Sunday, February 22, 2015

Measles Vaccine - A Right to Refuse Treatment

It’s been amusing to watch Rand Paul, a doctor, trying to ‘clarify’ comments he made suggesting that vaccines for kids should be a matter of parental choice.  Conversely, Rick Perry some years ago had to walk back his aggressive pro-vaccine stance, when he championed mandating HPV vaccines for young girls.  This political clumsiness is not restricted to the GOP.  In 2008, both Barack Obama and Hillary Clinton argued that 'more research was needed on vaccines' potential side effects'. Presidential candidates, it seems, have not all been vaccinated against Panderitis.  

Of course, I recognize an informed individual’s right to refuse treatment.  An adult with appendicitis has a right to refuse appendectomy, against the advice of the surgeon. 

"You mean I didn't have to get sick?"

Does a parent have a right to deny the measles vaccine for their kids?  I don’t think so.  Here’s why.
  • Medical evidence provides overwhelming support for the vaccine’s safety and efficacy.
  • Unvaccinated children pose a health risk to other school children.
  • The claim that any vaccine causes autism has been vigorously refuted.
  • Adults do not have an absolute right to deny children medical care.
I doubt that a 15 month old child can make an informed choice about the measles vaccine.  Would those infants who have been denied the vaccine, support this decision when they reach the age of understanding?

Parents have rights also.  They have the right and the responsibility to make health decisions for their kids.  This right, like all rights, is not inviolable.  Parents should not be able to deny a life-saving blood transfusion or curative chemotherapy to a minor child who does not have the capacity to understand the ramifications of a denial of care.  In contrast, some kids should be permitted to make their own decisions even if they have not reached the age of majority.  A 17 year old Jehovah’s Witness, for example, has a more legitimate argument in turning down a blood transfusion than would a 5 year old. 

Immunizations are a towering achievement of the medical profession that has saved millions of lives.  No, they are not perfect, but they work much better than nearly every medical treatment that doctors prescribe.  Moreover, vaccinating kids offers a public health benefit that extends far beyond the youngster who is vaccinated. 

If you are a libertarian who is suspicious of government, then go make a sign and protest.  This is your right.  But, vaccinate your kids.  They have a right to good health.  And, so do the rest of us.

Sunday, February 15, 2015

Is Your Doctor 'Aware'?

Every doctor understands what the phrase, doctor aware’, means.  This is the phrase that hospital nurses record in their nurses notes when they have notified the doctor, usually by phone, on a patient’s issue.   Once the ‘doctor is aware’, the nurse is in the clear and has transferred responsibility for the issue to the physician.
Here are some samples of doctor awareness.

Phone Call Notification                                           Nursing Record

Doctor, Mrs. Leadbelly just vomited.                       Doctor aware!
Doctor, Mr. Wobbly is dizzy.                                        Doctor aware!
Doctor, the ultrasound showed a gallstone.         Doctor aware!
Doctor, Mrs. Hothead has a fever.                             Doctor aware!

Physicians often roll our eyes over these conversations.  Some of these notifications are communicated in the middle of the night about patients we do not know.   Although we can’t usually address the abnormal finding directly at that time, nor do we often need to, once we have been made ‘aware’, the responsibility of the entire case is now ours.   For example, if we are awakened by a nurse asking if she can give antacids to quell a patient’s heartburn, we are likely to agree with this seemingly reasonable recommendation. The chart will record that we are ‘aware’.  If that ‘heartburn’ turns out to be a harbinger of a more serious condition, then the physician will be liable for his action.

If  it's more than heartburn, will we end up in the dock?
Before you pounce on this doctor accusing him of haste and sloppiness, keep in mind that we handle hundreds of these calls every year.  If we were to run to the hospital on every one of these calls to see the patients personally, we’d have to live in the hospital like a medical intern. 

A standing joke between physicians and nurses is after a nurse reports an abnormality to the doctor, the physician wryly responds, ‘I am not aware!’

One particular vexing example of this is when a nurse calls me at 8 pm as the attending physician wants me to approve that the patient can be discharged home.   Often, one of my partners has seen this hospitalized patient during daylight hours.  As I have no knowledge of the particular patient, I am reluctant to sign off on the after-hours hospital discharge, which would force me to accept enormous responsibility on the appropriateness of sending the patient home.  In the most recent example of this, I told the nurse that I cannot clear the patient as I was not involved in the case.  The attending physician must make his own independent decision if his patient can be sent home.  Of course, the attending doctor who is asking me to approve hospital discharge is engaging in the same ‘Dr.Aware’ procedure at the physician level.   Familiar with the concept of CYA?

We do the same thing with our patients.   When patients reject our medical advice, guess what phrase we enter into the record.

Sunday, February 8, 2015

FDA and Herbal Medicine - Caveat Emptor!

Many of my patients are taking herbal supplements, or so they think.  This herbal and health supplements industry likely is envied by traditional pharmaceutical companies.  The latter has to spend zillions of dollars proving safety and efficacy to the Food and Drug Administration (FDA).  Many of these drugs are cast aside during the approval process or afterwards when serious side effects become known or a new medicine is proved safer and superior.  While it’s not quite a crapshoot, there is a strong element of chance at play here.

Roll the Dice with the FDA?

Herbs and the supplements that are saturating our airwaves escape FDA scrutiny.  They will only draw governmental fire if they are deemed to be dangerous.  They are required to use certain language in their promotional materials that differs from traditional FDA approved prescription medicines.  Take a look at this example:

Fosamax:  The FDA has approved this for the treatment and prevention of osteoporosis
Glucosamine chondroitin:  Promotes bone health

Somehow the vague but promising phrase, ‘promotes bone health’ is supposed to insulate the company from a claim that it is approved to treat an actual disease.  However, for most of us, promoting bone health sounds like it’s designed to prevent osteoporosis, which is exactly the intent of the company’s marketing folks.  The language may be legally distinct from the Fosomax verbiage, but it sure sounds the same to me.

The FDA has a very light regulatory hand over dietary supplements making sure that there are no overtly misleading claims and that the product contains what the label states it is.  There is no FDA approval of efficacy as is required for prescription pharmaceuticals.

With a market worth billions of dollars, would you prefer to invest in a pharmaceutical company that might need 7 years to bring a drug to market or in a supplement manufacturer that only needs to cross over a few speed bumps before marketing potions that combat fatigue, joint pain, depression and memory lapses?

It amazes me that the public swallows millions of these pills in the absence of medical evidence of efficacy.   Who says that Americans are not a people of faith?

Recently, a New York State investigation discovered that 4 out of 5 herbal products tested contained none of the herbs listed.  The investigation examined herbal products at some little known ‘mom & pop’ pill shops including Walmart, GNC, Target and Walgreens.

If a company is peddling a placebo, can't it at least accurately label the herb?  If I'm buying a jar of snake oil to ease my rheumatism, or should I say to promote good joint health, then I expect that the useless elixir won't be lizard oil, olive oil or motor oil.  

Sunday, February 1, 2015

Medicine is an Art and Science

Medicine is an art, not a science.  We’ve all heard that maxim before, but what does it actually mean for living, breathing patients?

Physicians rely upon knowledge and experience when we advise patients.   We try to stay current on relevant medical studies to guide us, knowing that the latest medical ‘breakthrough’ may be debunked in a few years.  Seasoned physicians resist the temptation to abruptly change their medical advice based on a single study, even if published in a prestigious journal.

Knowledge and experience are important, but judgment trumps them both, in my view.   The best clinicians are those who consistently exercise excellent medical judgment.

A knowledgeable physician may be able to recite a dozen explanations for your high calcium level.
An experienced doctor can expertly perform a colonoscopy having mastered the technique.
A physician with a high level of medical judgment knows that surgery is wrong for a particular patient, even though medical textbooks and journals recommend an operation. 

Judgement Outweighs Knowledge

Keep in mind that medical judgments are not right or wrong.  Physicians on the same case may have differing judgments and recommendations.  This is a typical scenario in the medical universe which can be vexing to patients and their family.

Consider a few typical patient vignettes which call for medical judgment.

A cardiologist recommends Coumadin , a blood thinner, to start today to treat a patient’s heart condition.  The gastroenterologist wants to delay this for a few weeks as the patient has a duodenal ulcer that could start bleeding once the blood thinner begins.   When should the Coumadin be started?

A man undergoes a CAT scan of the chest which shows a 1 cm nodule in the lung.  The nodule is slightly larger than it was 6 months ago.  The patient is a smoker.   The location of the nodule is at high risk for a serious complication if a biopsy is done.    Should the biopsy be done to determine if a cancer is present?  Considering the risk of the biopsy, should the lesion be watched with a repeat CAT scan done in 3 months to see if it is enlarging or remaining stable? 

A patient is seen by a surgeon after a severe attack of abdominal pain, which resolved.  The patient was immobilized during the pain and was seen in an emergency room where he was found to have a gallbladder full of gallstones.   The surgeon is not certain that the gallstones were responsible for the pain.  The patient is very frightened that if nothing is done, that the pain might return.  Should the surgeon remove the gallbladder, which might have nothing to do with the pain, or advise watchful waiting?

Medicine is art and science.  If I’m sick, I’ll skip the scientist.  Give me the artist.