Archives for November 2015

Shetal Shah, MD, FAAP

ANTI-VACCINE COMMENTS HARM PUBLIC AND PRIVATE HEALTH

For pediatricians, it was déjà vu all over again.

Almost 6 months since a measles epidemic that began in California ended, sickening almost 150 – mostly un-immunized people with a disease that was eliminated in the United States over 15 years ago, three years removed from a whooping cough outbreak in Washington State and after another record year of California whooping cough cases, the public health utility of vaccines is again in the news.

As presidential hopefuls continue campaign efforts to earn our trust, it is worthwhile to remember what happened earlier this year when they shared a nationally-televised stage. Comments made by high-profile political figures about the safety and timing of vaccination again brought the issue of immunization safety to the forefront of public interest.

Then last month, an article in the Proceedings of the National Academy of Sciences (partially funded by the National Autism Association and Autism advocacy group SafeMinds) found no autistic behaviors in monkeys given vaccines. Microscopically, the brains of these animals also did not resemble those of autopsy specimens of children who had autism.

As a pediatrician who cares for sick children and works to keep healthy children healthy, doubt about vaccine safety is concerning because it nurtures misinformation about immunization, leading to potentially even more outbreaks of vaccine-preventable disease across the country.

As both a physician and a parent of two fully immunized children, I am disturbed about the hijacking of medical fact for political purposes and its interference with our partnership with parents in maintaining their child’s health.

Vaccines are safe and do not cause autism. A 2007 study published in the New England Journal of Medicine found no association between vaccines, the mercury-based preservative thimerosal contained within them and autism after testing over 40 different neuropsychiatric measures. Nine studies over more than a decade and sponsored by the Centers for Disease Control (CDC) – found no link between autism and immunization.

The Autism Self Advocacy Network states that perpetuating claims of a link between immunization and autism distracts “from real and pressing issues facing the autistic community.”

The Vaccine Schedule is safe, well tested and the only scientifically-based regimen to administer vaccines safely and effectively. The landmark 2013 Institute of Medicine report entitled, “The Childhood Immunization Schedule and Safety,” found “no evidence that the schedule is unsafe.” Any other calendar of vaccination should be considered experimental by traditional methods of scientific rigor.

Vaccines save lives. Last year the CDC, reported childhood vaccination prevents 322 million cases of disease (roughly the US population), 732,000 deaths (approximately the population of Detroit) and saved over 1.38 Trillion Dollars (roughly the Gross Domestic Product of Spain) in healthcare costs over the first few years of life. It is precisely these facts that led the Institute of Medicine to declare vaccines the “most effective and safe public health intervention to prevent serious disease and death.”

The CDC named vaccination one of the ‘Ten Great Public Health Achievements’ of the last century. The Society for Pediatric research, in partnership with 4 other leading child health organizations including our 60,000-member American Academy of Pediatrics, highlighted ‘Life saving Immunizations’ as one of the ‘7 Great Achievements of Pediatric Research.’

Vaccination prerequisites, such as requirements that children receive certain vaccines prior to school entry or that health care personnel are current with immunizations are not a political issue. These requirements are the only scientifically-tested means of attaining immunization rates which are high enough so those who are medically incapable of receiving vaccinations – such as children being treated for cancer – are also protected via herd immunity.

While the percentage of vaccinated children required to achieve herd immunity varies with each disease, the policy evidence clearly indicates that relaxing such standards, such as creating state-based “philosophical exemptions” to immunization, encourage outbreaks of vaccine-preventable disease.

Unfounded concerns over administration of “too many vaccines,” has potentially contributed to lower than target goals for vaccines against tetanus, whooping cough, 2 types of Hepatitis, several bacterial infections, infectious diarrhea, cancer-causing strains of Human Papilloma Virus and influenza – the most common vaccine-preventable disease. Low rates of vaccination coverage for these infections prevent the medical community from fulfilling the full public health promise of immunization.

Pediatricians and parents want the same things: the best care for their children and to protect them from harm. Immunizations given at the right time are one part of a national child health strategy that works best when parents’ questions about vaccination are answered by pediatric physicians and we all cooperate in the shared goal of keeping your child well.

As a scientist and a researcher who is actively seeking the cures of tomorrow, I can only hope my efforts have the health impact, success and safety of vaccines. Blanket statements by public figures questioning immunization safety gradually decay the public trust they seek to earn, and perpetuate a reprehensible practice of politicizing scientific inquiry.

Dr. Shetal Shah, MD FAAP is Secretary and Legislative Chairman of New York State (District II), Chapter 2 (Long Island) of the American Academy of Pediatrics. The views represented are his own. Follow him on Twitter @NICUBatman.

Gopi Desai, MD

WORKLOAD, NOT HOURS, CONTRIBUTE TO RESIDENT FATIGUE
Generation R: The Rushed Resident

As a medical student, I recall senior physicians commenting how current residents have it easy because of strict, 80-hour workweek limitations. These senior doctors reminisced about their training and described stretches of 2-3 days when they did not leave the hospital. As I started residency, I thought to myself, “This can’t be so bad,” compared to working 72 hours consecutively.

In an attempt to ease my anxieties I convinced myself that while residency would be challenging, it would be manageable because we had laws to limit the amount we worked.

Then reality set in – residency was far from easy. At first, I figured there were growing pains and once I became more efficient and confident, this “paradise residency,” senior doctors described would magically appear.

Now as a 3^rd year resident I have come to realize that this paradise does not exist.

My generation of trainees is challenged with cramming an increasing amount of work into a shorter amount of time. From 1990 to 2010, annual admissions to major teaching hospitals increased by almost 50%. In the same time period, residency positions grew by only 13%[1]. While physician extenders such as nurse practitioners and physician assistants have mitigated some of this increase – there is no doubt that overall workloads have increased.

As our nation collectively focuses on decreasing healthcare costs, length-of-stay is decreasing, leading to an increased turnover of patients in the hospital – many of whom have complex medical histories, complex co-morbid conditions and higher levels of acuity than even a decade ago.

Further, each of these admissions and discharges carries an exponential increase in the amount of resident-generated paperwork, much of which does not improve care but results from compliance with ever-changing insurance and medical-legal concerns.

This translates to increased volume of resident duties with less time to do it all. To cope with these realities, residents have evolved to become more efficient and to multitask. This inevitably sacrifices certain areas of medical care and training, by detracting from time that could be spent with patients or in didactics[2].

The issue of resident fatigue and burnout is not a simple one. Decreasing the amount of time spent in the hospital, with the aim to reduce medical error and resident fatigue, is a good start. However this is an insufficient intervention to tackle the complex problem at hand. Studies regarding the benefits of reduced resident work hours are inconclusive[3]^,[4]. On the other hand, studies that reduce resident workload have been associated with improved resident satisfaction, increased duty hour compliance and increased participation in educational activities[5]^,[6].

As the medical field begins to take more seriously the issues of resident burnout and fatigue, one thing is clear: it is the workload, not the work hours which needs to be addressed.

Dr. Gopi Desai, MD is a third-year pediatric resident at Weill-Cornell Medical Center and NY Presbyterian Queens and a member of the New York State (District II), Chapter 2 (Long Island) Resident Committee of the American Academy of Pediatrics.

 [1]Goitein L, Ludmerer KM. Resident workload-let’s treat the disease, not just the symptom. JAMA Intern Med. 2013 Apr 22;173(8):655-6.

[2] Block L¹, Habicht R, Wu AW, Desai SV, Wang K, Silva KN, Niessen T, Oliver N, Feldman L. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013 Aug;28(8):1042-7.

[3] Choma NN, Vasilevskis EE, Sponsler KC, Hathaway J, Kripalani S. Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0. JAMA Intern Med. 2013 May 13;173(9):819-21

[4] Sen S, Kranzler HR, Didwania AK, Schwartz AC, Amarnath S, Kolars JC, Dalack GW, Nichols B, Guille C. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013 Apr 22;173(8):657-62

[5] McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010; 362(14):1304-1311.

[6] Thanarajasingam U, McDonald FS, Halvorsen AJ, et al. Service census caps and unit-based admissions: resident workload, conference attendance, duty hour compliance, and patient safety. Mayo Clin Proc. 2012;87(4):320-327.