“We should be as demanding of ourselves as we are of those who challenge us.”
Dr. Jerome Groopman, writing in the New Rupublic
Writing about the medical decision-making surrounding vaccines proved to be sketchy. Yesterday’s post brought stinging criticism from both sides of the debate. A pediatrician felt the structure of the post was patronizing. Just an hour later, a skeptic sent me the same message–patronizing. This was educational.
Criticism is taken seriously here, especially when it comes from both sides of an argument. The reflex: Perhaps its useful to write more on the matter? (It’s funny; writing that sentence caused me to think about my childhood. My younger brother and I would often find ourselves in conflict with our parents. My reaction was always to argue, explain and make the case. My brother never did this; he simply ducked quietly into the weeds, a master of inflammation avoidance.) True to my childhood self, then, here is a reach for clarity.
First is the question of why a cardiologist would insert himself into the vaccine debate? It’s not your fight. Butt out.
Medical decision-making: Vaccines, as therapeutic interventions performed in well people, highlight the issue of patient-centered decision-making. My field, cardiology, is currently undergoing a major transformation in this area. The pivoting involves a culture shift, from one of paternalism to one of shared-decision making. It’s been a remarkable thing to witness. Cardiologists are learning that in science and medicine, the rule is uncertainty. The goalposts move. Look no further than the new cholesterol guidelines. For decades, we were certain that lowering cholesterol was better. So sure was the establishment that cholesterol lowering was made a quality measure. Good doctors had patients with low numbers. Now look: the new guidelines completely upend that idea. Living through these sorts of medical reversals, learning from history, celebrating uncertainty and striving to improve communication is why medical decision-making intrigues me.
I believe this is the golden era of communication in medicine. In the previous generation, doctoring involved mastering one or two approaches to a problem. Take this or you will die. Now, with the vast array of treatment choices, the challenge is much more about helping patients navigate the expanded menu. It’s a good problem to have, having more available treatments that is, but it presents a different challenge. Humans are complicated. We come with different perspectives of risk, different goals of care, different incentives and different views of science even.
Vaccine Creep: One critic noted my failure to mention vaccine creep. In adult medicine, a common problem is poly-pharmacy. Each individual drug may be reasonably safe and effective for its intended disease. But given together, with 5 or 6 or more other chemicals, there are likely to be important interactions. This week, for instance, the NY Times covered a study that persuasively suggested muscle side effects from statin drugs may be related to drug interactions.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
So it’s reasonable, at least in my multiply-concussed radiation-exposed head, to consider the aggregate effects of the increasing number of vaccinations given to babies. Are we totally satisfied that aggressive modulation of the immune system in healthy children has no significant risks? We can just keep adding vaccines? The more the better? I’m just wondering out loud. Is it heresy to even have the thought that early and massive infant vaccination will some day look like ear tubes? Less is more in almost every other aspect of medicine, just not in infectious disease?
The ice is really cracking now. I should turn back. But let’s not; let’s chance it and go further:
Hep B vaccine in babies? I have yet to hear a convincing reason to mandate vaccinating a newborn for Hepatitis B–a blood/body fluid transmissible disease. (I looked through 6 pages of a Google search. It yielded recommendations, associations and speculations.) It’s not because we think 5-year-olds will be exchanging body fluids on a bloody sports field, is it? It’s not for convenience or adherence. Because surely we aren’t saying that we think parents can’t be relied on to bring their older children in for a beneficial treatment. No misunderstandings please. I’m not suggesting Hep B vaccine is dangerous or that it is a bad idea–I am glad I am protected–but is it wrong to question the net clinical benefit of giving Hep B vaccine to a newborn who lives in non-endemic suburbia and was born to an HBV-negative mom? I’m just asking. Maybe someone has a convincing scientific explanation; it’s just not on the first 6 pages of Google.
Caregiver fatigue: Here, I should have been more understanding. Cognitive doctoring is difficult. I come home after office days completely and utterly drained. It’s exhausting to repeatedly explain that good sleep, good food, good exercise and good attitudes crush any medicine or procedure–even those advertised on the evening news. Even more tiring is the attempt to convince Americans that they don’t need procedures or pills or roll-on hormones. Pacemakers are easy to implant; convincing someone they don’t need one. That’s another matter.
Another problem is that curiosity and skepticism make office work much harder. When I was less skeptical–when I unquestionably followed expert guidelines, for these are the experts after all–office days were more productive and less exhausting. “Yep, you need that cholesterol drug, no question about that.”
I strongly believe a solution to the caregiver fatigue problem is to approach it like the Finns approach education. One of the reasons Finland has a superior education system is that they value teaching. Right now, in the US, we don’t value the teaching aspect of doctoring. That needs to change–even though it would lower my salary.
Right of self-determination: Finally there is the issue of individual freedom and mandate overreach. Are we a country that will tolerate mandated medical interventions? I think not. Forbes journalist Mathew Herper writes extensively (and expertly) on the Merck HPV vaccine Guardasil. In this post, he makes the argument that aggressive efforts to mandate the Merck vaccine–just 2 years after the Vioxx debacle–caused a backlash against a safe way to prevent some forms of cancer. After reading his post, I can’t help but wonder whether a gentler less authoritative approach would have resulted in more widespread acceptance of Guardasil. I guess the question is: how much protection can doctors expect to mandate in a country that doesn’t meaningfully limit guns or tobacco sales?
Now I’ll get back to cardiology.
JMM
