Ed’s corner of the web

I can get a little moody and punchy when I’m short on sleep, so my reaction was not particularly favorable a few mornings ago when I opened up the AMA Morning News in my inbox and read the first headline:”Study indicates MMR vaccine may not be linked to autism.”  I think I nearly had a stroke.  I may have yelled, “Gee - you think?” out loud to the empty room, but I can’t fully recall.

For background, AMA Morning News is a daily digest of medically relevant news that’s compiled and sent out by the people at the American Medical Association.  The idea is to keep the busy doc apprised of what’s going on in the world of medicine and medical science.

The article attached to this particular headline referenced a newly-published study on PLoS ONE (the online journal for the Public Library of Science) that shot down the contention, made 10 years ago in a much-derided study by Dr. Andrew Wakefield, that measles virus - obtained through MMR immunization - persisted in the guts of kids with autism and possibly was involved in autism’s pathogenesis.  What followed from Dr. Wakefield’s study was heightened vaccine fear-mongering and strengthening of antivaccination movements in the the US and UK, the unfortunate results of which can been seen now in the recently reported outbreaks of measles in the UK and the US (without - it should be noted - any change in the incidence of autism).

In the last few years, the idea of a link between vaccination and autism has been thoroughly debunked by several large, rigorous scientific studies.  Unfortunately, the public has been a little slow to catch up with the data (which is actually one of my big gripes with the American Academy of Pediatrics), and a lot of unwarranted, even counterproductive, fears regarding vaccines still remain.  This headline, instead of reflecting the consensus state of the medical scientific community (minus a few whackjobs), played more to those unfounded fears of vaccines.  The likelihood of vaccines being linked to autism is vanishingly small, well beyond what any reasonable person would require for convincing.  But a headline that says “MMR vaccine may not be linked to autism” gives a very different impression.  To someone who has been fighting against those fears and misinformation for years, it was not a welcome sight - and especially upsetting coming from the AMA.

So I wrote a letter.

To Whom It May Concern,

I was greatly dismayed when I opened up my inbox this morning to see this headline in today’s edition of AMA Morning Rounds: “Study indicates MMR vaccine may not be linked to autism.”  I’m not sure how this headline made it past your editors, but the implication it gives is that there is still significant doubt as to whether MMR is linked to autism, when in fact there is none.  This lack of association has been established and reestablished by study after stronger study, and for the AMA – of all organizations – to imply that there is still doubt is a reflection of either base ignorance or refusal to accept the data.  I’m not sure which is worse.  A more appropriate headline would have been, “Study reaffirms lack of link between MMR vaccine and autism,” which is a much better reflection of the article’s actual contents.  If the AMA is going to continue to be a trusted source of news and information for doctors as well as patients, it needs to work harder to avoid the irresponsible, obfuscating language that I read today.

Sincerely,
Edward Chung, MD

In my irate, sleep-deprived state, I wrote a complaint letter to the feedback email address at AMA Morning News.  I didn’t really expect to get a response; I just felt better having aired my opinion.  And a little part of me thought that maybe somewhere, somehow, someone would read it and realize that what they had pulled was not cool.

You can imagine my surprise, then, when a couple days later I got this:

Dr. Chung,

Thanks for writing. You’re right…that headline could most certainly have been written better. In fact, you already wrote what would have been a more appropriate headline for that news item. I’ll discuss this with the editors at U.S. News Custom Briefings, which the AMA partners with to produce Morning Rounds, in hopes of not repeating this in future issues.

Thanks again for writing, and thank you so much for your membership with the AMA.

Sincerely,

(name redacted)
Manager, member communications
American Medical Association

Not bad!  It wasn’t defensive, back-pedaling, or falsely apologetic (ie. “We’re sorry if you were offended by what we wrote.”).  It was, “Our bad, you’re right, we’ll fix it.”  Kudos to member communications at the AMA.  Now they’ve gotta be careful.  If I continue to get positive feedback for airing my opinion, I just might have to do it more.

A tip of my hat goes out to David Campbell, a biology teacher at Ridgeview High School in Orange Park, FL.  The NYT recently published an article detailing his difficulties in teaching evolution to his Biology I class.  I thank my Dad for pointing the article out to me.  The battle of evolution versus creationism (or Intelligent Design or whatever else they’re trying to disguise it as these days) has been particularly heated in the past several years, and public schools and their school boards have been the front lines in this debate.  The fact that there’s a battle at all is somewhat of a sad indictment of the status of science education in this country, but that’s a topic for a whole other series of posts.  Beyond all the posturing and rhetoric in the blogosphere is this single human trying his darndest to make a difference in an steeply uphill struggle.  It’s easy to sit at the keyboard and say, science teachers should do such and such, evolution should absolutely be taught in the classroom, etc.  But the details of how to do that in a real school with real kids is a much more complex issue.  Here is a dude who is actually there, walking the walk, pursuing not only the noble goal of teaching science, but also promoting the concepts of evolution.  In Florida.  Hard core, man.  Keep fighting the good fight, sir.

What a crazy few weeks it’s been.  For those of you who know me personally (and I think almost everyone who reads this blog does), you know that we are in the throes of a tricky move.  Moving is enough of a pain when it’s uncomplicated.  But for this move, we’ve had a six-week gap of homelessness to fill.  The lease at our old apartment ran out on 7/31, and our landlady refused/was unable to give us an extension to get us to our condo closing date on 9/14.  If it was two weeks, we could’ve crashed on couches of local friends.  But a six week term left us no alternative but to find some kind of temporary housing.   Not wanting to move into a place and then move again in six weeks, we planned on putting the vast majority of our stuff into storage, finding a furnished apartment, and living out of suitcases until we moved into our condo.

The first part was easy - thank you Gentle Giant.  The second part, though, was an unanticipated complete pain-in-the-butt.  Having two cats whittled down the number of available places considerably.  Not wanting to pay over $3000/month in rent whittled it down considerably more.  I went online to try to find prospects.  Craigslist was mildly productive, but nothing fit our needs.  I reluctantly paid for access to Sublet.com and found their listings to be both skimpy and completely out of date - worthless and a rip-off.  An online site designed to help people on sabattical find housing gave me a couple email addresses, but nobody replied.  I finally thought I had found a place right in the Back Bay, but the realtor I dealt with there was the most flaky, impossible-to-reach, unprofessional, non-committal person in that industry I have ever had the misfortune of working with.  As you can probably guess, that fell through.  After a couple stressful days where I made sure our tent and sleeping bags were in good order, I managed to grab a little one-bedroom furnished apartment in Allston in a place that specializes in short term furnished rentals.  Whew!

After a lot of packing, cleaning, heavy lifting, cursing, and unpacking, we’re now more or less settled in our temporary digs in Allston.  It ain’t the Ritz, but it’ll work for the next several weeks.  We’ve already enjoyed exploring some of the great ethnic eats in Allston and are looking forward to more yummy food in the weeks ahead.  Carisa has also taken a great liking to the gas stove, which enables us to have the wild luxury of multiple pots cooking at once.  You have to realize that on our old derelict electric stovetop, we had four burners, only three of which worked and only one of which was full-sized.  When you put a normal-sized pan on that one full-sized burner, you couldn’t fit anything else on the other burners.  And as it was, that one full-sized burner was tilted enough to prevent any more than a fraction of the pan from coming into contact with it.  We weren’t channeling Julia Child so much as Lewis and Clark.  And don’t even get us started on the oven.

So it’s been a crazy and stressful last few weeks, but we now have a little lull before moving into our real home.  The last few weeks haven’t been altogether unenjoyable, either.  We got to see Shakespeare on the Common (at least until the second act got rained out), we’ve been out picking wild blueberries, Carisa’s mother and sister visited, and we even got to eat at L’Espalier while it was still at Gloucester St.  I had no home internet access for a while, which was actually delightfully liberating, but now I’m able to blog again with abandon on my laptop.  Apologies to those of who missed seeing more frequent updates (all 2 or 3 of you).  I didn’t get sick or go on vacation, although I think a vacation sounds like just the thing right now!

I gotta hand it to the Chinese - with their remarkable Olympic opening ceremony this last week, they showed just what a strong authoritarian regime directing a large population acculturated to obedience and uniformity can accomplish.  And I truly don’t mean that in any negative sense.  China’s amazing display was all the more amazing because we all knew that such a thing could never be replicated anywhere else in the world.  I’m not sure what London has planned for 2012, but I think the planners for that event just started sleeping a lot more poorly.

News broke earlier this week about the fake firework “footprints” that were part of the opening ceremony.  Most people were either not terribly surprised or not terribly concerned.  Now today we have news that the cute pigtailed girl in the red dress singing “Ode to the Motherland” was, in fact, lip-synching.  Why?  Because the seven-year-old with the wonderful voice, Yang Peiyi, wasn’t as pretty as the nine-year-old Lin Miaoke that we all saw on TV.  The solution to this non-dilemma was to dub Yang’s voice over Lin’s singing.

To me, this is much more upsetting than some computer-generated fireworks, not the least because you’re teaching a little girl that it’s not true talent that matters, but good looks.  The corollary lesson is that you can cover up deficiencies with a pretty veneer.  But why stop there?  If you’re going to make a substitution with these two girls, why not have Chow Yun Fat at the piano dubbed with a Lang Lang recording?  Or have Zhang Ziyi become president while Hu Jintao continues to pull the strings in the background.  Why not?  Because it’s ridiculous, that’s why.  It’s ridiculous and it rails against the values we should be promoting in a society (crap - now I’m sounding like a Republican), not to mention in seven-year-old girls.

Much talk has been made of the pretty facade that China has worked so hard to place over the country in the workup to the Games.  Every now and then we scratch or rub away the gold plating and are disappointed by the leaden core we glimpse beneath.  This definitely wasn’t the first peek, and I’ll be shocked if it’s the last.

You might say I’m a well-traveled vomiter (vomiteer?). I’ve puked in several different countries around the world, not to mention over international waters, and I’ve had some sort of GI distress in 6 continents (only because I haven’t been to Antarctica yet). I love to travel, but somehow the damn food gets me every time. I don’t go out of my way to eat chilled monkey brains or day-old street food, but I’ll be damned if I travel somewhere just to eat American peanut butter and energy bars for two weeks. I think one of the strongest expressions of culture is via food, and I would feel shortchanged if I didn’t have the opportunity to taste the native flavors of a new destination.

You can imagine my dismay, then, at a recent report from the journal Clinical Infectious Diseases, which demonstrated persistent contamination of vegetables with coliform bacteria despite cooking.  Coliform bacteria are those bacteria which normally reside in the gut but can end up in unwanted places, like on your dinner plate, due to poor food hygiene practices.  These are the guys that gave Montezuma his revenge.  Turns out that these buggers can persist in cooked veggies, even when served hot.  So it seems like I’m doomed to playing Russian roulette with my gastrointestinal health even if I forgo the fresh salad for a side of steamed vegetables.  Sometimes you just can’t win.

This story came to my attention via P.Z. Myers and his Pharyngula blog. I’ll let you read the story for yourself.

Say what you want about whether the kid, Webster Cook, was malicious in his intent or not. There’s little excuse for the reaction from the church and its supporters. Physically confronting the kid? Calling it a hate crime? Comparing it to a kidnapping? Sending death threats? Overblown and totally inexcusable.

The fact that the campus Catholic organization receives university funds is also troubling, if not entirely surprising.

If any of the hateful people who sent this kid emails damning him to Hell or phone messages threatening death think that Islamic fundamentalists are wacko, they should look in the mirror.

Shadowfax wrote a nice little post today about docs who “practice scared” - those poor souls (I think every doc knows at least a couple) who order tests and call consults left and right, worrying constantly about this zebra* or that, admitting everyone who sneezes. It’s an interesting problem, one which I deal with almost every day I’m at work, and one for which I don’t think there’s an easy solution.

What struck me the most about Shadowfax’s post was his idea that fear of litigation, which is unfortunately bandied about a lot in the practice of medicine, is often used as a scapegoat or excuse to cover up the real reasons for practicing scared - usually the fear of missing a diagnosis, ordering the wrong treatment, or doing unnecessary harm to a patient. This idea really rung true to me. As real as the threat of litigation may be (and one could argue a long time about the relative size of this threat), I feel it’s used too often by doctors to justify actions they don’t feel they would do otherwise. Fear of failure is always going to be there, and rightly so. But coating that fear with a veneer of victimization by the malpractice industry is intellectually dishonest and accomplishes nothing.

You’re going to make mistakes. You don’t know everything. You’re human. I think once young, apprehensive doctors can get their head around those ideas (and some, it seems, never really do), they take a giant step towards the best practice of medicine. Not that errors are good, but once you allow yourself the intellectual freedom to make mistakes and miss things, you not only gain the ability to sleep at night, you also think much more clearly. Your brain is suddenly free of the noise of unnecessary worry and better able to perform its higher functions of reasoning and judgment. Instead of the equivalent of thinking, “Don’t mess up. Don’t mess up. Don’t mess up,” all the time, you become free to make rational decisions based on logic and the best evidence.

And notice how I said that the goal of all this is providing the best practice of medicine. This is should not be confused with being as thorough or as cautious as humanly possible, as these are very different things. Sure, you could do a million dollar workup and shotgun therapy on every person who walks through your door. Sure, if you did this a thousand times, you might pick up a couple diagnoses here or there that you wouldn’t have otherwise. But along with those couple extra diagnoses, you would also be saddled with a couple extra cases of cancer from all the radiation you ordered, more than a couple cases of significant side effects from medications you gave unnecessarily, and billions of microbes that are now resistant to the antibiotics you prescribed so liberally. Here, small short term benefits come at the cost of greater long term detriment.

Fear being a part of the human condition, it’s only natural for us medical professionals to have the fears that we do. It’s necessary to understand one’s fears in order to better manage them, but passing the responsibility for that fear on to the bogeyman of malpractice litigation prevents doctors from performing that crucial, honest self-examination. I don’t expect doctors to become cold, emotionless, computational machines (although that could be kinda cool), but I do expect them to try to rise above their fears for the sake of their patients. Far from being a service to their patients, doctors who test and treat too liberally cause more suffering than they relieve.

*Zebra is doctor speak for a wildly unlikely diagnosis, eg. African sleeping sickness in a healthy American kid with a fever.

Carisa and I had the pleasure this last Saturday of attending the wedding celebration of Mary Ly and Chin Song. We knew Mary from the Korean language classes we took through the Brookline Center for Adult Education, and we were happy for her, if a little sad to see her off to the West Coast.

I had brought my camera along in hopes of adding some interesting angles or framings of the wedding, but I soon found my efforts to be completely unnecessary. There were two photographers, two videographers, and even a lady running around carrying a slave flash on a pole. Far from adding anything to the photos, I had to throw elbows to even get the few snapshots I did. And even when I wasn’t fighting for physical space, I had to deal with errant flashes and video camera lights messing up my metering and white balance (you can see the cool bluish light from a video camera in the picture above).

Failed attempts at photography aside, we had a great time. The reception was at Jin Asian Restaurant, a monolith of a restaurant rising above Route 1 in Saugas like some mythical Chinese palace. The meal was ten courses and almost solid protein - cold cuts, mixed seafood, lobster, chicken, fish. My personal trainer would’ve been happy for me. We didn’t even see carbohydrate until the ninth course. The first plate appeared a little after seven, and we finally finished with cake at around 10:30. It was a very filling meal.

Intermixed with the steady stream - river, really - of food were games, toasts, dances, cake cutting, speeches in three languages, and a slideshow. Mary had two costume changes. Chin (who is Korean) made a game attempt at a speech in Vietnamese. Mary (who is Vietnamese) whipped out some perfectly-inflected Korean that made my jaw drop to the floor. When Carisa and I finally rolled out of the parking lot of the restaurant, we knew that we had never seen a wedding like this, and we felt very lucky to have had the opportunity. So thanks to Mary and Chin for throwing a great party, and best of luck to the two of you as you depart on your grand adventure.

Other photos from the wedding.

I got a message in my inbox a couple days ago highlighting a recent controversy in infant formula. Now infant formula is controversial enough to begin with, so some sort of brouhaha is certainly nothing new. But this one struck me as, if not sinister, certainly a little troubling. Evidently a particular market-leading brand of organic infant formula is being sweetened with sucrose as opposed to the lactose used in other brands of infant formula. Since sucrose tastes more sweet than lactose, this gives the sucrose-sweetened formula a sweetness equivalent to “grape juice or Country Time lemonade” as opposed to the “unsweetened apple juice” of other brands. Maybe this substitution is a simple cost-cutting measure instead of a concerted attempt to sway a baby’s formula taste preference - maybe. In either case, sucrose is also less preferable to lactose because it might cause more rapid tooth decay. We cannot be sure at this point if, by feeding our babies sucrose-sweetened formula instead of lactose-sweetened, we are giving them an early sweet tooth that has the potential to lead to nutritional ramifications down the road (obesity, diabetes, etc.), but at the least it sounds like a bad idea. Consumers and physicians, take heed.

Photo by Wendy Harman

Carisa and I went to see the new Indiana Jones movie last Friday.  Meh.  While it was not quite the childhood-ruining, franchise-destroying crap that Episode I was, there were no terribly redeeming traits about it, either.  (Spoiler alert!)  Returning a crystal skull to a hidden temple in the jungles of South America at least sounds like a cool plot on the surface - but when you mix in nuclear testing, commentary on McCarthyism,  alien coverup conspiracies, and cute CG animals, the idea sort of gets lost in all the noise.

The Indy franchise has always had a gritty flavor, so the hyper-real CGI liberally sprinkled throughout the movie feels contrived and out of place.  What was supposed to be a breathless action sequence gets ruined by Shia Lebouf going Tarzan through a CG forest with an army of CG monkeys.  Yes, an army of CG monkeys.  Might as well be Ewoks.  I didn’t even mention the CG prairie dogs.

Cate Blanchett is underused but is still ten times more memorable than Indy’s sidekick, for whom you hardly care when he gets sucked into another dimension.  (Seriously, another dimension.  Is this still Indiana Jones?)  The batty, nearly aphasic kidnapped archaeologist adds nothing to the story.  At least it was good to see Karen Allen as Marion Ravenwood again.

Oh yeah - the movie ends in a wedding.  Honestly, as I continue to type this stuff, I have to remind myself over and over that this really was an Indiana Jones movie.

I could go on and on, but I guess it really doesn’t matter.  The movie is going to make (and already has made) a jillion dollars.  People are going to go see it regardless of what the reviews are (just like I did) because of the history of the franchise.  I know that sequels don’t automatically have to suck, because there have been examples of ones done well (immediate example: Temple of Doom).  So I free up 2+ hours of my time and pay 12 bucks to go into a movie like this hoping, perhaps naively, for something that enriches an entire franchise’s mythology, adds to the magic of a fictional world.  And it hurts when, more times than not, the expectations come crashing down and the movie ends up sucking.  You wonder if the people in charge are just asleep at the wheel, if they made the mistake of taking themselves too seriously, or if they’re just turning the crank to print some money.  In any case it’s a damn shame.

Ok - lament over.  I hear Iron Man is pretty good.