Sunday, June 10, 2018

Ah, Summer...When We Get Kids Ready for College: Meningiococcal Vaccines

It's right around this time of year when some of my families are looking forward to high school graduations. Some of these kids I've seen for a long time, and now they are becoming adults. Some are preparing for college, and it's during this final summer that they are facing all of the details of making the move from living at home to living away at the colleges they've chosen.

So I thought I'd take a moment to share a question I often get at this time of the year when parents and their college-bound children are faced with vaccination requirements. The big one seems to be meningiococcal vaccine, often called by its brand name, Menactra (1).

Nisseria meningitidis (NIS-air-e-uh men-in-JITE-ti-dis) is a type of bacteria that has been around for a very long time. It's not a new bug. It's also not an uncommon bug--and many people carry it around without developing disease (about 1.3 to 1.5% according to most studies, or about 13-15 people in a thousand). There are several "serotypes" or subtypes of it, with some being more prone to cause disease than others. Meningiococcal meningitis (MM) is an infection of the meninges, the layers of tissue that surround and cushion the brain and spinal cord. It's not pleasant, and it can kill. If it doesn't cause death, it can still leave survivors with lingering problems with brain function, although these are usually more annoying than serious. It can be treated successfully with antibiotics.

Several years ago there were a couple of outbreaks of MM at Princeton and University of California, Santa Barbara, among students residing in dorms. National Meningitis Association reports on a few others that have occurred since then at other colleges. Prior to that time, there wasn't any commercially available vaccine in the U.S.--there wasn't enough demand for it. Because although N. meningitidis is a germ that lives in the upper respiratory tract, it hardly ever causes disease. In living situations in which a lot of people are living together (large dorms, military barracks, prisons) some types of MM can spread to others pretty easily.

So the Centers for Disease Control have recommended immunization against MM for everyone for a long time--might as well get everyone vaccinated, since you don't know who is going to go on and do what, right?

After the Princeton and UC outbreaks--which was caused by a specific subtype, "B"--colleges decided that they wanted all their incoming students to have the MM vaccine. A "B-type" vaccine wasn't available here, so industry developed a couple.

It's fortuitous that a short while ago I ran across an article in Family Practice News that discusses the history and utility of the B-type vaccine. So with college preparations coming up, and a new crop of my former-youngsters going on to become young adults at college, I thought I would share.

You can link to the article above, but here's the gist.

The article focuses on subtype B vaccines, which are strongly recommended to students coming to college but not officially recommended by the CDC. The "polyvalent" Menactra and similar products are intended to prevent several subtypes (A, C, Y, and W-135). Two other products are designed for subtype B (Trumenba and Bexsero). The former, polyvalent vaccine, is recommended by the CDC for all kids at ages 11-12 and a booster at ages 16-18. The B type is mainly recommended by the pharmaceutical industry, as in this ad by GlaxoSmithKline. The article's authors suggest that the high price of the men-B vaccines ($300/dose) is money that may be better spent on other health issues and prevention, and their argument is posed regardless of insurance coverage.

Insurance doesn't mean you don't pay for it--you just pay for another way, as such costs are absorbed by the entire risk pool. A kind of tax, if you will.

Men-B is harder to transmit. There has to be actual contact, like kissing for example (and of course kissing never happens in college!) whereas other MM types can be spread by coughing and other non-direct contact. Interestingly, N. meningitidis is what we call "fastidious"; it is very picky about where it lives, and it readily dies on inanimate surfaces.

Men-B immunization is an example of how the pharmaceutical industry capitalized on a couple of small outbreaks that led to some fatalities and a massive freak-out, amplified by trial attorneys filing lawsuits against colleges. The high price is said to seem small "when it's your child...".

So what about the other types of MM?

If you do the math, MM occurs at a rate of about 18 per 10,000,000 people or about 1 in 500,000. Your kid has a higher chance of dying in a car accident, on a ski trip, or just going to an alcohol-soaked frat party. It's true that many parents view the low risk of vaccine-related serious side effects as worth the price. Witness this quote from the FPN article above:

“As a mom, I would say, if my kid got this disease, and I had had the opportunity to prevent it, and I didn’t, I would kill myself,” said Martha Arden, a practicing physician and the medical director of Mount Sinai Adolescent Health Center’s school-based health program in New York City.

But then there's this data from the CDC:


Clearly, rates of this disease are going down. This may be due to more vigilant immunization, or some other cause--the data aren't clear on this. Down below, we see that the highest rates occur in infants--who aren't eligible for the vaccines until age 9 months--and older folks, who are often infirm, and thus more susceptible.


So what's a parent to do? What do I advise my families?

  • The risks of MM are low. The disease is treatable if caught early. 
  • The risks of the vaccine are also low, but the shots can be expensive. In the official data from the studies of Menactra and similar products, rates of serious adverse events were 1 in 50 persons vaccinated (ages 9-12 months) and 1 in 77 persons (ages 11-18)--way higher than even getting the disease in the first place!(2)
  • Ultimately, the young person and the parents have to decide what risks they are willing to live with, and how much hassle they'll be willing to put up with from the college health service if they don't vaccinate.
  • Anyone in active, ongoing homeopathic treatment for any chronic condition, I'd forego the shots for now.
  • If you are a parent or young person who generally likes to avoid vaccinations, especially for diseases that are uncommon or preventable by other means, it's a fairly safe bet that not getting these vaccines won't harm you.
  • If it were my kid, I'd be more concerned with: safer sex practices, risks of depression and suicide, the risks associated with alcohol and drug use, food availability (yes, a bigger problem among college students than most parents realize), and all the other hazards that come with being a young person out there in the world for the first time.
  • But hey, if you want to vaccinate, go ahead.
Good luck to all my college-bound patients and their families this fall!

--------------------------------------------------------------------------------------------------------
Notes:
1. Menomune and Menveo are two other brand names licensed in the U.S.
2. Definitions of "serious" vary by study, but generally include allergic reactions, some potentially or actually fatal, and a variety of conditions related to inflammation of the nerves such as Guillian-Barre syndrome, seizures, visual problems, and so on.



Monday, April 16, 2018

The "lasso of truth"? Dr Jen Gunter and Other Critics--Why so angry, dawg?!

I get regular blasts from various medical sources. Here's one I got today:

There's a link to see this better below.
I know this sort of case. I see these kids in my office and although the remedy Lyssin (also called Hydrophobinum) is useful in some kids (and sometimes adults!) with violent tendencies, as described by Dr Zimmerman in the post Dr Gunter shared on her blog, there are other remedies that are very useful as well.

I looked over her blog and I can point out a few things that are useful to think about:

1. Not everything she has to say is flippant scientific nonsense. She's got things to say about everything from abortion research to fetal tissue to sexual health--and it's all stuff she can lay some legitimate claim to, even if she's doing a lot of editorializing, because she is a gynecologist.

2. A lot of it is flippant scientific nonsense. I say this because having an opinion about a natural phenomenon isn't science. It's editorializing about a point of view. Immediate assignment of a thing to a category "real" vs. "not real" based itself on the fact that the news is in a category (in this case, "homeopathy") just isn't scientific.

3. I think many people forget that being an MD doesn't by itself make a person "scientific." Although the hard sciences (chemistry, physics, biology) underlie medicine, the employment of these sciences is a tool that operates within a model of the world that is fundamentally thought to be material and objective, and that this material world is fully knowable within a framework that is applicable across cultures, societies, and all individuals.

"MD" is a professional degree, not an academic degree; it argues to society that a person has mastered certain skills, not that the person fundamentally understands and routinely employs a strong philosophical razor that at once views all natural phenomena skeptically and  yet admits to the basic "unknowability" of the world. Put another way one ought to view things in the world with both a skeptical reserve and a child's open wonder at the world's as-yet-unknown possibilities.

I've seen young children with ADD/ADHD, anxiety, violence, etc., all appropriately shopped around to all manner of pediatricians, psychologists, behavioral analysts, pastors, and child-life specialists all to little avail (and much expense and work for the parents as they try to modify the kid's behavior). Then I give one remedy to the kid--and keep in mind the kid's spent most of the visit in my waiting room playing with LEGOs (or tearing the place up)--and a few weeks later it's like a miracle.

What am I supposed to do with that?

Medically, and according to "normal science" (in the vein of Thomas Kuhn), I just gave the kid some sugar pellets that contain no useful medicine that doesn't work according to any known model of pharmacology.

Scientifically, we could argue that the kid got better because of some random event--although that seems rather hard to argue, since random events happen all the time. Why this one? Why this time?

We could say it's the "placebo effect"--although that's kind of weird since the child really didn't seem very interested in the case taking (mostly grown ups talking) or the pills (to him, just candy). So that seems rather implausible.

So what happened?

And this is my complaint about Gunter and other critics like her. They are angry. Gunter's blog is sharp, cutting, and dismissive (and issues f-bombs in her blog from time to time). Here are some quotes from this story about a case of child behavior disorder treated with Lyssin:

"This is so ridiculous it is offensive," and "This whole idea would be ridiculous if it were not so enraging."

Enraging?

The Syrian government's gassing of its own civilian citizens is "enraging". The South Pacific Gyre Garbage Patch is "offensive". I have to wonder what fundamental personality issue operates in critics like Gunter that they feel actual anger about these things. She does note that a lot of adherents of natural medicine--which she clearly has an issue with--may make medically unwise decisions. But then what's unwise?

What a lot of docs and medical "skeptics" fail to understand is that each of us is telling a story. We are living that story. People like myself, professionally trained, can be advisers of what to do and what to avoid, what is likely to help and what's likely to harm, but in the end it's still not our story. It's the patient's story. When docs push people to accept what they find unacceptable, it is an aggression against that patient's dignity, an affront to their autonomy. When docs dismiss out of hand the touchstones of a patient's (or parent's) journey toward health, it is itself a social violence.

Their response, "Stop! Stop! Stop! Stop listening to that nonsense! It's bad. It takes your money. It's unscientific. It makes me angry to see you doing something I am sure is stupid!"

If that's your point of view, maybe you're in the wrong business.

Medicine is at its core an empirical science. Despite "evidence based practice" and large population studies, and experiments, and a humongous corporate medical-industrial complex worldwide, in the end, every patient is a new case study. As we say in science "n = 1".

Hippocrates, Avicenna, Qi Bo and other ancient physicians understood this. In the 1500s and going forward, European physicians began to study health and medicine in a more reductionist way. This has led to great things: modern surgery, antibiotics, effective cancer therapies, and vaccines (not all that unrelated to homeopathy, I would point out to both allopaths and homeopaths!)

But it has also led to a hubris, a belief in contemporary views of communal experience versus individual experience, and a dismissive attitude toward the fundamental unknowability of the individual case. When a case doesn't turn out as expected, most of today's physicians throw up their hands and attribute the outcome to chance, to something we don't know yet, to nature's mystery...but they don't go the next step and ask why?

I know, it might be genetics we don't understand yet. It might be subtle environmental toxins. It might be...what? Belief? Mysticism? The fickle hand of God? Astrological influence? Tachyons?

I totally get the notion that there's a lot of stuff out there that's crazy, dangerous, and intentional exploitation. I really do get it. But then to apply that fact to a blanket argument that everything that hasn't been validated in a large population study, or by a pharma company's clinical trial, or that doesn't fit into medicine's current materialistic, objectivist framework is stupid and worthy of actual rage is just, itself, intellectually lazy.

Pundits like Gunter aren't going away. Physician skeptics like Stephen Barrett, Harriett Hall, and Edzard Ernst, I'd argue that they perhaps have reputation (and possibly, money) at issue. Theirs is perhaps an anger at medical alternatives that stems from a vested interest in maintaining a brand. Others, I think their skepticism is better placed: they worry about the waste and loss that may result from people trying things that they don't approve of because they don't fit the model of normal science. It's humanistic, perhaps, and maybe the anger is frustration--after all, any practicing doc loses people to the mysteries of disease, despite all of our "scientific" might.

It doesn't have to be this way.

Taking the phenomena of human experience, studying it with science, recognizing the incrementalism of knowledge, and adding a healthy dose of humility can lead to the practitioner to peace and an acceptance that, in the end, it is the patient's journey.

We're just along for the ride.

Peace.








Tuesday, March 13, 2018

Welcome Back

I had a very busy 2 months during which I taught a medical-surgical nursing course, a deep immersion into complicated subject matter, which I had not taught before, so I had to hatch everything anew. I had a lot of fun but it was also a lot of work, since I'm already teaching an overload and seeing my usual compliment of office and hospice patients. Whew!

So what's happened over the past 2 months?

First, The Pennsylvania House of Representatives seems ready to take up House Bill 100, which would remove the formal physician-collaboration requirement currently in force. Why do I care? The main reasons are these:

  • The Institute of Medicine, the Office of Technology Assessment, and other major organizations support this as a means of expanding health care access.
  • No study has shown that these agreements add to patient safety. NPs seek physician guidance even without such a requirement when conditions warrant.
  • The requirement often interferes with NPs attempting to open practices in medically-underserved areas, such as inner cities and rural areas. In such cases this is often because either the NP cannot find any physician willing to join a collaborative practice agreement, or because the physician practice charges so much for the service that a new practice cannot afford it. 
Take that last point. If my doc backs out at some point, I might have to close my practice. This happened a few years ago when my former doc, Dr. John Sullivan, retired. There was about a year there when I wasn't sure I'd be able to keep my doors open!

The PA State Senate has already signed off on this legislation. It has a lot of support in the PA House. If passed, Pennsylvania would join over 20 states in which full NP practice has opened the market to greater health care access and innovative team-care models.

The map suggests that states in which physician organizations have the most influence
also have the most restrictive practice laws. Many Western states
which have vast rural areas have been the most innovative in changing those laws.
Map from Alvernia University, 2017. 


What can YOU do? If you are a Pennsylvania resident, call your representative now! The bill is up for consideration this week. Ask that it be voted out to the full House for consideration (where the bill has enough co-sponsors that it is likely to pass). AARP is among the many organizations that supports this bill, and they have set up a hotline for you to dial direct to your representative. That number is The number is: 844-250-5540. Thanks for your support!

So what else happened?

Well with that course I just finished teaching I was reminded of how disdainful I've become about hospital-based health care over the last several years. Now, for the past 2 months, I've been steeped again in hospital practice, culture, and method. I'm reminded of why I left it.

I've been reminded of how much hospitals have grown into sprawling corporate enterprises. Yes, these corporations do good, and the people in them mean well. But it's interesting to see the students' eyes opened to all of the real tensions at work in our health care system, as they themselves are learning new skills. Money, corporate hierarchies, professional jealousy, how the poor are treated differently than the rich by these systems, the emphasis on cost cutting...it really changes their framework of understanding. They go from wide-eyed young people intent on helping others, to seeing how the system--what I often call here "The Factory"--really operates.

Medical-surgical nursing is still the "bread and butter" of what students learn in a nursing program. So having the opportunity to spend a lot of time in this world again after being away from it for several years reminds me of how much money drives a system that is supposed to help people.

I get it. We all need to make a living. But at what cost to our morality? My hope is that having access to students of the art allows me and my colleagues to mitigate that financial influence.

I was also reminded as to how little alternative medicine has penetrated the classic hospital-based care setting. There have been advances, with pet therapy, music, and art being introduced to many hospital units. But aromatherapy, herbalism, homeopathy, chiropractic, yoga, and all sorts of other useful tools are still rare to non-existent. At Penn State Harrisburg, we try to incorporate some of these modalities into the education of our students, but it's an uphill climb, given all of the more traditional things they have to learn, as well as the general lack of interest in alternative therapies among hospitals and many physicians.

Well that's it for now. I expect to be more active again with this blog now that the first half of spring semester is over and I concentrate on my other classes as well as my practice.

Be well!

Sunday, December 31, 2017

A New Year

I'm about to embark on quite a busy semester, as I'll be teaching an "overload", so I will try to maintain some regularity with my posts this spring. Here are some things I'd like to see in the new year.

Health Care Coverage

Despite having control of the federal government, Republicans have been unable to "repeal and replace" Obamacare. The ACA is deeply flawed, but it was a move in the right direction. It doesn't matter if one believes health care is a social and political right, the preponderance of evidence indicates that seamless access to basic health care adds to the wealth and prosperity of a nation. I like that. And if you've ever struggled with insurance issues--or of not having insurance at all--you might get what I mean. You should be able to go to see a provider and get the standard, evidence-based tests and interventions, without having to make a bunch of phone calls, set up a spreadsheet, and doctor-shop. You damn sure shouldn't have to avoid or delay care because of coverage issues.

The ACA has shown itself to be surprisingly difficult to get rid of, but because of political posturing and playing to philosophical ideals, it's also been frustratingly difficult to fix and improve. I hope that in 2018 we'll see society come together on this. The law has been resistant to repeal because when you ask people about its provisions (e.g., keeping your children on insurance until age 26, no refusal of coverage for pre-existing conditions) they like that stuff. The current government sees that and doesn't want to mess with it, but they've used it as a political cudgel for so long, they're stuck! I hope that people will turn their desire for seamless, effective health care into political change in the new year.


The News Gets "Real" on Health Matters
I don't have a whole lot of hope for this one, but I'd like to see news outlets start doing a better job of reporting on health and medical research. 


News organizations often grab stories that are "sexy"--even if they are wrong. An example is a story that came out in 2015 two years about chocolate being good for weight loss. The study was real. It was done by a journalist with a PhD in biology. The results were real...ish. In fact Dr. Johannes Bohannon, writing in Gizmodo, submitted several "junk-science" papers to real journals and fewer than half were rejected because they were junk. The rest were accepted.

The 24-hour news cycle, the profusion of websites and social media platforms require mountains of new content. News organizations tend to not hire journalists with good science credentials, out of concerns for cost-savings, and consumers are poorly informed about what good science looks like. The result is a lot of crappy science gets published without so much as a thoughtful review. Dr. Johannes' study of chocolate did show a correlation between eating chocolate and losing weight, but that statistical result had all sorts of flaws associated with it. Chocolate's not a bad thing, but the sugar and fats can be. Chocolate can have some favorable effects--if nothing else it is enjoyable to eat! But it's not a cure-all, and eating a lot of it won't make you lose weight. Yet the press--print, broadcast, and web--all ran with this story, passing it from one to another until it became a "fact." People can decide that they'll accept the "facts" they like, and call the ones they don't "fake", but Nature eventually wins every time. A strong belief in fake facts won't save anyone from this inevitability.

It would be nice if new organizations and social media would police this better, but I think it will have to come from skeptical consumers to really break free of the hysteria and nonsense that have come to permeate health news.

Investing in Our People's Health

I don't get it. We have really good hard evidence that taking care of kids is good for society. It doesn't just make us feel good. Taking care of kids means more money in your pocket. It means more productivity. In short, taking care of kids is an investment in the future of our society. Yet we continually act in ways that makes it harder for kids to succeed.

A recent example is the difficulty we're having in restoring funding to the Children's Health Insurance Program (CHIP). Everyone thinks it's important. Everyone wants it to get done...and yet it still hasn't. School lunches. School nurses. Health education and gym. Music and the arts. These things we sacrifice when we're told to tighten our societal belt. We keep acting like making life meaner, drearier, and hungrier will somehow make society "better".

In 2018, I'd like to see a growing realization that when we keep our kids well-fed, active, and cared for, everyone will benefit.

Want to see less drug use among inner city kids? Want to see better test scores? Want to see suicide rates drop, collage and trade school enrollments rise, and a drop in opioid deaths? If we want to see that we need to start putting our money where our hearts are. I'm not saying we need to throw money at every problem. But there are a lot of really good things we can do with the money we have, and a little bit more spent on our kids (and a little bit less making rich people richer) would improve everyone's lives.

Well that's it for now. I hope to be publishing a couple of papers on the science of homeopathy soon, and am currently working on a study of the use of mind-body techniques and their role in preventing cancer recurrence. How much I'll get done in the spring, I'm not sure! But then there's summer, which seems a long way off right now (brrr!). Best wishes to my readers in the New Year!


Sunday, November 12, 2017

Fall Home Care

It's autumn and for a change I don't have any major philosophical stuff to blog about. I thought it might be a good time to share some of my home care pearls for colds and such.

In my pharmacology class at Penn State the students just had their unit on respiratory drugs. It's a good time to discuss a few of the things that people use on their own for colds, flus, and what my grandmother used to call "logos-on-the-bogos"...basically just feeling kinda cruddy, when the weather turns colder and wetter.

Echinacea (Echinacea species)

By Jacob Rus - Own work, CC BY-SA 2.5
The Purple Coneflower has been in use for minor infections for a long time. I use and recommend it for not only colds and flus and such, but also for minor skin infections. I've used it as a supplement for more serious conditions as a co-drug with antibiotics for, say, pneumonia or dental abscess. For the lay person, echinacea is a good way to try natural medicine.

I generally recommend liquid supplements, since many powdered herbs in capsules don't get absorbed well and don't have a very long shelf life. A dose form called the standardized dry extract is like a liquid form that has been re-dried to a powder and formed into a capsule or tablet. Liquigels or "gel-caps" are another dose form with good absorption and a decent shelf life.

There a myth about echinacea that it can be taken daily to prevent colds. This doesn't work, and several research studies have shown this to be true. However, taken for short periods of time at the very onset of an illness it actually does help! The German E Commission, that country's foremost clearinghouse on the benefits and safety of herbal medicines, notes that echinacea really works to boost immunity. They also note that continuous daily use of echinacea can "burn out" the immune system. I generally recommend 2 to 3 times daily dosing for 3 to 5 days for adults.

There's a concern with echinacea: people with auto-immune or auto-inflammatory diseases like rheumatoid arthritis or ulcerative colitis should use echinacea with professional supervision as it can actually make those conditions worse.

Elderberry (Sambucus niger)

By Pollinator. Released under GFDL
I love this stuff! Unlike echinacea, elderberry has not shown any tendency to activate auto-immune diseases. It's also kind of tasty --compared to the more herbal flavor of echinacea. It also has a great extra feature for colds and sore throats and such: it calms and soothes irritated respiratory passages.

It can be taken in any number of ways: liquid syrups and extracts, many available at regular drugstores; or it can be taken as a tea. Add a bit of honey and you've got a great natural and effective cold remedy! I'm not pushing any particular brand, but just to give you an idea of how far this tree-herb has gotten into the market, check out Sambucol Original Formula (Swanson Health Products). This stuff comes as an easily-dosed liquid, a kids' formula, and even as gummies! 

Like echinacea, this stuff doesn't prevent colds and such. It's relatively cheap and it can shorten the duration of and improve one's comfort with a cold, flu or sore throat.

Goldenseal (Hydrastis canadensis)

I include this here as what NOT to do. Goldenseal actually does work. This bitter, yellow root herb activates the immunity found on the surface of mucus membranes, including the nose, throat, and sinuses. It's also pretty potent. I reserve the use of goldenseal for cases of sinusitis, but it can aggravate people whose symptoms are actually from allergies. It can also adversely affect the digestion. Goldenseal is a good example of something that people often use casually but incorrectly, and I strongly suggest it be avoided unless advised by a professional with herbal medicine training.

Other things to not do:

  • Don't use any products labelled "homeopathic" unless directed by a professional. Many manufacturers add a little bit of a homeopathically potentized ingredient to their products so that they can get around FDA restrictions on disease-labeling. Unfortunately, this has led to some problems, such as with the product Zicam. The homeopathic version has actually caused loss of smell in some people. Swanson makes a "homeopathic" Sambucol. I recommend to my patients that they do not purchase this variety.
  • Don't take any herbal or natural products daily for more than a week to 10 days. If one is getting worse despite self-treatment, doesn't it make sense that one maybe needs to get checked out by a medical provider? 
  • Don't take high potency homeopathics without professional supervision. Every year I see non-medically trained people selling high potency (200c and higher) homeopathic remedies to prevent the flu. The influenza virus itself is available as a homeopathically-prepared product called Influenzinum (in-flu-en-ZI-num). High potency remedies prepared from viruses are supposed to be "prescription only", but I can tell you that every year I hear about people finding this stuff from online sources. Physician and homeopathy inventor Samuel Hahnemann himself observed that high potency remedies "leave their mark" on the patient and can cause disease. Studies have found that this sort of "homeopathic vaccination" only works about half the time--not any better than the conventional flu shot, and often worse than that.
A final word on the cold and flu season...

Don't forget about the easy stuff:
  • Wash your hands! Handwashing (and alternatively, the use of hand sanitizer) is the single best thing you can do to avoid catching a cold!
  • Rest. Missing sleep and pushing yourself too hard decreases immunity.
  • Honey and lemon. Lemon refreshes and stimulates the system, according to Indian (ayurvedic) medicine, and honey soothes the respiratory passages and has its own antiviral properties--and it's delicious!
  • Salt water gargles and/or the use of nasal washing (neti pot). The water should be lukewarm and the water mildly salty, not disgustingly salty. About a 1/2 teaspoon of salt to 1 cup of water is fine. For minor sore throats and coughs, the use of salt water helps to loosen mucus and soothe the membranes. It's one thing that regular doctors and nurses often recommend that I heartily agree with!
  • Lavender. Lavender in a steam or heated diffuser is soothing to the respiratory passages and is mildly sedative. A few drops of genuine lavender oil in a diffuser can help the fussy child (or adult) with a cold or flu to sleep more restfully. There are many places to get diffusers for use with essential oils, and these can be found in stores and online.
This blog today is educational only, and many of the things I have said here can be found elsewhere online. If you have a medical issue that requires further exploration or advice, please see your health care provider. Be well!


Monday, October 9, 2017

Is There a War On Somewhere?

I get perhaps a dozen email blasts a day, and several medical journals a month. One blast caught my attention with the headline "On Statin Denial and Cult Diets" in the Sept. 14th issue of Patient Care. Steven Nissen is a cardiologist at Cleveland Clinic and a leading advocate of the use of statins like Lipitor or Zocor to reduce cholesterol and prevent heart disease. He's got a good reputation, and is a pretty good guy--he helped to expose the problems with the Merck pain drug Vioxx, which was causing heart disease. So this isn't about him. It's about what his words represent.

The article shares a transcript from Dr. Nissen's remarks in a video on MedPage Today in which he says that there's an internet cult against the use of statin drugs. He reports that statins reduce disease and death. He leaves out that this is only in people with heart disease risk or existing disease. He argues that the "supplement industry..." makes "...claims" for these alternatives that are "not based in good scientific studies." That's not strictly true, although my bigger worry is how poorly regulated that industry is. He worries that all this loose talk on internet message boards and various websites is "harming the public" and that physicians should "fight back against...these wacky diets" claimed to reduce cardiac disease.*

He's right about some of these things, and overstates others. Ok, no one's perfect. But what really caught my attention and made me take to the keyboard was his statement, "We have to fight back with good facts and good science [emphasis mine]."

Why is there always a fight? Who is fighting whom, and why? Is fighting something they teach in medical school?

For many years I have been observing this. I'll hear doctors and nurses say things that disparage the choices patients make to pursue an alternative therapy or not take a recommended drug. I've had students, nurses, and physicians privately call choices to not vaccinate or take a certain medicine "ignorant" or "stupid"--sometimes with venom--as though the patient's choice is a personal attack on the clinician himself.

Recently I've begun to ask myself, "Who are we 'fighting' against?"

I think I mentioned previously that I had a patient who died of breast cancer because she would not pursue the usual treatment of surgery and chemotherapy. I was sad when I learned about her eventual death, but I was not angry with her about it. She was intelligent, and she had a number of personal reasons she wished to avoid the customary treatments. I discussed my concerns with her, but she remained adamant, and alas, she died for it. But that was her path, her story, and she chose to walk that path and tell her story in her way. It was not about me.

So why do so many doctors and nurses think it is about them?

I get it. It can hurt to see people do things that don't work. You think this doesn't happen to me? In my world, not doing homeopathy causes active harm (and despite the claims of some so-called skeptics, I have seen it occur enough times over 20 years that my observations carry some weight). I won't get into the "why?" of that; I'll just say that this thing cuts both ways. The only difference? I don't take it personally. Medicine's not a cause. It's a walk.

It bugs me no end, all this talk of "convincing" people that something's "right" and another thing is "wrong" and by extension the "wrong" things are "fads" or "quackery." Mainstream docs and nurses want to fight against patients' choices. Me? I wish I could convince them that there's no fighting to be done here. Rather, engage. And engagement means sharing facts, sharing the pros and cons of a therapy, and then, if refused, aid the patient in getting the best out of the choice they do wish to make.

Now I will say that model of medical caring takes some time and patience. It takes knowledge. And it can turn out in unpredictable ways. These are not features that are welcomed at The Factory. They are not features that reflect well on the public's health, but then my "patient" is not the public. It's a person. That clarity helps me sleep well at night. I don't toss and turn because Mr. Smith won't do what the research says is generally good in aggregate data sets of thousands of individual research subjects.

I am aware that some choices may have an impact on the general public's health and safety. Vaccination is said by many to be such an example. "If you don't immunize against such and such, it harms everyone..." well, yes and no. In cases like these I have to remind people that first, the public is not my patient, and second, often such impacts are overstated and the consequences are not so dire. It's as if a few people don't immunize against whooping cough will lead to the deaths of thousands. As I reported in a previous post, that vaccine may not work as well as we thought--so where are all these deaths then?

But then I think that some people need to feel like they are fighting a good fight, so fighting against their patients' "bad" choices feels good to them. I treated a lot of AIDS patients. I felt like I was fighting a good fight--against AIDS, not against some of my patients who made choices that didn't work out, but that did accord with their story.

Good research helps to guide us. It suggests what things work well, and what things may not work as well. But new research comes along and we have to adjust our "helpful" directives. It does not personalize care very much, but it does make The Factory efficient, and in the aggregate, it appears things are improving--but such general improvements in large numbers speak not at all to a person's private health journey.

"Good practice" is a summary statement that informs us about what works in most people most of the time within a set of limitations that are dictated by what practice research gets funded, a slow-to-change medical culture, and the demands of moving people efficiently through The Factory.

I try to help my students get their heads around this. After all, Nursing is not about getting people to "do what I tell you," rather it is to help people see what will help them survive and thrive, and to do so within their own "story". Such a story may involve their own legends ("My uncle took those drugs and he got terribly ill from them"), their own religion and spirituality (as in some who refuse certain procedures or drugs because of their beliefs), and their personal and family ties, as well as their sense of self.

I tell my students, it is very arrogant for us to see our patients otherwise. Nursing actually has a theory that addresses this--Imogene King's theory of goal attainment. The "goal" we wish to reach is the patient's, not ours, and it's arrived at by mutual agreement. This does not mean we do whatever the patient wants. It doesn't mean we let people actively ruin themselves. After all, no fresh hip replacement patient wants to get up and do physical therapy. We coerce them to it, good naturedly one hopes!

But it also means we aren't "fighting" against them. We're not soldiers. We're guides.

With patients, this means listening, understanding, and accepting what their goals are, and having the humility to realize that the story they wish to tell may not be the story we thought we would tell about them.

*By the way, to view a counterargument that suggests that some diets can reduce or eliminate heart disease, see this video by Dr. Dean Ornish.

Sunday, September 17, 2017

Pertussis Vaccine May Not Work as Advertised  


Really?

At the recent annual meeting of the European Society for Paediatric Infectious Diseases (ESPID) in Madrid Dr. Stanley Plotkin, of the Global Pertussis Initiative, gave a report that the vaccine against this disease seems to drop in effectiveness as children grow into adolescence. Pertussis is also known commonly as "whooping cough" for the spastic fits of coughing followed by the classic "whoop" often heard as the sufferer gasps for breath at the end of the fit.

This comes as no surprise. I've been a nurse for 30 years, a nurse practitioner for 20 years of that time, and I've seen cases of whooping cough, or some milder variation of it, every year for decades. The first time I saw it was in the emergency room where I worked as a nurse, and the doctors told me this happened sometimes, even in vaccinated persons.

This was in the late 1980s, after a version of the vaccine was developed that contained no actual cells of the bacteria (Bordetella pertussis)--and was called "acellular" (A-CELL-yoo-ler) pertussis vaccine. Previously, the version developed early in the 20th century was a mix of whole cells that had been killed. The problem was side effects, as the vaccine contained a more potent mixture of substances that could initiate immunity, but also initiated more harmful side effects in some recipients. So the acellular type, which contained only certain fractions of the immune-activating pertussis bacteria, was invented.

So by the late 1990s, as a nurse practitioner, I started seeing more "failed" pertussis vaccinations. This makes sense, given what the research seems to show: By the late 1990s you could expect that younger people with the "safer" vaccine mixture were old enough to be seen in a young adult medical practice. Dr. Plotkin's evidence is persuasive, citing studies done in both animals and humans that suggest that the vaccine tends to moderate symptoms, but may not protect against getting the infection. Researchers with the Kaiser Permanente insurance group in California found that protection from pertussis falls to 69% after the first year of vaccination to 9% by the fourth year after.

The report goes on to suggest several strategies for improving immunization of people for this disease, which involve coming up with a better vaccine, adding "adjuvants" (chemicals that irritate the immune system into a stronger immune response) and increasing the frequency of vaccination shots for teenagers and adults.

I take away two messages from this report.

First: I told ya so. Clinicians have, in my view, been overselling both the necessity and the effectiveness of vaccines. I believe this has been done because there's a collective belief in the value of this approach to public health, which enables clinicians to collectively ignore or downplay the importance of things like access to nutritious food, clean water (think: Flint, Michigan!), the inherent inequity in our society between the well-off and the poor, and the lack of health access for the poor and people of color. In short, it's a medical solution to a problem which is in large part due to political and social causes. It's a band-aid.

I'm not saying vaccines are worthless. I'm not saying they shouldn't be used. I am saying that we've created a blame cycle that places the burden for disease prevention on parents, requires vaccination as a public health measure, consistently ignores variant vaccine experiences, and can proceed--guilt free--in the face of gross social inequity regarding access to the things that best support health. We push vaccine programs, while states cut funding for everything from school lunches, to school nurses, to pre-K programs, after school programs, and adequate teacher salaries. Politicians shut down initiatives to address a grossly inadequate minimum wage. We jail parents--especially fathers--for trivial drug offenses, even while assuring that the schools their now-fatherless children attend will be underfunded. In short, we can blame parents for one small disease while many more damaging "diseases" go unaddressed.

Second, to paraphrase a common theme these days, I don't think we can "shot" our way out of infectious diseases. The model we have of immunizing to prevent, and giving more and more potent antibiotics to treat, infections is not sustainable. I'm not saying we shouldn't have an armory with some important immunizations. I'm not saying that antibiotics should never be used--heck, I prescribe them myself sometimes! What I am saying is that we need to bring two things to health care: more imagination and more justice.

More imagination would include recognizing and supporting alternatives to The Factory's current care model (see "A few quick bits" from May 7, 2017 for more on "The Factory"). I have used homeopathic remedies successfully to treat whooping cough. It doesn't always work, but then I have other things I can add, including herbals, to improve the experience until it passes. Chinese medicine and similar medical alternatives can also be effective. Despite a mountain of evidence supporting chiropractic for back pain, "Regular Medicine" often ignores that this option even exists--I rarely see MDs developing any network of local, trusted chiropractors (or any responsible alternative medicine providers) to whom they can refer patients suffering from the musculo-skeletal or other persistent problems we all experience so commonly.

More justice would have to include more elements of society than just doctors and nurses. It would need to include the public, politicians, members of industry and so on. It's a society-wide project. Indeed, most of the things we have defeated here in America--tuberculosis, cholera, parasitic diseases, AIDS-related deaths--are still widespread in many poorer parts of the world, mainly for lack of resources. While vaccination programs do help, they do not help as much as simply treating other countries fairly in the world marketplace.

The ESPID meeting this year revealed a sobering truth about vaccination in general: it's not as simple as it appeared to Louis Pasteur in the 19th Century. Indeed, in his time a lot of people drew water from public wells, sewer systems were often inadequate, indoor plumbing hardly existed, and doctors hardly ever washed their hands before touching their patients. It took a nurse--Florence Nightingale--to recognize that fresh air, healthy food, clean water, and sanitary hospital wards were necessary to stem the tide of infections at the war hospital at Scutari, Crimea. In those times, it's hardly a wonder that vaccination seemed like a magic bullet. But even then, it wasn't.

I would encourage the parents in my practice, the next time your kid comes up for vaccination with "Tdap" or "DTaP" (two of the vaccines given at certain times depending on age) if the doctor even knows about this report from ESPID. What do they have to say about them? I don't think they'll back down from the recommended vaccine. To be fair, in some cases they shouldn't, because some kids are at risk for severe consequences from whooping cough. I'm more interested in knowing what sort of conversation ensues. I tell my students: don't scold. Don't browbeat parents with data. Don't lay a guilt trip on them. Engage.

It would be interesting to find out how the doctors and nurses, when faced with an evidence-based question, actually respond. You can email me at info@altmedresearch.us or comment on this blog.

Sunday, August 20, 2017

Alternative Therapies and Cancer

I was listening to Science Friday a few days ago and heard about a study out of Yale that found that those folks who use alternative therapies instead of standard medical therapies to treat their cancer are twice as likely to die from their cancer. So I thought: "This would a be a great thing to blog about," and I looked it up on the internet. Here's a sample of what came up...









I did my best to blank out the banner ad there. Don't want to impugn any company that wants to advertise on CNN.com! But look at that headline. It seems rather broad, don't you think? It could sound like any alternative therapy in the service of cancer treatment doubles the risk of death. You could read it as "choosing alternative cancer therapy instead of" rather than "in addition to" standard treatment is a risky venture.

In the writer's defense, it did go on to state exactly that, but you know how it is these days. With memes and clickbait and flashy headlines bouncing around on everyone's Facebook feed or Twitter account or randomly popping up when you're googling "alternative medicine", it's easy to see how this might be interpreted.

So I used my fantastic university access to pull the article (which is in electronic publication as of August 10th for a planned release date in print of January 2018). I'll add that to Science Friday's John Dankosky's credit (who was filling in for regular host Ira Flatow) he was careful during his segment to make sure that listeners understood that this was the use of alternative medicine (AM) instead of standard therapy (ST--chemo, radiation, and surgery).

Here's what I found.

First, the researchers did not do a prospective study. That is, they didn't subject cancer patients to randomized treatments of AM versus ST--that would be unethical anyway! What they did do was examine the records of some 560 patients who got ST for 4 types of cancer: prostate, breast, lung, and colon, and matched them to the records of patients who were similar in age, sex, etc. but who opted instead for AM alone to treat their cancer. Ok, so far, so good. The groups were similar enough.

They looked at 5-year survival. This is a pretty standard measure of successful cancer treatment. Basically, if you live 5 years after treatment, you're probably good to go. Here's what they found...

58% of the people in their sample who chose exclusively AM had survived for at least 5 years, in contrast to 78% for all 4 cancers. In statistics, there's a thing called "hazard ratio"--basically, the risk of a chosen hazard (in this case, death). This ratio has to be compared to an "index standard" which is given the number "1". This "1" represents the hazard under standard conditions. The standard condition the authors chose was ST. So, statistically, people choosing AM alone had a hazard ratio of 2.21 to 2.50* or they suffered the "hazard"--death--at twice the rate of those choosing ST.

But there's more.

The study broke out the data and is publishing "survival curves" for all patients and survival by each of the four types. This gets interesting.

Colorectal cancer survival had the widest gap between ST (about 77% survival) and AM (about 30%) at 7 years of follow up.**  The narrowest gap between choosing ST versus AM was prostate cancer, at about 90% and 84% surviving 7 years, respectively. Breast cancer had the clearest display of results clearly favoring ST, more or less matching the overall curves I discussed earlier. Lung cancer looked the worst, with ST survival at about 35% and AM at about 12%. Other cancers? Well, they weren't examined so we don't know.

There's a lot we can ask and say here. What fraction of the deaths may have occurred because of the ST? After all, the commonly-used cancer drug doxorubicin can cause fatal heart failure in some unlucky recipients. This was not able to be teased out of this type of study. The authors note that prostate cancer cases were often early stage and followup--even out to 7 years--may have been too short. However one wonders to what extent an ineffective but largely harmless AM choice might have on reducing prostate cancer deaths compared to ST, which is much more likely to cause serious side effects.

Of note, the striking difference in breast and colon cancer survival rates may reflect the very good protocols now in place for these types of cancer, especially when caught early. Contrast this with lung cancer, which fares poorly with ST anyway. The study also isn't able to highlight individual stories of success with AM--and I have found that such stories are a big driver in why people tend to consider AM-alone as a possible treatment option in cancer. One of the big reasons people say they want to consider AM alone is their impression that ST "poisons" the body, and makes it harder for the body to fight the cancer on its own. In some cases they may be right, but in the aggregate, it seems it is generally not true, at least for some types of cancer.

On my website, under the Medical Conditions section, I share my view that when a cancer has good protocols and high rates of cure, it makes sense to do the ST and use AM as a supplemental therapy to strengthen the system and reduce side effects and the long term effects of ST's like chemo. When someone has a cancer with a poor prognosis under ST, the calculation becomes more difficult. AM alone may be worth a go. If anything, this study tends to reinforce what I was taught in homeopathic training and what I have observed in practice.

The authors argue that the results of this study can be used as a tool to discuss with newly-diagnosed patients with cancer, or with those presenting after a period of time when they've been trying AM exclusively. You know, like, "Oh yes, a study found that using alternative medicine alone to fight cancer means you're twice as likely to die of it." That's efficient if a doctor wants to convince someone to suck it up and take the chemo, but it's hardly a fair and accurate discussion of the results. I don't argue here for AM as a singular cancer treatment--after all, this study didn't state what "alternatives" to ST were used by the cases examined in the study. I suspect the "alternatives" were all over the place. In my practice I have found that "alternative" may mean anything from isopathic homeopathy, to a whole foods diet, to antineoplastons, to healing with crystals, to barking at the moon.

Thus perhaps this study is more about "proving" the superiority of regular medicine to anything else. The authors probably didn't mean to make that socio-political leap on purpose, but no analysis of this study would be complete without paying attention to that point.

The authors meant well, I think. Cancer physicians get really demoralized by the endless parade of deaths they witness. Cancer treatment is still very much a work in progress. So it makes sense that this study would be seen as a way of shaking some "sense" into people who are either scared of ST, or convinced AM is better--or both. However I would argue that it's only part of the story, and the science on this is by no means complete. This study isn't the end of the matter.


Notes:
* This range reflects the 2 types of statistical tests the authors used and is too technical to be of any use to us here. I included both numbers for completeness--and it gets at the "twice the risk" piece being quoted in the news.

** The average followup of all cancer cases in the study was just over 5 years, but some cases had less or more, so individual graphs show this variability. It's not an error.

Tuesday, August 8, 2017

The "Death" of Obamacare?

Well, the summer's now at it's slackest moment: It's August and all the representatives are home for the rest of the summer...after having failed to "repeal and replace" the Affordable Care Act of 2010. It's common knowledge now that conservative politicians consistently ran on promises to do so. Now that their caucus hasn't been able to come up with a passable plan, Obamacare remains in place while the states and the President try to figure out ways to sabotage it.

Meanwhile, the ACA is more popular than it's ever been!

There's way too much to say about the ACA and the tortuous process of getting from what came before to what we have now. There's been so much written and said about it: It's good. It's bad. It's merely an insurance market reform law. It's socilism. It's "imploding"...or it isn't. With that said, I will focus on here is what the symbol of the ACA says about how our society is evolving.

A few general facts (1):


  • Despite our ardent love for a "market-based" private health care system, Medicare remains extremely popular among those older Americans likely to vote against changes in the health care system, and for the repeal of the ACA.
  • Despite spending more money per-capita on health care than any other country (Switzerland is a distant 2nd place), many of our health care outcomes (e.g., life expectancy) lag behind our lesser-spending neighbors in the developed world.
  • Americans pay more for medical technology and prescription drugs than citizens of any other country.
  • It's not all bad: we have a lower cancer death rate than most countries. We visit the doctor less often than people in developed countries (so why is insurance so expensive?)

So in the 2000s it became apparent that having tens of millions of people uninsured was both a drain on our economy, and a kind of shadow tax on people with insurance, since the payees--doctors, hospitals, and medical products services--weren't simply going to accept non-payment from those uninsured people. The costs were "shared" by charging higher premiums to insurance holders.

Although many developed countries have a single health care payer system--Canada and Britain are the common examples--not all do. Moreover, as President Obama said at a press conference prior to the ACA becoming law, health care is about 1/6th of the American economy. You can't just change that overnight. Fair enough.

But it seems that, in spite of all the protest against the ACA (it was never worse off than about 47% popularity), now that it is threatened, a lot of people are speaking in favor of it. It's funny, I still routinely hear from some patients, and many nurses and doctors that "Obamacare" is what's causing all the problems in health care. Truth is, some of those problems are caused by Congress not fixing some of the problems that cropped up with it as it rolled out. Republican congressmen were too busy trying to repeal it entirely to take the time to fix it. Besides, if they fixed it, then they couldn't use it as foil against Democrats.

If to some this sounds like an editorial, it isn't. I'm just stating the facts (and by the way, none of these facts pay any tribute to Democrats, so I'm not writing a nakedly partisan essay here).

So this is where we are. Why?

Ok, now I'll editorialize!

For a long time, we were a frontier culture in a vast land. While we've always had differences, some severe (anyone remember something called the Civil War?) we've always had this sense of optimism, that just over the horizon, there lies a new land that offers a hope for a new day. Over the course of the 20th century, that frontier came to an end, and now even Alaska is settled all the way to the North Slope. Yes, there are still broad tracts of empty land. There are still new tomorrows to the west (or the east, if you're already out west). But by and large, we feel each other, our neighbors and our nemeses, people we know and people who seem strange and foreign to us, and there's no place to go.

So we've become more tribal, and this has been abetted by the internet. Demographic studies have shown we are tending to move to be with those "like us." Political districts reflect this as well, and a growing number of congressional districts are essentially uncontested. Wealth disparity continues to grow--America has a high disparity between the rich and the rest of us, higher than Europe and Canada, and even higher than much of northern Africa; we're better in that respect than South America and China, but roughly equivalent with Russia (of all places!)--so many of us feel a pinch.

A social conversation has begun to arise about this. What do we do now that we have nowhere else to go, nowhere else to conquer? How should society regulate itself? Am I responsible for my neighbor? One of the recent issues debated in the attempt to repeal the ACA concerned private buyers of insurance on the exchanges who didn't like paying for a basic menu of health care services that they might not ever use--like a man paying for a policy that must include maternity care.

On the face of it, it does seem kinda stupid...until one factors in the relatively low fraction of the cost of that care as it is distributed among many thousands of ratepayers, versus the much smaller fraction of ratepayers who actually use it (women of childbearing age) who would be charged much more without those non-user contributors. Funny, I think was a guy named Jesus who said something about loving our neighbors--what did he mean?

Am I responsible for my neighbors?

If one teases out the scenario, the sense of it sharpens. The man, paying a fractional cost for maternity care, actually gains benefit in unseen ways, like the fact that affordable maternity care lessens infant sickness and death and thus removes hidden costs from society at large--and thus from him as well, at least incrementally. Treating health care costs like an a la carte menu pays homage to our rugged American individualism, but it neglects the complexity of a society whose frontier safety valve shut off nearly 100 years ago. In the end, we all pay anyway.

How should society regulate itself?

In the past doctors were private agents, and so were hospitals (where they even existed). Insurance companies often operate on a for-profit basis, as do ambulances, some hospitals, many nursing homes, drug companies, and the list goes on. But that profit is made on goods and services that an increasing number of Americans see as a "public good", or a "right". Recently-convicted investor Martin Shkreli raised the price of dapsone, a very old and very generic (but also very necessary) drug by 5000% before public shaming caused him to dial it back a bit (it's still unnecessarily expensive)--because he could. It's no crime to price gouge, even when it comes to a matter as serious and as necessary as medical care. Capitalism is king. Or is it?

I have no issue with people getting paid, and I have no issue with private concerns existing to develop and provide unique and valuable services to the sick--heck I'm one of those people who do so! But I think one has to also be aware that the massive scale of some enterprises in health care, the importance of some of its products (like dapsone, or Epi-Pens, or Narcan), and the interconnectedness of that industry, combined with emerging expectations of Americans, has caused us to begin to entertain the possibility that rampant health care capitalism may not be the solution that many believe it is. Maybe it isn't especially moral to get as rich as possible on the backs of sick people.

Finally, I think it is dawning on people that we struggle with an essentially human, and especially American, sense of privilege. We want the best; who doesn't? But when does the "best" begin to come at the direct cost of another, and when--because of that interconnectedness I spoke of earlier--does it actually begins to incur indirect costs to us? 

People say they don't want the high taxes that come with single payer health care, but studies have shown we're essentially paying a "tax" anyway, in the form of high premiums. But instead of that money going to the common good, it goes into the pockets of dirtbags like Martin Shkreli! How is that better?

People say they don't want their health care "rationed"--and yet they seem to have accepted exactly that from heath insurers, who deny unneeded MRIs, CAT scans, new drugs, and unproven therapies. Is that rationing, or is it rationality? In the latter case, people seem to be willing to pay a "tax" to have their care rationed (or rational)--and give a nice extra bit that goes to corporate profit, or to the multimillion-dollar salary of a non-profit executive. (2)

Personally, I'd rather pay a tax I know is going to make my health care easy and portable, and keep the "extra bit" in my own pocket!

But hey, I'm fine. I have good insurance and a job unlikely to end abruptly. But I guess bad things could happen to me too, so I have a stake in this I guess. People need to start thinking more like this in order to hedge against the inevitable--and needing health care is pretty much inevitable, even if for reasons political, religious, or personal one were to choose not to use it. (3) So we better start having this conversation more explicitly. It needs to stop being about Republicans and Democrats, liberals and conservatives and greens and libertarians. The conversation needs to be about "real" things. How can we talk about the utility of a "free market" when that market is clearly opaque? (pardon the pun) What are the real, if indirect, costs to each of us when millions go uninsured or underinsured? Whay are we really paying so much for medicines? (Hint: it ain't research and development.)

Next time you're ill, try pricing the estimated total cost of the affair beforehand. The answer you'll get: "We can't know that until we see you." Show up and ask, and they'll say "We have to run some tests." Inquire on the price of those, and you'll find no answer forthcoming. Being sick isn't what it was. Like our former frontier landscape, health care in America has modernized: it can do a lot, and there's a reasoned approach to doing it. Maybe it's time we stopped treating ourselves like we're living in the 19th century. Maybe we need to start talking about how we're going to deal with reality and stop talking about if we'll deal with it.

(1) For the sake of time, I didn't cite these, but the facts can be verified easily with Google searches on the relevant terms. Or you can take my word for it.
(2) The CEO of Blue Shield of California was paid over $3,500,000 in 2015.
(3) Wake up at 3 AM with appendicitis, and see if you still feel like health care is a "choice" you can opt to not use!



Tuesday, July 18, 2017

Vaccination, Health Care Workers & The Law

Public domain from Wikimedia Commons
I just read an interesting article from one of my regular web news services, this one from The Clinical Advisor. Their regular feature Legal Adviser (July 13, 2017) shares a case of a nurse who was fired for refusing an employer-mandated Tdap (tetanus, diptheria, pertussis) booster vaccine for all employees at the hospital. Part of the driver for this was known occurrences of outbreaks of pertussis--whooping cough--which still occur despite the fact that most children are routinely immunized against whooping cough. In fact I still see some patients and families with this condition, which is uncomfortable, but usually self-limiting and non-fatal. (Even though this shouldn't happen, it does. So much for the power of vaccination.)

In vulnerable people, like infants and children, older adults, or people who are sick or have faulty immune systems, it can be very serious or fatal. So it's easy to understand why hospitals want their employees to be immune to it. If one would come down with it, they could certainly infect such vulnerable individuals.

The summary of the case is that a nurse didn't want to get the booster. The hospital wanted a note from her doctor as to why she shouldn't receive the vaccine. The nurse suffered from various allergies and a condition called eosinophilic esophagitis (basically a kind of autoimmune heartburn) and was anxious the vaccine would cause problems related to these conditions. The doctor issued a letter stating the nurse was "medically exempt."

The hospital said this was not enough. They listed the 9 conditions officially listed as reasons to not get the vaccine. They wanted the physician to be more specific. He wrote back to the hospital about the patient's history of "various allergies" and how she was "terrified" of getting the vaccine.

The hospital's employee health services coordinator told the nurse that the doctor's note did not meet the definition of medical contra-indication detailed in the product's official literature and told her to get the vaccine or get fired.

The nurse declined to comply and was fired.

She sued under the Americans with Disabilities Act, but the suit was dismissed in Federal Court, because the employer did try to accommodate the employee: Her provider was to state which specific condition, of the 9 listed, the nurse had in order to exempt her from getting the booster shot.

The Legal Power of Words...

I spared you the technical details of the conditions because they weren't anything this plaintiff had, and are mostly pretty uncommon, so most people don't have them either. Game over? Not quite.

The hospital wanted one of those words. The physician's second letter emphasized the nurse's "anxiety" about the vaccine. That wasn't going to satisfy them. So what could the physician have done differently?

The last condition on the list was "altered immune competence." The plaintiff had this, that is if one considered "competence" to be a system that functions as it should. Typically, regular health care professionals--doctors, nurses, etc.--would consider "competence" to be like "strong enough" and would perhaps interpret "altered immune competence" to mean "lowered immunity." However "altered" means just that--not the regular way it works. The nurse's immune system certainly wasn't working as it should, she had allergies, environmental sensitivities, and an autoimmune condition!

I read this article and decided that I would have responded to the hospital's second request for detailed information by stating that the patient has "altered immune competence"--which is technically accurate from this professional's point of view. Using that logic I could build my case: The patient's condition of "altered immune competence" makes it likely that a revaccination may lead to untoward or catastrophic medical consequences, based on the manufacturer's own data. Further I would have suggested appropriate accommodation (such as reassigning the nurse or asking her to wear a mask during disease outbreaks publicized in the public health notices of her locality).

Fact is, I probably would have done this at the outset, which would have nixed the back and forth communication between my office and the employer. I can't promise this would work, but I think it has a better chance of succeeding, because employers--especially hospitals--are exceedingly legalistic. They also don't like to lose. They want people to comply (sounds like a topic for another blog post!).

This case fell apart because the court found that the ADA doesn't require accommodation for "purely personal reasons" (the nurse didn't want the vaccine and was anxious about it). The court further ruled that "Whether or not the hospital should 'require employees to obtain the vaccine is not a question for the Court to determine.'" Which makes sense. They are judges, not doctors.

Take Home Messages
First, if you have a problem with an employer-required health act, like a vaccination, ask yourself why. If it's personal preference, don't lead with that. It's a loser.

Second, even though there are usually specific reasons listed in the "official" literature for not receiving such interventions, like a given vaccine, there's usually some wiggle room, because many "specific" reasons aren't as specific as they sound. People need to discuss these in a more effective way. For example, the nurse could have asked her physician which of the 9 conditions he or she was concerned about, or potentially could be applicable.

Third, realize that employers have concerns too. They don't want to intrude on the particular medical relationship of individual employees, each of whom is unique. And they want to be covered legally. The reason for refusal needs to be, and appear in print, legitimate.

Occasionally I am asked to issue a letter of medial exemption for patients, usually kids, to avoid certain vaccines. I never issue such letters unless there is a legitimate reason to do so. However, as my first duty is to the patient, I must weigh each request in the context of the total medical picture. Many of my patients have some alteration of immunity. Some such "alterations" may be easily recognized--such as immune depression due to chemotherapy. Others are more nuanced, such as cases of multiple allergies and sensitivities, or ongoing treatment for a condition related to immune competence. This could include a host of things such as asthma, repeated infections, and other immune-related issues.

Thus, I advise parents/patients that not getting a vaccine comes with certain risks. I state this in my letter and in my chart notes. I also use clear, definitive language that helps the school nurse or the employer to understand how the medical condition of the person is related to the vaccine and its risks. I often advise delay rather than a permanent exemption. After all, I don't know how long it will take to treat someone. Let's wait until things stabilize and re-evaluate.

So I'll go back to my first take-home message to come to my last: If no real contra-indication for something like a vaccine or other employer safety measure exists, then patients need to be prepared for what happened to the nurse in this story. We can believe anything we wish, but others are not required to believe it too. If one chooses to live a certain way, one must sometimes accept that consequences attach to that choice. Fortunately, there are enough folks out there like myself who can accept the people whose choices stand apart from the crowd.

Here's wishing you lots of good health...and few "employer mandates"!