Allergies, Vaccinations and Non-profit HMOs
Dr. Marc Siegel has been appearing frequently on TV and in print addressing Americans' fears about possible bioterrorist attacks. Our government gives us advice, but as Dr. Marc says, "this business about duct tape and plastic and gas masks is ridiculous; not only wouldn't it work, not only is it unnecessary, not only is the wrong message being sent, but it is also making plenty of money for hardware stores and duct-tape companies." So do we have anything to fear from an attack? Ask Dr. Marc today. --The Editors
Dear Dr. Marc,
The number of people affected by food allergies--especially peanut allergy, the leading cause of life-threatening food allergic reactions--is growing. Many of those affected are children. In highly allergic people, anaphylaxis can cause death within minutes. Even minuscule exposure--oral, respiratory or tactile--can cause a reaction. There is presently no cure. Strict avoidance is critical. Given these factors, can you comment on the issue of keeping peanuts and peanut butter out of schools and other public places--particularly those that serve children--as a way of minimizing the hazard to their lives? In doing so, can you address the issue of community responsiblity versus individual rights in considering disabilities?
This is a very important question. Let me begin by saying that there is a treatment for anaphylaxis; rapid injection of epinephrine followed by steroids can be lifesaving, and people with known life-threatening food allergies should carry an epipen with them at all times. In the case of a child this may be administered quickly by the school nurse. Your question regarding human rights is a more difficult one, since food allergies may be hidden, but only in a small number of cases, even with allergies on the rise. Still, since the outcome may be so drastic, I am compelled to believe that such a food as peanut butter, which has a fair number of allergies attached to it, should be kept off the school menu. In this case the risk to a few outweighs the benefit to the many. There are other high-protein foods to eat, after all, though kids may not favor the healthiest of foods. I think community responsibility in this case requires preserving the safety of the individual.
Dear Dr. Marc,
More states are about to cap damages for pain and suffering in malpractice cases, and otherwise reduce the accountability of insurers, bad doctors and profit-motivated hospitals for the harm they do to people through slipshod medical care. Insurers want to increase profits by cutting down on the amount of doctor time and hospital time that patients use. They have been doing this in recent years through capitation, restrictive formulas, bogus "customary rates" and by routinely denying coverage for expensive treatments, among other things.
One of the few things that gives them pause in their drive to reduce the quality of care is the fact that if they go too far and kill someone, they'll have to pay out of another pocket, through malpractice judgments. But if their malpractice liability exposure can be cut down to a predictable and manageable level, then the consequences of bad medicine will be just a cost of doing business. Insurers will be freer to refuse to include the better doctors and hospitals in their networks, putting many out of business. Is there any possibility that medical associations or doctors in general will figure out that these legal "reforms" are bad for good doctors?
Los Angeles, California
Your equations give too much weight to doctors and not enough to the insurance companies that you properly assail. Of course doctors should be held accountable and are being held accountable for practicing bad medicine. But doctors should not become the fall guys for big business. Imagine if a doctor insists on a test but the patient's HMO refuses to approve it, so the patient who can't afford it won't pay out of pocket. The way the law stands now, the doctor can be sued but not the insurance company. I think that's wrong. What's required is a fundamental rethinking of the laws that regulate these practices.
Dear Dr. Marc,
I've got a query about routine vaccinations for babies and children. I have a healthy 9-week-old baby girl. I don't think that I am sufficiently knowledgeable about the subject to give my "informed consent" for beginning the vaccination procedure. I have numerous concerns ranging from thimerasol, aluminum and possible unknown pathogens in the vaccines to the potential long-term systemic consequences of bypassing the body's "normal" immune response to disease. I've basically been told that refusing her shots is neglectful and equivalent to inviting raging pestilences upon her.
I am not remotely opposed to allopathic medicine--I've benefited from it too many times for that. Yet I'm still unsure. I don't want to act against my better judgment and risk her long-term health for the sake of avoiding controversy. While I know you can't tell me what to do, I hope you can provide me with a little more information about the risks involved with immunizations.
This is a difficult question to answer, because the long-term data isn't there to show harm from the latest vaccines, which do not have the aluminum or mercury content of their older counterparts. On the other hand, much of the rationale behind mass vaccination is to protect a society from a disease, which makes the argument for vaccination difficult to apply on a child-by-child basis. Overall, I'm in favor of taking the vaccines, after carefully considering what is known and what the purpose of vaccination is. But vaccine manufacturers must be held to a very high standard.
Dear Dr. Marc,
What scares me as a pharmacist is the Bush double talk on drugs. I think he sincerely believes that African AIDS patients can be successfully medicated for $300 a year. If he thinks these prices apply to patients in the US, he is being deceived. If he extends this misconception to a national prescription plan for seniors we are all in trouble. NPR reported last week that Mozambique had contracted with a pharmaceutical company in India to buy generic AIDS drugs for about $300 per year per patient. Unfortunately big business, which controls the Republican Congress, will never let US tax dollars be spent on cheap generic drugs from India.
I would add that I do believe these drug companies charge what the market will bear. (See my article "Drug Ad Wars," The Nation, June 6, 2002). In addition, with HIV they have a captive audience, in that these drugs are clearly lifesaving. I agree with you that $300 per year is unrealistic. On the other hand, I also believe the prices charged are inflated by the drug companies. They talk of research and development costs, but the prices charged largely reflect the mega-advertising that, of course, helps create the demand to back the prices. What a cycle!
Dear Dr. Marc,
My best friend has been dating a woman on and off for the past two years. Unfortunately, he appears to be the only person who knows this woman that isn't convinced that she suffers from acute Munchausen syndrome. She has claimed to have everything from cervical cancer (although she swears she hasn't had a hysterectomy) to von Hippel-Lindau syndrome. The woman also regularly complains about any number of aches, diseases, "surgeries," etc. I'm not exaggerating when I say that her complaining is nearly constant. My friend (and only my friend) believes every word and considers her the world's most extraordinary woman for persevering through her afflictions.
My question is twofold. First, do you have any suggestions on literature to present to my friend to ease him into the idea that this woman's illness is mental and not physical? I'm convinced that he is doing nothing but making her condition worse with his continued acceptance. And second, how does one approach a person one believes to have Munchausen's? Or is it even worth bringing it up with them?
Try to make sure that your friend knows that she should be seeing a good internist, who can help sort through this situation. Beyond that, my advice is to stay out of it, as painful as that proves, unless he comes to you for advice. You should know that Munchausens is a difficult diagnosis for an internist to make, because we are in the business of trying to solve medical problems by taking a history, and giving a patient the benefit of the doubt that he or she is telling the truth. But after awhile, and after several blind alleys, I admit I can get a sense that someone is either psychosomatic, or simulating the illness for the purpose of bringing out some deeper rooted problem, as in Munchausens. I would not encourage you to delve further into this, it is hard enough for any doctor, internist or psychiatrist, to treat this condition. If you explore the web to find out more info on the matter, you could catch the internet disease which occurs when a barrage of symptoms and examples confuses the web surfer. Better I'm afraid, in this case, to stay out of it, and simply wish your friend luck.
Dear Dr. Marc,
I read your recent response to a question about HMOs, and I think there are some things you can learn. I think the essential thing is to differentiate for-profit HMOs from nonprofit HMOs. As I work for one of the two nonprofit HMOs (Kaiser-Permanente) I am aware of, I have some insight into how care is delivered and about denial of care. How we care for people is much different from any for-profit group. Look into it.
The second point I would make is physician motivation. I am a surgeon. Outside of Kaiser-Permanente, a surgeon is paid by the operation. Inside KP I am paid to take care of people, not to operate on them. I have a hammer, but my patients look like people to me, not nails.
Dear Dr. Loren,
I understand the distinction you're trying to make between Kaiser and the more conventional for-profit HMOs. But the basic structure of approvals and denials is the same, which is at the heart of the insurance-run model that I'm criticizing. Furthermore, even though you work for Kaiser, I'm afraid you may not know it from the patient's point of view. It's difficult to know what frustrations they're experiencing, especially from the inside of an operating room, when the patient is asleep. You boast that you work for a salary, not for a fee, but there is no guarantee that not being paid by the case automatically causes a change in attitude toward altruism--many salaried people just want to get home when their assigned hours are up. Finally, I am concerned by your use of the hammer metaphor; in fact, a surgeon's tool is a scalpel, a deft, artistic instrument in the right hands. A hammer, on the other hand, conveys something else. Just a metaphor, but as you probably know, a metaphor is never only a metaphor.