On Wednesday, we took Polly to the doctor for her eighteen month check-up. On the way there, I watched my speedometer closely and used cruise control on the highway because I was nervous, and I always drive too quickly when I’m nervous. Every trip to the doctor carries a bit of tension for me - there’s always the possibility that they’ll find something wrong – but this trip had some extra worry added to it. This was the first trip to a new doctor for us, and I wasn’t sure how it would go. You see, Ava and I have chosen to use a non-standard vaccination routine for Pip and Polly. This makes us less than ideal patients for many physicians, and it takes some work to find one that will work with us. I had spoken to this one on the phone a couple of weeks earlier about our choices. At the time, he was amenable to working with us, but I was still worried that once we were actually there, this willingness would come with some caveat or a lecture about how we were needlessly exposing our children to death or dismemberment.
The question of vaccinations is a tricky one. Prior to the mid-1990s, medical authorities recommended that children receive a diptheria, tetanus, and pertussis (DTaP) shot, a measles, mumps, and rubella (MMR) shot, and a polio vaccine. Since then, the number of vaccines recommended for children between the ages of 0 and 6 has more than doubled (see here for each year’s recommendations). That’s a lot of shots and a lot of foreign substances being pumped into little bodies. It makes me nervous, especially because we don’t really have any long-term data on what all these new vaccines will do. These vaccines can be tested for safety over relatively short time periods, but there are no long-running studies on how something like the early use of the Hepatitus B vaccine might relate to levels of cancer, Parkinson’s, Alzheimer’s or other diseases later in life. And now that so many vaccines are being pumped into kids all together it will be very difficult to untangle the mess if something does come up in another twenty years. Given this uncertainty and the historical experiences with drugs like Vioxx, Ava and I are hesitant to over-vaccinate our children, especially for things like Hep A and B which are diseases associated with drug use, high risk sex, and poor sanitation and ones like chickenpox (varicella) and flu for which the most significant harm is usually the loss of work hours for a parent.
Compounding our hesitation is the reality that vaccines are big business for drug companies. Getting a vaccine included on the list of recommended shots can generate a large chunk of relatively consistent money for the company that produces the vaccine. This gives drug companies plenty of incentive to get as many vaccines included on the list as possible. Where there is incentive, there is money. It seems hardly coincidental that the rise in the number of recommended vaccines corresponds relatively well with the explosion of big money politics over the last fifteen years. Money talks in many different arenas whether it’s spent on lobbying, marketing, clinical trials, or handouts.
The drug companies are also pushing these vaccines at the individual level as well. We got a reminder of this the first time we skipped a scheduled vaccine. About a week after our doctor’s visit we received a postcard in the mail from our insurer. The postcard helpfully suggested that we had missed one of the normal shots. At the bottom of the card was a disclosure statement. The postcard had been paid for by Wyeth Pharmaceuticals.
In thinking about this recently, I’ve come to realize that I don’t blame the individual drug companies for any of this. They exist in a profit driven system where survival is predicated on selling as much stuff as possible. A good company is going to use as many ways as it can to stay in business. It is unfair to demand that they act as some kind of public trust when their ultimate survival is not protected by the public. This doesn’t make me any less suspicious of their influence. It only acknowledges that this influence is a product of structural constraints, not individual avarice.
Our concerns about vaccines and the influences at work in their usage have made finding a doctor a challenge. In Cincinnati we got very lucky. After a bad experience with Pip’s first pediatrician, we went to the internet and tapped into the social network discussions around alternative vaccinations to find a doctor who would be willing to work with us. We were pointed to one who turned out to be better than we could ever have expected. His entire practice bespoke a certain skeptical distance from the normal business of medicine. First, all appointments were scheduled for thirty minutes. Second, he had no nurses so that entire half-hour was spent with him. He did all his own measurements. He administered all his own shots. Third, he had no drug company paraphernalia or hand-outs lying around his office. There were no posters on the walls, no pens with drug ads on them at the reception desk, and no freebie drugs stashed away in a drawer of the examining room. Fourth, he made careful distinctions between conditions that should be treated with drugs and ones like common ear infections or pink eye which given the right attention and a reasonable amount of time, the human body can take care of by itself. All of these things gave us confidence in him and made us very comfortable in following his advice when it came to vaccinations (his preference was to administer the older vaccines – DtaP, MMR – and hold off on the newer ones unless a specific reason suggested itself (i.e. rotovirus for kids in daycare)).
When we moved to Lexington we had to start all over again. Going back to the internet, we searched again through the local internet discussions. Not surprisingly, there were very few names that came up as possible candidates. But again we got lucky. There was a newer family physician in one of the outlying towns who was willing to work with families like ours. After calling him up and discussing our preferences with him, we made an appointment for 10 AM on Thursday.
We got there a few minutes early so that I could fill out the new patient paperwork that is always a part of the first visit with a new doctor. There was no one else in the waiting room so I let the kids wander around and check things out. The office was a new one with cream colored walls and benches upholstered in dark green leather. On the magazine rack were several current issues of popular weeklies like Sports Illustrated and Newsweek, a requisite copy of the children’s story of the Bible, and a book on the palliative properties of different foods. Pip and Polly picked through each of these in turn while I worked my way through the various forms. During that time another family came in with a little girl about Pip’s age. The two sized each other up from opposite corners of the room.
And then came a reminder that replacing our doctor in Cincinnati will be almost impossible.
As I was filling out the final form in the stack, another person walked in the door. I looked up long enough to see that it was a woman, tall and thin with thick blonde hair that hung down past her shoulders. She wore a fashionable camel hair coat and the pressed black pants and black heels of a well-paid professional. I did not see her face, but I imagine her makeup and jewelry matched her obviously expensive and well-tailored clothes. Now, the office in which we were seated was that of a family doctor in a smaller town in central Kentucky. Most of the vehicles in the parking lot were either small sedans or large pick-up trucks. The family sitting across from us in the waiting room was dressed in jeans and sweatshirts as was the receptionist behind the desk. None of us looked like this woman. Before she said a word, I decided that she was a drug rep. This guess was verified when she asked the receptionist if the doctor was in and whether the office needed any more of something that sounded like ‘hyproxin.’
In college I spent two semesters working in the engineering division of a medium-scale electronic components factory. About once a month, a salesperson would come in and spend the day in our office. I think his name was Harry. He would usually bring us lunch and a few trinkets to share and would spend the day making his way around the office to the different engineers. He would ask what they were working on and suggest, or give a demonstration of, products he had that might be useful. Harry was a doughy guy, short and slightly unkempt, but with a likeable smile that allowed you to blow him off if you needed to. Every once in a while someone would seek him out to ask about a particular component, but usually his mode of operation was to start a conversation and see if it would lead to something. In general, the longer he got to talk with an engineer, the more likely it was that he could find a sensor or motor or electrical component that the engineer could use.
After seeing this drug rep, I pondered what would have happened in that engineering office if she had come in instead of Harry. The fundamental pattern probably would not have been different, but the promise of face time with a woman from whom these men would normally get no more than a few seconds of attention is a powerful force. I imagine the amount of time she would have gotten with all of those male engineers would have been noticeably greater. And, as a result, she probably would have sold more stuff than Harry.
Like that engineering office, the medical profession is a male heavy arena. This leads me to believe that the same principles I know to be true in that engineering office are applicable to doctors, namely an attractive female salesperson is likely to get more time and more attention from a doctor than her position as a drug salesperson might merit. And as with the engineers, more time equals more possibilities for finding or convincing doctors that she has something that they ‘need.’ As I discussed above, the potential for that kind of influence is worrisome. It’s also a troubling reminder of how screwy our health care system is that the prescription drugs we buy are being pushed to doctors using methods very similar to those used to sell sports cars and beer.
When I mentioned all of this to Ava, she brought up another salient aspect of this situation. The drug rep has access to the doctor in ways that are difficult for a patient to discern and evaluate. There is a fundamental lack of transparency about these relationships that makes it impossible for a patient to make an informed judgment. We can’t know how drugs are being marketed to the doctors, what information the rep is providing, or what the doctor does with this information. There is essentially no way for the patient to parse the influences at work in the doctor’s decision-making process. The doctor may hand off all the drug rep interactions to a third party in the office in order to keep some distance from the sales pitch. The doctor may lap up every free meal and golf outing the drug rep can provide. We just can’t know. It’s another one of the pitfalls of our current system. We are forced to trust that our doctors have the time, patience, and self-awareness to filter through the wash of information provided by a drug rep. Such trust is difficult to justify. Human beings are just too susceptible to suggestion and impulse. And the drug reps spend plenty of money and effort to sway things their way (see this article from The Atlantic for some examples).
Despite all of this, I will go back to this doctor. For one thing, the appointment went fine. The doctor was friendly and comfortable talking about our options and choices. He was good with the kids and did not try to constrain Polly too much in the process of examining her. It was a straightforward and no-nonsense visit to the doctor. For another, we don’t have that much of a choice. If we want to do the vaccinations our way, this is our guy. We too have our structural constraints. We sacrifice one set of choices in order to exercise another.