
Webpage: Johns Hopkins Medicine, Booster Shots and Third Doses for COVID-19 Vaccines: What You Need To Know, Accessed 11/04/21, https://www.hopkinsmedicine.org/health/conditions-and- diseases/coronavirus/booster-shots-and-third-doses-for-covid19-vaccines-what-you-need-to-know
Article: Heterologous SARS‐CoV‐2 Booster Vaccinations – Preliminary Report, Atmar et. al., Accessed 11/05/21, https://www.medrxiv.org/content/10.1101/2021.10.10.21264827v2.full.pdf
Webpage: Northeast Georgia Health System, COVID-19 Booster Shots and Third Doses: What you need to Know, Accessed 11/04/21, https://www.nghs.com/2021/09/28/covid-19-booster-shots-and-third- doses-what-you-need-to-know/
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Team Member Introduction: Who am I and Why do I COVID Care?
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My name is Matt Huston and I’m a first-year medical student at the Boonshoft School of Medicine and am interested in Emergency Medicine, health equity, and global public health. I grew up in Northeast Ohio and received my Bachelor of Science in Biochemistry and Molecular Biology from Otterbein University. I am passionate about these issues because of the impact I’ve seen Covid have on patients and their loved ones.
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Question I am answering:
What are “Breakthrough infections” and should I be concerned?
Take Home Points:
- “Breakthrough infections” are infections that occur in individuals who have been fully vaccinated against Covid-19.
- Breakthrough does not mean the vaccines aren’t working. They are still working to keep people out of the hospital, prevent death, and reduce risk for long-COVID syndrome.
- Other vaccines also have small percentage breakthrough infection – also presenting with much more mild illness than in unvaccinated individuals. Influenza, Shingles, and Measles are examples.
- Vaccinated people who have breakthrough infection are less likely to pass the virus on.
- Infection (or reinfection) with Covid-19 can occur in people who are fully vaccinated and who are unvaccinated. No immunity to Covid-19, from infection or vaccination, is perfect protection.
- However, the rates of serious infection are MUCH higher in unvaccinated folks than the rates of breakthrough infections in vaccinated folks.
- Most importantly, vaccinated folks experience much more mild Covid symptoms with a breakthrough infection and have a much lower rate of hospitalization and an even lower chance of death. This is because the vaccine did its job by signaling their own immune system to have some level of defense ready to fight when needed.
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Resources used to answer this question:
- Image: CDC, CDC COVID Data Tracker, accessed 10/30/21, CDC Link
- Article: New England Journal of Medicine, Covid-19 Breakthrough Infections in Vaccinated Health Care Workers, accessed 10/30/21, NJEM Article
- Article + Graphs: New York Times, Who Had Covid-19 Breakthrough Cases?, accessed 10/30/21, NYT Link
- Article: NPR, Breakthrough infections might not be a big transmission risk. Here's the evidence, accessed 10/30/21, NPR Link
- Article: Fox News, COVID-19 breakthrough infections with sever outcomes compromise 0.01% of cases, accessed 10/30/21, Fox News Link
- Article: Johns Hopkins Medicine, Breakthrough Infections: Coronavirus After Vaccination, accessed 10/30/21, Johns Hopkins Link
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Image 1: CDC, CDC COVID Data Tracker, accessed 10/30/21, CDC Link |
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Image 2: New York Times, Who Had Covid-19 Breakthrough Cases?
accessed 10/30/21, NYT Link |
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Team Member Introduction: Who am I and Why do I COVID Care?
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My name is Shay Guthrie, I am an M1 at Wright State Boonshoft School of Medicine. I was pregnant with my son when the Covid Vaccine was made available and I could not get it fast enough. Though I was nervous because pregnant people were left out of the vaccine trials, I trusted the scientists and my physicians who recommended I get the vaccine to protect my life and to pass antibodies to my unborn child. I wanted to take part in this because I have seen how the spread of mis-information and dis-information can negatively impact people’s health and I wanted to do what I could to combat the problem. My goal now and as a future physician is to be a safe/non-judgmental person that patients can ask all of their questions to and to provide them accurate and trustworthy information.
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Question I am answering:
How does a vaccine go through the formal approval process and why was the Covid-19 vaccine able to get approved so quickly?
Take Home Points:
More of the Story
There are six general steps to vaccine research and development. The exploratory stage and pre-clinical stage is the longest part of vaccine development lasting anywhere from 1-10 years and often vaccine development gets stalled in this stage due to potential toxicity or lack of protective immune response. Researchers study the infectious organism that is causing illness and they figure out a way to create a vaccine candidate. For the pre-clinical portion, researchers are testing their vaccine on animals to ensure safety and potential immune response.
Once the vaccine passes out of the pre-clinical phase, vaccine developers submit their findings to the FDA in an Investigational New Drug (IND) application. After careful evaluation of laboratory practices and manufacturing technology among other safety checks, the FDA gives clearance to move to Clinical Development. Clinical Development occurs in three phases. Phase 1 includes giving the vaccination to 20-100 healthy volunteers who have not been exposed to the disease. They are carefully followed to ensure no adverse reactions as well as to study dosing. Phase 2 studies are done on 100’s of people with different health statuses and from different demographics. The increased number of participants gives researchers insight into common side effects, dosing and effectiveness. Phase 2 studies also involve a control group that either receives a FDA-approved vaccine, a placebo or another substance. During Phase 3 trials, the vaccine is given to thousands of participants and more safety data and information regarding effectiveness of the vaccine. There is also a control group during this phase which is used to see whether the vaccine is effective in reducing incidence of disease. The large number of participants alerts researchers to any less common side effects. Clinical development typically takes 5 or more years.
The next step is Regulatory Review and Approval. At this time the FDA uses a team of physicians, chemists, statisticians, pharmacologists/toxicologists, microbiologists, postmarketing safety experts, clinical study site inspectors, manufacturing and facility inspectors and communications experts to review data to determine if the vaccine is safe and effective as well as to ensure manufacturing can be done with quality and consistency. Once approved the vaccine can be manufactured and given to the population it was developed for. FDA continuously monitors for quality control.
The COVID-19 vaccine went through all of the above steps, but at a much faster pace by removing usual financial and logistic barriers due to the severity of the global pandemic. Researchers had been working for many years prior to the pandemic to create vaccines against coronaviruses like SARS and MERS. Scientists were able to quickly identify the SARS CoV-2 genetic sequence because of the previous research and then create the vaccine using mRNA technology. This mRNA technology had also been studied and used for over 30 years already. The US Government invested money into manufacturing much earlier than usual in order to get the vaccine out to as many people as possible as soon as clinical trials concluded and Emergency Use Authorization was granted. Clinical trials usually take place consecutively, however, with this vaccine they were partially overlapped. Finding vaccine volunteers was much faster and easier due to so many people excited and willing to sign up for the clinical trials, decreasing recruitment time and effort usually needed during these phases. Assessing the vaccines effectiveness and potentially side effects was much faster due to the large number of vaccine volunteers for each vaccine studied.
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Team Member Introduction: Who am I and Why do I COVID Care?
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My name is Kyle Henneke. I am a third-year MD/MPH student here at BSOM with experience in public health and a lot of interest. I completed my MPH in May 2021 with a certificate in Emergency Public Health and have done a number of things with COVID-19 response here in the U.S. including humanitarian deployment, contact tracing program leadership, and clinical research on vaccine hesitancy.
I care very much about the goals of public health which include education and advocacy. As a future physician with public health training, I feel I share in the responsibility of combatting misinformation to give people the opportunity to make wiser decisions for the health of themselves, their loved ones, and their communities.
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Question I am answering: No, Really – What is MIS-C?
Take Home Points:
- Multisystem Inflammatory Syndrome is a condition caused by an overwhelming immune response to COVID-19 infection in children/adolescents.
- Incidence of MIS-C shows that it remains a rare, though, serious condition associated with COVID-19 infection or exposure within 4 weeks of symptom onset.
- Criteria for this condition include having a fever for at least 24 hours with a known COVID-19 positive test or exposure within 4 weeks plus severe symptoms involving at least 2 organ systems and lab abnormalities indicating inflammation.
- Most common symptoms in order from most to least: gastrointestinal (abdominal pain, diarrhea, and/or vomiting), rash, respiratory (cough and/or sore throat).
- The heart is of particular concern with MIS-C and hypotension/tachycardia (dangerous low blood pressure/racing heart rate) generally results in ICU admission for critical care.
- The health care team for MIS-C treatment can include the primary medical team, cardiologist, and rheumatologist among others and most children recover after treatment in the hospital.
- Now that children 5 years old and up can get vaccinated, scientists expect the numbers of MIS-C cases to decrease. Vaccination should prevent this serious complication of COVID-19 infection but now we will have scientists tracking this and reporting this data for us to confirm.
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More of the story:
Multisystem Inflammatory Syndrome in Children, more commonly referred as “MIS-C” has gotten a lot of attention lately – particularly with the rise of the COVID-19 Delta Variant. Some may ask the question “What is MIS-C?” but having wrapped up my pediatrics rotation and talking with many parents, it’s clear that this question is more complicated than it seems. What many parents may be asking their healthcare providers likely concerns:
- Is my child at risk?
- What are the signs and symptoms I need to look for at home?
- How serious is it if my child is diagnosed with MIS-C?
How Common is MIS-C, Really?
According to the Centers for Disease Control and Prevention (CDC) COVID Data Tracker, MIS-C in the
U.S. reported by state health departments remains a rare, but serious, complication of COVID-19 among children and adolescents. 1
As of October 4, 2021, data reported to the CDC directly by state health departments shows:
- Total # MIS-C Patients That Meet Case Definition: 5,217
- Total # MIS-C Deaths That Meet Case Definition: 46
- 50% of MIS-C cases were between ages 5-13 years old
- Nearly all (98%) had a positive COVID-19 test
- Majority (60%) were boys
Ohio was in the top 8 states with the most reported MIS-C cases – rivaling Texas, Louisiana, Florida, Illinois, and New York.
What is MIS-C?
This condition is probably best described as a delayed, but overwhelming response by the immune system to COVID-19 exposure. While many children with COVID-19 infection may be asymptomatic or have mild symptoms that pass, some will develop this condition as much as 4 weeks after infection. It resembles conditions such as toxic shock syndrome and Kawasaki disease – which won’t be discussed here but are still worth reading about. This month, we’ll be walking through what many parents seem to ask the most about MIS-C and what we should be prepared to discuss with our patients and their families.
Is My Child at Risk?
This is a large concern shared by many parents and is important to cover during COVID-19 education with families. Recent data tells us that MIS-C remains, overall, a very rare condition and a large majority of children exposed to COVID-19 will not become this seriously ill. However, most children that develop MIS-C will need an ICU admission and critical care support. 2 It’s important to stress that vaccinating yourself against COVID-19, wearing masks while in public, and encouraging safe public health strategies
within your child’s school remain the best ways to protect them.
Now that more and more children can receive COVID-19 vaccination, the hope is that the risk of MIS-C will decrease. While data is still being collected to follow this trend, all major health organizations, like the American Academy of Pediatrics, the American Academy of Family Physicians, and the Infectious Disease Society of America, recommend vaccination for all who are eligible.
What Are the Symptoms to Watch For?
Primary diagnostic criteria:
- Child/adolescent age <21
- A fever (100.4° F) for minimum 24 hours
- A temporal association with COVID-19
- Other considerations include illness requiring hospitalization, two or more organ systems affected, lab evidence of inflammation, and no alternative diagnosis found.
Most common symptoms/signs (in order):
1.) Gastrointestinal – abdominal pain, diarrhea, and/or vomiting 2.) Rash
3.) Respiratory – cough and/or sore throat2
Will MIS-C Be Serious in My Child?
Yes. Most children need ICU critical care treatment in the hospital.
Of particular concern for MIS-C patients is cardiac complications, especially considering many end up in the ICU due to hypotension and tachycardia, requiring medications called pressors and/or IV fluid resuscitation – a concern that has not changed after over a year of monitoring and treating MIS-C cases.2,3 While most patients will exhibit cardiac inflammation, as evidenced by increased cardiac
enzymes and EKG changes, it’s important to note that for some patients the heart may not be affected
at all. For suspected MIS-C, a cardiologist will be involved for cardiac monitoring and serial testing.
In terms of treatment, many hospitals have a standing protocol that includes steroids and IVIG therapy so as not to delay treatment. However, most therapies will be managed and followed by a rheumatologist.
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Resources used to answer this question:
- CDC COVID Data Tracker. Accessed November 3, 2021. https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance
- Radia T, Williams N, Agrawal P, et al. Multi-system inflammatory syndrome in children & adolescents (MIS-C): A systematic review of clinical features and presentation. Paediatr Respir Rev. 2021;38:51-57. doi:10.1016/j.prrv.2020.08.001
- Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-System Inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 Infection: Review of Clinical Presentation, Hypothetical Pathogenesis, and Proposed Management. Children. 2020;7(7). doi:10.3390/CHILDREN7070069
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Team Member Introduction: Who am I and Why do I COVID Care?
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Hi! My name is Kehinde ‘Kenny’ Agoro, and I am an M1 at Boonshoft School of Medicine. I unfortunately dealt firsthand with COVID-19 and have also lost many loved ones due to negligence centered around extreme misinformation and outright mistrust of both public health and health care officials. I am in support of the GREAT and passionate work that has been done, especially as it pertains to education, transparency and a thorough plan of action set in place to address this current crisis. I find it a personal obligation to stand alongside those willing to combat misinformation around the COVID-19 pandemic by assisting with the dispensation of quality resources and reliable information to answer the questions of our community as best I can. I want to continue learning, to become a better voice/advocate, and to ensure that the concerns of the community I serve are met with answers worth trusting.
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Question I am answering: How do we avoid feelings of frustration and anger when people don’t follow medical advice?
Take Home Points:
- Am I actively listening to others first?
- STOP and REALLY listen. Do not listen to respond but listen to understand.
- Ask questions next. “What have you heard about the vaccine?” “What do you know about COVID-19 and what are your thoughts?”. “What do you care most about in these pandemic times?”
- Ask permission to share your perspective. This creates a welcoming and inviting atmosphere.
For the most part, people rarely want unsolicited advice.
- Watch your tone. It is easy to get passionate about matters such as COVID-19 but pressuring and badgering creates tension that doesn’t make for effective communication.
-People are not wrong about their emotions and what they feel. Emotion is a main driver for decision-making more so than having more information.
- Cognitive understanding is not alone a satisfier for behavior change. People want to know that you value their experiences and perspective. “When a person feels thus understood, one does not feel alone”.
- Respect a person’s decision to ultimately disagree with your perspective. Respecting decisions places value on a person’s humanity and ultimately prevents damaging relationships.
- Be proud of the work you are doing to make our communities safer and do not get discouraged. Remember that you are doing good work that is equally difficult. The information you are sharing is not “common sense” and often isn’t effective in just one conversation to make the change you desire to see. Let people know you are willing to chat more in the future.
-Remove the burden of convincing from your shoulders. Support instead. Educate. Empower.
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More of the Story
“Whose line is it anyway?” Whether you’ve heard this question in reference to the television show or in association with the dialogue of a particular script, the phrase asks who is supposed to speak next. The question might arise in moments of confusion and
disorder, for example during a stage play when a character has forgotten their line or when two characters mistakenly speak at the same time. What happens however when there is no script to follow and this same kind of communication barrier exists in real time and during conversations pertaining to matters of health, particularly in the case of COVID-19?
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Not only are we dealing with the coronavirus and the crisis it has ensued but also a social virus and crisis fueled by misinformation through social media. This makes it very easy for a person to engage in material that confirms their own thinking, unfortunately at the cost of further perpetuating their belief in conspiracy theories, rumors, myths and false information.
So how can we both help and limit our frustrations down the line? First, STOP and REALLY listen. Do not listen to respond but listen to understand and do so authentically. Listen for key words that might reveal reasons for hesitancy to adherence of COVID-19 recommendations or vaccinations. Listening obliterates communication barriers and leads to positive outcomes by reducing stress, suspending bias, creating room for richer dialogue and increasing the potential for joint decision making.
Before spewing information about all your knowledge and facts, remember that you are speaking to another human being whose concerns or thoughts may not reflect your agenda. Always ask questions first. “What have you heard about the vaccine?” “What do you know about COVID-19 and what are your thoughts?”. Asking questions provides less judgment or room for assumptions that contribute to resistance. It is not enough to give information. Gathering an understanding of the actual information a person needs to make informed decisions is key. It is important to know who you are speaking with.
Tailor your message accordingly. People are motivated for different reasons.
Understand as the conversation ensues that people are not wrong especially as it pertains to their emotions and what they feel. Do not tell people they are selfish but rather encourage them to make a difference in the lives of those they could be helping including family, friends, loved ones and the community at large.
To effectively listen, do not interrupt, speak over or be so eager to make a correction. When tension may arise, do not dismiss it. How often have we dismissed people as uncooperative because they did not follow our advice? Remember it is more important not to seek cooperation but to seek understanding of barriers to communication and the causes of resistance. In doing so, we diffuse conflicts and move towards acceptance of the reality in front of us as it truly is.
Usual responses to people skeptical of our ideas is to avoid them and so too do those who do not agree with our points of view. In blocking space for shared perspectives, we limit what we can learn and how
to better introduce information. Listen to what you don’t want to hear! In an experiment led by Dr. Martin Bass it was found that the greatest predictor for whether a patient would report feeling better after one month was whether the patient said the physician had listened to the patient’s description of the illness at the first visit. Patient’s predicted reporting of getting better was linked to whether they felt they could discuss their problems fully and with a physician that was able to appreciate what it meant to them.
Be well prepared and equipped to share actual sources with people because this makes for honest communication. Review information with people in real time and help them to understand the information you share by walking through it together. It is not enough to encourage research but rather more effective to engage a person. Show not tell is the key. This is an optimal moment to correct misinformation and to potentially alter decision making.
It is a gift to provide your attention to someone else and one might find that in doing so, a significant kind of trust is built where, as a result people become more open and share information that they otherwise would not have. Offer people an opportunity to continue the conversation with you later if necessary. People might have questions they want to ask, and they might feel better about the information you have shared with time.
Check for nonverbal communication, both your own and the person in communication with you. When sharing advice with family note that the words used as harmless to you can set off emotions simply because of your proximity to the individual. Information sharing does not require arguing. Ultimately people want to feel empowered to make the right decisions for themselves.
There is a concept known as psychological reactance which speaks to the idea that when someone is told what to do, they tend to do the opposite. This is part of the reason why people tend to be dismissive despite information from top scientists and experts. People enjoy their freedoms and because of this it is important to not approach information sharing as an elitist to avoid being perceived as a person who is arrogant or wants to control others.
It is important to put yourself in the other person's shoes. Imagine their world and the barriers they might face which might aid in their resistance. It is easier to spew facts than to get into someone’s mind, but far more often is the goal of adherence obtained through mutual understanding.
In the end ask the person how they feel about what was shared. Respect a person’s individuality, involvement in decision making and most importantly, the personal autonomy to do with the information shared what they please. There is a difference in convincing a person and educating them to provide options for good decision making. You do not have the responsibility for other people’s actions. I’ll leave you with the famous quote from Mahatma Gandhi, ‘Be the change you wish to see in the world.”
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Resources used to answer this question:
Webpage: CNBC Make It, How to talk with your older parents about the COVID-19 pandemic—and have them actually listen, accessed 11/8/21, https://www.cnbc.com
Webpage: UNICEF, How to talk to your friends and family about COVID-19 vaccines, accessed 11/8/21, https://www.unicef.org/coronavirus
Webpage: Behavioral Scientist, Why Are People Ignoring Expert Warnings? Psychological Reactance,
accessed 11/8/21, https://behavioralscientist.org
Webpage: APA PsycNet, Problems in communicating psychological understanding: Why won't they listen to me, accessed 11/8/21, https://psycnet.apa.org
Article: ScienceDirect, The importance of physician listening from the patients’ perspective: Enhancing diagnosis, healing, and the doctor–patient relationship, accessed 11/8/21, https://www.sciencedirect.com/science/article
Book: Patient-centered Ethics and Communication at the End of Life, Ch. 5 ‘Why won’t you listen to me’,
accessed 11/8/21, https://books.google.com
Webpage: AMA, COVID-19 vaccine hesitancy: 10 tips for talking with patients, accessed 11/8/21, https://www.ama-assn.org/delivering-care
Article: FPM, Reducing Frustration and Increasing Fulfillment: Reframing, accessed 11/8/21, https://www.aafp.org/fpm
Website: Riverhead Local, When patients just won’t listen: Reframing, accessed 11/8/21, https://riverheadlocal.com
Magazine: Agile Record, Listen each other to a better place p. 52-54, accessed 11/8/21, http://citeseerx.ist.psu.edu
Website: HSE, What to say to someone who is going through a tough time, accessed 11/8/21, https://www2.hse.ie/wellbeing
Website: NCBI, Top tips to deal with challenging situations: doctor–patient interactions, accessed 11/8/21, https://www.ncbi.nlm.nih.gov
Website: Cultural Health Solutions, Why Your Family Won’t Listen to Your Health Advice, accessed 11/8/21, https://www.culturalhealthsolutions.com
Website: Today's Veterinary Business, Fix The Disconnect, accessed 11/8/21, https://todaysveterinarybusiness.com/fix-the-disconnect
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