An Unexpected Gesture

I have several families in my practice who have delayed vaccinating their children.  (Don’t get me started!)

One such family came in today for the final vaccination of the childhood series.  The little boy is 4 years old and he was receiving his second dose of MMR and varicella (conveniently packaged in a single dose vaccine called MMRV).  He was a little scared, of course and asked me a question as I was preparing the vaccine.

“Can you put it right here?”

I turned to look at him as he pointed to the inside aspect of his forearm.

“Well, the needle has to go in the fatty bit of your arm and there isn’t enough fat there.  How about we put it up higher on the back of your arm?”

He agreed with a nod of his head.

I cleaned the back of his arm with a swab of alcohol and gave him the needle. There was not a whimper.  He took it like a man.

As I was back at the desk, finishing up the clinical note and completing his immunization record he walked over to me and said “Thank you, Doctor” and gave me a hug.

A hug! For giving him a vaccine.

Well, I’ll be damned.  He just made my day.

Higgledy Piggledy

Higgledy piggledy
Wiggledy wump,
I met a man
Who caught a mump:
With his left cheek lumpy
And his right cheek bumpy –
Higgledy piggledy
Wiggledy wump.

Higgledy piggledy
Sniggledy sneezle,
I met a man
Who caught a measle:
With his chest all dots
And his face all spots –
Higgledgy piggledy
Sniggledy sneezle.
– Alligator Pie, Dennis Lee, 1939

I read this book to the kids the other night.  My daughter loves the illustrations and this one in particular.  She asked me what a mump and measle was.  I explained that they were illnesses caused by germs (viruses) but that most of us don’t get them anymore because of vaccines. She kind of understands what vaccines are, I explained how it’s a needle that she gets that protects her from illnesses like the one described in the story.  She seemed satisfied with that, so we continued reading the book.

But my mind stayed on Higgledy Piggledy, primarily because of the news recently.  There have been outbreaks of measles in a few Canadian cities, mostly in communities where the vaccination rates are frighteningly low.  In the nation’s capital, Ottawa, a young boy contracted measles after returning from the Philippines, a trip he took with his parents.  The child wasn’t vaccinated.  Upon returning home, he became ill and went to not one, not two, but three different walk-in clinics (including an emergency room) before getting diagnosed. Meanwhile, the child was infecting his classmates at school, not to mention a potentially vulnerable population in the ER.  Within a few weeks, another four cases were confirmed.  Another outbreak is also happening in British Columbia.

I’ve written a lot about vaccines.  I’m not going to belabor the point, I believe vaccines work and I believe they are safe.  I don’t believe they cause autism and I believe that, in the end, after all is said and done, vaccines save lives.

Back in 1939, Dennis Lee was born. Decades later he wrote a poem about mumps and measles.  He likely had the illnesses as a child.  He probably recovered.  Not everyone he knew would have been that lucky.

Please vaccinate your children.

A Frightening Trend.

Day 12. This is actually a lot easier than I thought it would be, writing a post everyday.  I actually look forward to it!

And, yes, I’m back, despite my little rant yesterday, which in case you missed it, you can read here.

What’s on my mind today?  Vaccines.  I know, I know, it’s a volatile topic and I’ve discussed it before, but you see, the baby is 8 weeks old today (my goodness, when did that happen?) and he will be going for his first set of vaccinations next week. For me, it’s a no-brainer that he will be vaccinated.  All of my kids were vaccinated.  I didn’t even give it a second thought.  Now, that’s probably because I am a physician and a rational, logical human being.  Okay, that last part was a bit of a dig.  I am just so sick and tired of parents thinking that just because they’ve done their “research” on vaccines (ie. have read about Wakefield, everything that Jenny McCarthy has to say on the subject, and discussed it with their “friends” on countless message boards), does not mean that they understand the science and study behind creating a vaccine.  These parents haven’t seen the devastation that Polio caused, they haven’t seen what congenital Rubella syndrome looks like, nor have they had to tell their son that they may never be able to father children because the Mumps caused orchitis and has the potential to limit his fertility. And let’s not forget the risks of meningitis from certain strains of pneumococcal pneumonia, Measles, and rarely, chicken pox.

I was a resident in family medicine working on the Pediatric ward when a 15 month old girl was admitted with seizures.  She had been diagnosed with pneumonia 2 days earlier.  Blood cultures revealed a particular strain of bacterial pneumonia.  This strain is one that is covered by a vaccination available here, called Prevnar-13.  A review of this child’s medical records showed that her parents declined all vaccinations.  The seizures were eventually controlled, she was diagnosed with encephalitis and a few weeks later was found to be completely deaf.  Totally preventable had she only been vaccinated as an infant.

At least once every few weeks I see a news article about an outbreak of a vaccine-preventable illness.

It’s becoming so common these days, it’s actually starting to scare me a little bit.  If we continue down this path of non-vaccination, herd immunity is going to fail.  We will see the resurgence of illnesses we haven’t seen in twenty or thirty years.  I have never seen a case of measles but I’m sure one day, at this rate, I will.

What’s next?  A North American outbreak of Polio?

I kinda hate the Internet.

Warning – somewhat of a vent ahead, again.  Remember this post?  I’m kinda coming back to it.

The last thing I want to do is offend my readers, but this is my blog and I should be allowed to say what I want, when I want to, right?  Now, I know that my being a physician can be a bit tricky.  While I strive not to provide overt medical advice, I can’t help sometimes to want to talk about medical issues from a personal perspective.  Does that make any sense?

So here’s the thing – despite me using the Internet for my own selfish purpose (ie this blog), I am actually kinda hate it.  I am sick watching (ie reading) strangers discussing their medical issues or their children’s medical issues and vilifying the doctors that care for them.  I used to frequent a few message forums, mostly for entertainment purposes, but constantly found myself drawn to the “health/medical” posts.  Most of the time, I can remember shaking my head at my computer, wondering how some people can be so daft, or shocked that someone would ask a message forum for medical advice about whether they thought their kid should see a doctor.  (If you’re asking the question, the answer is probably yes!)  I made the mistake on a few occasions to post a response.  Big mistake!  I’m not actually seen as an expert by these people.  I am just a GP who can’t possibly know everything.  Yet, the “research” the parent has done over the course of a few days or a few weeks, is far more inclusive than anything I’ve learned in my years of training.  Gee, thanks.

I know what you’re thinking – why bother to visit these sites?  My answer – because I want to know what kind of (mis)information is out there, so I’m prepared to fight it in the office.  I have already made leaps and bounds in my knowledge around the “MMR causes Autism” controversy.  Having read books like, “The Panic Virus” and “Autism’s False Prophets“, I am now armed for those parents who refuse the vaccination.  Unfortunately, it doesn’t seem to matter to most of them, which is quite shocking to me actually.  They would rather believe the stories on the Internet than sound scientific results.  They would rather believe the pseudoscience than tried and tested science.   They really don’t seem to care that they are putting other children at risk by not vaccinating their child.  Their reliance on herd immunity is misguided, because in point of fact, herd immunity is waning.

The vaccine debate is just one of hundreds of discussion points, but it’s the one that comes up the most often in my office.  I would say that about 2-3/10 parents are refusing or delaying their child’s vaccination. That frightens me!   Last year, there was news of a pediatrician refusing to care for children whose parents didn’t vaccinate.  I totally get it.  Sure, it’s an extreme reaction on the part of the physician, but this particular physician felt that parents were not trusting in her expert opinion.  How can she care for their child if there is a fundamental lack of trust?

Medicine has come a long way in the last 100 years. Science continues to advance and yes, maybe in 10-15 years, we might learn that A+B does not equal C like we thought it did.  Case in point: hormone replacement therapy once touted as the savior for post-menopausal women was actually found (via the Women’s Health Initiative in 2003) to cause more harm than good.  This is the nature of the scientific method. Develop a hypothesis, design a study to test it and wait for the results.

I’ve never experienced it myself, but I often wonder what it was like for the older doctors whose opinion was respected for what it was.  Paternalism aside, patients and the public looked up to physicians.  There isn’t much of that going on these days.  Patients are showing up for appointments already having diagnosed themselves.  Patients are not afraid to question their diagnoses, and in fact feel quite entitled to do so.  Now, don’t get me wrong, I have no problem with discussing my findings with patients, and explaining to them my rationale behind said diagnosis.   It’s the attitude that I find offensive.  It’s the sense of entitlement from these patients that I have a problem with.   I didn’t spend an extra 12 years in post-secondary education to be put down by someone who thinks they know better because they read about it on the Internet.  It’s insulting.  I wouldn’t dare tell a mechanic how to fix my car.

I’m not a perfect physician – I never claimed to be.  But I would like to be respected for the years I put in to my training and for the continued self-education I engage in on a daily basis.

Is that too much to ask?

1 week to go!

As the clock ticks down towards October 3 (my return to work), I have started to refresh my memory on the common stuff that patients come into the office for.  You know – birth control/family  counselling, back pain, high cholesterol, diabetes follow-up, new baby/well-baby visits, depression/anxiety – the bread and butter of family medicine.  Medicine is constantly evolving, there are always new guidelines that need to be reviewed, new updates on the treatment of such and such. It’s hard to keep up with it all. I often find myself looking something up while the patient is in the office with me.  Some docs might think that’s the wrong thing to do (gotta make sure we don’t look like we don’t know something!), but I think the patient actually appreciates it when you’re honest about stuff like that.

Anyway, here are a things that I’ve reviewed:

1) new immunization schedule for infants/children:http://www.health.gov.on.ca/en/public/programs/immunization/docs/schedule.pdf

2) enhanced 18 month WBV:  http://www.children.gov.on.ca/htdocs/English/topics/earlychildhood/health/enhanced_18-month.aspx, with information re: Austim screening tools

3)Osteoporosis guidelines (these actually came out late 2010, I’ve been procrastinating a bit): http://www.cmaj.ca/content/early/2010/10/12/cmaj.100771.full.pdf+htm

I have to question the wisdom of the new changes to the immunization schedule, mainly the change back to giving one dose of MMR at 12 months and  the second at 4 years (when it has been given at  12 and 18 months for the last few years).  How does one explain this to parents? More importantly, will parents think this change is due to the increasing paranoia in the mass media regarding MMR and its purported links to Autism?  (Note:  that theory has been officially debunked in the scientific community; google “andrew wakefield fraud”, “Lancet retracts Wakefield”).  And while I’m on the subject, can I just say how much I hate it when parents tell me they are going to delay “certain” vaccines until their child is older.  I have yet to have anyone give me an adequate, sound, evidence-based reason.  If there is one out there, please, would someone kindly comment and tell me?

As I’ve mentioned before, generally I am looking forward to getting back to work so I can reconnect with all my patients and get my “doctor groove” on.  But there are a few folks that I am already dreading to see – the so-called “heart sink” patients.  My fellow physicians out there will understand who I mean.  These are the patients, that when you see their name on your day sheet, your heart literally sinks. You know it’s going to be a painful visit.  For these are the patients that whine. Life isn’t fair to them. Their pain is beyond their control, “I need more oxy’s doc”. Then there’s the patient who just can’t cope – she needs “stress leave” for a bullying boss. Then there’s the one who has environmental illness and is allergic to everything- no, wait, she left my practice, didn’t think I had enough time for her. Riiiight.  This coming from the woman whose 15 min appointments always lasted 35-45 minutes.

Sigh … so yes, I am looking forward to returning to work.  It’s time. If nothing else, it’ll force me to get off the Internet during the day (except for this blog, of course), to be present in the moment with my patients, to affect change in those who are willing and able.  But overall, to provide for my family.