An ethical dilemma? Measles vaccine or not?

     Andrew Wakefield is a former British surgeon and medical researcher who published articles which he said related Measles vaccine as a cause of a new form of inflammatory bowel disease he called autistic enterocolitis. Medically there is not such a disease recognized. He also said that the MMR (Measles, Mumps, and Rubella) vaccine may have caused autism in children who received it. There is absolutely no evidence that such is case. Multiple blinded medical studies have been done and there is no evidence of any kind of a causative relationship. Others have suggested that the mercury (thimerosol) used in some vaccines as a preservative and antiseptic could be toxic to infants and might play a role in causing autism. Again multiple studies have been done looking for such a connection. None was found. Now thimerosol is only used in tiny amounts in influenza vaccine. It is not used in an other vaccines that are given routinely to children
     Multiple lawsuits have been filed in all directions. Dr. Wakefield's article which was found to have tampered with results, unethical recruitment of study patients, invasive and harmful tests performed on study patients without approval of ethics committee among other more minor but still significant problems with the data. There was even evidence suggesting that Dr. Wakefield was paid by a legal group to produce this article, that he had applied for a patent for a single Measles vaccine which he stood to make money from should MMR become suspect and be withdrawn, and also a test kit for this supposed new form of inflammatory bowel disease.      .

     Wakefield's conclusions were broadcast in the media worldwide and resulted in fear of children's vaccines and a drop off of the vaccination rates. It is estimated that MMR vaccination rates in Britain dropped from 92% to 73% in the late 1990s after Wakefield's press conference raising the concerns about MMR which he raised in his article in Lancet, the British medical journal. The effect was less in the US but it is still estimated that as many as 125,000 children born in the late 1990s in the US also were not vaccinated due to this scare. Many children therefore got sick and some died from complications of measles. The lawsuits have subsided. Lancet retracted the article and 10 of the 12 coauthors of the original Lancet article withdrew their support for the conclusions. Wakefield left England after losing his medical license to practice there. He is still trying to do research in the US and is still claiming that his research was honest, that there was no deceitful data changes and that there is still a reason to be concerned about the MMR. He still has a small group that supports his conclusions. But the greater medical and scientific community agrees that he is a fraud and there is absolutely nothing to fear with MMR and a bowel disease or autism or any developmental behavioral problems.
     What does all this mean for society? How can one man and at best a very bad medical study, at worst a completely fraudulent publication perpetrated in order to make money have such a broad effect on medical care world over? I recall a few years ago when my grandson started daycare, my daughter in law was concerned. She knew there were some parents of children at the daycare who were not vaccinating their children because of just these fears. She then had concerns about her own infant who would be at this daycare and subjected to exposure to these children and their possible illnesses before our grandson's own vaccinations would have had a chance to take effect. It does become a personal issue when a family member might be involved. This is sort of like the Ponzi scheme of medicine. It doesn't affect people's wealth but instead may affect children's lives. It is true that every area of human endeavor has its bad people who don't care about doing harm to others, whose self interest outweighs any concern for others. However, it is particularly heinous when that person is in the field of medicine. People generally tend to trust their own doctor and by inference the medical profession at large. They would normally believe these allegations coming from a researcher and printed in a prestigious journal like Lancet. Of course, they would react with fear concerning their own children. The legal system and the medical self policing system (British Medical Council, Lancet) and the media itself have more or less shown Wakefield for what he is, but there are still concerned parents out there who don't know the whole story and still wonder. What else could we have done? We are limited in a free and just society in order to protect the rights of the innocent. But I sometimes wonder if the rights of the fraudulent and the criminal are protected too strongly in our Western democracies. What do you think? Send me some comments. Let's get this comment section going!

Chronic Post Cancer Pain-- A Study

     I ran across this article summary on chronic cancer related pain. This study confirms what I have written about here on this blog before. Most of the pain is related to cancer surgery. This news is certainly not very reassuring for me personally. I had completed a course of physical therapy for my post melanoma surgery pain. I was able to take a trip to southeastern Asia in November and did OK. But now the last few weeks, I have been doing more work on my laptop computer, writing and clearing out stuff I no longer want on it, backing up what I do want, etc, and now my arm is bothering me again. The physical therapist I saw before had determined that my ergonomics are not so good for my neck and shoulders and arms when I work on my laptop. So this may be why my arm is flaring up again. I have put back on the "tennis elbow" counter force brace around my lower arm and it helps a little. Is it bad enough to go back for therapy again? I do have a prescription to go back if I need to. I will wait a little bit before I decide to do that. I have reinstituted the exercises that the therapist had shown me. What does all this mean? Well if you read below, it apparently means that I could fall into the 40% of people who still have chronic pain 2 years after surgery. Of course, to keep it in perspective, I am only 8 months from my surgery. We are cancer survivors so I guess we all probably determine that we will have to put up with the pain; we are alive afterall. But what does this say about our cancer treatments and quality of life afterwards? There is certainly room for improvement. I do feel that the medical profession tends to ignore this problem.

Read the following summary of the study. Hit Read More
Pain in cancer survivors persists at 2 years post-Dx

Feb 3, 2011

Urology Times E-News

One-fifth of cancer survivors, including those surviving prostate cancer, have current cancer-related chronic pain at least 2 years after their diagnosis, say researchers at the University of Michigan Health System, Ann Arbor.

A study by the Michigan team, published online in Cancer (Nov. 18, 2010), showed that more than 40% of patients surveyed had experienced pain since their diagnosis, and the pain experience was worse for African-Americans and women.

Adults of ages between 18 and 90 years who had prostate, colorectal, breast, lung cancer, or multiple myeloma at least 2 years to the start of the study were included. Participants were recruited from the Michigan State Cancer Center Registry.

Other findings included:

The most significant source of pain was cancer surgery (53.8%) for Caucasians and cancer treatment (46.2%) for African-Americans.

Women had increased pain, more pain flares, more disability due to pain, and were more depressed than men because of pain.

African-Americans with pain reported higher pain severity, expressed more concern about harmful pain treatment side effects, and had greater pain-related disability.

"All in all, the high prevalence of cancer and pain and now chronic cancer pain among these survivors, especially blacks and women, shows there’s more work to be done in improving the quality of care and research," said lead author Carmen R. Green, MD.

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Jobs -- A personal history.

     All of the talk recently is about jobs -- that is the lack of them, and the political pressures to produce more jobs to turn our economy around. Unfortunately a lot of people have probably recently received the infamous "pink" slip lately. Social Science research has shown that "'Tis Worse to Give Than to Receive." Emplyers have a 100 percent increased risk of heart attack in the week after firing an employee. I am not sure if that applies when 10 or 20% of a workforce is let go. Still it has to hurt the administrators somewhat because it means there is no money coming in and no economic growth, if for no other reson. And yet 20% of Americans would like to fire their boss. Only 20%, sounds very low, doesn't it?
      Now that I am in retirement, I began thinking about my past jobs over the years. I read somewhere that the average American holds 9 different jobs by the time he/she is 32 years old. This of course reflects all those summer jobs as a teenager and college student. I began to review my past jobs. I decided to list my previous jobs just to demonstrate to myself and perhaps future descendents how a life can evolve through work. Read on about my work history and its implications. Hit Read More.  
      My first job was lawn mowing for my mom and dad and for my grandmother at her farm. That is how I earned my very first cash. I recall counting those few dollars and hoarding them away. I did help teach at Summer Bible School but that was unpaid volunteer work.  Many young girls at that time earned money by babysitting. But I only recall one such job. I was hired to keep the three children of the local high school math teacher and basketball coach. I was to show up at 9 in the morning and keep the children all day until about 5 pm when I was due at practice for a high school play. I had to feed the kids lunch and get a dinner ready for them before I left and would be replaced by a grade school girl in a pass off of responsibility. There were two boys probably about 6 and 8 years old and then there was a toddler in diapers. Well shortly after I fed the kids their lunch, the two boys asked if they could go outside and play. It seems too strange but in those days this was common; kids would disappear into the backyards of neighbors  and roamed the neighborhood with other children, playing kickball and softball. Well as I cared for the toddler I realized that I had lost track of the two boys; they were not in their home's yard nor in immediate neighbor's yards. Even then as the responsible party, I felt some discomfort with this. So I packed up the baby into the stroller and took off worriedly looking. It took me quite a while to find them about 2 blocks over playing baseball. I suggested they come home but they balked and I didn't know how to exert any power to get them to come home. So I nervously took the baby home and put him down for a nap and every now and then snuck down the street a little to see if the boys were still down there. When it came time for my mother to pick me up and take me to play practice I noticed the toddler climbing the stairs with poop dripping out of her diaper. Well, I couldn't run away and leave that cleanup to the grade school student so I began working to clean up the mess. My mother even stepped in to help me so that it would get done a little quicker. As a result I arrived about 30 minutes late to play practice. When the drama teacher who was also a very strict social studies teacher found out I was late because I was babysitting for the basketball coach, he had a fit and I knew he was going to make trouble for me and for the coach. I don't think I ever babysat again after that. It was not a job for me.
     Summers later in high school and into my college years as well, I worked as a carhop at a local drive-in. The drive-in opened at 4:30 every day and stayed open until all the cars were gone and none were entering the parking lot, usually somewhere around 11 PM. My only night off was Monday night when the drive in was closed. I remember feeling sorry for myself because I missed the late afternoon and evening and its cooling activities -- a time of day that I convinced myself was my favorite. I think it only became my favorite when I started working at the drive-in. It was kind of an interesting job -- you got to see all the local people, and you got to serve some kids you knew from high school. That could be fun or it could be miserable depending on the kids. The owner's son also worked inside as the soda jerk ( and he was one -- a jerk, I mean). I had kind of a crush on him so I tried to be real cool when dealing with him. Of course, like any food job, your pay was mostly tips, though I did get a small hourly payment.
     My town had the county fair every August, and for a few summers I worked doing some bookkeeping, and writing checks for services for the county fair during its run. Those were short jobs, only about 3 weeks long. But it was fun working with responsible adults as a new experience. Of course, the work was basicly just clerical but I didn't know any better so I felt very important. I was working in the office there in the main building of the fair. Wow! Bigshot!
     One summer during college as I began to think about going to medical school, I decided I should take a job as a nurse's aid at a nursing home. I felt I should do some sort of medical work and get my hands dirty, so to speak to see if I could take that kind of work and to make sure I wouldn't be too squeamish. I found a nurse's aid job in Rockford with just those characteristics. I did fine with the caretaking and the bathing of patients and the cleaning up of their incontinence. What I had the most trouble with was dealing with the behavior of the other nurse's aides. Many of them worked harder at avoiding work than they did at the job. And if another aid sherked her job, that meant I had more work to do by having to process more patients because she would only finish getting two patients ready for bed.  I was too responsible to sherk my responsibilities toward the patients assigned to me. I guess that was a good sign about my character, but I had trouble dealing with these situations. The work was otherwise not hard. One summer I worked the nurse's aid job during the day starting at 7 am, and the car hop job in the evenings. I always came home kind of wound up from the drive-in and couldn't always get right to sleep, so mornings came pretty quickly. I must have become quite sleep deprived because one night near the end of summer, I fell alseep driving the 25 minute drive home, and rolled the used car my father had bought me earlier that summer, totalling it and lacerating my scalp and my arm in the process. But I was enormously lucky in that accident; we just lost the car, but no other major injuries. That would seem to indicate that I shouldn't work two jobs and deprive myself of sleep in the process, but what did I end up doing? Going to medical school and becoming a doctor, a profession which probably produces the most sleep deprivation of all.
     In college, I took on a job working serving food in the dorm cafeteria. I had to wear a uniform, and worked either serving food on the line, or managing the beverages, pouring milk into glasses, and keeping the juices and water pitchers filled. I also typed people's termpapers and other writing for other students who didn't know how to type. I had audited a typing class in high school so I was quite a good typist.
     I also worked in an unpaid capacity to man the college radio station for some hours, spinning some music and just filling in with various raconteur sometimes by myself and sometimes with another college gal. That was kind of fun, but you really didn't get much feedback. I never knew how many listeners we had. In some ways it was like doing this blog; you really didn't know what kind of effect you were having. As far as I knew then I could have been just talking to the air waves, and right now I might be just writing to that great wireless network somewhere between the cosmic plasma and reality without any intelligent beings intercepting my words ever.
     During one summer in college, I got a job at a factory that made batteries of all shapes and forms. My mother had worked at this factory in Freeport, IL when she graduated from high school. She sort of pushed me to apply there for the summer. I could stay in Freeport with my aunt and uncle during the week and them she would come to pick me up and bring me home for the weekend. I usually worked the 2 PM to 10 PM shift so I never saw my aunt and uncle. They were in bed asleep by the time I walked home from the job. It was a very lonely job. That job was working on an assembly line. The factory had set up a summer line using temporary summer help. It was kind of difficult to make friends with the others on the line. First we were all trying to work fast doing one thing to move the line fast, so you couldn't always converse. And if you did converse, the topics were uninteresting. I had little in common with these folks; they spent Monday through Wednesday talking about hanging one on the last weekend, and Thursday and Friday talking about how they were going to party the coming weekend.  It was hot, and messy and boring. I complained to my mother about these concerns and she said, "It's good for you. You are seeing how the other half lives." I didn't exactly know what she meant by 'the other half,' but I probably made some sort of unconscious decision that I was not going to be in that 'other half.'
     After I graduated from college in microbiology form University of Iowa, and was set up to start medical school in the fall at the University of Wisconsin, the UW found me a job for that interim summer, working as the microbiologist in an entemology lab on campus. My work was to try to find out if certain pesticides would be broken down by microorganisms in the soil. Basicly I was crushing up apple maggots and culturing the result out to identify the fungi and bacteria from the guts of these little creatures. Strangely enough, that was a very fun summer. The other lab workers there were great fun. And our lab was one block away from famous Babcock Hall in the Dairy department, with its famous ice cream productions each day. We always took an afternoon break and went and got an ice cream cone. My college roommate had come to Madison with me since she had the summer free before starting teaching in CA in the fall. She found a job selling encyclopedias door to door (a job that is obviously totally obsolete now). But this meant that she worked evenings and I worked 8 to 5 Pm in the entymology lab. We had come to Madison to keep each other company and we never saw each other. I got into the habit of walking over to the UW Student Union and sitting on the Terrace writing letters to college friends. Low and behold, that is where I met the man that would become my husband a year later. So, yes, it was a very fun summer!
     During the summers of the first 3 years of medical school, I got a job in the State Lab of Bacteriology. Mostly I streaked out stool samples looking for Salmonella or Shigella, stool pathogens. Then we had to do recultures and chemical analyses to identify and type the pathogens. It sounds like a rotten job, but it really wasn't a bad job either. It was 2 blocks away from Babcock hall in the other direction. Also the ice cream cone breaks.
     Then came internship and residency at Mount Sinai in Milwaukee. Those years occurred during the years that I had my children. That is another story that there may be a chance to tell on another occasion. After residency and the birth of my second child, I began my internal medicine practice at Milwaukee Medical Clinic where I practice for 34 years, retiring 2 years ago.
     If I count up all these little and very huge jobs, I arrive at 12 different jobs from about age 16 to 30. Of course, in my case I was working through about 10 years of schooling at the same time. That changes the picture a little bit. Once I settled into my medical practice I stayed put for 34 years before retiring.
     It is interesting to look back at such an long productive work life and recall the people that I had contact with as fellow workers, as bosses, and later as patients. Though I enjoyed the science of many of my later summer jobs and the science involved in being a physician, I think that the most rewarding part of any and all of these jobs was the personal interrelationships that they created -- some temporary but many lasting a lifetime. I really would not have lived my life any other way. It was terrific!  

Obituary tells a story!

     Being a retired physician has prompted me at times to think about the patients who were part of my medical practice and the mechanics of medical practice itself. Now that I am a patient myself, I have reviewed my office visits by how they would appear from the other side (patient side)  of the desk.
     What prompted me to delve into this path of thought was the discovery of an obituary of a former patient of mine. Now I am not an obituary reader, though I am told many people my age are. But I just happened to find this one and low and behold it was for a patient whom I remembered well. M. P. had been in my practice for many years. She really didn't have too many of the chronic diseases that plague most older women. I recall a little bit of diabetes which really didn't require any meds and some high blood pressure that was controlled on 1  med. I know she developed an underactive thyroid while in my care and I had started her on daily thyroid hormone replacement. She had a lot of difficulty whenever she received any kind of diagnosis, and she was very concerned about having to take any kind of medication. Since the thyroid condition would require her to take meds every day for the rest of her life and to occasionally to have blood tests to check on the correct dosage, she was very down about this. She would whine in the office about, "how was she going to do this? How could this have happened to her?" etc. etc. She was also often going on about various family problems that seemed too much for her. Sometimes she would go into the family issues a little and they were usually stories about inter personal relations of some sort. She really didn't have family members who were abusive, or in trouble with the law or anything like that. But the interpersonal problems often were a burden for her. So I recall looking at my schedule and seeing her on the schedule and knowing that I would have to gear up my cheerfulness to get her through the visit and also to get me through the visit.
     So I was quite surprised to see this sentence in the obit that I found: First her many friends and relatives were listed. Then, "M and her husband of 60 years had many close friends before and during their mariage that they maintained over 60+ years. Described by many as a "true lady", M was known for her friendliness, charitable spirit and insistence on putting the needs of others before her own. Her kindness and generosity will never be forgotten."  This did not seem to be the woman who I saw in some ways whining to me during every visit in the medical office. Which is the correct picture? Or are both views true?
     I began to review my own recent medical visits to my own doctors from my view and then how they might seem from the doctor's side of the visit. The doctor sees the patient for a very short time, especially now adays. He/she doesn't know anything about the patient from anywhere else in the outside community. The patient feels the pressure of time of that office visit and has to quickly and emphatically get across to the doctor what is bothering them. There often is not enough time to put these complaints into perspective. I know the difficulty I was having with arm pain after my melanoma surgery and I had to convince my doctors of the degree of this discomfort if I wanted to achieve any success in the treatment of these problems. I particularly felt this need when I returned to my plastic surgeon with these complaints. I felt he was not giving credence to the problems. I guess I did whine a little more than I am used to, but he felt I was under the care of a physical therapist and the therapist reported I was improving so the surgeon felt he didn't need to do anything further. Yet he was the one who had started the pain, obviously, so I felt a strong need to get my suffering across to him against the time pressure that I also felt as the patient.
     So if there is such a vast difference between who people are in everyday life and who they have to be when they go to the doctor, how can the relationship between patient and doctor resolve itself? An excellent question! I think that the oness is on the doctor. He/she must realize that this paradox exists. And the doctor must create sensitivity and listening  and observation skills that can detect the patient's needs and make the patient's communication more efficient. And patients must ask questions and not be shy with the doctor. It turns out that the visit to the doctor's office is one of the most important interpersonal communications that take place in our later life. Each participant needs to understand this and realize how easy it is for this communication to go wrong. I just know that I don't want to be misinterpreted in my visits like I misinterpreted poor M. P. Lets hope that all of you feel comfortable enough with your physician to bring up your concerns and let's hope you have a skillful physician who appreciates the complexities of these interactions.

Note: At the beginning of this post, I used the caduceus, a universal symbol for the field of medicine.  I plan to use this symbol in the future also when the topic is medical. It is familiar to most everyone as an apparent snake, or sometimes two snakes entwined around a pole. The origin of this symbol is quite interesting. Check upcoming posts and I will explain its origin. You may be surprised.