Pediatricians versus the Dunning-Kruger effect on vaccines

I don't know if I could be a pediatrician right now.

True, I probably don't have the personality to be a pediatrician, at least not a primary care pediatrician on the front lines. After all, if I did, I probably wouldn't have become a surgeon, much less a hyperspecialized cancer surgeon. One reason (among many, of course) is that I don't have the patience to deal with non-vaccinating parents, particularly parents with massive cases of Dunning-Kruger disease. The same goes for being a pediatric nurse practitioner or nurse, who are also on the front lines in dealing with the antivaccine movement. In any case, you remember the D-K phenomenon, don't you? It's the phenomenon whereby people who are unknowledgeable or incompetent about a topic have a falsely elevated estimate of their own knowledge base. In the antivaccine movement, the D-K phenomenon tends to take the form of parents who think that their University of Google knowledge trumps the knowledge of physicians and scientists who have dedicated large swaths of their lives to the rigorous study of conditions such as autism and the question of how vaccines work.

Nowhere is the D-K effect more intense and painful to behold than at blog with a name so arrogantly misplaced that it lights up the planet with its waves of burning stupid. I'm referring, of course, to The Thinking Moms' Revolution (TMR), where the denizens think so highly of themselves that they refer to themselves as "Thinkers" (yes, capitalized) and dismissively attack (using arguments of pure pseudoscience and nonsense) the medical profession, scientists, and those who follow the science to realize that, no, vaccines don't cause autism, and, yes, vaccines are effective and far safer than letting children suffer "naturally" from the diseases that vaccines are designed to prevent. The mothers who blog there also give themselves annoying pseudonyms like DragonSlayer, Goddess, Mountain Mama, Sugah, and Professor. So, naturally, the TMR bloggers are the most insufferable non-vaccinating parents you will ever see, and they like to brag about it. I just saw an example of this the other day that caught my attention and made me contemplate at how difficult it must be to be a pediatrician now. Not only is pediatrics one of the worst-reimbursed specialties, but pediatricians have to put up with moms like The Rev (those 'nyms again!), describing incidents like this description of one of the "Thinkers" telling her fellows about being fired by her pediatrician for not being willing to vaccinate:

Let me set the scene for you.

A bitter cold Friday night in Chicago. Some Thinking moms decide to get together to break up the monotony of a seemingly endless winter. Several bottles of yummy wine lay interspersed among their mostly green, mostly raw, mostly organic food fest. They laugh and talk and enjoy one another’s company. The topic turns to pediatricians.

“I got fired from Dr. * this week.” Says, the youngest one of the bunch. This Thinker has a remarkably healthy child who eats well and is developing normally with no learning disabilities or developmental delays.

“Whaaaaaat did you just say?” We all rubbernecked, saucer-eyed and slack jawed in her direction; our delicate sips turning into large lapping gulps.

“Yep, he sent one letter certified and one to my house . . . Not sure what the point in that was.”

The funny thing is, I totally pictured many of the "Thinking Moms" to be just like this, a crunchy, woo-infused crowd hanging around with each other and getting drunk while they bask in each other's self- and group-perceived awesomeness and commiserate with each other over glasses of wine, tales "biomedical" quackery to treat autism, and stories of mean and nasty doctors who have the temerity to insist on treating their patients according to the standard of care on vaccines to protect their patients. I realize that this is a controversial issue among pediatricians, and I can see both sides of the argument. Some pediatricians, noting that vaccines are critical to preventing serious childhood diseases and that nonvaccinating parents take up a lot of their time (which is not billable beyond a certain point) and potentially endanger patients in the waiting room, particularly if there are immunocompromised patients there, decide not to deal with the hassle anymore. There's also an issue of conflict and trust, wherein nonvaccinating parents don't trust the doctor who is simply trying to do his best for their child, and the doctor doesn't trust the nonvaccinating parent to do what he recommends. Such doctors might reasonably conclude that it would be better for all concerned if the parents found a different doctor for their child. As one pediatrician put it:

If a family refuses to vaccinate after a discussion of the issue, he tells them "there are so many things we're not going to see eye-to-eye on."

On the other hand, some pediatricians, seeing their duty to their patients and feeling very reluctant even to be perceived as abandoning their patients, much less actually "abandoning" them. In any case, contrary to the conspiratorial twaddle peddled by "Thinkers" like The Rev, pediatricians are under an extreme ethical dilemma when confronted with nonvaccinating parents. Evidence-based medicine tells them that it is very important for the child's health that he receive his vaccines on time. When the parents prevent this (or prevent any vaccination of their child at all), they prevent the doctor from providing what he knows to be the best care for the child. Faced with such compromised care, the ethical dilemma often leads to a choice between keeping the patient and continuing to try to bring the parents around or setting them free to prevent the disruption of his practice and the potential endangerment of his other patients. There's a third choice that some pediatricians no doubt make, and that's to give up in weariness and stop mentioning it. Morally, a lot of pediatricians can't make that choice, and more power to them. Perhaps that's why there appears to be a trend among pediatricians to "fire" patients, as this young "Thinker" was fired from her pediatrician. One notes that it's still clearly a minority of pediatricians.

In fact, this young "Thinker" described by The Rev has exactly that issue. She goes on and on, asking what will she do if her child gets sick and she doesn't have a doctor who knows her child and whom she trusts. (Why she trusts a doctor who wants her to vaccinate her child when she doesn't, who knows?) Leave it to the "Thinkers" to claim that it's all about the money:

“Well, first off . . .” said my tipsy brilliant Thinker-friend, “There is no way to code ‘baby got weighed and measured, is well fed and perfectly healthy.’ You are taking up their billable time with your healthy baby! Vaccines are what make the ‘well baby’ visit a ‘well baby’ visit. You have every right to challenge your dismissal from their practice.”

This mother is just plain ignorant. First off, the young mother can't challenge the dismissal of her child from the pediatrician's practices, at least not if the pediatrician followed the laws of the state in which he practices. She (and the other "Thinkers" who chimed in) also don't know much about medical billing, either. All it would take would be a look at the list of billing codes to know that well baby visits are indeed billable as routine infant or child health checks, complete with CPT and ICD-9 codes. For those codes, it doesn't matter if the child gets an immunization or not. My guess is that this young mother probably had an insurance plan for her child that covered well baby visits 100% but required a copay for vaccines, which is likely why she didn't get a bill for those visits in which her child didn't get a vaccine, not because the pediatrician didn't bill for them.

In fact, depending on the practice, vaccines can be money losers for pediatricians. Indeed, a study from three years ago by athenahealth found that in almost half the cases, payments for vaccines weren't enough to cover the cost of storing and administering them. A study in Pediatrics from 2009 concluded that for privately insured patients pediatricians vaccines produce little or no profit and that when losses from vaccinating publicly insured children (i.e., receiving Medicaid) most pediatrics practices lose money from vaccines. Indeed, a recent news report indicates that it's gotten so bad that pediatricians have become very dissatisfied with insurance and government reimbursement for vaccines to the point that 10% of pediatrics practices admit to considering not offering vaccines anymore, instead referring their patients elsewhere for them.

Another rather hilarious claim is that "nurses can't harass" you about vaccines. "Harassment." You keep using that word. I do not think it means what you think it means. Of course, what these "Thinkers" refer to as "harassment" is no doubt nothing more than the nurse doing her medical duty according to the standard of care to ask the parents which vaccinations the children have had and to suggest trying to get their vaccines up to date. It's part of the frikkin' pediatric history and physical, fer cryin' out loud! That's why it's no surprise that nurses, at every visit, will ask the parents about vaccines and suggest to nonvaccinating parents that they start getting their child caught up on recommended vaccines. It's their job!

What's really depressing is what The Rev recommends to maintain the health of her children:

It is in our child’s best interest to build a team of healthcare professionals. After all, we all share a common goal: the health of all our child, right? A couple pediatricians, a chiropractor, a whole foods nutritionist (who understands grains and the gut), homeopath, naturopath, and homotoxicologist are all good team members. The pediatricians and healthcare professionals are covered by insurance so you can have as many of these on staff as you want! I enjoy having a few doctors because then I can weigh what one says against the other and decide for myself what the best course of action is for my child. For instance, my daughter had bronchitis three weeks ago. I tried my best to tackle it with essential oils and homeopathy, two methods of preventative and responsive medicine that are often quite effective for my family. They’ve helped assuage eye twitches, nausea, ear infections, minor allergic reactions, bruises, eczema and a myriad of other ailments. But, this bronchitis was nagging despite the fact that she did not have a fever and was still very active. She needed an antibiotic, so I took her to a pediatrician who prescribed one. My children do not get them very often, so I was willing to take the risk, off set them with probiotics, and make some dietary changes for the duration of their use. Days after she got the clean bill of health, she came down with an ear infection. Some Galilean olive oil with a dab of Thieves and she was good to go. Sometimes allopathic medicine is an option. Sometimes, simply educating ourselves about proper nutrition and preventative care is an option, too.

Yes, The Rev recommends trying quackery first, and when that fails acquiescing to those nasty, reductionist pediatricians and their big pharma-produced toxic chemicals. Just hope that the disease isn't serious enough that, by the time The Rev abandons quackery and chooses real medicine, it's not too late for her child.

Maybe that's why she concludes her nauseatingly self-congratulatory post by congratulating mothers who have gotten letters firing them from their pediatricians' practices because they are now "Thinkers":

If and when that letter from your pediatrician arrives? Consider it a victory. You are now a Thinker, and you have been invited to take an active role in guiding healthcare policy in this country. May I gleefully suggest there are several medical, chiropractic, whole-health physician practices in your urban/suburban areas that will be more than happy to care for your child? Investigative physicians that treat the individual child are out there.

Sorry, Rev. None of what you've written above sounds even remotely like thinking, much less "Thinking," to me.

More like this

Anon, do you really deny your grandchildren both pizza and ice cream? Wow. That must make you quite unpopular.

So, anon, would you rather a grandchild get the PCV13 or Hib vaccine or get bacterial meningitis? Answer the question.

Do not let the fact that one of the contestants on the present "Dancing with the Stars" program is doing well, despite losing both kidneys and legs below the knee due to bacterial meningitis. While she is performing well, I am sure the time spent dealing with kidney transplant medications is not pleasant.

So, really, is it safer to get those vaccines or bacterial meningitis? Give us an answer. You have two more tries.

lso, PMID: 19423079 is interesting in that it explores how inflammation from a vaccine (typhoid) can alter brain activity and connectivity in an adult resulting in mood changes.

Specifically:

Inflammation-associated deterioration in total mood was also associated with a marked decrease in activity within amygdala, a region central to processing emotional information from faces. Connectivity analysis also showed that inflammation-associated mood change modulated the connectivity between sACC and arMPFC, a region activated when thinking about others, and with right STS and amygdala, regions implicated in processing social/emotional information from faces. These changes might under-pin the marked reduction in social behavior associated with acute sickness, possibly reflecting an internal self-reorientation of attentional focus (9) and the heterogeneity of symptoms associated with inflammation-associated mood change.

So, I ask myself, what happens when a one day old infant or a two, four, six or twelve month infant gets a vaccine, what type of inflammatory response occurs? What is the magnitude and duration of the inflammatory response? Are there changes in activity and connectivity in brain regions that are implicated in empathy and social/emotional processing (like we see from above study or other important changes)? If changes do occur, how long do they last? How does this inflammatory response differ among individuals? i.e. how does genotype, how do other developmental (prenatal) occurrences impact this response?

You can call that “a just asking questions ploy” or “weaseling”, I just call this critical thinking and trying to fill voids in our collective ignorance. IF you have answers to those questions or could point me in the direction where I can find answers, then just do so. From what I can tell, we do not have data to answer these questions, hence large scale prospective studies are warranted.

Not by that study, which showed that the eight healthy male adults who got the typhoid vaccine had a transient dip in mood three hours later, along with transient changes in activity/connectivity that were consistent with some of what's known about the neurology of depression.

And if there's one thing about infants between the ages of one day and twelve months that's been completely stable over a very long period of time and comprehending both the pre- and post-vaccine era, it's this:

They're extremely subject to sudden, rapid, transient shifts in mood.

Because, you know. If vaccine-induced inflammation was having a significant effect along those lines, they'd have gotten moodier. And autism isn't:

(a) a mood disorder;
(b) inflammation-related;
(c) immune-mediated; or
(d) demonstrably linked to vaccines in any way.

You're basically saying:

"There's a tiny study here about the neurology of illness-related low mood, which resembles that seen in low mood of unknown etiology. A large-scale prospective study of infants seeking the answers to questions that are utterly unconnected to it in every way is therefore warranted."

I wouldn't call that "weaseling," necessarily. But I wouldn't call it critical thinking, either.

Take a look at the lawsuits against Pharma. I once was prescribed Paxil and had awful side effects. Several years later…….
Glaxo Agrees to Pay $3 Billion in Fraud Settlement

Oh, look, it's time to randomly change the subject!

Here. Now kindly stop barfing up stuff that you're too passive aggressive to bother thinking about.

anon:

How about staying on topic?

How about defending your inane statements about vaccine adjuvants?

How about answering Chris' questions about specific vaccines?

Perhaps you want to consult Heather Fraser, before you post any more comments here.

#513 continued-" What type of immune reactions are present in the brain of autistic patients?
In our study, we have demonstrated a marked increase in neuroglial responses, characterized by activation of microglia and astroglia, in the brains of autistic patients. These increased neuroglial responses are likely part of neuroinflammatory reactions associated with the central nervous system's (CNS) innate immune system. In innate immune reactions of the CNS, microglial activation is the main cellular response to CNS dysfunction. This is in contrast to adaptive immune responses, in which lymphocyte and/or antibody mediated reactions are the dominant responses. In our sample of autistic patients, microglial and astroglial activation was present in the absence of lymphocyte infiltration or immunoglobulin deposition in the CNS. It also was associated with increased production of pro-inflammatory and anti-inflammatory cytokines such as MCP-1 and TGFß-1 by neuroglia."

The meaning of neuroinflammatory findings in autism

Explain in your own words (1) what this means or (2) if you cannot, why you have seen fit to leave it here.

ann @ # 508: I'm trying to figure out what the link to this study about short duration psychiatric manifestations (depressions for ~ 3 days) in adult men following S. typhi vaccines, is germane to the topic of infant vaccines.

http://www.ncbi.nlm.nih.gov/pubmed/19423079

Are infants and young children, every vaccinate against typhoid?

http://www.vaccines.gov/diseases/typhoid_fever/

"There are two vaccines to prevent typhoid. One is an inactivated (killed) vaccine gotten as a shot, and the other is live, attenuated (weakened) vaccine, which is taken orally (by mouth).

Typhoid vaccine is recommended for:

Travelers to parts of the world where typhoid is common (NOTE: typhoid vaccine is not 100 percent effective and is not a substitute for being careful about what you eat or drink.)

People in close contact with a typhoid carrier

Laboratory workers who work with Salmonella Typhi bacteria

Inactivated Typhoid Vaccine (Shot)

Should not be given to children younger than two years of age

One dose provides protection. It should be given at least two weeks before travel to allow the vaccine time to work

A booster dose is needed every two years for people who remain at risk

Live Typhoid Vaccine (Oral)

Should not be given to children younger than six years of age

Four doses, given two days apart, are needed for protection. The last dose should be given at least 1 week before travel to allow the vaccine time to work

A booster dose is needed every five years for people who remain at risk

Either vaccine may be given at the same time as other vaccines."

ann @ # 508: I’m trying to figure out what the link to this study about short duration psychiatric manifestations (depressions for ~ 3 days) in adult men following S. typhi vaccines, is germane to the topic of infant vaccines.

There is no link. It's an eensy study that it's arguably not wrong to say may, perhaps, turn out to have implications for the etiology of depression in some people sometimes some day.

Also, it was of some inherent interest. I thought.

But it says nothing about vaccines generally. Or infants. Or neurodevelopment.

Take a look at the lawsuits against Pharma. I once was prescribed Paxil and had awful side effects.

What awful side effects?

Had you been informed they were possible?

Was it prescribed to you because you went of your own volition to a physician, reported symptoms of depression, filled a prescription for Paxil, then took it with full knowledge that you were free to discontinue it at any time?

Several years later…….
Glaxo Agrees to Pay $3 Billion in Fraud Settlement
http://www.nytimes.com/2012/07/03/business/glaxosmithkline-agrees-to-pa…?

There's no question that they're wicked capitalists who are as prone to corporate malfeasance as any. Or that antidepressants are both overprescribed in themselves and by doctors who don't know much about the drugs or the condition. They're also frequently wrongly prescribed. And possibly underprescribed, to some demographics.

Furthermore, they're not very effective for a lot of clinically depressed people. And they often have bothersome side effects.

Here's a challenge for you.

See if you can identify the serious problem and/or group of people afflicted by it anywhere in there, from the perspective of anyone who had a heart..

#508
FAQs: The meaning of neuroinflammatory findings in autism
http://www.neuro.jhmi.edu/neuroimmunopath/autism_faqs.htm

...is completely consistent with all the other evidence strongly suggesting that autism is innate and unrelated to vaccines:

These observations suggest that the adaptive immune system does not play a significant pathogenic role in this disorder, at least not during its chronic phase, and that the main immune mechanism involves predominantly innate immune reactions.

Says so in so many words elsewhere in the FAQ, too, pretty much.

Are there changes in activity and connectivity in brain regions that are implicated in empathy and social/emotional processing (like we see from above study or other important changes)?

I forgot to say:

It's a myth that people with ASDs lack empathy.

And not a pretty (or empathetic) one.

@ ann "There are some busy bees posting here this evening, aren’t there?"

It is what one with middle insomnia does. Too tired to study, and too intelligent to watch Guy Fieri on the Food Network channel for the hundredth time.

In my previous comment @497, I should have stated "why does anyone tolerant ads that even remotely look like an article" instead of "allow." It is their publication, they can run it they way they wish; I just won't be buying a book that is advertised the same way the wootastic crap is marketed. And, I am glad I know the difference between PubMed and PubMed Central, thanks Narad.

Nothing of substance next; just my rant about ads. I had to stop reading the Psychiatric Times (I know; not a journal.) because they weren't content with ads thrown all over the page; now it has to open with an overlay ad before I can even read the page.

It is what one with middle insomnia does.

Ah. What a drag. One empathizes with one. And sympathizes.

They say that regular bed- and wake-up times help. And morning sunlight.**.

I find that reassuring. But only notionally. I've never noticed that they do.

**When it's in one's face really shows one's age. ("Maggie May.")

So, anon, would you rather a grandchild get the PCV13 or Hib vaccine or get bacterial meningitis?

Stop the diversionary tactics: answer the question.

Seemed to have slowed down here at RI...

You guys chewed up all your dog toys!

I will respond if I have time to the posts directed at me (other than the one from PGP, she is a bit too off the wall for me), I just have a lot of other things going on in my life right now that are higher priorities.

Thanks

By skeptiquette (not verified) on 27 Mar 2014 #permalink

*seems*

By skeptiquette (not verified) on 27 Mar 2014 #permalink

skeptiquette: I'm not off the wall, I just hate hypocrisy. Playing both sides of the fence on the vaccine issue is annoying. Either admit you're anti-vax, or stop posting.

By Politicalguineapig (not verified) on 27 Mar 2014 #permalink

That is just my perception, it could change based on new findings...

By skeptiquette (not verified) on 27 Mar 2014 #permalink
It is what one with middle insomnia does.

Ah. What a drag. One empathizes with one. And sympathizes.

Segmented sleep was the norm until the 19th century. I've got the ol' free-running disorder instead, which can be medicated down to DSPD.

Playing both sides of the fence on the vaccine issue is annoying. Either admit you’re anti-vax, or stop posting.

One might note that many have expressed annoyance at your seemingly bottomless reserve of baseless generalizations, but I don't recall anyone purporting to issue "orders" over it.

One empathizes with one. And sympathizes.

Thanks, ann. I never found sleep hygiene all that helpful either.
The psychologist at the sleep clinic called the CBT "sleep restriction" experiment before I was going to. He saw how much worse it was making me. And, yes, it was.

Sunlight does help, yet the sun is rarely out anymore.

Oddly, and quite accidentally, I found dehydration causes enough drowsiness to reduce my total awake time in the wee hours. But, that isn't a trade-off I am willing to make for obvious reasons.

I hope you find better rest, yourself.

Narad,

Surprisingly, I was aware of segmented sleep being normal in centuries past. Learned that reading one of the sleep apnea boards. I think my biggest issue is silent reflux. I wake up suddenly for no apparent reason, yet I am never anxious or worried or anything; just wide awake.

I dodged RLS, but did have some PLMD when I first started cpap. Luckily that resolved as I didn't need one more condition.

Glad to read meds help you. I don't think people realize how easy it is to take sleep for granted, but you learn fast when sleep isn't easy anymore.