(I posted a version of this little essay some years ago at the request of Maggie Mahar, but I think it’s an important issue that’s worth dusting off and putting out there again.)
We want competent physicians, but we also want compassionate ones. How do we get them? Is it nature or is it nurture? Is it more important to search out more compassionate students, or should we instill compassion somehow in the ones we start along the training pipeline? I think the answer lies in nurturing what nature has already put there.
My background is in pediatric critical care, which I have practiced for thirty-five years. Throughout most of my career I have taught medical students, residents, and fellows. So I have seen young physicians as they made their way as best they could through the long training process. I also served on a medical school admissions committee for some years and interviewed many prospective students, so I have had the opportunity to see and speak with them before the medical education system even got hold of them. I think the main principle to keep before us is not so much to figure out a way to teach compassion, but rather to devise ways such that the training process does not reduce, or even extinguish, the innate compassion all humans have toward one another. Unfortunately, our current way of doing things does not do a very good job at that task. But I do not think our present state of affairs is anyone’s fault. We are hobbled by our success. Some historical background is helpful, I think, to explain what I mean.
When my grandfather graduated from medical school in 1901 he had only a few tools to help the sick. He could do useful things to help injuries mend. He had the newly discovered techniques of aseptic surgery, as well as ether to allow him to do it painlessly. Other than that, though, he did not have much – narcotics to relieve pain, powdered digitalis leaf to help a failing heart, and a few other things. Mostly, though, he had bagful of useless nostrums. Some of them were even harmful. Because he had little to offer, compassion figured prominently in whatever therapy he did. It had to.
When my father graduated from the same medical school in 1944, things were better. Surgery had advanced further from his father’s day, although only brave surgeons entered the chest cavity. There was sulfa, and penicillin soon became available, working miracles with previously deadly infections. Streptomycin and later drugs made the scourge of tuberculosis treatable. He soon had some drugs to treat high blood pressure, which by then had killed his father, plus a rapidly enlarging stock of other useful drugs to put in the black bag he took on house calls. But there were still many things for which he could do nothing. For a heart attack he gave some morphine to take away the pain and then waited to see what happened. If a cancer could not be removed surgically, he had nothing to offer. Although my father’s black bag held more than his father’s had contained, compassion was still a crucial part of my father’s armamentarium. As for his father, it had to be.
I graduated from medical school in 1978. If scientific medicine was just spreading its wings during my father’s training, I experienced it in full flight. By then our medical-industrial complex had rolled out nearly all of the varieties of therapies we have still, although of course we have polished and improved them. What has happened, I think, is not that we have become less compassionate on purpose, but that we came to act as if we no longer needed the compassion of my father or my grandfather’s era, now that we had so many really useful and exciting therapies to offer.
I also think one other historical change is key to understanding how our young doctors react to the experience of seeing death and dying. In my grandfather’s era, it was an unusual person, even an unusual child, who had not personally seen someone die. Children and young adults saw how those around them behaved and reacted to death. If they became doctors, both they and their patients had shared this common experience, so both knew how to act. I saw death for the first time when I was sixteen on my very first day working as an orderly in our local hospital. I was giving a bath to an old man; he looked at me oddly, and then he was dead. None of my friends or schoolmates had ever seen such a thing. I still recall it vividly. I also remember well how helpful the nurses, all women in their fifties or sixties, were to me afterwards. I watched them wash the body, a once sacramental task now largely done by nurses in hospitals instead of families in their homes. They were respectful, but matter-of-fact as they went about it. After all, it was a natural thing.
I think compassion for others is innate in all of us, although it is stronger in some than in others. All of us possess an inner light. Perhaps that opinion makes my theology show, but I think it is fair to say our medical school selection process already skews toward selecting students more compassionate than the average person. We need to encourage that quality, certainly, but that is not the key issue in my mind; mainly we need to prevent medical training from driving it into the background, belittling it, or even snuffing it out. So I do not think we need so much to ponder how to teach compassion as we need to find ways of letting students’ natural humanity shine through. For medical educators, that would seem to me to be good news. Framed that way, it ought to be doable – but how?
There are many things in medicine that can be taught with the old “see one, do one, teach one” model that those of us older than fifty remember. We also remember never seeing a faculty attending physician in the hospital at night, because, after sundown, the place belonged to the residents. Even during the day, attending physicians were more likely to be found in their offices or their research laboratories than out and about on the wards. I learned how to intubate a baby and place an umbilical artery catheter from my senior resident, who had learned the year before from her senior resident. But my senior resident was not much help when a premature baby died; she was as much at sea as I was. All she had learned about that from her senior resident was to cultivate a sort of hard-boiled persona. We aspired to it partly because it gave us a mental escape hatch in those situations. But mainly it was because nobody showed us any other way.
How to show that other way? In my mind, there is no substitute for senior, seasoned physicians demonstrating, in the moment, how to let out our own innate empathy and compassion. Good, experienced physicians are comfortable admitting their medical ignorance and failures to families; nothing terrifies residents more than that. When they see it in action, students and residents respond with a version of: “That’s why I became a doctor.” Structurally, medical education has already made great strides in the right direction. We now have rules for resident supervision that involve much more oversight, even at night, than I ever had. This was done mostly for patient safety, I think, with education as a secondary and really unintended consequence.
So the opportunities are there – we just need to implement them better. For example, after an unsuccessful resuscitation and a death, the folks with the grey hair should spend as much time discussing with students and residents the psychic dimensions of the death as they do the sequence of medical decisions. Most of my colleagues already do that to varying degrees, but it should be an expectation.
We should never again send a resident, alone and emotionally at sea, to comfort a grieving family without backup. We do not do that for complicated invasive procedures; we should not do it for this other, equally important task either. Certainly some organized instruction – seminars, discussion groups, lectures and the like – can be part of the process. But the training curriculum is already stuffed with subjects. Taking residents by the hand and leading them through these experiences does not require another fat syllabus. It only takes a little time. If we want to foster compassion in our students we should ourselves show them compassion for the situations we put them in. We should let their innate, inner compassion and empathy find an outlet and breathe free.
The recent prominence of the MeToo movement has shined a light at many places in our society where insidious or even obvious sexism against women has long gone unremarked. Even when noticed it’s just shrugged off as the way things are. In honor of this MeToo was named Person of the Year for 2017 by Time Magazine. Medicine is no exception to this pervasive problem. A very interesting recent essay in the New England Journal of Medicine examines why this is and what we could do about it.
It’s well documented women are vastly underrepresented in leadership positions in medicine, such as full professors and department heads. This is in spite of the fact the proportion of women to men in medical schools is roughly equal and has now been so for over 15 years. Last year the number of women admitted to medical school even slightly outnumbered men. This graph shows the trends over the last 50 years.
In spite of the steadily increasing proportion of women in medicine the culture of medicine has not caught up. Certainly one can postulate the number of women in leadership positions will increase because typically these positions are held by physicians at mid-career or older; it may take time to generate women physicians with sufficient quantities of grey hair. But I’m not so sure about that. Note from the graph the number of women has been close to that of men for nearly 2 decades. My own field of pediatrics has been at least equal in the proportion of men to women for decades, and for the last decade or so the number of women pediatricians has actually been larger than men. So if it were just a matter of time in rank women should have caught up, at least in pediatrics. Yet this hasn’t really happened. Why is this? One thing observers point to is that women are more likely to interrupt their careers for child-bearing and other family reasons. At least in academic medicine such pauses in one’s medical career can be huge set-backs. My answer to that is, so what? Change expectations of what an academic medical career means. That would actually be a good thing. Along with the author of the essay, I think the answer clearly runs deeper; women physicians are simply not respected to the same degree as are their male colleagues, not by the medical system and apparently not by the public. That’s how deeply the sexism is ingrained. The essayist offers an example of this phenomenon.
A recent study of speaker introductions at internal medicine grand rounds revealed that even when women are acknowledged as physicians, they are more likely than men to be introduced informally: women were referred to by their professional titles 49% of the time, as compared with 72% for male speakers. This finding has important implications. Calling women by first names in a setting in which men are referred to by formal, professional titles is a tacit acknowledgment that women are perceived as less important, even as their contributions are publicly recognized during grand rounds.
I’ve been practicing medicine for 40 years now and have long noticed women physicians are far more likely to be addressed by their first names, even by those who rank below them in the hierarchy. Of course the fact the majority of nurses continue to be women can be a bit confusing to patients who make assumptions. Yet this occurs constantly in spite of today’s large and obvious name badges and prominent labels on coats identifying women physicians. We cannot change patients’ attitudes much, although I gently correct them when they make this mistake. But we can change our own behavior. We can also give equal pay for equal work. It’s well documented women physicians make significantly less money than do men for doing the same thing.
There is another fascinating aspect to this issue. There is some research suggesting women physicians provide overall better care, possibly by being more likely to adhere to evidence-based medicine standards. Some observers have added to that explanation the higher likelihood of women physicians to work in a collaborative manner with the rest of the care team. The study examined 30 day hospital readmission and mortality rates for a large number of Medicare patients. The differences in patient outcomes between women and men physicians were significant and persisted across multiple disease categories. That’s pretty strong stuff.
The same issue of the New England Journal also provided a vignette of one of the most famous of women physicians, Dr. Helen Taussig. Dr. Taussig more or less invented the specialty of pediatric cardiology and her name remains attached (with second billing!) to a common pediatric cardiac surgical procedure, the Blaylock-Taussig shunt. The essay author wonders:
Since that time, how many Helen Taussigs have we lost to discrimination, harassment, and marginalization? And how many more will we lose if things don’t change?
Forty years ago I was fortunate to have been trained by 2 extremely gifted women who took different approaches to the obstacles they faced. Both possessed spines of steel and they needed them. My fellowship mentor overcame first polio and then the grinding annoyance of belittlement at an extremely stodgy medical center, one actually renowned for its male stodginess. Her progression to full professor was inordinately delayed. She was often assumed to be some sort of social worker. Because she covered several clinical services it was her habit to wear her various pagers on a cord around her neck. Incredibly, I met one physician who assumed she was “some kind of beeper repair lady.” She was a perpetual winner in the resident polls for teacher of the year; the department chair finally told the residents they had to select someone else for a change. And, of course, her patients adored her. The higher-ups . . . not so much, as the kids say today. She was known to seek them out in their comfortable lairs and make them less comfortable by confronting them in her calm yet firm way. Another of my mentors took a quite different approach. She was one of the giants of pediatrics and was among the founders of neonatology. No one messed with her because she met sexism head on, wielding a figurative 2 by 4 that she used to whack, among others, the chief of surgery on occasion. When necessary she could swear like a sailor. Tough doesn’t even begin to describe her. She succeeded and thousands of premature babies benefited.
These women took very different strategies dealing with sexism. And, as was said of Senator Elizabeth Warren, they persisted. But the thing is, it need not have been that way. That’s the point.
Vaccines have been hailed by virtually all medical experts, as well as medical historians, as the among the greatest triumphs of public health to occur in the past two centuries. Yet since Jenner first proposed vaccination for smallpox using the vaccinia, or cowpox, virus there have been both skeptics of its effectiveness and people who thought it was dangerous. That is, they had the risk/benefit ratio of vaccination exactly backwards, believing risk high and benefit low. They also often ridiculed the entire procedure, even from the beginning, as this 18th century cartoon shows — Jenner is the fat gent kneeling by the cow.
Against this constant background of vaccine denial, things changed two decades ago when Andrew Wakefield published his now notorious claim of an association between the MMR (measles, mumps, and rubella) vaccine and autism. The claim has not only been soundly refuted in a large number of well-controlled population studies, but Wakefield himself has been stripped of his UK medical license for unethical and fraudulent practices related to his publication. The paper itself was retracted by the journal Lancet, an extraordinary thing. Wakefield left the UK and moved to Texas. But the damage had been done. Vaccine hesitancy increased, not just for MMR but for all vaccines. The rise of social media, particularly Facebook and Twitter, appears to have amplified the effect. But did it? We do know there is more anti-vaccine noise, but has this resulted in decreased uptake of vaccines? Most importantly, has this led to an increase in vaccine-preventable diseases?
Measles offers a good example to examine because, not only did it feature in Wakefield’s original claim, but measles is highly infectious with a high attack rate among susceptibles and the vaccine is highly protective. In the pre-vaccine era the attack rate for measles was at least 95% and most persons had had it by early adulthood. It is not a trivial illness; the death rate is around 1 per 1,000 cases and there is a substantial risk for complications and life-long disability. It does seem clear from epidemiological work that decreased vaccine prevalence has been linked to measles outbreaks in Europe and the USA. But are these isolated pockets in the population or part of a larger trend?
Before examining if these thankfully still isolated instances represent some broader trend it’s worth looking closer at vaccine denial. A key problem is that we don’t know if such denial is more common now than in the past or if today’s media environment has just made it noticeably noisier. This interesting study from the UK examines the profile of the typical vaccine denialist. Recurring themes found among surveys of such people is a belief in many conspiracy theories, suspicion of authority, and feelings of disillusionment and powerlessness. Particularly interesting to me was the first of these. In general, conspiracy theories are attempts to explain events as the secret acts of powerful, malevolent forces. For people who believe these things, particularly those who participate in social media, it is a simple, even natural thing to add vaccine denial to their stock of other conspiracy theories. There is also often a general animus toward mainstream medical practice in general.
So, to address my question in the title: What do we know about if vaccine denialism has affected overall vaccination rates in the USA? I’m pleased to note that recent reports from the CDC that at least cover the past five years indicate not much has changed. There are definitely pockets of low rates, and it’s interesting how measles seems to find those places where herd immunity has dropped sufficiently low to allow disease to break out. This is an abject lesson for all of us. The figures are compiled by the CDC from vaccination records from the individual states. Here is what they found about vaccine uptake for MMR, DTaP (diphtheria, tetanus, and pertussis), and varicella vaccines among children entering kindergarden.
During the 2016–17 school year, kindergarten vaccination coverage for MMR, DTaP, and varicella vaccine each approached 95%, and the median exemption rate among children attending kindergarten was 2%; these rates have been relatively consistent since the 2011–12 school year.
The legal principle that the state may compel vaccination to attend public school for the safety of other children was established over a century ago. All states allow some exceptions, although they vary in the specific categories allowed. The number of children who had some sort of exemption from vaccination has been steady, as the CDC notes. There are medical reasons for a child not to receive vaccines, but most of the exemptions are for religious or philosophical reasons as determined by the parents. California recently caused quite a stir among the vaccine denialist world by eliminating the philosophical exemption option if a child wanted to attend public school. They filed a spate of lawsuits against the state, all of which have been denied.
When I started reading about this subject I had been discouraged by the headlines from Europe and California. But the extensive CDC compilations remind us that, in spite of all the sturm und drang in social and other media, the overwhelming majority of Americans support vaccination.
I’ve been practicing pediatric critical care for over 35 years. Like many of my colleagues in my age cohort, when I started there was no formal certification process and few formally organized training programs. Those of us who were interested just started doing it and learned a lot of it on the job. Most of us came to critical care after training first in other pediatric subspecialties, such as pediatric anesthesiology, pulmonology (lung diseases), or cardiology.
Few medical subspecialties can point to a founding mother or father, but in pediatric critical care it’s fair to say our founder was Dr. Jack Downes of the University of Pennsylvania and Children’s Hospital of Philadelphia. Dr. Downes began the first designated PICU in 1967. He was a young faculty member who had trained in pediatric anesthesia who took his experience working in the polio wards to bring together in one place all critically ill children, rather than scattering them all over the hospital as had been the previous practice. His original six bed PICU has now ballooned to over a hundred beds and remains one of the premier PICUs in the country. Its contribution to the subspecialty is immense, both for what was discovered there and for the large number of prominent pediatric intensivists Dr. Downes has trained. He recently sat down for an interview to describe his and our specialty’s journey.
Dr. Downes’ fundamental observation is really very much common sense: if you bring together the sickest children in one spot the physicians, nurses, and respiratory therapists who care for them are much more likely to get very good at what they do. Mortality statistics have reflected this. Specialized training also really matters. Yet our subspecialty is unusual in medicine in that we’re not confined to a single organ system, as most (although not all) are; we are generalists for the very sick child, caring for all aspects of their illness or injury. I did my general pediatric residency at Vanderbilt University Children’s Hospital in the 1970s. We had a room we called the PICU with excellent nurses but we had no formally trained pediatric intensivists — none. This is quite astonishing in retrospect because even at the time Vanderbilt was one of the leading pediatric facilities in the nation. Yet it had no intensivists because such people hardly existed. I believe Vanderbilt has now 20 of them or more. The development of pediatric critical care as a formal subspecialty of pediatrics has meant we have lowered mortality and morbidity of critically ill children dramatically. And it all began with Jack Downes. One key footnote to all this is that his initial experience came with polio, a disease which we have eliminated from our country thanks to vaccination.
Most physicians are increasingly forced to grapple with the problem of shortages in generic drugs. These are drugs for which the patent has expired and any company can make them. Certainly for those of us in the PICU it is a chronic problem because the majority of drugs we use are injectable medications that have been generic for many years. Hardly a week goes by I don’t receive a notification from the hospital pharmacy there is a nation-wide shortage of multiple vital drugs. On occasion we have been down literally to our last vial or two of a key drug. Hospitals often have to scramble to find them and sometimes share with each other. Injectables, medications we give intravenously or intramuscularly, are a particular problem because production costs are high compared with just making a pill or capsule that can be put in a bottle.
There are companies that specialize in making generics, but there are fewer of them than previously. This raises the possibility of price gouging when only a couple, or even one company markets a drug. Patients who need the drug may be forced to pay enormous prices if the company jacks up the price. There was a big media splash when so-called “Pharma-Bro” Martin Shkreli started a drug company and obtained the license to market pyrimethamine; he then raised the price from $13.50 to $750 per pill. This is an old drug to treat parasites, rarely used these days, with one main exception: immunocompromised patients with infections from toxoplasmosis. For them they’ll die without it. (Shkreli himself ended up going to jail for fraud related to something else.) Besides financial shenanigans, it’s also easy to see what could happen if only one or two facilities are making needed medications and their production facility goes down. This recently happened with makers of intravenous solutions, which are heavily concentrated in Puerto Rico. Hurricane Maria in 2017 devastated production and it’s still not back up completely.
Medications, especially generics, are vital to our medical infrastructure and our current system is not the best way to ensure a steady supply. A recent opinion piece in the New England Journal of Medicine discusses the problem and suggests an innovative solution. The authors’ idea is to create nonprofit entities with the mission of marketing generic drugs. Their profits, rather than going to stockholders, would go to production costs.
A nonprofit generic-drug manufacturer, which cannot sell equity shares, can initially be funded by philanthropic contributions. It can contract with existing manufacturing facilities or, if necessary, establish its own facilities and rely on guaranteed purchases by institutional partners, such as hospitals, health plans, and government agencies. These institutions, which need uninterrupted access to generic drugs and have a financial incentive to purchase them at reasonable prices, will provide a stable revenue source for the manufacturer.
Institutions such as hospitals can predict with good accuracy what their needs will be for common generics and could enter into contracts with producers to guarantee minimum purchases. This would protect the nonprofit from going under if a for-profit company were to start making the drug, then drastically drop the price to drive the first company out of business, then raise the price again; such a thing has happened in the past. The governing board of such a nonprofit could include some of its major clients, ensuring the company adhered to its core principle of producing generic drugs at an affordable cost.
In fact, such an entity is already underway, called Project Rx. It consists of a consortium of hospitals and health plans. The members are some big players, including Intermountain Healthcare, Trinity Health, and the Veterans Affairs system. The authors conclude:
The complex nature of market failures for generic drugs implies that a single alternative business model cannot address all aspects of this problem. We believe that Project Rx may drive other nonprofit and for-profit manufacturers to enter generic-drug markets, compete among themselves, and collectively improve market efficiency and broaden access to generic drugs.
I find the proposed scheme to be innovative and workable. I wish the Rx Project well.
It’s been a while since I’ve written about concussions in children, so I want to share with you some updates on the subject. The term concussion itself is centuries old, but even forty ago when I was in training the actual definition of concussion was vague. What was usually meant was that the patient got hit on the head and either lost memory or consciousness briefly, or at least wasn’t quite himself for some period of time afterward. These days we’re more precise than that, but concussion is still an inexact term. This is mainly because of our ignorance of the subtleties of how the brain works and how it responds to injury. Estimates are there are around three million concussions in children each year.
The formal definition of concussion is a transient interruption in brain function. By implication, various scans of the brain, such as CT scans or MRI scans, show no abnormalities. Since all the imaging studies are normal, defining concussion is necessarily imprecise. I’m sure one day we’ll have some kind of test that detects the reason for the symptoms of concussions, but right now we don’t have such a thing — concussion is an entirely clinical diagnosis, meaning there’s no specific test for it. The list of symptoms that can come from a concussion is a long one. Headache, dizziness, vomiting, and ringing in the ears are common. Various behavioral changes are also common, such as lethargy, difficulty concentrating, and irritability. The overwhelming majority of children who suffer a concussion, especially a mild one, recover completely. But around a fifth or so of children who have had severe concussions continue to have problems many months afterward.
There are several traditional systems for grading concussions. A commonly used one was published in 1997 the American Academy of Neurology. It was based on a grading system that ranged from Grade I (no loss of consciousness) up to Grade III (loss of consciousness, no memory of the event). You will still see this system quoted in many places but in 2013 the Academy revised their guidelines to stress the continuous spectrum of concussions and focus on the neurological examination of the child rather than memory or not of events. A major focus of the new guidelines was on sports and when an athlete can safely return to play, a common practical issue for young athletes. They emphasized that the younger the child, the more conservative the approach should be. Children who suffer a concussion are much more likely to suffer another, and potentially much more severe brain injury if they have a blow to the head before the symptoms of the first one have completely cleared. So-called second impact syndrome is a particular fear; I have seen a death from that. This is the important concept: a concussion is a form of brain injury. Some experts want to discard the term concussion completely in favor of something like mild traumatic brain injury. Old sports terms, such as “having your bell rung,” tend to downplay this reality. The wealth of recent research about chronic traumatic encephalopathy in football players, even those at the college level, demonstrates the long-term risks of repetitive blows to the head, even those not sufficiently severe to cause immediate symptoms. It is important to know that research on various kinds of helmets have not shown any benefit, at least yet. What has been shown is that early removal from contact sports makes concussions heal faster. Contact sports like football and hockey carry the highest risk, but as the image above shows, other sports like soccer and volleyball are often associated with blows to the head. And in those sports no helmets are worn. Here’s the bottom line, from Dr. Jeffrey Kutcher of the University of Michigan Medical School:
If in doubt, sit it out, . . . Being seen by a trained professional is extremely important after a concussion. If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor. You only get one brain; treat it well.
The American Academy of Neurology has an excellent resource page here, where you can find much useful information about concussions.
A recent article and accompanying commentary in the journal Pediatrics describe what we currently know about children who have died from influenza over the past decade or more. The Centers for Disease Control (CDC) has collected information about this since the 2003 – 2004 influenza season. In that first report there were 153 deaths. Since then there have been at least 100 influenza deaths annually among children. Several characteristics have not changed. About half of the deaths occur in children who were otherwise normal; that is, they had no underlying chronic condition that would predispose them to having more severe cases. Although the median age was 6 years, mortality was highest among the youngest children — those younger than 6 months. Most of the children who died, over 70%, had not been vaccinated against influenza. This is not a completely surprising finding since influenza vaccine is recommended for children 6 months or older. However, an important way to transmit the benefit of at least some immunity to infants and very young children is to vaccinate pregnant women since some protective antibody crosses over from mother to infant and lasts for several months at least. Currently only about a third of pregnant women are vaccinated.
Influenza is a stubborn and wily virus, traits that make designing a highly effective vaccine challenging. Its natural reservoir is several species of birds. It has 3 main subtypes, with the most serious disease typically coming from influenza A. The virus replicates itself in a way that results in frequent mutations, causing what is termed antigenic drift. This means the virus has the property of changing rapidly, making it something of a moving target for developing a vaccine against it. This is why our influenza vaccine changes every season in an effort to keep up with the rapid alterations. Immunity to last year’s version often doesn’t help much for this year. This also help explain why some years influenza is more mild, other years more deadly. There have been several severe pandemics from influenza when a particularly nasty version emerges, the most severe being in 1918-1919. That one killed over 50 million people.
These things make influenza vaccine one of our less effective vaccines. It reduces the incidence and severity of disease, but it cannot eliminate it outright, such as other vaccines directed against stable viruses like polio and smallpox can. Influenza is also notorious for paving the way for secondary infection from bacteria that happen to be resident in the respiratory system, such as staphylococci and streptococci. Many of the deaths are from such secondary infections. You can read much more about the details of the virus and its vaccine here and here.
In the USA the influenza season runs from fall until early spring. The graph above shows the past season’s trends in both documented and presumed cases (“influenza like illness”). The horizontal axis shows week of the year. The vaccine is based upon the best guess of experts who survey viral trends around the world. Some years they guess better than other years. It usually is available in October. The current vaccine is a killed one, meaning that, whatever you have read on the internet, you cannot get the infection from the vaccine. Two doses are recommended for children who have not previously received it (specifics here). Like all pediatric experts, I highly recommend it. Health care workers such as me are required to get it. I agree with the author of the commentary cited above that our best approach for reducing the death rate in children too young to get the vaccine themselves is increasing the vaccination rate in pregnant women.
Croup is an ancient illness — its very name comes from the Anglo-Saxon word to croak, which is what children with croup can sound like. The characteristic brassy cough sounds more like a seal to our modern ears, though. Also characteristic is a sound we call stridor, the sound of air rushing through a narrowed tube, in this case the child’s upper airway.
Croup is caused by viral infection of the region just below the vocal cords. One of several viruses can do it, but the usual offenders are members of the parainfluenza group. Although we have a vaccine for influenza, there is no vaccine to prevent parainfluenza; in spite of the similarities in their names, the two viruses are not related at all. The infection causes swelling, and the swelling causes narrowing of the airway. This makes it more difficult for the child to breath — in some ways it is like breathing through a straw — and the child has to work harder to get air in. This can make the child’s chest cave in the wrong way with each breath, something called retractions. Fever, if present, is usually mild. Here’s a neck x-ray of a child with croup. You can see with the arrow how narrow the airway, which on x-ray is a black air column, can be — often just a millimeter or so in diameter in more severe cases.
As with most viral illnesses, there is no specific treatment for croup. What treatment we have is directed at relieving the symptoms of throat pain and difficulty breathing. We do have several effective ways of doing this. Simple mist, as from a steamy bathroom, is a time-honored therapy to help a child breath and it helps with the throat pain. Croup generally occurs during the colder weather months. Another old remedy is to take the child out into the cold night air for a few minutes. I’m not sure why, but I think this actually helps, perhaps because cold shrinks the inflamed airway tissues. Inhaling a mist of the drug epinephrine definitely shrinks the swollen tissues, although it only lasts for an hour or two. The steroid drug dexamethasone, either orally or by injection, has become a standard therapy for moderately severe croup and it is quite effective because steroids reduce swelling. This therapy takes a couple of hours to work, though, because it needs to work its way into the tissues via the blood stream to exert its effects. More recently we’ve sometimes used inhaled steroids delivered as a mist, and that has been shown to improve the situation by directly delivering the steroid to the the affected area. Acetaminophen or ibuprofen can treat fever and throat pain.
When should you bring your child to the doctor for croup? A good rule of thumb is if your child has stridor when sitting quietly, termed stridor at rest, or if there are any retractions present — both of these are indications for an evaluation and possible therapy with epinephrine or dexamethasone. Another reason would be if your child refuses to drink enough. If your child has fever and drooling, refusing to swallow, as well as difficulty breathing that could be a much more serious infection called epiglottitis. That requires immediate attention in the emergency department.
We always see a few children in the PICU with severe croup, usually those who need repeated doses of epinephrine or are working very hard to breath. On very rare occasions we need to use a breathing tube and a mechanical ventilator for these children to bypass the obstruction until it clears on its own. Nearly all children, however, recover from croup with no complications.
Burnout has been a descriptive term for years, but lately psychologists and others have assigned it specific characteristics with a view toward being able actually to study and measure it. One common definition of burnout is a state of chronic stress that leads to physical and emotional exhaustion, cynicism, detachment, and feelings of ineffectiveness. The PICU environment is often one of high stress, so it’s a place where this can happen. We’ve known that informally for a long time. The best measure of this probably is that you don’t find many pediatric intensivists my age (66) who are still practicing; a large number go into something less stressful and with more regular hours. A recent study appearing in the principal journal in our field, Critical Care Medicine, attempted to measure more precisely how common burnout is among my colleagues. There have been many studies about burnout in physicians generally but none specific to pediatric critical care.
The authors used a voluntary online survey in which they identified by professional societies and other means 686 pediatric intensivists and asked them to answer a series of questions. Note this means the subjects were self-selected, decreasing the power of the findings. Also note how few pediatric intensivists there actually are in this country — we continue to have a shortage. The questions were in the form of an often used and validated tool for assessing burnout — the Maslach Burnout Inventory. 253 intensivists responded. Full disclosure: I didn’t respond, mainly because I just didn’t get around to it.
The subjects had ages between 41 and 60 years (I would have been a big outlier in this age spread), were 60% male, and 69% had been in practice for more than 10 years. The great majority were married and had children. The most common practice setting was an academic hospital or a community hospital affiliated with an academic center, which is in line with where you will find PICUs. The authors found that half the respondents scored high in at least one of the three burnout subscales. Emotional exhaustion, at 34%, was the highest, followed by low personal accomplishment at 21% and depersonalization at 20%. Burnout was twice as common among women physicians than among men. What the MBI defines as severe burnout was present in 21% of the respondents. That last figure is pretty high. For comparison, though, burnout rates among all physicians have been reported to be as high as 50%, with emergency medicine physicians reporting the highest rate. But you need to be careful here. I have no symptoms of burnout; I also didn’t do the survey. We need to beware of sampling error issues, with the most burned out physicians taking the time to do the survey. A recent survey of family practice physicians who had been in practice for 5 years or more illustrates this. In a survey of 2,099 physicians with a 100% capture rate, burnout was reported in 25%, half what other surveys with nonrandom samples have reported. The capture rate was so high because they rolled the survey into board recertification. That’s still a lot higher than we would like, of course; if I were in charge I’d aim for a practice environment that resulted in figures of 1-2% or so. So maybe pediatric intensivists are pretty much like everybody else.
Burnout does have consequences. A third of the respondents to the PICU survey reported symptoms of severe psychological distress during the previous month. Burnout has been linked to early retirement or changing practice fields. What do we know about preventing burnout? Interestinly, most of the literature on the subject points in particular not to the life and death decisions aspect of practice. A big thing is workload, something that should be obvious; work people to death and they will crack. Nearly as important as workload are the relentlessly annoying bureaucratic things physicians are increasingly required to do. These are things that take us away from the bedside, and recent time flow studies document that physicians are spending less and less face to face time with their patients and more time facing their computers. For a lot of the day we’re not doctors at all — we’re clerks. I can vouch that hardly a day goes by when I don’t open my institutional mail and find yet some new thing I’m supposed to do or check. Nothing, absolutely nothing, is ever reduced — things are continually piled on. It all adds to workload and to the feeling administrators don’t really understand or respect what practicing physicians actually do.
I’m not burned out myself. In fact, I’ve never felt burned out. I’m really not sure why this is. But I think it’s because I’ve managed to end up in work environments that are a good fit for me. I’m grateful to have lucked into that (and it was luck) because I continue to enjoy PICU practice. Studies like this, however, should remind us burnout continues to be huge and growing problem in our physician workforce. Many facilities are taking baby steps to address the problem by reducing the bureaucratic burden with nonphysician helpers. But the workload issue will be a pernicious problem. Specialties like pediatric critical care are already short of practitioners, so just adding more physicians is difficult. Besides, adding more physicians to a PICU practice increases costs without generating more revenue, and I doubt any institution will be enthusiastic about doing that. There are no workload standards to point to as benchmarks.
I’m not sure what will happen with the burnout issue. But I think we’re reaching some kind of critical threshold that will demand institutions address it with fundamental alterations in practice management, not just Bandaids that keep physicians from rising up in revolt but still keep the pot simmering. I’ll probably be retired by then, but maybe not.
Our human view of reality partly evolved through understanding things by observing subsequent events. Fifty thousand years ago imagine one proto-human saying to another, or however they communicated back then: “Don’t eat those berries – you’ll get sick afterwards.” Or an experienced proto-human might point to black clouds in the sky and predict severe weather was sure to follow. These things were learned and passed on through noting what tends to follow what. Such observational skills contributed to how we became the creatures we are, how we surpassed other species in development and achieved mastery of the word around us. But even many millennia ago I’m sure this habit of thinking created problems. What if it was a mere coincidence B followed A, and there was no causal link at all? If one is predisposed to view one thing as a consequence of another thing because it followed afterwards serious mischief is possible. A person violates a social taboo and disaster follows – cause and effect? Of course that’s true, if you see the world that way. In thirteenth century France, or for that matter in seventeenth century Massachusetts, an old woman nobody liked might pass by a neighbor’s house and glare at a milk cow blocking her way. Afterwards the cow goes dry. Arrest the witch!
This inherent way of looking at the world, often termed the fallacy of post hoc, ergo propter hoc (after that, therefore because of that) is deeply embedded in our human consciousness, in the way in which we explain events in the world around us. It often continues to serve us well today. Consider the old Vaudeville joke: “Doc, whenever I do this I hurt!” To which the physician responds: “Then stop doing it.” Common sense, right? Well, in the world of vaccine denial, this primeval human instinct can significantly cloud our thinking.
For those of you not familiar with this topic, there exists a substantial group of people who claim vaccines don’t work. More than that, they believe vaccines cause substantial harm. Why do they claim this? You could say their answer is partly theological: they already believe, a priori, vaccines are harmful, and once one believes that the only thing needed is to discover precisely how vaccines cause harm. I follow the vaccine denial world a bit online and it’s fascinating to watch them chase first this butterfly, then the next, pursuing the One True Cause of vaccine harm. They’re not looking to understand, really, they’re looking for evidence of what they already know to be true. Not surprisingly, some of the “proofs” they arrive at for vaccine harm contradict one another, providing another interesting parallel with medieval scholastic theology.
Vaccine denialists have a particular problem dealing with the science of epidemiology. You will read multiple online claims vaccines killed or injured a particular child because the child had problems after receiving a vaccine. In fact, it’s so obvious to them they are astonished anyone would question that, for example, a child who dies of sudden infant death syndrome (SIDS) and who received a vaccine several days previously was not killed by the vaccine. Post hoc, ergo propter hoc. Of course we use epidemiology to evaluate this issue. Just on the face of it, vaccines are given so frequently in the first 6 months of life that there is a large pool of infants who have been recently vaccinated. The pool is orders of magnitude larger than the incidence rate of SIDS (3 per 1,000). So a significant number of SIDS victims will have been recently vaccinated. The way epidemiology evaluates questions like this is to do case-control studies. Many of these have been done; all show show no adverse effects of the vaccine. Some actually show some protective effect of vaccination against SIDS.
Epidemiology is the study of diseases in populations. Over the past century it has become extremely sophisticated in how it answers questions such as the one at hand: “Do vaccines cause X (fill in whatever your particular claim of harm is for X)? Several standard epidemiological methods have been used to address this question, including case-control and cohort studies. Vaccine denialists, in my online experience, are simply either unwilling or incapable of dealing with the ramifications of this important field of medical research. To some extent I sympathize with them; understanding epidemiology is tough. They can be incredulous that I don’t accept that some event following a vaccination is obviously caused by it. Yet the key goal is to eliminate the “burn the witch” tendency humans have always had.
I’m actually not optimistic the core base of vaccine denialists is going to give up their theology any time soon. Many have invested enormous emotional energy into that world view, and change is very difficult. Many have children suffering from disorders for which we don’t have any good explanations, and “vaccine injury” provides a comforting way both to explain their child’s problems and to blame an outside agent for the problem. Of course the epidemiological evidence is that vaccines are extremely safe and effective. They are the most low risk and high benefit therapies modern medicine has to offer.