Monday, October 12, 2009

Some Doctors Are Poopy-Heads: Influenza Immunization, Reticent Healthcare Workers, and the current H1N1 Swine-Flu Pandemic

Medscape is a popular site for medical professionals. They run a closed forum for doctors and nurses. There should be no surprise that some discussion concerns the response of the medical community to the current pandemic crisis. A few recognized authorities have posted matter-of-fact pieces about the importance of doctors and nurses getting immunized, so as not to spread influenza to vulnerable patients.

You'd think that doctors and nurses would be almost unanimous about getting the flu vaccine to ensure they don't inadvertently expose vulnerable patients. You'd think they'd expect their peers to roll up their sleeves for the good of the profession's image as well as sound patient care. You'd be wrong.

It's a closed forum, so I won't reveal the words or screen names of other participants. If you happen to be a medical professional, however, you can join in the fray here:

To summarize, the discussion starts with a video clip of Paul G. Auwaerter, MD discussing New York State's recent decision to require healthcare workers to receive this year's influenza vaccines, and urging his peers to roll up their sleeves to get on board, even those not legally required. It's here:

(for access to this, you just need to register for the site. It's only the professionals' area you have to be validated to join).

The professionals' closed debate about this video clip begins with 18 comments--all decrying the vaccine, the concern about pandemic, and the "state tyranny" of requiring physicians to receive it to continue seeing patients. This is unanimous condemnation of doctors being expected to put up with a tiny inconvenience and a remote personal risk in order to protect their own patients. So, I contributed the following:

#19 of 28, Added By: SteveMDFP, MD, Family Medicine, 9:55PM Oct 07, 2009

The comments here currently are quite hostile to the idea of mandatory immunization for healthcare workers. I have to disagree with a couple of issues, but agree on one significant point.

Required immunizations for the public would be a violation of rights. For a licensed healthcare worker, however, the question is different. Retaining the PRIVILEGE of legally treating patients could reasonably include ensuring that these licensed individuals have minimized the possibility of transmitting influenza to frail individuals. There may not be double-blind placebo-controlled clinical trials to prove that immunizing healthcare workers reduces risk to patients, but it's not hard to make the argument based on current (imperfect) knowledge. I think the New York State decision is a bit intrusive, but not entirely unreasonable.

I do have a concern about the H1N1 vaccine, however. I think trace mercury or tiny amounts of aluminum pose no credible risk. However, the possible use of squalene as an adjuvent in this somewhat novel vaccine may reasonably raise serious concerns. "Gulf War Syndrome" has been epidemiologically linked to troops receiving the military anthrax vaccine (which contained squalene). Injected squalene causes an auto-immune syndrome in lab animals. If squalene is used in this vaccine, there is no possible way to demonstrate that it is "safe" from causing an autoimmune syndrome that may not become apparent for months, and could cause devastating, progressive injury for years. See:
Antibodies to squalene in Gulf War syndrome.
Exp Mol Pathol. 2000 Feb;68(1):55-64.

Personally, I won't be taking the injected H1N1 vaccine, unless I'm certain it does not contain squalene. I would not hesitate, however, to take a FluMist version.
You'd think pointing out that the thrust of Auwater's encouragement to be vaccinated is all about protecting their own patients would shift the tone of the remaining debate among my peers. No, more direct language is needed. The next response asserts that physician transmission of influenza is vanishingly rare, and that the respondent has never taken the vaccine and never transmitted influenza virus to a patient. Good golly, high school health students know you don't have to already be sick to be able to pass respiratory viruses around. But sometimes even experts need to be reminded of the basics. My reply:

#21 of 28, Added By: SteveMDFP, MD, Family Medicine, 2:59AM Oct 08, 2009


See also extensive discussion here:!comment=1

You write, " [essentially, two decades and half a million personal encounters did not result in a single transmission of flu, and xxxx doesn't take the flu shot. --- actual words removed for confidentiality] ..."

I'm sorry, this just doesn't hold up. Influenza is roughly the most contagious disease known. Maximum viral shedding begins *before* onset of symptoms. Most infections are undiagnosed, and some are experienced as simple colds or are totally asymptomatic.

Published studies do demonstrate reduced risk of patient death when health care workers get the flu vaccine. It's entirely plausible that you had asymptomatic influenza many times and exposed dozens or hundreds of patients, several of whom may have then died of pneumonia without "influenza" being diagnosed in them or you, or anyone else. Or perhaps the number of avoidable influenza-related deaths from your work really is zero, but maybe the first avoidable nosocomial death will be this January in a patient of yours. If a doctor taking flu shots for a whole career prevents only a single avoidable death in a vulnerable patient, would that not be plenty reason to take the vaccine every year?
That link refers readers to another discussion thread, in which the originating essay calls physicians who refuse immunization as "Dumb Asses" because of their ignorance of the issues at hand and needless risk to their own patients. Most physicians responding denounced the indignity and outrage of such ungracious language and disrespect of peers.

I am reminded of Semmelweis, who discovered that hand-washing by obstetricians could save the lives of ten percent of women who had deliveries performed by doctors. His evidence was incontrovertible. Physicians' resistance to the innovation was stubborn and unreasoned. In the face of ongoing needless patient deaths and irrational obstinacy by his peers, Semmelweis called his disbelieving colleagues murderers. This is a tad stronger than "Dumb Ass." Today, he is regarded as one of medicine's truly great heroes and pioneers.

Finally, one contributor pipes up that we should, indeed, act to avoid infecting our patients, and protect their health, even if there's a very small personal risk by taking the vaccine.

You'd think that reminding a doctor of the biology of disease transmission and the vulnerability of some of our frail patients would settle the matter. You'd be wrong. The original respondent to my first contribution then casts doubt about virus shedding during infections, and on the existence of influenza infections that cause no obvious illness in some individuals. Sigh. I do teach medical students, and I expect such questions from some of them. Not from a highly-experienced peer. So, I was forced to carry coals to Newcastle:

#25 of 28, Added By: SteveMDFP, MD, Family Medicine, 7:47AM Oct 09, 2009


There is nothing new or esoteric about the knowledge that infections with influenza virus can display a range of symptoms from severe to asymptomatic, including viral shedding by asymptomatic individuals. Reference to these issues is here:

That you or I have had influenza SYNDROME rarely does not mean we haven't had influenza INFECTION many times.

You simply cannot know with confidence whether you have had an influenza infection in any given winter, or whether you have exposed frail patients. There is no way to know whether you've infected a patient who then develops pneumonia 5 days after the last time you saw him/her.

You want more than one peer-reviewed published study to demonstrate that health care workers getting influenza vaccine reduces death rate of patients? Most of what we do as a matter of clinical practice standards has no such level of support. Where's the evidence that performing a physical exam on a hospitalized patients improves outcomes? You won't find such a study. But what would you think of a doctor who simply never uses a stethoscope or touches a patient, or looks at a patients body?

Similarly, can you find a randomized controlled trial to show that wearing sterile surgical gloves for surgery reduces post-op infections more than simple handwashing, with surgery done with bare hands? I'd be shocked if you could find a study to support this. But what would you think of a surgeon who did surgery with bare hands?

The rationale for expecting health care workers to receive influenza vaccine is straightforward and commonsense. The risk or inconvenience of this is far less than the risk of seeing patients with infections. The potential hazard to frail patients from unimmunized healthcare workers is substantial, in the minds of the best-regarded clinicians who have examined all the available evidence.

The burden of proof here should be on those who say health care workers needn't be expected to be vaccinated (absent a decent contraindication).
Sigh. The collective response is then two more posts citing side effects of the vaccine and envisioning doctors being crippled en mass. Sigh. As if these were syringes of plague, not vaccine. These are doctors. I swear, the vetting to get access to these forums is rather rigorous. This is like having to introduce an SAE-certified auto mechanic to an exotic instrument known as a socket wrench. Yes, socket wrenches can hurt you, the ratchet mechanism could fly apart and a fragment could hit you in the eye. Your arm could slip and hit a hot exhaust pipe. It could fall and hit your toe. People have died from using socket wrenches, I'm sure. But auto mechanics use them because its part of the job they signed up for. Sheesh. Then my colleagues cite a lack of randomized, controlled trials to prove that influenza vaccination of doctors saves patient lives. My reply:

#28 of 28, Added By: SteveMDFP, MD, Family Medicine, 2:44AM Oct 11, 2009

This is misleading. "Lack of evidence of efficacy is not evidence of lack of efficacy." Readers would do well to look at the actual article referenced:
Influenza vaccination for healthcare workers who work with the elderly

There is published research showing a significant decrease in patient mortality when healthcare workers are immunized. See:
Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients.

Again, this is far stronger evidence than we have for supporting other clinical practice standards. Can you find comparable evidence to support wearing sterile gloves for surgery instead of just a hand scrub? But what would you say of a surgeon who only washed his hands, and then performed surgery with bare hands?

Level of evidence ethically necessary to prescribe a treatment is different from the level of evidence ethically necessary to mandate a practice standard among practitioners. It's unnecessary and unethical to insist on such a level of evidence before implementing a standard of professional practice.

Level of risk to a practitioner in being immunized is infinitesimal in comparison to the level of risk suffered by a patient cared for by a practitioner shedding influenza virus. We really should try to kill as few patients as possible, and insist that our peers do likewise.

Sunday, May 10, 2009

India's 'Untouchables' and the West's Addicts

The "untouchable caste" of India, the "Dalits," are culturally in much the same position as addicts in the West. They are commonly viewed with fear, disdain, hate, and revulsion. Their lives, human value, and sufferings are typically discounted. For example, when a Dalit dies, the event is often treated with little concern, a mere footnote on society's functioning.


Some in India have come forward to address the plight of the Dalits. Progress has been made, but at a slow pace. Mahatma Gandhi championed this cause decades ago. He successfully freed India from British colonial rule, but made only small progress in addressing the plight of the Dalits. Political and legal problems, even on a global scale, are easier to fix than cultural attitudes.

If one imagines a service program designed to help the plight of a population of Dalits in India (perhaps an educational, nutritional, or legal aid program), one can envision predictable issues which need to be considered.

The biggest issue would be staff attitude. Many or most might be expected to approach their duties from an enlightened stance, having examined and worked through their prejudices. But others would be expected to approach their employment with a residual attitude of superiority, condescension, and even hostility. The obligations of duty of care and other ethical standards can be forgotten in the face of such prejudice.

A rational service program would have to be carefully designed to detect poor staff attitude or poor program policies and procedures, with vigorous mechanisms for correction. The centerpiece of such quality control would need to be systems for concerns and grievances of clients to be solicited, listened to carefully, and addressed with respect and compassion.

It would be utterly inadequate to require client grievances to be submitted in writing; this is difficult for many on psychological grounds, and often impossible on literacy grounds. It would be utterly inadequate for grievances to be heard first only by the supervisor of an employee. In any organization, supervisors and subordinates ALWAYS develop interdependent relationships which hamper the freedom of a supervisor to address client grievances objectively. Superiors and subordinates generally anticipate a long relationship in which easy relations are essential to be able to work productively and effectively. In essence, there can be a real conflict of interest for any supervisor to be the primary mechanism of hearing of grievances by any client in ANY service organization.

It would be utterly inadequate for such quality control measures to depend upon client questionnaires being distributed and handed back to program personnel. Any client feeling fear (rationally or irrationally), would not want that questionnaire to be seen by program personnel, and would tend to self-censor or "whitewash" any concerns in any such document.

A rational system would have to be designed with an independent ombudsman or "office of the client advocate" who could hear grievances in any form and investigate, with resulting recommendations to be addressed at high levels.

Most organizations with active internal quality control mechanisms employ "exit interviews." Most commonly, exit interviews are given to employees leaving a business as a way to raise and address problems which current employees may not feel free to bring up, for fear of retribution. The same kind of process can, however, be employed with clients of service organizations. These need not necessarily be face-to-face interviews with every exiting client. The process could be carried out by phone or written questionnaire, and might be done with only a statistical sampling of clients. As with exit interviews for employees, an effective approach would not be to question only those leaving in good standing, but also those who are fired or quit.

Any kind of service organization without vigorous quality control procedures in place can be expected to suffer characteristic aggravations. Clients who do not feel able to have grievances and concerns listened to within organizational channels will tend to carry their concerns elsewhere. Such unanticipated and less-effective channels can include public word-of-mouth, stories in the press, reports to outside governmental authorities, malpractice suits, and even criminal complaints to law enforcement. When one sees a service organization having clients raise concerns in unusual venues, such as within advisory councils, the primary lesson to be gleaned, I think, is that effective internal quality control measures are deficient.