A Letter to Parents Concerned about Vaccines

Below is a letter I have written to parents who are hesitant about giving vaccinations to their children.  I don’t know who it will convince, but I needed a respectful and informative way to follow up with parents who expressed concerns or declined vaccinations, and this is what I now share with them after such visits.  This is written not with the goal of exhaustively proving the case for vaccine safety and efficacy, which would require a longer treatise, but simply to address a few major points trying to address the sources of such parents’ fears and doubts about vaccines.

Dear concerned parent,

I understand that you have concerns, doubts and maybe fears about immunizations, and that as a result you may have chosen not to immunize your child. This is an emotional topic, and I know it is sometimes hard to even articulate exactly what those fears are—you may just feel uncomfortable about them. I appreciate the opportunity to share my perspective with you, and I commit to discuss this with respect for your rights and responsibilities as a parent. But I would like to share my perspective with you in hopes that it will help you to think about immunizations.

Here in the 21st century, many of us have an inherent suspicion of anything synthetic or artificial and are trying to get back to what is naturally healthy. We know that processed foods are bad for us and whole foods are much better. Even though I am a physician, I share those biases. Further, while we may rely on the health care system for certain needs, we tend to have less than full trust that the health care system is really always oriented for our best interest. We also tend not to trust the government, and since immunizations are controlled and pushed by both government and giant companies, they are a natural object of suspicion for us. Plus, there is much written on the Internet, and it is hard to know who really has the correct interpretation of the facts and often even what the facts really are.
Regardless of the reasons, once fear or mistrust has developed, it is very hard to overcome. You may read a lot of positive information about vaccines and still feel uncomfortable. As you think about vaccines more, you may develop more specific questions that you need answered. But I want to tell some history behind the development of two particular vaccines.

The first known immunization was with smallpox in China in the 15th century. Smallpox was a disfiguring and frequently deadly disease present throughout human history. The Chinese developed methods where dried scabs from a smallpox patient would be applied to a patient who had not had smallpox; the inoculated patient would develop a much milder form of smallpox and would become immune to the disease. This type of immunization was later introduced into England and North America in the 1720’s. Later in the 1760’s it was observed that dairy workers would never get smallpox, and it was postulated that they had immunity to smallpox because they had already had cowpox, a related disease that is much milder in humans than smallpox. In the 1790’s Edward Jenner developed a method to vaccinate humans with the cowpox virus to induce immunity against smallpox. During the 1800’s the virus used for immunization against smallpox was changed to vaccinia, another similar virus. Smallpox was eliminated from the United States by 1897 and worldwide eradication was finally accomplished by 1979. For most of us, smallpox is now simply a vague and distant historical fact, rather than the terrorizing disease it once was.

The reason I recounted this story is to remind us that immunization is not quite as new as we tend to think, and that horrible diseases can sometimes be completely eliminated through immunization. Every one of the vaccines we use today has an interesting story that could be helpful to understand, but there is one other story I’d like to tell in this letter, that of the MMR vaccine.

The MMR vaccine is a three-in-one immunization that provides protection for measles, mumps and rubella, but I will focus on measles. Measles in its current form has been present since about 1100 AD. Measles is one of the most contagious viruses known to man; nine out of ten nonimmune people in a room with a measles patient could be expected to get infected. Measles causes a high fever, a rash, and many possible complications including diarrhea, pneumonia, or brain infections. In the United States, measles may kill about 3 in 1000 people infected, but in developing countries it may kill 20-30% of those infected. The measles virus was first isolated in cell culture in 1954 and the first measles vaccine was licensed in 1963. There were several early versions of the vaccine including an inactivated (killed) virus and a live attenuated (i.e., weakened) vaccine. There were also several more weakened viruses studied, but by 1968 an even weaker live attenuated version was licensed, and this version has been used in the United States ever since. In 1978 the CDC announced a campaign with the goal of completely eliminating measles from the country, and by 1981 the number of cases annually had dropped 80%. New outbreaks of measles in 1989 prompted a recommendation for a second or “booster” dose of MMR to increase immunity to nearly 100%. Measles was virtually eliminated from the USA by 2000, but unfortunately, that is not the end of this story.

In the case of vaccines, although there may have always been some level of fear about them, those fears were multiplied when, in 1998, Dr. Andrew Wakefield published in the Lancet, a prestigious British journal, a study proposing a link between the MMR vaccine and autism. The study had a huge effect on public opinion and has given a great deal of fuel to the fire of the ongoing fears and doubts of many about immunizations. However, it turned out that Dr. Wakefield’s research was fraudulent, which ultimately resulted in the loss of his medical license and the retraction of his publication by the journal. Since then, multiple studies of millions of vaccinated vs. unvaccinated children have repeatedly failed to find any association between MMR and autism, but the fear lives on in spite of that. It turns out that doubt is even harder to eliminate than measles itself.

The Disneyland measles outbreak of 2015 has shown us that, when the number of children who are vaccinated drops below some threshold, some vaccine-preventable illnesses can resurge in the population. So in reality, every time a family chooses not to vaccinate a child, the risk of vaccine-preventable diseases actually rises for the entire community.

Can side-effects occur with immunizations? Absolutely, but serious side-effects are exceedingly rare. Some people have written their experiences on the Internet to discourage others from immunizing their children, but while those stories may foment our fears and doubts, those individual horror stories often contain many false assumptions and draw many inaccurate conclusions. It is very easy to stir up fear with even incomplete or inaccurate information, and very hard to eliminate fear once it exists.

Here are the facts as I see them about modern immunizations:

  • Immunizations have resulted in the elimination or dramatic reduction of many childhood diseases.
  • The illnesses that are preventable by vaccines range in severity from “major inconvenience and expense” to disfiguring and deadly, but are mostly forgotten because most of us have never seen cases of those diseases.
  • To maintain the benefits of immunizations, they have to continue in use by a certain percentage of the population as long as the virus continues to exist anywhere in the world. Once usage drops below some level, a vaccine-preventable disease can make a resurgence in the population.
  • Although doubt is very difficult to dispel, there is overwhelming evidence of the extremely high safety of vaccines, making their risks very low versus benefits that are very great.

I hope this is helpful to you as you consider whether to immunize your child. I believe that immunizations were perhaps the single greatest advance in health care in the 20th century, but we have to continue to use them to continue to reap their benefits.

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The gospel, racism, reconciliation, and America

I had the experience today of participating in Shiloh Missionary Baptist Church’s dedication of their new building, and then on a whim after that service, my wife and I went to the theater to see Dinesh D’Souza’s film “America.” The first experience was profoundly moving, and the second was very affirming in a powerful way when juxtaposed with the first, for reasons I’ll explain.

Shiloh Missionary Baptist Church is a black church that has met in the facilities of Grace Presbyterian Church, my church, for the past seven years. My church is mostly white, although we have a smattering of other races sporadically represented. During those seven years our church has lived harmoniously with Shiloh, meeting at different times of the day. We’ve had a few events and services together. Of note, we never charged (or even permitted) Shiloh to pay anything for the use of the facilities. There was never any dissension in our fellowship about this, or really ever any discussion: it was assumed to be the right thing to do.

I wept through much of the dedication service today. I wept when Shiloh’s pastor, Dr. Raymond Franklin, thanked Grace for allowing Shiloh to freely use the facilities for seven years. I wept when I heard about Shiloh’s rich 130 year history in Alexandria. I wept when Bob Vincent described how God first bound his heart together with that of one of the other black pastors, Freddie Banks, through a prayer time together where Bob unexpectedly found himself praying like a black preacher and Freddie’s tears covered Bob’s back in a kind of baptism. I wept as our church’s worship team sang two songs and our pastor, Bob Vincent, preached as the guest pastor. As my friend Dirk Margheim said, “our pastor did us proud.” He expounded on Matthew 16:18:

And I also say to you that you are Peter, and on this rock I will build My church, and the gates of Hades shall not prevail against it.

Bob pointed out that gates are defensive structures. He reminded us that when the church is on the defensive, she tends to lose, but on the offensive, she cannot be resisted. He used this as a charge to Shiloh to not sit back and relax in their new building, but to reach out to the community around them.

Near the end of the service, Pastor Freddie Banks stood up and said, “no other church in Alexandria would have done what Grace did for you.” I can’t remember if he said “no other white church,” but that’s what I thought he meant. I don’t know if he is right or wrong about that, but I think that was how he felt. Black and white churches are very far apart in so many ways; I hope he wasn’t right, but he could be. There were at least 12-15 other black pastors present for this dedication service. Ours was the only white pastor, and we were the only white people.

As we closed out the afternoon with a meal together in their new fellowship hall, I realized how much I was going to miss them. I thought we needed to look for ways to cooperate together in ministry.

Now for the second half of this story. As my wife and I headed home after the service and meal, we decided to see what was at the theater. We ended up going to Dinesh D’Souza’s film, “America,” mainly because it was starting in ten minutes. We knew almost nothing about it. We didn’t know that we were going in to a documentary-style, narrated film with a strong political message. (We had shunned his previous flick, “2016: Obama’s America,” and forgotten all about it.) Basically, this film seeks to refute the growing anti-American movement that has recast our nation’s history as overwhelmingly evil: we stole this country from the Native Americans and the Mexicans, we stole the lives and work product of the slaves, the rich only get rich on the backs of the poor, America is an evil imperialistic nation, etc. He affirms the wisdom of the constitution as providing the basis for the ultimate abolition of slavery, gives a defense of capitalism as the best means of egress from poverty of any secular system ever created, and then gives us some chilling warnings about the threats to our freedoms today.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the pursuit of Happiness.

So today I experienced a worship service that both demonstrated the ability for the races to reconcile while also demonstrating how far apart the races can still remain, and watched a film that showed our nation’s troubled past, the amazing freedoms and opportunities available in this nation which are unique in the world’s history, and the dangers that still exist to those freedoms. We’ve come very far, yet have so far to go. Both settings served as powerful reminders to me of the grand stage of God’s work in his people: we have been saved by the sacrifice of Christ on the cross for our sins; we have been set free, but we struggle to work out that freedom in the day to day world; we still face great enemies in our own flesh, in the world’s system, and in the Enemy of our souls who would devour us if he could.

I don’t know how much longer our freedoms in this nation will last, or how long prosperity will be the rule rather than the exception. Both seem dangerously precarious. According to some, both are already gone, or perhaps never existed, but I don’t think people who claim such things really know what kind of poverty still prevails throughout most of the rest of the world. I do know the outcome of the spiritual battle: Christ has died, Christ is risen, Christ will come again. But days like today make me say all the more, “Thy will be done on earth as it is in heaven.”

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TigerDocs Keynote 2014

I was honored to give the keynote address at the LSU Family Medicine Residency in Alexandria, LA last night. I was program director there from 2005-2013. ~~~

I want to thank the graduating class for asking me to speak at their graduation tonight. You guys have worked hard for the past 3 years and you have really contributed in many ways to making the residency better…even if you gave some of us a few more gray hairs in the process. Each graduating class always has a certain personality, and yours has been particularly creative and energetic. And as far as giving this keynote, I’ve listened to a few of them over the years, and I can tell you it’s not easy to make a great speech. My impression is that what you really want is a little bit of inspiration in a short enough package not to keep you too long from what you really came here for tonight, so that’s what I’m going to try to deliver.

What I want to talk about is our healthcare system and where we fit into it. Let’s face the fact that our health care system today is struggling to redefine itself. Americans are proud of their healthcare system and by and large sneer at other systems around the world, yet we all know it is so dysfunctional in so many ways that things simply have to change. I think the reasons so many Americans love our system is because of advances in certain fields, and the rapid access to life-saving care from some of our biggest killers: like intensive care of the sick and very premature newborn, advances in cancer care, the way cardiac catheterization has revolutionized treatment of heart attacks, and advances in trauma care. And another huge area that doesn’t get enough recognition is immunizations. Each of those areas has seen such advances in the last 20-30 years that they have probably each individually helped to increase the lifespan of Americans. But these areas are really islands in a stream that is confusing if not downright impossible for the average American to navigate and the fact that, in spite of all those advances in care, many Americans have difficulty finding (or affording) reliable access to quality primary care, where many of those emergency types of problems can be prevented. So this graduating class is entering a field where they are desperately needed, and you are joining the workforce on the side of the equation that most needs improvement.

So what are the problems with our primary care delivery system, and how is our system going to fix itself? Without wading into any hard data, I’m going to touch on broad aspects of these questions from two perspectives: the needs of patients, and the needs of the primary care physicians themselves. In many ways for many years, these two sets of needs have often competed with each another, with one or the other sets of needs sometimes winning out over the other, but with the two seldom being well balanced.

• Patients need access to their physician and they need care that is timely, competent, efficient, and cost-effective. Good communication is essential, and empathy and compassion facilitate the trust that is needed for the relationship. But when patients’ needs are considered to the exclusion of the needs of physicians, without solving any other problems that make our system dysfunctional, you end up with physicians who are stressed out, overworked, and burned out.
• So on the other side of this equation, physicians need decent hours, they need enough sleep, they need a reasonable amount of financial reward for their labors, and they need to be able to manage their stress. They need time with their families and they need some healthy recreation. But when physicians’ needs outweigh the patients’ needs, you end up with a system of care that is organized around the physician, and you end up with limited hours of access, long wait times to get appointments, slow communication, and so on.

I think in the older-school style of practice, the needs of the patient were paramount and the needs of the physician were considered virtually not at all. The problem is that many of these physicians really spent very little time with their families. You have a lot of kids who resented their parents’ medical practices. I think the current generation of physicians really has rejected the older model; they value time with their families and they are trying to find ways to limit the intrusion of their medical practice into that time. But I think in many ways the pendulum has swung too far that way, and for a sustainable solution we have to find ways to balance the two needs so that both are met.

So what do patients tend to experience today in their encounters with primary care?
• Before they ever choose a PCP, it’s hard for patients to tell who really provides the best care. They mainly go by reputation in the community, but the larger the community, the harder that may be.
• It may be hard to find a PCP who is accepting new patients.
• Once they get in, it may be hard to get appointments when they need them.
• Patients often find it hard to afford their visits, insured or not.
• Patients may not be able to afford their medications, or to navigate insurance requirements for them.
• Anytime the patient gets referred to any other provider they stand the chance of their care getting more fragmented and difficult to manage.

From the PCP’s standpoint, their problems look like this:
• Flat or decreased insurance reimbursement
• High costs and inefficiencies associated with using an EMR
• Pressure to see more and more patients resulting in less time spent with each patient
• Ever-increasing paperwork required for prior authorizations
• More and more time spent appealing insurance denials, not to mention time spent trying to keep up with the constant stream of new medical knowledge, changes in reimbursement rules and new CPT codes every year (and all of this with the move to ICD-10 looming somewhere in the future).

Our system is undergoing such rapid change due to so many pressures that the practice of medicine today hardly resembles anything our forefathers would recognize. Hippocrates would shudder at the distraction created by the computer screen in our visits. The computerization of medicine, like it or not, is one of the hallmarks of modern clinical practice. Has it been a good thing, or a bad thing? All emotional reactions aside, I think we can say there have been some harmful effects, and many of the supposed benefits haven’t been realized. In many cases we spend our time entering the data into a computer, never to see it return in any useful form. But the government has forced us to do it, and like it or not, we can’t change it.

Or can we? Pressures like this one are increasingly causing physicians to look for alternative practice models that will enable them to restore control of their practices and lives. One thing is clear: many doctors are not happy in the current environment and are trying to find ways to become happy in their practices again.

Now I don’t have to tell this audience why primary care is still a wonderfully rewarding profession. (Or maybe I do after talking about all those problems! I’ll remind you as we wrap up in a few minutes.) But with system pressures like those, is it any wonder that PCP’s are seeking alternative practice models? That stream of new models started with a trend toward outpatient only care and leaving inpatient care to hospitalists, and has continued on from there.

• Many more physicians are now seeking employed positions versus owning and operating their own businesses. This gives the promise of being free from administrative headaches, to “just focus on practicing medicine,” (leaving the business aspects to others). This works out pretty good for a lot of people, but the problem is the loss of control, and many physicians find the pressure to see more patients really increases. From what I’ve seen, the larger the system the physician is employed by, the more loss of control the physician tends to experience, and the more pressure to see volumes of patients.
• Another approach would be to eliminate third-party payors altogether and instead take money only directly from patients. This is the so-called “direct care model.” Some physicians sought to charge very high retainer fees leading to the moniker “concierge medicine,” but the more “blue-collar variety” with more affordable fees has helped many physicians break free from the bureaucracies of Medicare and insurance companies, reduce their patient loads, and become more accessible to their patients. What’s not to love about that? Although this model is still fairly young, some direct care practices have been around for more than 10 years, so it may have some sticking power. (Many of these practices advocate to their patients to buy very high-deductible, catastrophic type of insurance policies and to only use them in cases of real emergencies, and they point out that this is more akin to how we use other types of insurance, such as homeowner’s insurance and car insurance. We don’t use those types of insurance for regular maintenance and minor repairs on our homes or cars, nor should we use health insurance for common, predictable needs.)
• But it isn’t only physicians and patients who are frustrated with the insurance system. Employers are looking for creative ways to manage the healthcare costs of their employees. Although it’s easy to imagine that some employers might want to try to short-change their employees and shift more of the costs of health care their direction, many smart companies are figuring out that the healthier their employees are, the happier and more productive they will be. So this is a case where making good health care more accessible and less expensive for their employees can really help with the morale and productivity of the workforce. One of the products of this thinking is a new model that doesn’t really have a name yet, and for now I’ll call it Employer-Based Primary Care. Here the employer directly pays for and manages the primary care delivery to its employees. This is a very new model that a few of us are trying out, and although the early results look pretty good, we’ll have to stay tuned for a few years to see how this one turns out.
• But in spite of all these (and other) varieties of practices that have proliferated, I’m happy to tell you that traditional primary care is still intact. Just yesterday I talked with one of our graduates, Dr. Lynda Odom–who is here tonight–who is settled in a traditional practice at a small hospital, seeing patients in her office, taking call in the emergency room, seeing her inpatients, and caring for patients at the nursing home. She’s happy as a clam! So there are many models out there, from old to new, that can work well for you as doctors and for your patients.

Primary care is absolutely essential and what I want to encourage this graduating class about is that it is still possible to find highly satisfying and rewarding ways to deliver primary care, and that there are new models out there that may help to strike a better balance between the needs of the patients and their physicians than was possible in the past. There may be other, better ways yet to be discovered that you all will play a part in creating.

And there are some aspects of high quality primary care that will never change, so as I close tonight I’m going to remind you of something I told this graduating class as they began residency. Probably the most important skill of the primary care physician is that of being an empathetic listener. Listening to your patients both helps you to understand your patient in the ways that you need to, and helps establish the connection between you that leads to mutual trust. When patients talk about a bad experience with a doctor, they often say “she didn’t really listen to me” or “he just really didn’t care.” Also, 90% of your diagnosis comes from the history and physical examination, and most of that comes from just the history itself. I have a patient whom I have only seen once so far, who came in as a new patient after a hospitalization for a series of problems. I listened carefully to her symptoms and reviewed her hospital records and realized there was an abnormal finding on a CT scan that correlated with her symptoms, but hadn’t yet been explained. Ultimately that led to the patient being diagnosed with stage IV colon cancer. I still haven’t seen that patient back in the office again, but I’ve talked with her on the phone a few times and she’s grateful for the part I played which really only involved listening and a little attention to detail.

However else our models of care change, the basic skills of a good PCP will always remain essential. You all have learned them well. You are ready to jump in and begin changing what will be many thousands of lives across your careers. I know you may not feel very ready right now, but you are more prepared than you realize. Whatever other challenges come, remember the basic lessons you learned as a resident, and listen carefully to your patients. I am proud of each one of you, of who you are, of what you have accomplished, and of what you’re going to do in the world. Thank you for inviting me back to share with you tonight, and God bless you.

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