Sunday, March 27, 2011

Do Vaccines Cause Autism? A Victory for Science

Ohio made national news twice in one week, and the Cuyahoga River wasn’t even on fire.
First, Obama and his entourage flew here to headline the conference, Winning the Future Forum for Small Business, when he addressed small business leaders. He referred to the ‘reinvention of Cleveland’, a term that suggests we are experiencing a renaissance here, an event that most of us are unaware of. In any event, when a president flies in, it offers an opportunity to think, particularly if you are held hostage on the highway awaiting the presidential motorcade. Then, you can ponder how late you will be for your destination.

Education, one of my preferred issues, also made headlines. A Mount Vernon, Ohio teacher was accused of infecting his curriculum with creationism, among other allegations which readers can discover with a single click after a Google search. Ohioans follow the creationism issue closely and pride ourselves on being more enlightened than many spirited evangelists from the Sunflower State who tried to convince us a few years back to accept ‘intelligent design’ in the classroom. Their design was both intelligent and transparent. ‘Teach the controversy’, they argued. However, acknowledging that a controversy existed would provide them with a victory. There is no controversy. Creationism and its repackaged cousin intelligent design are not science and cannot be permitted to masquerade as such.

Science won a victory in Washington, D.C. recently. The U.S Supreme Court ruled that folks who claim injury from a vaccine may not sue the manufacturers and must rely upon the vaccine compensation system, called the National Vaccine Injury Compensation System (VICP), that was designed 25 years ago. The 6 to 2 vote suggests that this was not a close legal call. The case before the court involved parents who alleged that a DPT (diphtheria, pertussis and tetanus) vaccine caused permanent developmental deficits and seizures in their child. They sued first in state court and then in federal court when the special vaccine tribunal, referenced above, ruled that they did not prove that the DPT vaccine caused the injury.

The VCIP, or ‘vaccine court’ system, is an excellent institution that serves everyone’s interest. This court has special knowledge and expertise in vaccinations, much more so than would a jury of one’s peers have in an ordinary trial. If this court is persuaded that a claim meets their burden of proof, then compensation is speedily awarded. Granted, these petitioners may not strike lottery gold, as they might in traditional civil litigation, but they will be promptly and fairly compensated. More importantly, this system protects vaccine manufacturers from defending a deluge of annual lawsuits from folks who are convinced that their products have harmed them or their kids. Although I believe that most of these claims are sincere, the vast majority of them are unfounded. They are based on emotion and fueled by a vocal minority of anti-vaccine enthusiasts who try hard to transform anecdotes and vignettes into science.

We all are aware of a belief that measles vaccine can cause or worsen autism. This has been a wrenching issue for many families who are convinced that measles (MMR vaccine) or other vaccines caused their children to develop this serious illness. These anecdotes have been widely reported in the press and generate understandable sympathy from the public. Sympathy, however, is not science.
At this point, there is no scientific evidence that any vaccine causes autism, a finding that has been upheld by the VICP repeatedly.

While every vaccine, including measles, has potential side-effects, these are rare events. Health experts strongly advise that risks of harm from routine vaccinations are much less than the risks of not having immunity to various communicable diseases.

Autism is a mysterious and serious illness. We all hope that medical research will lead to understanding the cause of this disease and to effective treatments. So far, the verdict on the measles vaccine in the case of MMR vs Autism is not guilty.

Who says there is only bad news coming from the nation’s capital? The judicial branch of government performed superbly in this instance. We owe much gratitude to our founding fathers, who so intelligently designed our government.

Sunday, March 20, 2011

Unneccesary Breast Biopsies: Needle Biopsies vs Scalpels

This is a family blog. At times, I have had to expunge comments for inappropriate content. My criteria for comment eradication include:

  • Raw language
  • Personal attacks
  • Overt commercial objectives
There was a time in my lifetime when breasts were considered an inappropriate topic in public discourse. You never saw Little Ricky suckling his mother’s milk on I Love Lucy. These days, of course, breast references and actual images are chic and ubiquitous. Relax, parents. The remainder of this post will remain family-friendly, so there is no need for you to consult your 14-year-old on how to implement parental controls on your computer.

Here are 3 recent breaking breast developments that all inquiring minds will want to be abreast of.

  • Landmark medical study concluding that many women with breast cancer do not need to undergo pain and expense of removing lymph nodes. They do just as well if their nodes are not disturbed. Why does this matter? See prior landmark Whistleblower post.
  • U.S Representative Michelle Bachmann (R-Minn) pushed back at First Lady Michelle Obama’s promotion of breast feeding, in a proposal to make breast pumps tax deductible. In Bachmann’s words, “I’ve given birth to five babies and I breastfed every single one of these babies. To think that government has to go out and buy my breast pump for my babies. You wanna talk about the nanny state? I think we just got the new definition of a nanny.”
  • New study of breast biopsies concludes that physicians have been performing surgical biopsies of breast lesions excessively, instead of using a less invasive needle biopsy technique.
Why does this matter? If the new study is correct, then benefits to women and the rest of us include:

  • Hundreds of thousands of women would be spared unnecessary surgery every year.
  • Hundreds of millions of dollars would be saved. Anyone out there think we could use this money in the health care system?
  • Fortunately, only a minority of women with breast lesions have cancer. For technical reasons, a surgical biopsy can make the definitive cancer surgery trickier than if needle biopsy were used.
The New York Times article also alleged that surgeons may be motivated to perform open surgical biopsies for personal gain, as needle biopsies are performed by radiologists. Could this be a turf issue? The article reports that employed surgeons performed open surgical biopsies in 10% of cases while their private practice colleagues did so in 35% of cases.  Was avarice at play here?  This Times was really 'milking' this explanation for the biopsy rate discrepancy.

All of these breast developments deserve to be supported. I celebrate any medical study that demonstrates that less medicine means more healing. With regard to the Bachmann-Obama duel, I think that Bachmann has a point. With our deficit and national debt rising beyond the stratosphere, is pumping taxpayer cash into breast pumps a national priority?

To the kids reading, who were hoping that this post would include some graphic and titillating images, I’m so sorry to disappoint you. If you are seeking carnal and prurient material, then just ask your Mom or Dad to take you to a PG-13 movie.

Sunday, March 13, 2011

Breast Cancer Breakthrough: Can It Break Through?

Recently, every newspaper in the country reported on a landmark development in breast cancer treatment. It is now clear that certain breast cancer women do not need to undergo removal of lymph nodes from the armpit as part of their treatment. This would spare them from the risk and discomfort of an unnecessary procedure. It is welcome news, particularly for those of us who argue that in medicine, less is more. This is an example of the benefit of comparative effectiveness research, a tool that can separate what patients truly need from what the medical profession believes they must have.

Let’s hope that breast cancer breakthrough metastasizes across the medical profession. Here’s what it accomplished.

  • It spares women from unnecessary surgery.
  • It saves money.
  • It demonstrates that physicians and medical professionals can serve the public interest.
  • It gives hope that all medical specialties will critically evaluate and justify the tests and treatments that we recommend to our patients.
Ironically, when the U.S Preventive Services Task Force (USPSTF) published their mammography guidelines last year, also arguing that less is more, they were assailed as medical traitors against women.

When it comes to breasts

There’s a tug of war

Some want less

And some want more.

Every practicing physician, medical educator and researcher should examine their own practices and medical advice. On what basis do we recommend our treatments? Do we do so because we were taught these practices in our training years ago? Is it from habit or adhering to the community standard? Is it because patients have such a high expectation of a medical intervention that we feel obligated to act?

Can anyone argue that patients are subjected to too much/many

  • Chemotherapy
  • Antibiotics
  • Colonoscopies
  • Cardiac stents
  • CAT scans and their imaging cousins
We are overtesting, overtreating and overwhelming a system that is sagging under the tonnage of well-meaning and ineffective medical care. I am not referring here to the universe of medical care that serves various constituencies’ economic interests. I speak here about physicians who are trying to do right, but are not accomplishing their objectives. Our aim is true, but we are misfiring.

Weeks ago, I reviewed an outstanding book called Overtreated, which I would mandate every medical student and physician to read as a requirement for maintaining their licensure. This theme is the thread that winds itself through the Whistleblower blog, to the delight of some, and the consternation of others.

If this recent breast cancer message caught fire, medical quality would be launched into the stratosphere. Then, true medical quality would be out of reach of the bureaucratic bean counters and pay-for-performance charlatans who champion medical quality as they proceed to dismantle it.

Let’s hope that this breast cancer study will become the mother’s milk of medicine.

Sunday, March 6, 2011

Sarah Palin and MDWhistleblower in the Crosshairs: Do I Have an ‘Image Problem’?

I recently posted a piece entitled, Health Care Reform in the Crosshairs, when I opined that Sarah Palin’s political ads with crosshairs superimposed on selected congressional districts were acceptable political discourse. Click on the link above to view the image that accompanied the post.

A reader sent me a private email suggesting that the crosshairs image was distasteful, particularly as one of the crosshairs was placed over Congresswoman Giffords’ district. The congresswoman was attacked by an evil murderer, and we all pray for her continued recovery and for the other victims and their families of this unspeakable attack.

In the private commenter’s own words, I think you should take down Sarah Palin's targets map on your most recent blog post. I don't understand its connection to what you're writing in any case. But the targets are aimed at congressional districts, one of which is Rep. Giffords’. Since she was actually shot and almost died, in seems a bit distasteful... This reader gave me a relevant link, which I provide here for those interested.

I had no knowledge of the location of the crosshairs, but I think that the image was the right one for the post. Should I remove it as was suggested? I am inclined to leave it be, as I do not believe that this ad can be rationally linked to the subsequent senseless violence that occurred. Moreover, military and firearm metaphors are omnipresent, as my recent post notes. Should they all be stricken from our lexicon? Sporting events are often reported and described in military terms, as are so many other events in our society. How many times do we read or personally describe an athletic outcome as a massacre? If we sanitize our communication to remove words, phrases and images that could also exist in a violent context, then life would be rather bland. In addition, we would argue until the end of time whether a particular phrase was over the decency threshold, an issue that our courts wrestle with every day.

Even the president recently described Governor Scott Walker’s plan to eliminate collective bargaining rights for public union members as an ‘assault on unions’. I guess that the word assault was deemed acceptable by the administration and passed through focus group review. A week after the president spoke, Labor Secretary Hilda Solis remarked at a speech to the Democratic National Committee on February 27th, “We help those embattled states right now where public employees are under assault.”

The liberal organization Moveon.org issued this statement to rally protesters against efforts to curtail union collective bargaining rights.

“We demand an end to the attacks on worker's rights and public services across the country.”

In my state of Ohio, where Governor Kasich is also pushing back against unions, protesters’ statements include:

“Kill the bill.”

“They’re trying to take away what we fought for all of these years.”

The italics in the above quotes are mine.

Obviously, there is speech that is over the line. I agree with the commenter’s implication that just because we have the right to express certain speech, doesn’t mean that it is right to do so. However, I believe that if removing the crosshair image from my post is considered the proper standard, then we will be censoring vast amounts of expression that deserves to be heard.

I thank this reader, whom I know personally, for offering her view to me, and now to the readers. I hope that they will share their views here also. Was the crosshairs image over the line? Should I take aim it and take it out? Let me rephrase that incendiary query. Should I gently and respectfully delete it?

Sunday, February 27, 2011

Free Drug Samples and Hospital Hotels: Which is the Greater Evil?

Many folks criticize pharmaceutical companies for providing physicians’ offices with free drug samples. They claim that this giveaway harms consumers because drug companies must raise their prices to cover the costs of these freebies. Of course, this is undeniable. Any business expense, such as payroll or advertising, has to be covered and is expectedly borne by the consumer. If a company chooses not to advertise, outsources manufacturing to a country with cheaper labor, offers limited benefits to its employees, then they can sell their product at a low price. In this hypothetical example, anemic sales may doom the company quickly.

Naturally, free samples are not really free. The rest of us pay for them. While this is true, I don’t think it is evil. Unlike the U.S. government, at least drug companies are covering their costs and not simply borrowing money every year to meet budget. Interesting concept.

Two of the community hospitals I work at have undergone transformations. One is owned by the dominant health care behemoth in Cleveland and has just completed a near $200 million renovation and expansion. The other smaller hospital is one of the few remaining Cleveland area hospitals that are still independent. I’d like to sneak there at night and hoist up a ‘Live Free or Die’ flag up the flagpole, to celebrate its independent streak, but I’m sure that there are video cameras everywhere and that I would be in violation of several bylaws. The apt punishment might be that I would have to spend a cold Cleveland night chained to the flagpole reading electronic medical record manuals out loud.

Both of these hospitals have private patient rooms that look more like hotel suites then hospital rooms. Patients are just a click away from work and play as there is wireless internet. Why do patients need flat screen TVs?  Perhaps,  they emit healing humors to help speed recoveries. Forget about those hardback chairs next to patients’ beds where visitors would stiffly sit. Now, there is posh furniture to sink into. Artwork is everywhere. Every new hospital these days is equipped with an essential architectural structure – an atrium.

What’s the angle here? Is this a marketing war between competing hospitals? Is the new comfort standard for a hospital similar to a high end cruise ship? That gives me an idea. What if a hospital system purchased a cruise line to serve as a floating hospital across the high seas? I’m amazed we haven’t seen this yet. Remember, you read it here first.

Get that gallbladder out!
Visit exciting ports of call!
 Enjoy world class entertainment! 
Splurge on our decadent midnight chocolate buffet!

Where’s the outrage here? Are these hundreds of millions of dollars helping sick people get well? Couldn’t this money be directed to a more worthy objective? Why aren’t health care reform-minded folks picketing and protesting? Or, does it make more sense to carp over free Nexium samples and pizza for the office staff?

It is true that physicians who have been actual patients gain a valuable perspective. I’m willing to make the sacrifice. Put me up in one of these carpeted, plush rooms with room service and soft music. It will be tough, but if it’ll help me to be a better doctor, then I’m willing to endure the pain.

Sunday, February 20, 2011

Health Care Reform in the Crosshairs

Last summer, at the Cleveland Film Festival, I saw a movie called The Lottery, which is still swirling in my head. It is a documentary about the enormous obstacles that true education reformers confront when they try to help our kids learn. The film was raw and powerful and made me angry. It led to many family discussions about the state of education in America and a search for a way forward. The film is certainly not a balanced view on this issue, and teachers’ union supporters who view it will need to have industrial strength antacids available. I found The Lottery to be more powerful than the more popular movie Waiting for Superman, which addresses the same theme.

Assuming the facts are as presented, viewers are shocked to learn how long and how expensive it is to remove an incompetent teacher.

The New York Times reported that governors across the country are seizing on the public mood and are working to dismantle the teacher tenure system, where jobs are protected regardless of performance. As an aside, the Times’ headline reads G.O.P. Governors Take Aim at Teacher Tenure. You recall after the recent tragedy in Tucson, committed by an evil madman, some had criticized prior political ads that included crosshairs superimposed on political adversaries. Yes, these were Sarah Palin’s political ads. Critics suggested that these ads were not only tasteless, but created a climate of incitement. Should the Times’ phrase Take Aim in the headline above have been sanitized? Who knows? Someone might read ‘take aim’ and think it is a call to arms!

I was asked recently if the medical profession had a mechanism to verify if our older practitioners had the necessary cognitive and technical skills to practice medicine. The answer is, no we don’t. While other professions have mandatory retirement ages, we physicians are firmly on a tenure track that has no endpoint. Physicians can continue to treat patients, and even operate, without any limitation of age or requirement to certify that our skills are sufficient. I think a reasonable argument can be advanced that we could do better.

There is an emotional aspect of the argument advocating periodic assessments of physicians because lives are at stake. But many professionals who don’t wield scalpels or colonoscopes can also put our lives at risk. If an engineer, for example, designs a bridge and miscalculates, a tragedy could ensue. Before we all agree that physicians starting at age 60 should undergo testing every 5 years, let’s consider which other professions should be included in this effort. Nevertheless, I feel we have an obligation to our profession and to the patients we serve to assure them that we still have the right stuff.

Teachers’ unions have been recalcitrant and oppositional for decades and they have squandered the public trust. Their enemy is not the GOP governors or a public who is now hostile to them. Teachers are victims of their own self-interest. The medical profession has failed many times by not reforming ourselves proactively. Then, outsiders ‘reform’ us and we gripe about our loss of autonomy. Haven’t we learned what happens when outsiders heal us? I think that medical reform needs to be square in our own crosshairs before someone takes aim at us.