The Red Button

I don't post all that frequently (yes yes, durr, that's obvious), so perhaps as a result of that, I try to make 'em count when I do. My rant about arguing with the Billing department at my old job related to a guy we were about to release on a blood thinner (the practice didn't want to pay for INR checks, because the guy was behind on his bill) got linked by the AAPA's Twitter presence, for example, and I liked how my own subjective view of a larger problem got some small and fleeting light shone on it. Swear words and all, btw, so good for AAPA on that one especially.

I'm presently in the midst of a kerfuffle with a family member about childhood immunizations. And I feel kind of bad, because this person is a pretty amazing parent, all in all, and the young kids involved are great kids. Their shots are all up-to-date as far as I know, and I miss those kids like crazy whenever I don't see them for a while.

But tonight this family member said something on Facebook about "wondering if (they) could trust the pharmaceutical companies and doctors" and about "finding the other side of the coin," when it comes to measles. To be fair, I was the one who brought up measles, quoting some statistics about how deadly a disease it used to be, as a way of showing that the 90-some percent immunization rate we have now is, y'know, generally a very good thing.

That's when Family Member trotted out an unsubstantiated claim that there have been "a lot of" recent sudden-death reactions from shots, among babies and little kids. And that's when I sort of lost it.

I get little clinical updates in my email inbox all the time. From my employer, from SEMPA, and from the various clinical resources I subscribe to and use online all the time. If there were a rash of deaths, linked to anything, I'd be hearing about it. Plus, as I said in response over Facebook, if there really was a problem that seemed to be linked to a vaccine, those big bad Pharmaceutical Companies would be pissing themselves over potential lawsuits, and pulling vials off the market so fast there would be little vial-shaped Looney Tunes-style clouds of smoke whenever we opened a box of the product. If you call them weaselly and profit-motivated (which by the way I wouldn't argue against), then you have to accept all the consequences of that, and see them through logically.

Along those same lines, when Family Member said that there were supposedly more deaths per year from reactions than there are from measles, I laid a logical smackdown: the whole reason measles deaths are so damn rare nowadays is because of the immunizations. You can't compare the post-innoculation mortality numbers from measles to the number of hypothetical, unproven deaths from the injection, without also factoring in the number of deaths that would happen if there were not immunizations. Apples to apples, please.

And so, thinking about how to explain this to a layperson, a good parent, a concerned citizen, and an intelligent person who just isn't used to thinking about this problem as the public health issue it actually is, I came up with the following scenario. Try it sometime on your vaccine-averse friends and family, and see how you do:

Imagine you are standing in a room. In front of you, on a console, there are two buttons, one red and one blue.

If you press the red button, ten little kids will die.

If you press the blue button, one hundred thousand little kids will die.

Put it like this, it's horrible and it's sad and it should never happen, but the right thing to do is pretty damned clear, right? You press the red button. You press the crap out of it, then you press it again to be sure the blue button won't somehow get pressed by mistake. And that's, in a sense, sort of how public health questions are/ should be/ need to be approached. It's a way of thinking that, thankfully, most people don't really need to engage in; we get to enjoy the illusion that these sorts of choices are only hypothetical, and beyond the reach of modern science and public policy. For people who really do work in Public Health, I imagine this discussion is even more maddening than it is for me, a humble Urgent Care Bear.

But wait, excuse me, I left out one very important part:

If you press neither button, a timer will count down from 30 seconds to zero, and then the blue button will be pressed anyway.

This, I think, is a pretty decent analogy for what a lot of immunization-averse parents are doing. The timer has a much, much longer countdown, but the basic idea is the same. Parents who want the best for their kids, don't know whom to trust, and can't possibly have all the facts they really would like to have in order to be 100.00% sure will often simply retreat from the conundrum, throwing up their hands in frustration.

And as a result, they don't press the red button, while not exactly pressing the blue button either. Which helps explain why, as a result, herd immunity has been declining slightly but measurably, and some medical practices are actually starting to refuse to see kids whose parents refuse to immunize.

Tick tock, guys, you need to make a choice. And again, the better one, or at least the less-horrible one, is to press the red button. That's obvious to just about anyone.

Ahh, but if that's true, then what's the problem? How does Jenny McCarthy (who for me, by the way, is most famous for being naked in Playboy when I was in my early 20s) get so much traction with her anti-vaccination propaganda? Why does my otherwise kind-hearted, smart family member treat the sketchy, anecdotal evidence as if it were as legitimate and relevant as the actual data?

As a parent, I understand this one far better than I understand it as a medical practitioner, and as a practitioner I understand it pretty well. It involves a subtle but important change to the first part of the rules:

If you press the red button, ten little kids will die. One of them might be your kid.

If you press the blue button, one hundred thousand little kids will die.

I honestly don't know what I would do. I know logically that saving 9,990 kids is a good and noble thing, and something I'd be proud to do. I know I'd probably sacrifice my own life to do it, if I had to, and that it would be "a good death," as Crazy Horse, the Klingons, and Batman would say. That's what I'd consider heroic, under most circumstances.

But to take the beautiful, amazing little kid that makes my days so rich, the one that adds so much that's good to what I've contributed to the world (and easily makes up for all the stupid stuff I've ever said or done out of fear or ignorance), and potentially just snuff out all the incredible, wonderful life she has ahead of her? Fuck you, buddy, this just stopped being interesting.

And that, of course, is how the argument works. How dare you even think about causing my kid harm!, people say, choosing not to acknowledge that crossing the street or driving to the park is far more dangerous.

But that's parenthood. We're programmed by Nature to be fierce protectors of our offspring. This is why I don't look down on people who have doubts about immunization, and I don't think people are necessarily being stupid when they don't immunize. (Yes, they are being stupid, actually, but it's stupid in a way, and because of something, that I empathize with.) People are being selfish, is what it is, and I empathize with that as well.

It's to our credit, in a weird way, that in the world we have made over time, we haven't had to make these kinds of decisions. We've done okay, as a society, because we don't need to make Sophie's Choice on any sort of a regular basis. We don't routinely give birth to four kids but only get to raise two of them past the age of 3 years old, anymore. We don't tend to die in childbirth all that often. We don't have any real first-hand experience, anymore, with polio or smallpox. So it's understandable that we're so very bad at thinking this way.

But all it would take is a couple of generations beyond the present argument, and I suspect we'd regain the kind of clarity we would need. I really hope it doesn't come to that. And in the meantime, as I've said in the past, if your kid isn't immunized, that's a shame, because now my kid can't play with yours, and you aren't welcome in my house. If we're going to decide as a society not to slide backward, I figure it has to start somewhere.

I am pushing the red button.

Hi.

There may be a few new visitors thanks to my essay over at Life With Levi, about co-sleeping with the toddler. So this is as good a time as any to re-introduce myself and the blog, and maybe explain why it gets updated so infrequently.

For several years, this was a story about an Arts-educated guy, finally admitting that while not going to med school as a 22-year-old douche was probably the right decision, it was nonetheless time to buckle down and get serious about joining the profession as a 30-something guy. Then, it was a story about the long and sometimes painful process of doing just that. In the last few years, with graduation and employment, it was a much-less-updated story about moving into the world of practice as a PA. The first job out of school was... not awesome. And it seems like more and more ER and other med-bloggers are closing down their blogs all the time. It's an odd situation for people who want to share ideas and observations, since so much tension still exists about HIPAA and whether it's possible to even be a medical person and a blogger (I think it certainly is, and there are steps you take that are not so difficult really, but even people who are cautious find themselves in more trouble than it's worth).

So at the moment, it's a very slow and gradual story, about how to put it all together. I'm a second-career medical practitioner, a stay-at-home dad, I still have that liberal arts point of view, and it's always nice to see new people around here. How are ya?

Fun facts

It's been... A while.

I couldn't talk much about my previous job because for a while there, I was just so darn new at it. Then, I couldn't talk about it because I hated it. Fnally, I couldn't talk about it because I signed a document saying I wouldn't say anything bad about them for a year.

Year's up - well, more than that, really - and honestly, meh. It was not a good situation, but everybody's had that feeling they're in the wrong place and should maybe be thinking about leaving. I was actually pretty lucky, because I suspect someone there must have realized, oh crap, we hired this guy and it's not what we advertised, and he's stubborn enough to sufer through it.

So I'm not mad. I'm not even frustrated anymore (which may have been the point of the one-year noncompete and nondisclosure, naturally). They gave me a big check in exchange for being cool about things, and I spent half a year doing nothing but taking care of my kid. Most people I know would be all over that, and indeed I am.

My new job, I can't talk much about because the group has a very intelligent policy about social media. But as I understand it, I am free to just make up unrelated and random crap as much as I want. I will maintain the same paranoia about patient info I've always had, and assume that of the twelve people who ever see anything I write here, two are related to the person I'm talking about. I'm also starting to think that every patient in every story from now on should be one of the characters from Yo Gabba Gabba, but that could just be where my head's at these days.

Working part-time iiiiiiis awesooooooommme!

More in the next little while.