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.

Sunday, January 25, 2015

Money Back Guarantee on Medical Care?

How many times each week do we hear the phrase, 'if you're not completely satisfied, we'll refund the purchase price - no questions asked."

This is more often a marketing ploy than a true money-back guarantee.  I have a sense that trying to obtain a promised refund on an item that dissatisfied us is about as easy and carefree as changing an airline ticket reservation or reaching a live human when our home internet service is down.   So, when the weight loss pills don't really melt the pounds off, don't be shocked if the check isn't in the mail when you mail back the placebo pills to a post office box several states away.  And, of course, you won't recover the shipping and handling costs.

Send Stuff to P.O Box in Southeast Asia

This is my opportunity to ask for help from my erudite readership.  What exactly is shipping and handling?  Doesn't postage already cover the 'shipping'?  $8.95 seems pricey for a 'handling' charge for anti-wrinkle cream or a set of steak knives endorsed by make-believe chefs.  I don't really want strangers handling my stuff anyway.  Are they wearing gloves, I hope?

I hear a commercial often for a zinc product that promises a full refund if the product does not shorten the course of the common cold.  I do have some medical training, as readers know.  Readers who are smart enough to understand'shipping and handling' are asked now to explain how an individual can assert that the zinc product was not effective.

The Complaint

"Please give me a full refund.  My cold lasted 6 days. Usually, I feel better by the 5th day.  Your zinc stinks."

The Response

"Thank you so much for your input.  All of us at Zinc Jinx, Inc.welcome customer feedback.  Please send urine samples for days 4,5 and 6 packed in dry ice at your own expense so we can verify that you were taking the product as directed.  Include all packaging including the shrink wrap around the bottle that you should have retained had you consulted our customer service web site prior to opening.  Expect a response in 6 weeks.  Even if your urine drug content is deemed to be sufficient, our on site cold and flu experts may conclude after impartial study that your cold would have lasted 9 days without our product."

I'm not offering an opinion on zinc's effectiveness in fighting the common cold.  I'm suggesting that it is not possible for a zinc swallower to really know if zinc expedited his recovery.  Belief is not evidence.  If we recover on day 6, perhaps, zinc was an innocent bystander receiving credit for a favorable outcome that it did not contribute to.

Sometimes, we physicians are lucky in the same way.  Our patients get better, as they usually do, and we get the credit. As we know, the converse is sometimes true.  We get blamed when we don't deserve it.

Should doctors offer a money back guarantee if our patients are not fully satisfied?  The zinc scenario illustrates how difficult it can be in medicine to assign credit or the blame for the outcome.  The only secure guarantee in medicine is that there are no guarantees. 

If any reader is not fully satisfied with this post, the full purchase price will be promptly refunded - no questions asked.  

Sunday, January 18, 2015

The Doctor-Patient Relationship, Is There an App for That?

I just deposited a check into my bank account by photographing the check with my iPhone and zapping it through cyberspace.  I realize this is ho hum to the under 35 crowd.  Soon, there won’t be any paper checks as the entire transaction will occur electronically.  As a member of the over 35 crowd (plus 20 years), I am wowed by this process.  I remember being astonished when my kids told me how they performed this same process months ago.   It’s the same amazement I experience when I first read about a new piece of technology called a ‘fax machine’.

You mean you slide a document into a machine and an exact copy emerges elsewhere?

In my younger days, depositing a check into a bank account meant waiting in line with my bank book in hand waiting for a living, breathing human to count and record my allowance and snow shoveling earnings.   The bank that my kids use has no physical offices.  It is entirely in the Twilight Zone.

Medicine will not be left behind here.  The manner in which medical care will be administered will be beyond what we can imagine.  We are seeing glimpses of it already, but our vision of its trajectory is limited.  There will be huge advances, but as with all technology, there will be a cost.  The traditional doctor-patient relationship will fade out as this will not be the bedrock of medical care.  There will be nostalgia for it from those who experienced it, much as I have warm memories of bank books, rotary phones, ice cream sodas and playing basketball after school in the school yard.

I’m sure there is technomedicine going on today that I’m not aware of and would be amazed by.  Smart phones will become medical diagnostic tools.

Easy Stuff
  • Tell Siri your history and send a photo of your rash to DERM APP and prescription will arrive at your door in 1 hour.
  • Place phone on your chest and cardiopulmonary data will be forwarded to your cardiologist who will transmit medication adjustments to you electronically.
  • Shine beam of light through a urine specimen which will confirm if urinary tract infection present.
Hard Stuff
  • Coronary bypass surgery performed robotically by a surgeon in New York City on a patient in Abu Dhabi.
  • Artificial organs created in 3-D printers.
  • Miniature cameras journeying through the digestive tract, circulatory system and major organs delivering customized treatment for various diseases.
  • Smart phone analysis of saliva sample which will screen for risk factors for 20 common chronic diseases that will have effective preventive strategies.
  • Satellite delivery of yet to be discovered form of radiation to the developing world which will decimate food borne illness.
  • Patient will place his palm on a glass and an electronic signal will be transmitted to internal organs whose function needs adjustment to treat disease or preserve health.
I worry about the collision of technology against the doctor-patient relationship, which is an ongoing conflict. For example, most patients and physicians do not feel that electronic medical records have nurtured the doctor-patient relationship.  I think it's been a wedge separating physicians from patients. Generally, the tidal wave of technology forges ahead with no true regard or attention to the ethical costs incurred.    Doing stuff just because we can doesn’t make it right.  Smart phones won't be smart enough.. Will there be an app for empathy, compassion, facial expression and listenng?  Perhaps, AppMD will be tomorrow's health care provider and physicians will join the ranks of typewriter repairmen and encyclopedia salesmen..