Why Can't We All Just Get Along?

As far as doctors go, I consider myself fairly knowledgeable when it comes to alternative therapies. Other doctors consider me somewhat left-wing in my practices and policies although in a generally right-wing profession such as medicine I guess that really doesn't say much. I regularly recommend that my patients try chiropractic, massage therapy, acupuncture, or naturopathic medicine. I am a huge breastfeeding advocate, and support mothers who can breastfeed their babies beyond infancy. I am very anti-circumcision. I appreciate the benefits of such 'crunchy' parenting beliefs as co-sleeping, baby-wearing, and attachment parenting in general.

So because I know few people in real life who think the way I do (not to mention the very real problem of not really having the time to make any friends in the city I've been living in since starting residency), I often rely on the internet for information and to find people with common interests. In particular, I am a fan of message boards. One such message board that I won't mention (it's not my intent to start a war) seemed to be exactly what I was looking for-- there were reviews of cloth diapers, vegetarian and vegan recipes, information on natural health and healing and all kind of great information probably considered 'off the beaten path'. Just one problem.

They hated me.

Well, maybe it wasn't 'me' they hated. After all, I hadn't contributed anything at that point. It was more a matter of hating what I (voluntarily or not) represent. I first realized this when I ventured into a forum on vaccination. Vaccines weren't something I had spent much time thinking about through my medical training-- in emergency medicine, the only vaccine that had a role in the emergency room was the Td booster, which we offered to everyone who came in requiring sutures who hadn't received the vaccine in the past 10 years. I didn't really concern myself with people who refused it-- just explained the indication and documented that it was offered and declined.

In family medicine, however, they became more routine. But still, I hadn't thought much about them. They were routinely given at 2, 4, 6, 12 and 18 months. Only once did a patient take me up on my quick "do you have any questions or concerns about the vaccinations scheduled for today?". He was concerned about the mercury in vaccines. I assured him that vaccines in Canada no longer contained thimerosal with the exception of the flu shot, and he was happy with that. At his next visit, the same father asked about the use of formaldehyde in vaccines. I told him that I didn't know, but that I'd be happy to look into it for him. We delayed his son's vaccinations that day.

The 'Vaccination' forum would have been much more appropriately named the 'Anti-Vaccination' forum. A few clicks was all it took to realize that the nature of the forum went far beyond having evaluated the literature and deciding that the risks of vaccination outweighed the risks of contracting vaccine-preventable diseases. That, I can respect. But instead these people have decided that the entire medical profession is, at best, a bunch of ignorant and obedient pharma shills. At worst, we are voluntary conspirators pushing dangerous interventions on people to benefit our own pockets.

I have to admit that when it comes to something as seemingly benign and beneficial as vaccination, we're probably not as critical as we should be. We know what we've been taught-- and that is that vaccines have been proven safe and effective, that adverse effects are rare, and that the benefits of vaccines far outweigh the risks. It's not 'dogma', it's not a belief system, it's simply presented in the same way as every other one of a million other pieces of medical information that we, as physicians, are expected to know. And as with anything else, we should be prepared to discuss it intelligently with our patients rather than simply shutting down at the suggestion that there may be more to it.

But the anti-medical sentiment runs far deeper than the vaccination forum. Among the opinions presented as fact are:

• Well baby visits are simply an opportunity to push vaccinations and berate parents who choose not to vaccinate.
• Well baby visits exist solely for the financial benefit of physicians
• Physicians receive kickbacks from pharmaceutical companies for prescribing their products
• Physicians make up statistics to coerce patients to agree to certain interventions
• Physicians are "unethical liars telling women rubbish to suit their own purposes" in regards to childbirth
• Obstetricians are "knife-wielding surgeons who are bound and determined to slice you open no matter what your wishes"

It actually makes my stomach hurt. Poll a thousand medical school applicants and I can bet you that not one of them mention the desire to have people accept their word without question or perceive them as superhuman among their reasons for pursuing a career in medicine. But many of them will talk of a desire to feel like they're helping people, and working to better patient's lives. During medical school we are never taught trade names for drugs-- we refer to all medications by their generic names and discuss only broad categories rather than specific therapies (i.e. "use a beta blocker for this condition" rather than "use metoprolol" and certainly never "use Lopresor") and have no contact with the influence of drug companies. Again, unless things are dramatically different in the U.S. the ideas expressed on this board are ridiculous.

But it's a sentiment that goes both ways. Allopathic medicine is slow to accept, let alone endorse, many branches of 'alternative' or 'complementary' medicine. It took years for acupuncture to finally be endorsed by the medical community in spite of years of evidence in support of its benefits. Recently, when my family medicine group discussed a case where a woman came into my colleagues office asking about her opinion on the naturopathic remedies that had cured her condition, my colleague had to admit that she had no idea what to say or how to handle the situation. I suggested having a naturopath come in to speak to our group about some of the principles of naturopathic medicine and alternative healing-- it's something I've always wanted to learn more about and clearly it was an area of weakness for my colleagues as well. Instead my suggestion was met with uncomfortable silence. Instead it was decided by the group that we'll be having an MD give us a talk on alternative medicine. Um... right. Talk about defeating the purpose.

The attitude that practitioners of alternative medicine have against physicians and the attitude that physicians have towards much of alternative medicine is only hurting the patient in the long run. A recent study showed that 63% of patients over the age of 50 were using some form of complementary or alternative medicine, and nearly 70% of these had not discussed it with their doctor. Many of these women on the anti-vaccination board were advising each other to lie when asked if their child was up to date on their vaccinations to avoid questioning and condemnation. That can't be good for anyone.

Traditional allopathic medicine has much to learn from the world of naturopathic and alternative therapies-- we should be keeping an open mind and ensuring that we have (at minimum) a basic knowledge of the therapies and techniques available. Alternative medicine would gain more acceptance by traditional medicine by shelving the adversarial attitude and through more rigorous scientific testing of their therapies.

It's too bad that each side has to feel so darned threatened by the other.

Open Season

Finally, after years of trying to convince people that the flu shot is actually beneficial, the message has apparently gotten through. Now, instead of running from the shot, people are lining up for it. It probably has more to do with the idea of bird flu coming to North America and wiping out life as we know it (please note the slightly sarcastic tone here) than with the public health benefits of vaccinating against influenza, but I'll take it.

It's about time the message concerning the benefits of the flu vaccine has been accepted. I've been touting it for about five years. Arguing with people who are convinced that it gave them the flu. Arguing with people who had a cold or a gastroenteritis after getting the flu shot and took that as proof that it didn't work. Trying to convince people that even if they don't think that getting the flu is a big deal, they could easily pass it to people before they know they have it-- and for those people, it might be a very big deal.

The problem with trying to push vaccinations in our society is that we live in a culture and time were the rights of the individual are prized above all else. The idea that something might be for the greater good of society is a foreign concept if it means sacrificing one's own personal rights. Introducing any foreign substance into our bodies has a risk, however incredibly small. Trying to convince someone that the risks associated with the elderly woman behind you in line at the supermarket catching the flu because she touched the counter right after you did are serious enough to warrant the barely-significant risk to you getting the flu shot... well, I might as well be speaking Greek.

And therein lies the problem. The idea of a greater good doesn't compute. Why should I get the vaccine if I don't care if I get sick, right? What other reason can possibly warrant vaccination? Why should I care if I accidentally pass the flu to an asthmatic kid who ends up in the hospital?

This is particularly the case with health care workers. In some paramedical fields, flu shots are mandatory for work during the winter months. This, predictibly, leads to tremendous indignant outcry. People don't like being forced to do things-- and being told that they don't have a choice makes people's backs come up. Unfortunately, though, I can see why making it 'mandatory' is necessary. The repercussions of a paramedic, nurse or doctor (particularly doctor, as calling in sick is often simply not an option) passing the flu onto patients who may be high risk for complications can be catastrophic. And even for those who don't have any particular objections to getting the flu shot, life can sometimes get in the way of good intentions. Making it mandatory and administering it at work catches the people who might remain unvaccinated out of apathy.

I got my flu shot last week. My husband, the paramedic, is still unvaccinated. And he won't hear the end of the nagging until he sucks it up and gets the shot. As we all should.

Just Do It.

Although maybe not what you think.

Just vaccinate your damn kids already. I am so tired of having the same argument over and over with people who 'know someone whose friend had a niece who got autism from a vaccination'. Sure they did. But right now there is a young boy on the pediatrics floor with meningitis because his mother didn't believe in vaccinations. When questioned further about her beliefs, the mother admitted that she didn't have any concrete evidence or research to back up her decision, but a friend of hers suggested that vaccines were like 'putting poison into her child'. So she put it off. And refused it when her family doctor offered it. Repeatedly. She had been meaning to do the research herself, she said, but she just didn't have the time.

Hope you have the time to deal with a brain-injured child.

I have yet to come across anyone who can provide me with actual fact-based evidence to support a decision not to vaccinate. Particularly with the tried and true vaccinations-- MMR and DTaP-IPV. I am more likely to understand the hesitation to incorporate the 'new' vaccines with the (albeit misguided) reasoning that new vaccines have less safety data backing them up. But childhood vaccinations have changed the face of disease in the past 50 years. Smallpox has been eradicated. Polio has been eradicated in the western hemisphere, with the exception of some confined outbreaks in religious communities that are anti-vaccination. Diseases such as mumps, measles and whooping cough are so rare that when a child is admitted with one of them, medical trainees parade through the room at a constant pace to see how it presents.

And with the newer vaccines (Hib, Menjugate) even during my short medical career we've seen the impact. Meningitis used to be a much more common childhood killer. Since the advent of the Hib vaccine (hemophilus influenza B being one of the most common causes of meningitis in infants and young children) the incidence of meningitis has gone down dramatically (I think it's by about 90 percent, but don't quote me). Epiglottitis, an airway emergency that we're taught to be suspicious of in any child coming into the emergency room with stridor and drooling, is actually now more common in adults.

This topic infuriates me. If anyone out there in cyber-land can give me evidence (and by that I mean peer-reviewed trials, not the word of your next-door neighbour) that backs up the decision to avoid childhood vaccinations, I'd love to hear it. Because every time I see another kid come in suffering from a vaccine-preventable disease, I have to bite my tongue not to point out to the parents that their inaction was directly responsible for their child's suffering.

Judgemental? Sure. But YOU try treating a kid with meningitis who, up until admission, was a totally normal kid and is now deaf and brain-injured. And then find out that mom had opted out of vaccinating because she decided to take the word of her cousin's friend over her family doctor or pediatrician. And let's see how judgemental YOU become.