Sunday, September 9, 2018

What do the Numbers Mean? A Story of Measles and Measles Vaccine

As I have mentioned previously, I'm getting email blasts every day from various medical news outlets I am connected to (some on purpose, some just come to me unbidden!), and this thing about "deaths from measles vaccines exceed deaths from measles in the U.S" plopped into my inbox at the end of August.

So I read it. Seemed like an "antivaxer" point of view so I fact checked it at a site called Ballotpedia, a source for fact-checking claims made by politicians and people running for office. The data are real, but the author points out that while there were 12 reported deaths between 2000 and 2016 from measles in the U.S., only 2 were verified as caused by the disease. In the same period, 104 deaths were reportedly caused after receiving the vaccine. However, they note, verification is sketchy because the Vaccine Adverse Event Reporting System (VAERS) takes reports from anyone, including lay-persons, and verification depends in large part on the contents of the individual reports.

This basically means we have numbers but no context. I'll try to provide some.

Measles is a leading cause of death among children worldwide. What this doesn't tell you is that measles deaths are connected to the level of development. Less development (clean water, good food, access to health care) is connected to a higher death rate. In simple terms it can be said that if you are poor, hungry, and exposed to lots of germs in your water source, or around untreated human waste, or exposed to high levels of pollution, and you are without access to doctors and nurses, you have a higher chance of dying from this infectious disease.

VAERS reporting just says that one thing happened (a vaccine) and then another thing happened (in this example, a death). By digging into each report, it is possible to sort out likelier cases of vaccine-caused-death and less likely ones, perhaps events that were linked in time to some extent, but there were other factors to consider as the real cause of the death.

In this, Ballotpedia is right, and so are doctors and public health experts. The Centers for Disease Control discusses this weakness right on the VAERS website. However, the difference between 2-12 deaths from measles and 104 deaths from the vaccine--no matter what the flaws in the VAERS reporting--is a big difference!

To antivaxers, these data would suggest that the "cure is worse than the disease", although that would be leaving out the millions of kids who were vaccinated without dying afterwards.

To vaccine advocates, this suggests that the vaccine-caused-death data are flawed, and even so, the disease is worse than the cure. Clinicians share horror stories of "unnecessary" measles deaths to drive the point home.

To me, both sides are wrong.

It is easy to blame a childhood death from a disease like measles on unruly parents who refuse to see the light of science, when it's possible that in any given case, there may have been other factors at work. Most measles deaths are caused by encephalitis, an inflammation of the brain, a condition difficult to treat with today's approaches (mainly steroids or immune globulins). It still works 95% of the time in kids and 75% of the time adults. Homeopathy has a number of remedies that may be helpful--although they don't get used much because most doctors don't "waste time" on such approaches. Belladonna (first stages), Stramonium, and Gelsemium are three remedies that have been used to good effect.

Measles encephalitis (ME) isn't the only potential cause of death, and ME itself can occur because of the direct effects of the virus or from the indirect effects of the immune system going crazy from the virus. Death can also ensue from pneumonia, shock, or other causes made worse by the measles infection. An early study found nearly 1/5th of deaths from measles were seen in persons with an underlying medical condition. Makes sense: if you're already sick, measles might make you sicker.

It is easy to blame a sequel, like death, on a vaccine if one thing (the vaccine) happened, and then another thing (death) happened, regardless of what mysterious process was actually going on underneath it all. The survivors of a death need a point of blame for the loss.

As many of you know, I'm not against vaccines. I'm not pro-vaccine either. For a lot of nurses and doctors, the broad strokes of the science and the potential for believing that one's work (i.e., immunizing large numbers of children) makes the world a safer, better place is enough to quiet any misgivings that arise from what are actually pretty isolated events. It is easy to see why doctors and nurses argue so urgently for scheduled vaccinations.

Parents, on the other hand, see only one kid--their own, and this focus can't accept the broad brush, the science of millions of other kids' experience with vaccines (other kids who are not their own). They want to untangle the matter, and if they cannot do so, it seems safer to avoid injecting their child with a product to prevent a disease they may never see. It is easy to see why some parents resist the pressure to vaccinate.

The email blast that started this blog entry is evidence that we aren't moving past this stage of the debate. It's still the same old thing. One side says the science is sound and that the aggregate good to the population outweighs the occasional catastrophe. The other side says, "Nope, not if that catastrophe might be my kid."

Interestingly, in a commercial for Bexsero, the moms argue that not vaccinating against meningitis-B "isn't a risk I'm willing to take." I commented on this in detail elsewhere in this blog. You know, when it comes to your kid, one's point of view could go either way. So whether one chooses the immunization route or not seems largely to depend on what risks, what threats, seem most immediate and dangerous.

This is the problem with this debate over vaccines.

I have yet to hear any public health advocates, politicians, parents, doctors, or nurses openly argue that individualizing approaches to immunization is a viable medical option. I have yet to hear any of these people argue that improving wealth equity, environmental science, and access to health care for all would also improve outcomes in measles--or any other of the many diseases we vaccinate against.

I suppose it is easier to carry on this fruitless argument than it is to come together to improve the foundational aspects of health that are so inequitably distributed in our world.


Sunday, September 2, 2018

Diets

Diets

People often ask me what sort of diet they should eat. Dr Samuel Hahnemann, the discoverer of homeopathy, had little to say on this matter. After all, considering how things were in the Eighteenth Century, just having enough food and clean water were significant enough issues. He hardly could have foreseen the glut of available food we have in the West today!

Florence Nightingale, founder of modern Nursing and head of the nursing staff at the field hospital at Scutari, Crimea during the Nineteenth Century, observed that food should be as fresh as was practical to obtain, and consist of good meat, starches, and the usual fruits or vegetables available at the time. Recovering soldiers who ate decent food recovered better.

When patients ask me about diet, I don't have a whole lot to say. Part of this is the practical matter of the visit: just taking a homeopathic case uses up the available time. But I suppose I could create a patient teaching tool about what constitutes a "good" or "healthy" diet. The problem with such an approach is that it's also important to know how a person eats now compared to what they think of as a goal diet. This is compounded by other issues.

What is their culture? Foods that may be culturally appropriate to one person clash with the culture of another. When I practiced HIV medicine in Reading, I had a lot of Puerto Rican patients, and I learned that the diet of Puerto Rico tends to be somewhat high in fats. That doesn't make it bad; it does present a different set of advisements about how to make such a diet healthier.

What comforts us? Doughnuts are not exactly health food, but once a week, on Sunday, I allow myself one, because I like doughnuts and they make me happy. Limiting my "doughnut happiness" to once a week has not harmed my mood, and has contributed to me maintaining a healthy weight. Foods we were raised on--back when the health of food consisted of just having what we thought was a "balanced diet"--nevertheless can evoke good memories and a good mood.

So for me, if a patient wants dietary advice, and depending on any existing medical conditions like diabetes or high blood pressure, I generally refer them to a registered dietician (insurance sometimes pays for this service) or a naturopath, if they want something more aggressively "alternative". The latter often involves avoiding certain things like gluten, whey protein or dairy, or a wholesale changeover to whole grains, raw vegetables and so on.

Having reviewed a lot of the scientific literature on this approach, I can safely say that...

1) Such radical dietary changes really work well for some people, and
2) They also don't seem to work well for everyone.

Part of the reason is purely practical. I often tell patients that "You've eaten a certain way your whole life. It's a hard thing to change when that is what you are are used to." And it's not just liking the food. It's finding it, preparing it--changing the very way you shop for and cook your food. It's a big change!

I've also run across countless specialty diets. Atkins, ketogenic, Zone, high-protein, Frances Lappe's Diet for a Small Planet--diets even come with political and social agendas! Such is the state of affairs in a society that has plenty of food (arguably too much food), and so much that is processed in factories, themselves fed by an industrial agriculture that relies on pesticides, herbicides, feedlot meat production, and genetic engineering.

What prompted this blog is an article I saw in The Atlantic about professor and speaker Jordan Peterson and his daughter's "all meat" diet, in which they eat literally nothing but beef and water. It's actually not the strangest thing I've ever heard of in that realm. Several years ago there was a fad of eating spoiled meat to relieve the symptoms of arthritis and other conditions. Spoiled meat stinks, so of course eating it indoors often posed a problem! An example is this report from Vice News. I gotta say, the guy doesn't look all that healthy to me, but if he feels it's working...

Anyway, I like the advice of author Michael Pollan: "Eat food. Not too much. Mostly plants." I don't follow it strictly, but it has guided me to reduce the kinds of things I was raised on and learned to love (burgers, doughnuts) and my diet has gradually become healthier. I'll add that it has taken years of little changes (and the help of my wife, whose diet is better than mine). Another author I like to emulate is Dr. Andrew Weil, whose advice generally points to a Mediterranean diet of more and varied grains, fruits and vegetables, smaller amounts of meat, and reduction of sugars, artificial fats, and foods that have been processed or raised with a lot of poisonous chemicals.

I've tried some of the "faddier" diets. Haven't stuck with a single one. I like the variety of a diet that borrows more from Mediterranean, Asian, and Central American cultures, who are less meat-focused. I've never tried a gluten free diet--I'm Southern Italian and the avoidance of really good artisanal breads and real Durham wheat pasta just doesn't fit. There's that "culture" thing again!

When patients tell me they feel better on a diet, especially avoidance diets (like gluten free, dairy free, etc.) I'm fine with it. In our society it's almost impossible to not have adequate nutrition if you supplement where needed with whatever's missing (vitamin D, vitamin C, etc.), so why criticize the diet if it makes people feel better. It's a trickier conversation whenever it is clear that the thing or things avoided are causing a person to feel unhappy, restricted, and afflicted though.

Take scallops, for example. For some reason they really make me ill. I avoid them. I can eat all other sorts of seafood like oysters, shrimp, and fish. Do I miss scallops? Maybe a little sometimes. Does it make me sad I can't eat them? Not really. But a nice loaf of handmade Italian bread? A hot, buttery croissant? A fresh baguette with goat cheese? If I started avoiding those things my life would feel like it's missing something. If I felt bad enough, I might reconsider, but I'd rather find another way to beat the problem.

Homeopathy takes another approach. Its theory and practice implies that we are, generally, genetically equipped to eat whatever we choose, and what we choose tends to be what we need--if we pay attention. Food allergies, food sensitivities, we propose, may owe more to regulatory imbalances that, in the absence of genetically-driven conditions like true lactose intolerance, if given the right homeopathic remedy, will resolve, leaving the person to eat as we were meant to.

Eating food. Not too much. And mostly plants.
Bon apetit!

Monday, August 20, 2018

Vice-shaming and the Burden of Being Wealthy

I think I may have coined a new term. I looked it up on Google and didn't see anyone else having ever used it.

The other day I was talking with my wife about how people often say disparaging things about others' bad habits. Not major things, little things. A bit of dessert. A cigarette smoked at a party. Gluten.

So I said "We like vice-shaming people." Cutting people down because they do things we think no one should do. "You give your child soda?" one cries out, alarmed. "You eat meat?"

I looked it up to see if it hits in a search, and it doesn't, so I hereby claim invention of the term vice-shaming: the act of disparaging, publicly or privately, the minor vices of others.

There are other terms that do exist, like "fat-shaming" or "body-shaming"--those are popular right now. And the thing is with these: there's sanctimony on both sides of it. On the one hand you could say, "You know, being overweight is unhealthy." And the target of that comment could respond "You know, shaming people you don't know anything about for its own sake is kinda mean." So I guess, the shamer and the shamed can both claim the moral high ground here!

I've been thinking about this for a few days, and here's what I've been working with.

Medically, shame is a loser. If one of my students tells a patient something like "You know smoking is bad for you, right?" I'm liable to take her aside and shame her a little, "You know, there's no evidence that line works to get anyone to change their behavior, right?" Of course the patient knows that, everybody knows that. (Or almost everybody...but there are better ways to figure that out.)

Shame is how we in society let others know they are doing something shameful, like being mean to puppies, or throwing litter on the street, or saying awful things in public. It's a form of social control. It lets people know there are standards of behavior and that they need to get in line.

But what works for, say, getting the government to change its policy regarding family detention (that is, the use of shame), won't work and isn't applicable to the private behaviors of individuals. More to the point, not all standards apply to all people at all times. For example, if a patient tells me he uses e-cigarettes, because it helped him quit smoking real cigarettes...what? I'm supposed to criticize that?

I've had students say things like, "I work in the ER and I see these people come in and they're fat and they're all eating McDonald's while they're waiting for the doctor to come in."

I might ask the student: How do you know this isn't the first time that person has eaten all day? How do you know this person can afford--or even find--better food in their urban neighborhood? How do you know this isn't all that person could afford, both in time and money, as he sits here waiting for a doctor who makes $175,000 a year, while he misses time at his second (minimum wage) job because of this injury or illness?

So people have vices. Big deal. Yes, it's our job as health care professionals to guide them into thinking about ways they might be able to minimize the impact of those vices on their lives. Some vices are more harmful than others. Some things aren't really vices at all; the category of "vice" changes with the times. Medical research into things doesn't always clarify. So a "vice" can be a judgement call.

I've had doctors (mostly in alternative medicine) call into question meat, wheat, corn, corn syrup, sugar, salt, alcohol, grocery store vegetables (pesticides), saturated fats, unsaturated fats, any fat, anything but fat and protein, snacks and "junk food", candy, donuts, fast-food...anyway, you get the idea.

Now I'm not here to tell anyone that a Big Mac is a-ok. But neither is one Big Mac the end of health as you know it. But to anyone who reads my blog even semi-regularly, that's probably obvious by now. Stuff-that's-not-great-for-you is also not stuff that is going to kill you if you indulge once in a while.

But this whole line of thought got me wondering about vice, and what we think of as vices, from both the standpoint of the person engaging in what they term a vice and from the standpoint of the person labeling another's behavior as such.

I'm not going to go into real vices here: chronic cigarette smoking, uncontrolled gambling, alcoholism, heavy drug use, sexual addiction and so forth. These are vices in the classic sense: repeated, habitual, obviously-harmful behaviors that reliably lead to severe medical compromise, and harm others around the person who engages the vice.

What I started thinking about is how we have begun to label things that cause little evident harm or at least ought not to, as "harmful" or vice-like. As I noted earlier, gluten, one of the protein fractions of wheat and related grains, has taken on the cast of a "vice" in recent years. Now I will be the first to note that I have had patients state to me that their avoidance of gluten has led to improvements in their symptoms--although if it were just that, they certainly wouldn't be seeing me at all, right? These folks tell me about how much they miss, by avoiding gluten. And I have to ask: This is food, right? How is it that our food causes us this much complaint?

Google this or talk to your friends or natruropathic (and some regular) docs and they will tell you. It's...
  • The way wheat is bred and grown today
  • Additives
  • Allergies
  • (unspecified) "toxins" either in the food supply or in the general environment...
...and so on. But I find the evidence for these causes unconvincing. Of course, I certainly advocate for a cleaner, healthier, more sustainable food supply, but I also have to question how it is that in one of the wealthiest societies the world has ever seen, we have to start treating everything we love as a "vice"--a harmful habit that must be broken. 

On the website HealthLine the author warns about acrylamides in potatoes--so we're not supposed to eat cooked potatoes? He pans white bread--failing to distinguish soft, gooey Wonder Bread from stout, delicious baguettes from the bakery--in favor of "less bad" wheat breads and even ezekial bread. I've had ezekial bread. It's not a food that makes me enjoy eating bread. Maybe that's the point.

Maybe that is the point. In our great wealth and ease, have we somehow translated this into physical ailments that arise from the fruit of that wealth and ease?

That may sound silly, but I recently had a French patient of mine tell me there's no talk of peanut allergies in France. It's not a thing. My wife edited this entry and said "Is that true, or is that just her view point?" So I looked it up. Yeah, it's mostly true. Peanut allergy occurs most in developed countries like the US, but not uniformly. It is less to non-existent in many developed countries, and appears now in some developing countries. The distribution doesn't make sense.

So let us suspend for a moment the belief that every physical complaint or disease must have a material cause.

Is it possible that many ailments--even very physical ones--stem from psychic imbalances? This is well-known to practitioners in homeopathy, Chinese medicine, and Indian (Ayurvedic) medicine, as well as wise healers, shamans, and others who admit to the possibility of both individual and social causes of disease that are energetic or psychic in origin.

I'm not saying "it's all in people's minds." That would be mean, true, but worse, it would miss the real understanding: that perhaps society itself can alter the way our bodies and our minds respond to that society, both its riches and its "vices". Suddenly the things we love become our enemies, poisons similar to chronic tobacco use, heroin, and unprotected promiscuity.

I know this sounds bizarre. But I think it is important to explore the question, because I think it is reasonable to imagine that both individual and collective thought can create physical disease. That seems pretty "magical", I know. And I have no proof of this--actually, I'm not trying to prove it here, although there are instances of this occurring, detailed in such sources as the New England Journal of Medicine, American Family Physician, and scholar Rebecca Kukla, but there are many others.

Accepting this for a moment as a thought experiment, we can ask several questions:

Does wealth and ease lead to physical illness beyond the material influence of the things we ingest? That is, does collective guilt or boredom cause our bodies to react in new ways, giving rise to new "diseases"?

As these emotions grow among us and become more common, shared among many, is one possible reaction for members of that society to begin to "shame" others on their engagement in what should be otherwise neutral impacts to the body (vice-shaming)?

In health care, can this translate into a collective professional culture that shames people for things human beings ought to normally tolerate well, like eating peanuts, or gluten, or even modest amounts of sugar?

I don't have answers to these questions, but in Nursing, we recognize that human beings are unitary beings of body-mind-spirit, and as such we can admit the possibility that the rise of "new diseases" might be less a product of material things alone (like "toxins") and maybe a product of less material origins, like fear, boredom, stress, guilt, and so on. Extending that, it is also possible to imagine that among many individuals, similar physical problems could be collectively shared.

It sounds kinda crazy, but my research into the connections between the body's immune system and the mind suggest it might not be so crazy. This is an idea in development, and I would welcome the thoughts of readers or this blog, patients, and friends on this matter.

Monday, July 30, 2018

A Few Bits From the Summer...

Even if I haven't been posting here in a while I have been writing. Recently I submitted the findings of a research study I performed to a medical journal. I said before that I was going to give my readers here a preview of the findings.

I looked at the data from a couple of years' worth of new patients, but when I did so, I did it by letting chance choose whose chart data to review. This means I didn't get to "cherry pick" all the good ones! As with any medical technique, some people didn't find what they'd hoped for; that is, they didn't get better. But the good news is that two-thirds of people did get better!

One of my goals was simply to try to determine how well homeopathy works in practice, rather than in clinical trials, which themselves are very controlled. I wanted to know: what do the numbers look like in the real world? The answer is, pretty good...and it also makes me glad that I have tended to choose homeopathy as my first choice for health problems.

I also wanted to know something about the kinds of problems people have when they choose homeopathy. The answer? Pretty much anything! And the advanced nature of some of the problems we found in the data may explain why some people who didn't improve much.

Often, people come to homeopathy after they've tried a lot of allopathic medicine approaches, and by the time a homeopath sees them, they're desperate. Nothing's working well. Their disease has advanced.  Could starting with a more natural medicine like homeopathy first, before things have gotten away from us, have a better chance of working while the disease is still minor? While this research doesn't conclusively prove that case, it is something I take away from the results.

And Speaking of Allopathic Medicine

This summer a few interesting research results came in through my email.

One was a video presentation by physician Jamie Koufman on the dangers of using proton pump inhibitors ("PPIs")--these are drugs like Prilosec and Nexium (just 2 randomly chosen brands) and I've discussed these before in a prior post. While I remain of the opinion that most drugs have their place, I also remain of the opinion that drugs are used way too often and for what are often pretty trivial reasons, or out of habit (and here I mean by doctors too).

Dr. Koufman, an expert on reflux (GERD) reports that PPIs are dangerous and often unnecessary. There was some evidence that PPIs could contribute to dementia, but more recent data have cast some confusion and doubt on this connection. However it remains true that lowering stomach acid chronically interferes with the absorption of some vitamins, increases the risks of some infections like pneumonia, lowers magnesium levels, and may reduce bone density. Koufman proposes recommendations that are proven effective and pose way less drug risk:

  • She recommends the use of "alkaline water"--water adjusted to a pH of 8. 
  • Reduce the consumption of red meat and dairy, especially at night.
  • Eat meals early enough in the evening to promote good digestion--too many people apparently eat right before bed!
  • Reduce or eliminate consumption of sodas and acid juices (most fruit juices). Soda especially tends to be manufactured with phosphoric acid, which lowers pH (makes more acid).

If you have to use a drug for an episode of heartburn or reflux, she suggests Gaviscon and similar products containing sodium alginate (basically seaweed), and mild alkalis like calcium carbonate.

"But what if my reflux is bad and hasn't responded to these kinds of things?"

Like I said, sometimes drugs have their place, but as I also said, consider specific lifestyle changes and natural medicine alternatives before you let a doctor just put you on a PPI. I myself have had great success in patients with reducing or eliminating reflux using homeopathy alone.

And a Common Antibiotic's Reputation Gets Worse

Fluoroquinolones (flor-o-QUIN-o-lonez) are a class of antibiotics that were developed to treat infections usually resistant to antibiotics. (Cipro and Levaquin are examples.) However I have observed them being over-used for 20+ years, often for simple urinary tract infections and such. As a result many infections have become resistant to these drugs as well. It's been reported that these drugs are now no longer recommended to treat gonorrhea, a common sexually transmitted disease that has become resistant to more and more antibiotics.

But that's not all. This summer the U.S. Food and Drug Administration issued warning that fluoroquinolones can cause neurological changes in the brain that can result in disturbances in attention, memory impairment, and delirium. Again, these drugs have their place, but perhaps that place is not "every time we think about using an antibiotic for anything"! I still use Cipro, but not as a first choice; rather I use it if a test has shown the infection is resistant to safer antibiotics like amoxicillin, clindamycin, or sulfa (or, if allergies to other antibiotics preclude their use).

Once, drugs like Cipro were famous for "exploding" achillies tendons (I've actually seen not one but two cases of this "rare" condition). We now have data that show that less dramatic side effects can occur, including problems with bones, joints, and muscles. The FDA has added warnings as well about the chance that these drugs can cause low blood sugar. While this may be unsettling to some, it can be fatal to a person with diabetes who is on insulin. Since diabetes is a very common condition, it may be a good idea to try something less hazardous first in people with this problem, to avoid catastrophic low blood sugar.

Drugs are useful, powerful tools. But our cultural tendency in medicine is to treat these agents like they are pretty much harmless. After all, despite accumulated research, PPIs are mostly available without even a prescription! Is this really wise? Or is it just good for drug companies? As a society we need to take a closer look at how drugs are regulated for sale, but as individuals we can at least stay informed and ask questions.

I plan to go in for a routine surgery this fall, and research has shown that a single dose of antibiotic given an hour before surgery significantly reduces the risk of infection. I'm allergic to the usual antibiotic given for this purpose, so I asked the doctor what would be given instead. You guessed it: Cipro! I asked about alternatives and he suggested a drug called Cleocin, which I have had before and done well on. It's a great old drug--and it too has side effects--but long experience has shown they are uncommon and usually not too bad at all. I said, "Let's do that."

The "take-home" message: ask!

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.