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.

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.

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.

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

Let me set the record straight first: I’m a huge NPR fan.  I think I first got hooked around 9/11, and I’ve been an avid listener ever since.  Of the six preset stations on the car radio, the other five combined don’t get half as much playtime as NPR, which in my neck of the woods is 90.9 WBUR.  I enjoy the high-quality reporting, the engaging interviews, and even the fun weekend shows like Wait Wait Don’t Tell Me.  I enjoy the whole affair so much that a couple years ago, I felt bad being a freeloader and started making yearly contributions.  And beyond simple enjoyment, I also find myself learning a lot from listening.  It’s become a significant and trusted source of information for me.

You can imagine my consternation, then, when a couple weeks ago my morning commute with WBUR was interrupted by an ad for a company providing ”detoxifying” services with “ionic energy fields”, oxygen supplementation, and nutrient supplementation.  I won’t give the name here for fear of upping the company’s notoriety somehow.  It was a rude, jarring, pseudoscientific intrusion into what was typically a very informative drive.  How could WBUR advertise this crap?  I knew they needed sponsors, as any public radio station does, but surely this was bending too low.

I almost blogged about my dismay that day, but work soon had me running around enough to forget that morning’s insult.  My wedding and honeymoon came and went shortly thereafter, and I returned to my happy NPR listening habits, past injuries forgotten.

Until today.

I’m driving up Route 2 towards Concord, enjoying ”Only a Game”.  The usual WBUR sponsor bit comes on, but this time instead of Landry and Arcari or the MFA, the nice female radio voice spits out the name of a school of homeopathy!  Let me say that again - homeopathy.  You have got to be kidding me.  What’s next - sponsorship from a Boston psychics organization?  Noni juice manufacturers?  WBUR already broadcasts Science Friday.  Maybe they should add Woo Wednesday to attract more sponsors.

So I’m calling out WBUR on this one, and I hope others do, as well.  And remember, WBUR, it’s only because I love you.  I know public radio money is not exactly overflowing, but there have to be some standards on who it’s ok to take money from.  Those who make their living duping their customers with potentially harmful pseudoscience should not be given the opportunity to spread their message on stations such as WBUR, stations that exist to educate and provide information.

For all of the ridiculousness that seems to happen in Massachusetts (stupid bomb scares, gorillas on the loose, the Big Dig, Mitt Romney, I do like to think that we’re ahead of the curve overall. So I was pleased to read that our state legislature was seeking to ban gifts to doctors.

Coming up through the ranks, it was easy to see the pervasiveness of drug company marketing in the form of gifts and freebies. Pens, notepads, microfiber lens cloths, and the occasional pocket guide were just the tip of the iceberg. The “Cipro breakfast” was well known among the medical students as a good place for a nice free meal. Drug-sponsored lunch conferences were always popular, and the exalted drug dinner, which we were rarely privy to as mere medical students, was sought after highly. Luckily, the idea that accepting these sort of inducements was, at best, ethically iffy and, at worst, altering our medical decision-making was filtering up through the medical school and medical staff. The behavior, if not frowned upon sternly, was at least questioned.

Unfortunately, here I am almost ten years later watching the same conflict play out. We already have a strong inkling that pharmaceutical company contact with physicians changes prescribing practices. Indeed, one would hardly expect the pharmaceutical companies to continue pursuing this expensive tactic if it didn’t work. Yet still we allow them easy access to medical students (this thread is disturbing to me), residents, and physicians through free meals, freebie items, drug samples, sponsored CME, and other such means. And even if you don’t believe a simple logo pen could affect someone’s medical practice, you have to admit it looks really fishy to a patient when you sign a prescription for them using a pen with the same drug’s logo on it. It’s just a bad idea medically and ethically.

So I, for one, will cheer on Therese Murray’s efforts in this regard, and I support other states’ efforts with similar measures. If you, as a physician, would rather not see the government stepping in in this way, then alter your actions so they don’t see the need to step in. As a practicing physician, I’ve tried hard to refuse any and all gifts or inducements from drug companies, even pens. I’m such a bastard that when I cover for another doc’s primary care practice, I won’t even sign for the practice’s drug samples. (And it even turns out that free drug samples aren’t the safety net we like to believe they are.) I think if everyone moves in a similar fashion to stem the tide of these inducements, the end result may very well be the better practice of medicine - based on the best scientific evidence, not on what ad we last saw - and possibly more cost-efficient medicine as we forego the latest shiny name brand drug for the generic that works just as well.

Throughout my residency, I never prescribed or recommended cold medicines to children under 12. The data showed them to be ineffective, and they were associated with cost and the potential for side effects - basically a no-win situation. I often got grief from parents looking for a quick fix, or at least some sort of intervention (to make the parents feel better, if anything), but I refused to budge. “Your child’s immune system is strong enough to fight this off on its own,” I would explain. “All we need to do during this time is to support her by keeping her well hydrated and her fevers under control.” I did feel bad that at least some of my parents were less than satisfied by this, but I couldn’t in good conscience do otherwise.

You can imagine my inner feeling of vindication, then, when the FDA recommended against the use of OTC cold meds in kids under 2 and announced investigation into use in kids over 2. It was one of those silent fist-pump moments. Now the FDA has announced some of the early results of that investigation, calculating that over 7000 kids under 12 visit ERs each year because of adverse drug events from OTC cold meds. While in the grand scope, this isn’t a huge number, it does seem like an enormous number once you realize that these events are - essentially - completely avoidable. We’ll see what comes next.

Remember “Super Size Me” with Morgan Spurlock, that self-sacrificing documentarian who ate nothing but McDonald’s food for a month?  (Ick - makes me shudder just thinking about it.)  Well, Gut (great name for a journal, don’t you think?) recently published an article that illustrates some of the biochemical effects of fast food consumption.  Subjects were instructed to eat at least two fast food meals a day and limit their daily exercise to less than 5000 steps (not a hell of a lot).  Even after just a week of this, over half the group showed abnormally elevated levels of a liver enzyme (ALT, for those who care).  These levels persisted for the rest of the 4-week study.  If I remember the documentary correctly, Spurlock experienced elevation in his liver enzymes, as well.  In fact, I think I remember his PCP seeming rather concerned by it.  Oh - and the average weight gain by the end of the study?  14 pounds.  As if we needed any more reason to shy away from those Big Macs.

I was asked recently to contribute to an article in our hospital’s medical staff news. The article is intended to take a brief look at the use of blogs in medical practice. Since I’m one of the younger staff members and also one of the more tech-friendly, I was pinpointed as someone to approach about this topic.

Now frankly, I can’t imagine practicing medicine without the internets. I rarely have to reach for a reference text anymore since I usually have a computer terminal readily accessible. I get regular emails updating me on the latest medical developments and studies. But as for blogs - well, I can’t say I get a heck of a lot of medical info from them. Sure, Medgadget is fun for the technophile in me, but I don’t get nearly as much relevant medical info there as I do from - say - Up to Date. And most medically-oriented blogs talk predominantly about patient anecdotes as opposed to the overarching studies that drive their care. But as I thought more and more about the usefulness of medical blogs, something occurred to me. I can read about meta-analyses and health care policy all day, but it’s still nice to hear about the actual practice of medicine from another human being in the trenches.  Medicine is still practiced between individual human beings with all their emotions, personality quirks, and biases, and these blogs help remind us of that.  So thanks to Orac, Shadowfax, and all those others out there who tell it like it is.  Keep up the good work.

Respectful Insolence

Movin’ Meat

Ten out of Ten

WhiteCoat Rants

Side note: Why is it that ER docs seem to blog more than any other specialty?

The New England Journal of Medicine, in an attempt to keep up with the times, has recently begun releasing articles of a certain import online prior to their publishing in the actual hard copy journal.  Cool, I say.  Today in my inbox, though, I got a link to an editorial entitled, “Intensifying Platelet Inhibition - Navigating between Scylla and Charybdis.”  Now I love Greek mythology as the next guy, but come on - the editors must have been smoking something when they let this title get by.  I know this is a top-flight academic journal, and I know this is “only” an editorial, but a title like reeks of the sort of pomp and self-importance that permeates only the highest of ivory towers.  Smells an awful lot like cheese, too.

Link to the editorial here.