The Novel H1N1 Vaccine

"Swine flu" or the novel H1N1 influenza this year has created an interesting mix of reactions. Since the first outbreak in March/April of this year to the declaration of a pandemic in June to the development of a vaccine, some have become terrified of this disease and others have become terrified of the vaccine. Should we vaccinate? Is the lack of widespread equitable distribution of the vaccine a failure on the part of the government?

The vaccine is created similarly to seasonal influenza vaccine, and side effects are expected to be similar. Several trials looking at dosing of vaccine and antibody titer response have shown that getting the vaccine effectively induces an immune response against those antigens. The hope is that this will prevent transmission of the influenza virus from an infected host to an immunized individual.

However, we don't have any data that this works. The theory is sound, but there are no studies on whether the H1N1 vaccine prevents infection. Indeed, it'd be hard to design a study; you'd have to randomize people to getting vaccine and placebo and see if they make it through the flu season without getting sick. So do you believe in evidence based medicine? If you do, you have to concede that all this hullabaloo over vaccination can't really be supported by numbers. We think it works, but we simply don't know.

I fully support getting the H1N1 vaccine; I believe in the biology and immunology, and I think it works. But not having numbers bothers me. What if the vaccine isn't all that good and only prevents 10% of infections? Are we spending our money wisely? Are we rationally weighing risks and benefits? That being said, there is a study modeling the cost-effectiveness of vaccination that suggests that vaccinating 40% of a large U.S. city with a 75% effective vaccine would avert 1468 deaths and save $302 million. This would require 3.3 million vaccine doses (if one dose is effective for an adult). I'm always iffy about modeling studies, but that's the best evidence we have so far.

Breast Cancer Screening II

The meta-analysis conducted by the U.S. Preventive Services Task Force result in these numbers: the relative risk reduction of screening mammography on breast cancer death in women 40-49 is 0.85 (CI 0.75-0.96; 8 trials). Due to the lower incidence of breast cancer in this age group, the number of people needed to invite for a screening mammogram to prevent 1 breast cancer death is 1904.

Therein lies the rub. Are we, as a society, willing to do 1904 mammograms to prevent one breast cancer death? Mammograms aren't completely benign. False-positive results are very common and lead to unnecessary invasive procedures and undue anxiety. This is not trivial; biopsies and surgeries as a result of false positive tests can be extremely costly and entail their own consequences. Other issues include discomfort of the procedure, overdiagnosis, and dangers of radiation exposure.

The problem is this: any woman would rather face the anxiety of a false positive test than have cancer. Furthermore, of the 1904 women screened, if you're the one with the actual cancer, then screening matters. But this kind of reasoning leads to a slippery slope. Why don't we mammogram women 30-39? They get breast cancer too. We'd have to do more mammograms to prevent a single death, but there are potential lives to save.

Where do you set the cut-off? If we do screening mammograms on women 40-49, we pay $190,400 to save one life (based on average cost of mammogram $100). Is that worth it?

Think of how many swine flu vaccines we could buy with that amount of money. (Don't worry, my opinion on the novel H1N1 vaccine is coming soon). My opinion doesn't really matter as I'm not going into primary care. But in looking at the numbers, I think it's reasonable to be ambivalent, and either side can be defended. For me, given a patient from age 40-49, I would assess her risk factors, and absent any red flags, I'd reassure her and schedule her for a mammography when she turns 50.

Breast Cancer Screening I

Recently, the U.S. Preventive Services Task Force (USPSTF) revised breast cancer screening guidelines to recommend against routine screening mammography in women age 40-49. This is a landmark change. Previously in 2002 the recommendation was routine screening mammography every 1-2 years for women 40 and older. The USPSTF is an independent panel of experts in primary care and prevention (not including oncologists) that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. This change in recommendation has garnered quite a bit of press and criticism from patients and providers alike. It is not clear-cut; the American Cancer Society and other expert panels argue against this change.

I think this is a great moment for several reasons. First, it is a bold move for the task force; how can you recommend against looking for something that kills so many people each year? Indeed, the USPSTF has remained neutral on many cancer-screening recommendations; they conclude there is insufficient evidence to recommend for or against screening for skin cancer, prostate cancer, or lung cancer. (I'm not even that ambivalent; I reviewed the literature on CT for lung cancer screening and concluded it is neither effective nor cost-effective.) But here, the USPSTF has taken a bold move, changing a previous recommendation to screen to one against it. Millions of women 40-49 have faced the discomfort of mammogram; many have had abnormal results; some have had cancers detected that otherwise would have been missed. Now, the USPSTF is simply saying stop. Don't do it. It's not worth it.

This is also a great moment because it shows that evidence is dynamic and recommendations evolve. What we learned as dogma (I'm certain this appeared on my Board examinations) changes. This is real life medicine. Nothing is certain; nothing is set in stone. As we learn more, we change what we do. Good doctors must be skeptical; they must challenge what is foisted upon them, and if new ideas persevere through those challenges, they must learn to adopt them. Research, and understanding the principles of solid research are fundamental to the practice of good medicine.

I'm going to reserve my opinion on the change for tomorrow's post. But I want to encourage you to look at the evidence. Why did they change their recommendation? Do you believe their reasons are valid? This is what I did as an undergraduate philosophy major. It doesn't matter to me what you conclude, only that you can support your reasoning. Don't use anecdote (we've all seen that unfortunate 45 year old who has metastatic breast cancer); don't use a gut feeling. Use real data. As much as you need to convince yourself. What will make someone a good doctor has nothing to do with whether they mammogram their patients 40-49; rather, a good doctor will think independently, use guidelines as guidelines, apply research to individual patients as best they can, educate the patient, and decide in a patient-doctor partnership.

Poem: Portland, 2009

Portland, 2009

Rain racing down eaves of the bus
like hair winding its way behind your ears,
and the chatter of droplets cast
white blurs over the faces - this
is what transparency is,
a city stirring and groaning
under the pressure of decompressing clouds,
weep and weep again, droplets
that sheer with acceleration
throwing motes of rainbow
through the windshield. A woman
stumbles on board, and the driver
does not press for a transfer.
Here, it is warm; the rumbling of womb
over bridge, the plumes of fog,
the soothing greens. Here, buses stop
for the biker, wheels leaving a wake,
water water everywhere.

You were never perfect,
and that's why I stayed.

900

It scares me that I'm 6 months shy of an MD. In 6 months, there will be an expectation that I know something, that in the event of childbirth, a car accident, a natural disaster, I will spring into action and make things right. If a flight attendant asks, I will be expected to stride to the front of the plane with confidence and resuscitate a peanut anaphylaxis or reverse a choking hazard. There will be a responsibility in 6 months that I act not out of self-interest but on the behalf of others, some of whom may be unable to advocate for themselves. In 6 months, my signature will no longer need a co-signature; it will have the force of an "order" and the gravity of a legal document. I will need to know when to ask for help, when to have someone double check my work, things that will not happen automatically. In 6 months, I will be responsible for a medical student in the same place I'm at now. Where will I be in 6 months? Will I be ready?

Conversations

One of the great things about interviewing for residency is the conversations with other applicants and interviewers. Talking to others allows me to gauge a nationwide opinion on medicine in general and anesthesia in particular. Most of my classmates applying into anesthesia are like me, looking to do fellowships, excited about research, interested in academic positions. But talking to those from other schools on the applicant trail introduces me to a wide array of other career goals, equally important and valid. Some are interested in private practice high efficiency anesthesia, others are interested in outpatient pain clinics, yet others are interested in regional techniques for local anesthetic blocks. Some applicants emphasize their leadership skills because of the increasing role of oversight of certified registered nurse anesthetists; others focus on their interest for one-on-one patient contact in high acuity surgeries. The other wonderful thing is getting a sense of where people think medicine and anesthesia are heading. Talking to peers, residents, and faculty from other institutions, geographical areas, and backgrounds is intensely enlightening. How do Kaiser doctors feel about the uninsured? How do county doctors think health care reform will change what they see? How do applicants feel about the programs at their home schools? Where do people think anesthesia will be in 10 years? Interviews, though exhausting, provide great opportunities for fascinating intellectually stimulating conversations.

Hand Film

I think this picture is fantastic. It's a print of one of the first X-rays, taken by Wilhelm Rontgen. The hand belongs to his wife Anna and was taken in 1895 and presented at the Physik Institut, University of Freiburg. Although the image itself might not be all that impressive, I'm astounded that just over a century later, we've transformed this into a critical medical field with rapidly changing technology and greater and greater precision. Image is in the public domain, taken from Wikipedia.

Medicare and Residency

Interestingly, Medicare also pays for residency education. Residents are the poorly paid workhorses that do the day-to-day work in hospitals and clinics. Although governmental subsidy of post-graduate training is not unexpected, the fact that Medicare covers it surprises me. Taxes collected for Medicare pay residency programs to train future generations of physicians. In 2008, 2.7 billion dollars were paid as resident salary and benefits, and 5.7 billion dollars were paid to teaching hospitals for indirect costs. Because funding has remained fairly constant, the number of residents trained is constant. However, we're reaching a point where there aren't enough doctors; patients are getting older, health insurance is expanding, but there simply aren't enough providers to see everyone. Furthermore, we can't increase the supply of doctors because Medicare doesn't have the money to do so. Even if medical schools increase enrollment (which they are), the physician supply will be limited by residency spots which, in turn, is limited by Medicare's budget. This is a strange and perhaps unwieldy system, but it seems to be here to stay.

Medicare and Money

Medicare, which provides health insurance to Americans 65 and older, will face a financial crisis. In the 2008 report to Congress, the Board of Trustees estimated that the program's hospital insurance trust fund could run out of money by 2017. This is a problem. Despite the health care legislation being discussed right now, it's not clear that government health insurance can remain solvent in the near future. Any new health care bill must account for long-term planning. Where is our money going to come from? How can we keep costs down? Can we guarantee that this major health care overhaul will remain stable in the future?

I feel that a solution to health care must encompass wide-reaching policies in different fields. For example, to keep Americans healthier and control costs, we need to target chronic diseases that are rising in prevalence like diabetes and obesity. To make headway on problems like that, we need to step out of the health care box and push for policies in other arenas. For example, how much does the government subsidize commodity food products like corn? Food companies have a huge incentive to produce corn products including high fructose corn syrup because the infrastructure and government favors this. But high fructose corn syrup products, fast food, soda, indestructible sugar-laden foods are all responsible for driving up our health care costs and increasing the prevalence of obesity and diabetes in children. If government is to take a stance on health care costs and if we are leaning towards a role of bigger government influence, then it needs to subsidize fruits and vegetables, not candy and chips. We need to favor local small markets rather than multinational corporations.

In the same way, we need to figure out how to prevent people from starting to smoke; prevention is a lot easier than intervention, and cheaper. There is a fair amount of research and a number of medications that help people quit tobacco, but what we need is research figuring out how we can stop people from starting in the first place. If we want to keep health care costs down and people out of the hospital, we need investigate how people make those personal choices.

We don't want to tell people what to eat or how much to exercise or whether they can smoke or not. We don't want to interfere with their personal decisions and free will. But if we're serious about taking on the responsibility of health care and if our funding is not inexhaustible, we need to put pressure on people to stay healthy.

How much money do we spend on mammograms and prostate cancer screening? How much money do we spend on getting kids to eat vegetables and exercise? Which, in the long run, is most cost-effective at increasing health? I don't know what the answer is, but I want to suggest that if we take a stronger stance on prevention, even if it means more government, we can get people to be healthier and perhaps save on our health care costs.

Art II

Why write? For me, writing provides a necessary outlet to organize in my head and express the complex emotions, unfamiliar situations, and difficult moments that are inherent to medical school and taking care of sick people. Blogging every day, even if it is not directly about my day-to-day experiences, allows me to decompress about the faults in medicine and brainstorm on ways to fix it. More and more, reflection is seeping into medical education, but I am not sure it should be universalized. Reflective writing works for me, but that doesn't necessarily apply to everyone. By now, most students know how they deal best with stress; writing is only one of many ways to let that out.

But stories and poetry are also more than that. Narratives are how we describe the world. No matter how hard science tries to sterilize or objectify medicine, it remains in a world of human experience. Each patient and her illness unfolds as a story over time. Each patient will tell a unique story, if only we listen. Stories are a dynamic, probing, and interactive art form. They challenge readers, create worlds, stimulate imagination, and confront human emotion. Underlying each different perspective is some unifying shared human experience, allowing great stories to speak universally.

In any case, art is important. What we create in this world lasts. Why do doctors take care of the sick, prevent patients from dying, try to extend quality of life? So those people can live and create and love. We are not an end in ourselves. We exist to support those human activities that create art, build community, push the frontiers of discovery, and celebrate humanity.