Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, October 27, 2009

More on H1N1 Flu; In Which I Call Dr. Anonymous onto the Carpet for Being a Wimp

The venerable Dr. Anonymous, although no longer technically incognito (like a certain dinosaur), has been busy of late. He's transformed himself from a full-fledged blogger into more of a media mogul, schlepping his trusty video camera hither and yon. He podcasts on Thursdays, and makes sure that Vegas is no longer confined to Vegas. He even has a regular gig on his local TV news. In the face of all this, he rarely writes true blog posts anymore. Leave it to me, then, to jump down his throat on one of the rare occasions when he actually does so.

His latest exposition is on the topic of H1N1 influenza. Bookended by a pair of very nice video clips, Dr. A sallies forth over well-explored territory, promulgating validated information about both the disease and the vaccine. After all that, though, here's where he falls down:
When it comes to immunization, it's definitely a personal decision.
Cut me a break! That's like going on and on about the risks of driving while drunk, and then saying, "It's definitely a personal decision." This is actually true. In fact, one drunk driver presents less of a numerical risk to the rest of the population than does one unimmunized individual during pandemic flu, especially if said individual works in health care. The DUI dude can only kill, at most, one or two carfuls of people, whereas the unvaccinated RN can wreak havoc throughout an entire institution.

Dr. A goes on to say this:
The only thing I ask is to just ask yourself this question - What is the risk to yourself (and your kids) if you DO get the H1N1 vaccine (mild side effects, in my opinion) verses the risk if you DO NOT get the H1N1 immunization?
Here's where I call WIMP*. Dr. A, you've just done an excellent job of explaining that the risks of vaccination are downright trivial, compared to the documented substantial risk of pandemic H1N1 influenza, especially to children. Why wuss out now and call on the patient to make the final determination of the balance of risk vs. benefit? You've just laid it all out for them. You need to take a stand and say that vaccination is the responsible course of action.

Patients are looking for our recommendations. When the issue is this clear cut -- and make no mistake, despite the pseudoscientific fear mongerers lurking around every corner, this is indeed one of the most straightforward decisions our patients are called upon to make -- we do them a disservice by wimping out and calling it a "personal decision".

Edited to add:

Every patient has the right to make "personal decisions" about whether or not to follow the doctors' recommendations. It is still our responsibility to come out and make those recommendations.

Man up, Dude.

(*Note to COG: that's not an acronym.)


At Tue Oct 27, 12:18:00 PM, Blogger Dr. A said...

Interesting analysis. And, I have never denied being a wimp. This post has come out of where I am at in working with my patients over the past 2-3 months when the real vaccine talk started.

Back in July and August, I took a pretty hard line with my patients that when the vaccine (both the seasonal and H1N1). The harder I pushed, the harder they pushed back and I knew that no one wanted to be immunized.

So, this post is exactly what I do with my patients. I present the facts how I understand them, and the patient makes the final decision - whether I agree with them or not.

You recommend patients stop smoking, don't you? You recommend your obese patients to lose weight, don't you? How successful are you at that despite your recommendations to patients?

Getting patients to perform a certain (healthy) behavior is difficult and is a part of the art of medicine. I have found this approach effective with my patients. Maybe your approach is more effective with your patients.

At Tue Oct 27, 12:43:00 PM, Blogger ShrinkingDoc said...

I'd like to speak from personal experience on something--it's a tad easier to get jabbed in the arm for a flu shot--done it twice this year plus once a year for as long as I can remember--than to lose over a hundred pounds. I've done that, too. NOT even a remotely close comparison.

Suck it up and get a the flu shots when they're available. Even though the vast majority of us won't get dangerously sick from the flu, though some will and we should all try to protect them, who the heck wants to lie in bed aching and coughing for a week? The chance of a problem from the shot--miniscule... I just tell it like it is.

I agree, man up.

At Tue Oct 27, 12:53:00 PM, Anonymous Lori said...

I wouldn't call giving your patients the facts wimping out. As doctors all we can really do is present the facts and give our recommendations. We cannot force a patient to get vaccinated. I agree with Dr. A. - when it comes to immunization it is a personal decision. We may not agree with what they ultimately decide, but it is still a personal decision to be made by the patient.

At Tue Oct 27, 01:16:00 PM, Anonymous Anonymous said...

I have to agree with the wimp call. While it's great that Dr. A laid out so much detail to combat misinformation, in the end he completely failed to recommend the vaccine.

At Tue Oct 27, 02:22:00 PM, Blogger Jon said...

Vaccines are extremely beneficial, yes, but are not innocuous. I've chosen not to get vaccinated for the flu in the past, and choose not to get vaccinated this year either.

Ultimately it is up to me. All doctors can do is educate and make recommendations, but can't make patients comply.

I don't vaccinate my kids with every new vaccine that comes down the pike, either, nor did my cancer kid get flu vaccines while immunocompromised from chemotherapy.

At Tue Oct 27, 04:02:00 PM, Blogger Cannwin said...

I'm just having a hard time processing the fact that a doctor just said "Man up, Dude."

I have a 2 1/2 year old that had pneumonia last year, as well as bronchiolitis and a nasty stomach virus that sent him to the hospital. He's been on Singulair all summer in an attempt to stop this nasty little cycle he's gotten his lungs into. Then this thing comes around and I'm really worried. Problem... no vaccines.

They are having a local clinic tomorrow but the doctor said that even when they were dosing just the under 4 y/o's they ran out in about an hour.

I'm nervous. Is there any way I can request a vaccine to be held aside for my kid!? What are my options?

At Tue Oct 27, 04:03:00 PM, Blogger Cannwin said...

Last time they had a clinic they ran out in an hour. Is what I meant to say.

At Tue Oct 27, 06:55:00 PM, Blogger Amanda said...

Coming at it from the patient perspective, I would say that Dr. A's presentation is the one I'd prefer (I'm more receptive to an educated suggestion/ recommendation rather than a didactic order), but I do believe that tacking on a final statement such as "I'd get one myself even if I weren't in healthcare," might be the final push some folks need.

I've watched my kids go through H1N1 and had it myself, and I've gotta say it sucked. And although I don't usually get a flu shot, this was one time I'd decided I'd deviate from my usual practice and get all of us vaccinated.

Whoops. Too late -- the vaccine didn't come out until a week later. Urrrrrgh.

At Tue Oct 27, 07:05:00 PM, Anonymous Anonymous said...

From the patient's perspective (ie, mine), when I hear a doctor say, "It's a personal decision," that pretty much means that the risks and benefits are basically equal. Since that's obviously not the case with flu shots, I agree that Dr. A should have been less wishy-washy with his recommendation.

At Tue Oct 27, 07:23:00 PM, Blogger Shay said...

Dr. Anon appears to be trying to have his cake and eat it, too.

At Tue Oct 27, 07:41:00 PM, Anonymous Anonymous said...

I don't consider it a personal decision if the ramifications of that decision will negatively affect other people. Vaccines are not 100% effective for all individuals. For those in which the vaccine is not 100% effective, herd immunity kicks in and protects those individuals as long as the others are getting immunized as well. Those who do not get immunized impact those for which the vaccine is not 100% effective.

Second, comparing a flu shot to the months needed to lose 100 pounds is not a fair comparison.

What you should be doing with your patients is overcoming their objections to the flu vaccine. Most likely, their objections are based on falsehoods spread by the likes of Jenny McCarthy.

Man up, dude.

At Tue Oct 27, 08:51:00 PM, Anonymous Anonymous said...

I give my patients the risk-benefit and pro's-con talk about vaccinations.
If they then choose not to get vaccinated, I call security, tie them to a table with their arms exposed, and vaccinate them!

Now which is more ridiculous,
forcing vaccinations, or recommending vaccinations and allowing a person to opt-out>

At Tue Oct 27, 09:59:00 PM, Blogger denverdoc said...

Damn, I can't even get an H1N1 shot yet. Denver Health informed me (at least they had the decency to return my call) that internists, since we don't see pregnant ladies and kids) could just take our place at the end of the line with everyone else. I feel like plastering myself against my exam room wall when H1N1 Mary comes in hacking and spitting and say you GOMER, get out of my exam room. I can do nothing for you!

At Wed Oct 28, 08:37:00 AM, Blogger Dragonfly said...

One reason a lot of people are citing as why they aren't getting it is that they think they have already had it and are not sure if getting the vax on top will have any potential benefit. I still think getting the vaccine is necessary and safe.

Got mine 2 weeks ago. No side effects. And it is free in Australia (not sure if it is elsewhere).

At Wed Oct 28, 09:45:00 AM, Anonymous TreBob said...

Sorry Dr. D, your analogy sucks. You can't compare getting a vaccination with drunk drivers unless you're saying we should all get rubber bumbers all the way around all of cars to protect us from the drunk drivers.

Look, here's the reality of the situation that ALL docs seem to gloss over. Here in Oklahoma we got 450,000 doses of H1N1 vaccine for 4,000,000 people. Hmm.. A little more than 1 out of 10 can get the vaccine (but we aren't rationing health care). I am not in a high risk group, I do not have any children or aggravating conditions that would be exacerbated by a mild flu. It would be irresponsible for me to get a flu shot denying someone who may have some REAL issues with a case of the flu, the vaccine they need. We are supposed to have some compassion for our fellow man and me risking a mild case of the flu for someone else is my way of benefitting society as a whole. To do otherwise would be selfish and uncaring.

And thanks to our government and healthcare providers who don't consider others, we are also short on the seasonal flu vaccine (you know, the one that kills 30,000 people a year) because we have to make the latest scare vaccine (can you say SARS, bird flu, mad cow, etc) available and ensure everyone and anyone gets a shot, whether it's a good idea or not.

As an aside, do you also discuss the amounts of thimerosal in the vaccines and potential ramifications of mercury poisoning? I'm always amazed that there are docs out there that will tell you to stay away from Tuna and tell you to get a vaccine shot full of thimerosal.

At Wed Oct 28, 08:49:00 PM, Anonymous Anonymous said...

Vaccines are not "full of thimerosal."

At Thu Oct 29, 03:14:00 PM, Anonymous Anonymous said...

Comment about WIMP not being acronimic duly noted.

At Fri Oct 30, 08:07:00 AM, Anonymous Craig said...

How is it a personal decision when the objects of the decision have no choice? What about the kids whose idiot parents won't have them immunized because a) they are idiots and b) they don't believe anything bad can happen. It's called magical thinking and it's the same type of thinking usually rejected by the same crowd when it's called "religion" or "faith".

At Fri Oct 30, 09:52:00 AM, Anonymous TreBob said...

Anonymous said...
> Vaccines are not "full of thimerosal."

OK, full is not the appropriate word, so let me pick another:

The FDA states the amount of Thimerosal in multi dose vaccines like the ones for influenza can be as high as 100 ppm (25 micrograms of mercury) although some vaccines with trace amounts can be around 10 ppm. The EPA advises against eating fish that have mercury concentrations in ranging from 1.67 ppm to 4.54 ppm.

So the multi-dose flu vaccines (one of the few vaccines still using Thimerosal) can have concentrations of mercury 2 to 20 times amounts the EPA says don't put into your body at all (many times more if you don't use the highest mercury concentrations in the fish, i.e. shark 4.54 ppm).

So, while you're right in that full isn't the right word. Let's use overloaded, stuffed, inundated. Any of those work for you?

At Fri Oct 30, 10:15:00 AM, Blogger #1 Dinosaur said...


Then again, no one has ever shown that thimersol in the doses present in vaccines has any adverse effects on humans. Period. Ever. Insinuating otherwise is akin to prohibitionists putting fish into bowls of ethyl alcohol, watching them die, and claiming that drinking it does the same to humans. The dose makes the poison.

Sometimes I find myself thinking, "I can't imagine being that stupid wouldn't hurt." Explains a lot, which is why I have more pity than contempt for stupid people.

At Fri Oct 30, 11:07:00 AM, Anonymous TreBob said...

#1 Dinosaur said...
> Then again, no one has ever
> shown that thimersol in the
> doses present in vaccines has
> any adverse effects on humans.
> Period. Ever.

Geez Doc. Got a news flash for you: I'm not stupid and your information is incorrect.

Acute mercury poisoning from thimerosal-containing products:

gamma globulin - Matheson et al. 1980

hepatitis B immune globulin - Lowell et al. 1996

thimerosal ear irrigation in a child with tympanostomy tubes - Rohyans et al. 1994

thimerosal treatment of omphaloceles in infants - Fagan et al. 1977

Sure seems like these folks all showed thimersol producing adverse effects (I'm assuming you think acute mercury poisoning is a bad or adverse thing). Even the short list that I (the stupid person) produced is larger than your "no one".

If thimersol is truly as innoculous as you want everyone to believe then why on earth would the industry and the government be reducing the amounts of vaccines containing thimersol?

In fact, the FDA says:

"Over the past several years, because of an increasing awareness of the theoretical potential for neurotoxicity of even low levels of organomercurials and because of the increased number of thimerosal containing vaccines that had been added to the infant immunization schedule, concerns about the use of thimerosal in vaccines and other products have been raised. Indeed, because of these concerns, the Food and Drug Administration has worked with, and continues to work with, vaccine manufacturers to reduce or eliminate thimerosal from vaccines.

Thimerosal has been removed from or reduced to trace amounts in all vaccines routinely recommended for children 6 years of age and younger, with the exception of inactivated influenza vaccine."

Sure seems like the potential for adverse reactions exist and that organomercurial poisoning has happend from thimerosal-containing products.

Even we stupid people can see that.

At Fri Oct 30, 04:34:00 PM, Anonymous Craig said...

Can't you read? It says "because of an increasing awareness of the theoretical potential for neurotoxicity". It does not say there is a potential for neurotoxicity. It means that people who didn't pay attention in science class can't understand that the FDA is a political organization which caved to public pressure.

At Wed Nov 04, 01:02:00 AM, Anonymous Flo said...

Our hospital has had 26 deaths and now has 11 pts in the ICU with H1N1. The majority of these people have NOT had comorbidities. The vax seems like the better choice to me.

At Fri Nov 06, 11:40:00 AM, Blogger Banshee said...

Well, nobody but the lucky and high priority few can get the vaccine anyway, so what's the point in wishing?

Personally, I'd recommend that everybody make one million dollars a year. Good luck with that....

(I don't grudge first responders the vaccine, but honestly, we're pretty much all on our own for this one.)


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