First of all, it is NOT because they make money from the vaccines.  I have seen this claim on forums, but it is just not true.  In fact, practices are happy if they do not lose money on immunizations.  The reimbursement by insurance companies barely cover the cost of the vaccine, much less all of the labor that goes into administering them. Vaccines are not a profit center for doctors.

The biggest reason doctors push immunizations is they really believe immunizations are critical to maintaining good health.  It is what they are taught throughout their training.  Numerous experts and professional organizations take the position that without the widespread use of vaccines, serious diseases would be rampant.  With all of this training and expertise supporting the use of vaccines, it just does not seem logical to them that a rational individual would object to their use.  Therefore, they conclude that anyone who objects to immunizations has to be either crazy or uneducated.

Secondly, they believe their role is to protect children.  Since, it is common knowledge that immunizations are so beneficial, it is critical that they do their best to overcome the objections of those parents who stand in the way of the children getting optimal health care.

Thirdly, the vaccines are not 100% protective.  Some individuals do not develop adequate protective antibodies when given the vaccines.  Therefore, if too large a portion of the population does not get immunized and thus the incidence of the disease increases, these immunized, but unprotected individuals are put at unnecessary risk.

Fourthly, the very palpable fear among physicians of being sued  has dramatically altered the way all physicians practice.    If a child ends up with brain damage following the administration of a vaccine according to guidelines, that physician is under no risk of being sued.  If a family tried to seek damages, it would be covered by the Vaccine Injury Act.  On the other hand, if a child is not immunized per parental choice and comes down with pertussis, for example, and has a bad outcome, the physician would be very exposed to the risk of being sued.

Next, we unfortunately live in a highly regulated society.  Every aspect of our lives is now controlled by some government entity or entities.  With regulatory agencies breathing down the necks of physicians it is problematic for physicians if a significant part of their patient population is not following the CDC guidelines.  This is even more true for those practices which are owned by hospitals and today most practices are owned by hospitals.

Last on my list is that it takes significantly more effort to care for families who do not follow the standard schedule.  If a child is brought in for his/her two month visit and just gets their shots according to the schedule, it is a very simple thing to roll out the typical two month shots and give them.  In contrast, dealing with a parent with concerns about vaccines or figuring out a schedule for those selectively vaccinating takes a significant amount of time.  Physicians are under significant time pressures, so anything that requires that they spend more time with a patient can put them on edge.

My last post was trying to promote a better understanding of those who do not immunize.  This one, is trying to improve understanding of the physician’s viewpoint.   I am not arguing for or against any of these opinions, just letting people know what is behind physician’s positions.

My next post will discuss why I give patients the freedom to choose.

It has become an increasingly frequent experience for parents, who have concerns about the safety of vaccines, to have very negative encounters when interacting with the medical system.  These interactions range from being treated as ignorant weirdos who need to be properly educated, to the outright refusal of care.  We are, sadly, now at the point where a majority of pediatric practices refuse to care for children who are not immunized according to the official recommendations.  Here is a typical vaccine policy from a local pediatric practice (http://www.parksidepediatrics.com/eResources/Vaccines/StatementonVaccines/tabid/150/Default.aspx)

My practice has the philosophy that parents, not the medical establishment, should be the ones choosing how or if they will immunize their children.  It is a matter of freedom, which to me, takes precedence over the science of immunizing.  I am personally in favor of vaccines and all of my children have been immunized according to the standard schedule.  However, I believe it is wrong for a physician to coerce a parent into vaccinating, when they are uncomfortable with it.  I believe each of us has the right to make our own decision and then we have to live with the consequences of that decision.  It grieves me, when I see the guarded or fearful look come into the eyes of a parent when I start asking questions about a child’s immunization history, because they are afraid of what will happen when I discover they are not immunizing according to the established rules.

This philosophy of freedom first, has certainly led to a boom in our pediatric practice as parents have sought a place where they can get medical care for their children, without having to endure an unpleasant doctor-parent interaction.   I now have had a significant amount of experience with selective and non-immunizers and I have some observations I would like to pass on to providers of health care to children:

1. These parents are NOT ignorant.  In fact, many of them are far more educated about vaccines than most pediatricians.  Most physicians would argue they have misinformation and one can discuss the accuracy of the data on either side of this issue, but the issue is not a lack of education.  It is ridiculous and insulting when providers browbeat these parents over and over about the issue of immunizations.
2. These parents are NOT weirdos.  These are very engaged, critically thinking parents, who are trying to protect their children from unnecessary risk.  The fact that a majority of the medical establishment does not agree with their conclusions does not make them weirdos or troublemakers.
3. These parents are NOT unconcerned about their children’s well being.  They are every bit as committed to their children’s health as the parents who willingly go along with the standard immunization schedule.  They have simply come to the conclusion that the risk to their child from immunizations, especially at such a young age is greater than the risk from the rare diseases that we are immunizing against.  Again, one can disagree with their conclusion, but it does not make their motives wrong.
4. I do not understand the reasoning, when a doctor says he/she will not take care of an unimmunized child because he/she is concerned about the child having proper medical care.  They claim that immunizations are absolutely critical to the well being of children, but then if a parent refuses to immunize, they tell the parent it is better for the child to have No care than to not have care the way they deem appropriate.  How is no care better for the child, than unimmunized care?  There are all kinds of areas where patients do not comply with our recommendations.  Why are immunizations treated differently than any other area of “non-compliance” where we take care of patients to the best of our ability within the context of that individual’s environment?  (I have my theories, but that is for another posting.)
5. Informed consent should apply to vaccines, the same as any other medical procedure.  A major tenet of contemporary medical practice is “informed consent”  The theory is that a patient is given the risks and benefits of any intervention and the patient then chooses whether they want to undergo the procedure or not.  How is it “informed consent” when one does not have the right to say “No”?  No intervention, including immunizations, is risk free and yet parents are only ever given the positives of vaccines, never any potential risks.  That is not informed consent.
6. There is a tremendous sense of disproportion on both sides of this controversy.   Every time a parent  puts their child in a car, they accept without hesitation, the risk that the child could be injured or killed during that trip.  At the same time,  those same parents agonize over the potential risk that a vaccine poses to the child, even though that risk is only a fraction of the risk we assume by putting our child in a car.  I am not arguing that a parent should not consider risk and benefit when it comes to vaccines, but I do not think vaccines are as dangerous as some would have us believe and parents need to keep things in perspective.  Pro vaccine advocates are just as guilty of overstatement.  To listen to the rhetoric, one would think that if a child is not immunized, they WILL get sick with one of these illnesses which we immunize against.  This is just not true.  Thankfully, these disease are all very uncommon and very few children, immunized or not, will develop them.  One can argue, that they are rare as a result of successful immunization programs and for some this is undoubtedly true.  At the same time, regardless of the reason, the low incidence of these illnesses does impact the risk-benefit calculations.
7. Unimmunized children are NOT sicker than immunized children.  There are no studies comparing outcomes of immunized vs unimmunizing children and unfortunately this kind of study will never be done.  However, as I mentioned earlier, I have lots of partially or unimmunized children in my practice.  I can say, unequivocally, that these children are not sicker than the immunized ones.  In fact, they are in the doctor’s office far less than their immunized counterparts.  I do think they are at a slightly increased risk from vaccine preventable illnesses, such as pertussis, but that is a risk these families have chosen to take, over the risk from the vaccines.  For every other illness, they are not sicker and for a few reasons may be healthier.
8. Unimmunized children are not a danger to immunized children.  Some argue that forcing children to be immunized or ostracizing those who are not, is for the purpose of protecting all of those children who are immunized.  Again, I question the logic.  In the first place, immunizations protect against very specific, but uncommon illnesses.  Since these diseases are so uncommon, it is highly unlikely that an unimmunized child will contract these illnesses and transmit them to immunized children.  Then if the vaccines are such successful sources of protection against disease, then even if an immunized child was exposed to a vaccine preventable disease through an unimmunized child they should be protected from getting the illness.  The reality is that these outbreaks that one hears about is mostly among immunized individuals and has little to do with a child.  This is not an argument against vaccines as vaccines do protect a majority of their recipients and even when an immunized person gets one of these illnesses it tends to be milder.  However, it is an argument against the emotional response of treating unimmunized children like lepers.
9. You catch more flies with honey, than with vinegar.  The vast majority of parents who come in opposed to immunizing their children do eventually at least partially immunize their children.  They are mostly looking for a physician who will listen to their concerns and allow them the time and freedom to move forward with immunizations when they feel comfortable and not be forced into a one size fits all mold.  They are very put off with the condescending, even hostile treatment they get at many physicians offices.  If the real goal here is to keep children as healthy as possible, treating these parents respectfully will get much more accomplished.  By badgering unsure parents into immunizing, you will get some more children immunized, but you will also build walls and resentment with those parents.  For those parents who are sure they do not want immunizations at this time, they will just disappear from health care all together and that is not improving the health of the children.
10. Physicians should be scientific about vaccines.  It astounds me how unscientific many physicians are about immunizations.  A scientist is always questioning and testing assumptions.  A true scientist looks at all possible explanations.  Very few physicians, who take adamant stands about the value of vaccines, have actually studied the subject.  They just quote what they were taught in medical school and accept the recommendations of the professional organizations as gospel.  If evidence arises that contradicts the assumptions, they just toss it away as irrelevant.  Obviously, we cannot independently study every topic with which we deal.  What I am asking is to keep an open mind, as we should with all subjects.

There is no question it takes significantly more time and energy to openly deal with this issue, but if our role as physicians is to be advisors and healers to our patients, it is right that we do so, regardless of the decision they ultimately make.

About fifteen years ago, Geraldine came to me as a new patient.  She was 78 years old and was having some abdominal symptoms.  She had already seen a few doctors over a period of time, but no one had been able to diagnose the cause of her symptoms.  I did a work-up on her and unfortunately had to tell her that her symptoms were coming from ovarian cancer, which at this point was pretty advanced.  Because of her poor prognosis, even with treatment, she opted to not be treated for the cancer.  In a matter of months she was too weak to get out, so I began to make house calls on her.  Every couple weeks I stopped by her apartment to check on her, but mostly we just talked.

During one of these visits she told me she was so appreciative of my having diagnosed her problem, even if it was not fixable, and for my coming to see her in her home.  She wanted to show her appreciation by doing something for me.  What did I want her to do?  She was quite weak, so I was not sure what to tell her.  However, I had noticed that whenever I came to see her, she was crocheting something.  I had recently read about a doctor trying to make those horrid office stirrups more comfortable by putting crocheted covers on them.  I told her about the idea and asked her if she could make a pair for me.  Geraldine was ecstatic and within a week she had made me a whole bag of crocheted stirrup covers.  A month or so after this, Geraldine passed away.

Our stirrup covers have now been replaced several times over, but to this day, whenever I use them, I am reminded of Geraldine and the simple task that brought a sense of purpose to the twilight of her life.

As a physician, I am often told by patients that they do not want medicine to cover the symptoms, but an answer as to the cause of the symptoms.  Until one knows the cause of the symptoms, it is impossible to prescribe the proper treatment.  We are currently living in a day where widespread unemployment, economic stagnation, out of control debt and mutually exclusive political philosophies are the symptoms of a serious and life threatening disease.   If we want a solution to all of the symptoms, we need to know the underlying disease process.

Economic activity occurs as people exchange money for goods and services.  The money that people use to purchase goods and services come from one of two places.  They either earn it through their employment or it is given to them through charity or government programs.  In the first case businesses employ people and pay them for their work.  In the second case, money is given to charities and government by businesses and employed individuals in order to be distributed to those who are not employed adequately to meet their needs.  In both cases, the bottom line is that money originates with businesses.  Those business may be multibillion dollar conglomerates or a child’s lemonade stand.

If we have a sick economy, it is because there is an inadequate amount of business to generate the money required for all of the needs.  This brings us back to the original question, “why do businesses exist” for if we do not know why they exist we will be unable to create the environment in which they can prosper.

Businesses do not exist to employ people.  They do not exist to provide health insurance or other benefits to their employees.   They do not even exist to pay taxes, so the government can fund its programs.  Businesses do not even exist to produce goods and services.  Large or small, businesses exist so the owner of the business can MAKE MONEY.  Employment, benefits, taxes, charity, production of goods and services all happen on the way to a business making a profit.

When the regulatory environment becomes too onerous or fear of litigation too great or labor too expensive or tax burden too high or demand for the output too low for the owners of the businesses to make an acceptable profit, the business will disappear.  When this begins to occur on a large scale the entire economy suffer and that is what is happening in our economy today.

For a variety of reasons, it has become socially unacceptable to pursue profit in our country.  Even our business students do not want to admit it.  At one time, our country was the best place in the world for a business to prosper, but that is no longer the case.  Until we once again create an environment where making a profit is laudable and doable we will continue to have a failing economy and we will ALL be poorer for it.

That is my diagnosis and treatment for the problems plaguing our economy.

Keith Stafford, MD

1)  A doctor is an individual who went to medical school and a residency to become a physician.  There are all kinds of ways of obtaining doctorate degrees in all sorts of fields.  I do not intend to diminish the accomplishments of those who earn doctorate degrees in various fields, but I believe when one says, I am going to see “the doctor” it should mean seeing one who has the training as noted above.  Numerous health care fields, like nurse practitioners, physical therapists and pharmacists are now awarding doctorate degrees as their standard degree.  I think this is confusing to patients and an attempt to obtain a status on par with physicians. There are many different health care providers, all with their individual and critical roles.  I disagree with the attempt to blur the lines between the different roles.

2)  A doctor has great amount of knowledge.  The education of a doctor  starts with many years of school (4 years of college, 4 years of medical school and 3+ years of residency) memorizing, learning and experiencing things that give him/her expertise in the field of medicine.  Throughout the career of a doctor, the learning never stops.  Today with the internet, it seems all one has to do is look up WebMD or Mayo Clinics and one can know as much as a doctor.  Certainly, the internet has expanded everyone’s ability to find information, but making a diagnosis or deciding on a treatment is much more involved than simply looking up a list of symptoms and there is the obvious diagnosis and treatment.   I wish it were that simple.  The fact is that human biology and behavior are far more nuanced than a simple matching of signs and symptoms.   While some things in medicine can be solved and resolved with cookbook formulas, much of it cannot and this is where the art of medicine and all those years of training and experience become so critical.  It is why a thinking doctor will never be replaced by a one size fits all computer.

3)  A doctor is a major influence.  Due to all of the education and experience a physician accumulates, society has granted physicians a significant amount of influence and authority.  That influence and authority is a great privilege and needs to be treated with even greater respect by the physicians to whom it is granted.  I sometimes wonder if many physicians are cognizant of the huge impact their words have on people.  A physician’s words and manners can be either soothing and healing or anxiety provoking and hurtful.  We doctors need to strive for the first.

4)  A doctor is an advisor.  I believe the primary role of a physician is to be an advisor.  It is my job to listen to the patient, examine as appropriate and analyze all of the available data and then render an opinion as to the appropriate course of action.  I do not get upset if a patient does not follow my advice.  It is their body and their choice.  Some doctors view themselves as THE AUTHORITY, but I believe this is the wrong approach.  There is a partnership that exists between a doctor and patient.  Each one brings things to the interaction that have to be considered.  Each patient approaches the situation from a different context.  It is not uncommon for a patient to have information of which I am not aware or had not considered.  I value this input from the patient.

5)  A doctor is a friend.  Over the years, many of my patients have become friends.  This is a wonderful aspect of being a family physician.  Whether or not I get to know a patient well enough to become a personal friend, my goal with all of my patients is to make them comfortable enough, that no matter the issue, they will be confident that my objective is to give them the same courtesy and rendering of my skills that I would give to my best friend.

“I had a really neat delivery this AM for a super sweet couple.  It was the mom’s 3rd baby and she  was laboring on her side.  (I have delivered all of her babies.)  When it came time to push, I left her on her side as she was quite comfortable in this position.  Baby was occiput posterior, so it took some work for her to push it out.  Dad was sitting on a chair next to the bed on the side mom was facing doing very encouraging, support person stuff.  I was sitting on the bed, behind the mother.  There were no interfering drapes or sheets.  Because of mom’s position, as the baby was coming into view, the father was as close to her perineum as I was, so he got to see his child’s birth in detail, rather than peaking from up above.  The really cool thing was that since the baby was OP, as it was born, it had its eyes wide open and was looking right at his father, so his father was the first person he saw instead of me.  Then this baby took a big breath and began audibly crying while the head was still the only part delivered, which added another unusual twist to the delivery.

It felt so right to me,  because with me behind mom and dad being so close and involved, I felt like I was not even integral to this delivery, It was just something, very personal, that this family was doing together.  Then the icing on the cake was that instantaneous eye to eye contact between father and son as the head emerged.  I so wish I had it on video.”

When one feels all of the pressures with this kind of job, it is this kind of experience that reminds one as to why you keep doing it.

I certainly do not mind being presented with a birth plan and using it to review a couple’s expectations and preferences.  However, in my opinion, it is far more important that one find an accoucheur (birth attendant) whose default style is in line with your birth plan, than trying to get someone to change their style to match your preferences.  In light of this I decided to write down my birth plan from the perspective of the professional who is being entrusted with caring for an expectant couple.  Here are my goals and preferences:

1. Give the couple the type of birth that THEY want to experience.  While most overt birth plans are produced from those who are looking for a natural birth experience.  Not everyone is looking for this.  I have some moms who want no medications at all and I have some who want an epidural placed in the parking lot.  Whatever the preferences, I will do my best to accomodate them.
2. Explain all interventions and get the mother’s permission, before doing them.  One of the biggest complaints I hear about unpleasant birth experiences is that things were done to them without them knowing what was happening.  While it is easy for a doctor to go into automatic mode, I do my best to not let that happen.
3. Alleviate fear.  One of my frequent statements about pregnancy is that it is the permanent state of paranoia.  Couples are often plagued by the “what ifs”  and modern obstetrics often adds to this with the constant pursuit of worst case scenarios.  While it is certainly true that bad events can occur during pregnancy, thankfully this is the exception and not the rule.  My job is to be alert for  problems without turning every visit into a worry generating experience and to reassure moms when there is no reason to worry.
4. Avoid Inductions.  I hate inductions.  Sometimes, inductions cannot be avoided, but even then I still hate them and really try not to do them.  No one knows what actually triggers labor, but one thing I do know is that forcing a uterus not yet ready to labor to labor is asking for trouble.
5. Encourage mothers to stay out of bed and in motion.  The best way to reduce discomfort and to move labor along is to stay out of bed and move about and frequently change position.  One can also use birthing balls, whirlpool tubs, showers, hypnobabies.  Doulas are welcomed as part of the birthing team and a great help in keeping the labor moving along in a productive manner.
6. Prefer no epidural.  If women want to have an epidural, they may, but my preference is no epidural as this allows for the most physiologic beneficial labor possible.
7. Keep the stirrups stowed.  When someone is ready to have their baby, the nurse’s automatically reach for the stirrups.  I tell them to put them away.  In my opinion, the stirrups serve no useful purpose and they impede a mother’s ability to find the most comfortable position in which to give birth.  I deliver women in whatever position they are most comfortable and have delivered ladies on their side, hands and knees, leaning over bed, standing, squatting, whatever works.
8. No episiotomy.  I avoid episiotimies.  (Hint:  when a doctor says they only cut an episiotomy when it is needed, they probably cut episiotomies on most of their deliveries)
9. Put baby on mother’s chest as soon as baby is born.  The baby goes from me to the mom, not the nurse.
10. Delay cord clamping.  I cannot say, that this is something that I fully understand, but it is frequently requested so I have incorporated it into my routine.
11. View Cesarean section as a negative outcome.  Again sometimes cesarean sections are unavoidable, but I never view them as equivalent to vaginal birth for delivering a baby.  Whenever, I have a pregnancy ending with a cesarean section I review the various aspects of the pregnancy and labor to see if I could have done something different to have ended with a vaginal birth instead of a cesarean section.
12. Maintain a relaxed environment.  Sometimes things can get pretty tense in the birthing suite, but it is my job as the team leader to keep things relaxed and low key.  I have no use for all of the drapes and masks.  I do  not even wear scrub suits (though my wife wishes I would).  This is how I got my nickname “Dr. Polo Shirt.”  I work at calling everyone involved in the birth by their name and try to treat them the way I would want to be treated.  
13. Care for the baby I deliver.  I really like it when I get to take care of the baby that I have delivered.  This is one of the services that is unique to family physicians who do obstetrics. Keeping the pediatric care with the same doctor who one has gotten to know throughout the pregnancy provides a level of comfort not available with most other care providers.

I recently found out that the word “blog” is actually an abbreviation for “Web Log.” A log consists of a series of entries denoting events that happen over time, so a blog is a longitudinal series of entries that recount events and thoughts that one has during a given period of time.

There are all kinds of health web sites out there and many extremely creative blogs exist. What do I hope to accomplish with mine? I guess it is a desire to put into writing some of the experiences and thoughts that occur to me throughout my day to day living. I have no idea if that writing will be interesting enough for anyone else to read, but I have always found that writing has helped me to clarify and organize my thoughts and so I write this blog first of all for myself. Putting thoughts on “paper” will cause me to flesh out some of the fleeting observations that I make over the course of a day.

One of the things I have always enjoyed about teaching, is when I teach others, I learn even more myself. When I organize concepts in order to publish a blog, it will help to enhance my learning. Others might also learn from the things I have learned.

Writing down our thoughts and saving images of ourselves is also the closest we can get to immortality on this earth. My father died when I was 24 years old. He was sick for many years before that and demented for a number of years prior to his death. I have no memories of the extremely intelligent and talented man, who was my father. Nevertheless, when I see things he made, view pictures of him and the people he knew and read things he wrote, I am able to form a picture in my mind of the man who was my father. I hope that at the very least, this blog will be an electronic web log to prompt pictures of the man I am/was in the minds of my children over the coming years.

The title “Healing Medicine” comes from the intent of most of the posts to be related to the world of medicine and how it interacts with individuals, identified by the medical world as patients. The practice of medicine is a noble calling, but today’s brand of medicine has lost much of its human touch and as such lost has lost much of the art of medicine that in times past brought healing despite a much smaller armamentarium of medicines and technology. I want to explore where we are today and what we have lost.

I bring to this blog my own personal unique way of viewing things and over 50 years of life experience. Since a large part of my day involves practicing medicine and I have been in the medical world for 36 years, much of it will relate to that. I have my own business and that is a major contributor to my life experiences as well. I am sure it will also involve my thoughts on other things that peak my interest. I hope all of that makes some interesting reading and more importantly provokes one to think.

Here goes: . . .