Commentary

Dr. Hickner’s editorial “Let’s talk about the evidence” (J Fam Pract. 2015;64:337) struck a chord with me. I am very supportive of evidence-based medicine (EBM), but am often dismayed by the lack of humility expressed by EBM leaders, including the US Preventive Services Task Force. We have so little evidence about much of what we do in family medicine, and most evidence comes from studies that are narrow by nature (reductionist research).

Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

For example, doing a physical exam is part of “laying on of hands” that is part of the art of medicine. Abraham Verghese, MD, MACP, has written and spoken about the importance of examining the patient and not just depending on data.¹ Yet elements of the physical exam, such as the pelvic exam example Dr. Hickner mentioned in his editorial, do not stand up well in EBM due to a lack of diagnostic accuracy. I’ll ask this: Who has studied the harm that may be caused by not examining our patients?

My physical exam “ritual” takes less than 10 minutes, and the value in the relationship I have with patients is more than a diagnostic exercise. Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

Joseph E. Scherger, MD, MPH
Rancho Mirage, Calif

1. TED Talks. Abraham Verghese: A Doctor’s Touch. TED Web site. Available at: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. Accessed July 20, 2015.

Author’s response:
Dr. Scherger makes an excellent point about the importance of physical touch for the doctor-patient relationship. The question is: What touching is appropriate? In my own experience, I have noticed that most—but not all—of the women I see are quite relieved that they don’t need yearly pelvic exams, and women I see for pap smears do not seem put off if I do not do a bimanual exam. The data are actually quite strong that routine pelvic exams in asymptomatic women lead to more harm than good. They uncover way too many false positives and almost no true positive findings, leading to unnecessary testing and treatment.^1,2

John Hickner, MD, MSc
Chicago, Ill

Dr. Hickner is the editor-in-chief of The Journal of Family Practice

1. Ebell MH, Culp M, Lastinger K, et al. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48:350–356.

2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421-424.

Dr. Hickner’s editorial “Let’s talk about the evidence” (J Fam Pract. 2015;64:337) struck a chord with me. I am very supportive of evidence-based medicine (EBM), but am often dismayed by the lack of humility expressed by EBM leaders, including the US Preventive Services Task Force. We have so little evidence about much of what we do in family medicine, and most evidence comes from studies that are narrow by nature (reductionist research).

Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

For example, doing a physical exam is part of “laying on of hands” that is part of the art of medicine. Abraham Verghese, MD, MACP, has written and spoken about the importance of examining the patient and not just depending on data.¹ Yet elements of the physical exam, such as the pelvic exam example Dr. Hickner mentioned in his editorial, do not stand up well in EBM due to a lack of diagnostic accuracy. I’ll ask this: Who has studied the harm that may be caused by not examining our patients?

My physical exam “ritual” takes less than 10 minutes, and the value in the relationship I have with patients is more than a diagnostic exercise. Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

Joseph E. Scherger, MD, MPH
Rancho Mirage, Calif

1. TED Talks. Abraham Verghese: A Doctor’s Touch. TED Web site. Available at: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. Accessed July 20, 2015.

Author’s response:
Dr. Scherger makes an excellent point about the importance of physical touch for the doctor-patient relationship. The question is: What touching is appropriate? In my own experience, I have noticed that most—but not all—of the women I see are quite relieved that they don’t need yearly pelvic exams, and women I see for pap smears do not seem put off if I do not do a bimanual exam. The data are actually quite strong that routine pelvic exams in asymptomatic women lead to more harm than good. They uncover way too many false positives and almost no true positive findings, leading to unnecessary testing and treatment.^1,2

John Hickner, MD, MSc
Chicago, Ill

Dr. Hickner is the editor-in-chief of The Journal of Family Practice

1. Ebell MH, Culp M, Lastinger K, et al. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48:350–356.

2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421-424.

Dr. Hickner’s editorial “Let’s talk about the evidence” (J Fam Pract. 2015;64:337) struck a chord with me. I am very supportive of evidence-based medicine (EBM), but am often dismayed by the lack of humility expressed by EBM leaders, including the US Preventive Services Task Force. We have so little evidence about much of what we do in family medicine, and most evidence comes from studies that are narrow by nature (reductionist research).

Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

For example, doing a physical exam is part of “laying on of hands” that is part of the art of medicine. Abraham Verghese, MD, MACP, has written and spoken about the importance of examining the patient and not just depending on data.¹ Yet elements of the physical exam, such as the pelvic exam example Dr. Hickner mentioned in his editorial, do not stand up well in EBM due to a lack of diagnostic accuracy. I’ll ask this: Who has studied the harm that may be caused by not examining our patients?

My physical exam “ritual” takes less than 10 minutes, and the value in the relationship I have with patients is more than a diagnostic exercise. Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

Joseph E. Scherger, MD, MPH
Rancho Mirage, Calif

1. TED Talks. Abraham Verghese: A Doctor’s Touch. TED Web site. Available at: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. Accessed July 20, 2015.

Author’s response:
Dr. Scherger makes an excellent point about the importance of physical touch for the doctor-patient relationship. The question is: What touching is appropriate? In my own experience, I have noticed that most—but not all—of the women I see are quite relieved that they don’t need yearly pelvic exams, and women I see for pap smears do not seem put off if I do not do a bimanual exam. The data are actually quite strong that routine pelvic exams in asymptomatic women lead to more harm than good. They uncover way too many false positives and almost no true positive findings, leading to unnecessary testing and treatment.^1,2

John Hickner, MD, MSc
Chicago, Ill

Dr. Hickner is the editor-in-chief of The Journal of Family Practice

1. Ebell MH, Culp M, Lastinger K, et al. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48:350–356.

2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421-424.

In my struggle to keep abreast of all things pediatric, I sample a variety of sources.

Of course each month I scan almost all of the abstracts in the journal Pediatrics. But to get a sense of what the nonmedical community is reading, I begin each morning with a cruise through the electronic versions of the New York Times and the Portland (Maine) Press Herald.

By lunch time I usually have hopscotched my way through the Wall Street Journal. And during our evening adult beverage quiet time, I amuse myself with our local daily. If a news story includes a link to an original article, I usually bore down deep enough to at least read the abstract. Keep in mind that this whole process of keeping current takes little more than a half an hour, 45 minutes tops.

It seems that psychology-related topics dominate the science and medicine stories that I encounter. This shouldn’t surprise you because most of us want to know more about why humans behave the way we do. We also wonder if animal behavior may provide some clues.

It may be because I was trained by careful and skeptical “hard” scientists that I have always read psychosocial and behavioral studies with several grains of salt. Despite my skepticism, I am not beneath embracing the odd study that seems to support one of my biases. The studies that don’t sync with my world view I quickly cast on the rubbish heap because the “sample group was too small,” or the “variables were not adequately controlled for,” or simply because I thought the study was poorly done.

It turns out that my skepticism has not only been well founded, but should have been broader in scope. In a recent study published in the journal Science, three young psychologists undertook a heroic and courageous effort to reproduce 100 studies from three leading psychology journals (Science 2015 Aug 28. doi:10.1126/science.aac4716). Chosen from a larger group, these studies were thought to reflect the core knowledge from which psychologists develop their understanding of such basics as learning, memory, and relationships.

The investigators found that in more than half the studies, they were unable to reproduce the results reported in the original studies despite the fact that in many cases, they were assisted by the original investigators in their attempts to replicate the conditions of the initial studies.

The authors quickly assert that their findings do not suggest that the original investigators were attempting to deceive. Nor does the failure to reproduce results necessarily mean that other future studies might confirm the original findings. Their primary point is that evaluating reproducibility is difficult.

However, this new study is troubling for two reasons. First, it casts even more doubt on the decision to expand the MCAT (Medical College Admission Test) by adding several hours of questions based on psychosocial topics in hopes of creating physicians who are more in tune with the emotional needs and social challenges of their future patients. If the results of more than half of the studies that might be considered the underpinnings of modern psychology can’t be reproduced, are we just asking aspiring medical students to learn a larger collection of half truths? And thus have medical students spend less time learning basic science and developing better critical thinking skills? There are better ways to sort for more empathetic and sensitive physicians than by building an unevenly weighted exam.

Second, although this study highlights the core of what makes science such a powerful and effective tool for discovering the truth, the anti-science folks will point to it as just another example of how we shouldn’t trust anything science tells us.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

In my struggle to keep abreast of all things pediatric, I sample a variety of sources.

Of course each month I scan almost all of the abstracts in the journal Pediatrics. But to get a sense of what the nonmedical community is reading, I begin each morning with a cruise through the electronic versions of the New York Times and the Portland (Maine) Press Herald.

By lunch time I usually have hopscotched my way through the Wall Street Journal. And during our evening adult beverage quiet time, I amuse myself with our local daily. If a news story includes a link to an original article, I usually bore down deep enough to at least read the abstract. Keep in mind that this whole process of keeping current takes little more than a half an hour, 45 minutes tops.

It seems that psychology-related topics dominate the science and medicine stories that I encounter. This shouldn’t surprise you because most of us want to know more about why humans behave the way we do. We also wonder if animal behavior may provide some clues.

It may be because I was trained by careful and skeptical “hard” scientists that I have always read psychosocial and behavioral studies with several grains of salt. Despite my skepticism, I am not beneath embracing the odd study that seems to support one of my biases. The studies that don’t sync with my world view I quickly cast on the rubbish heap because the “sample group was too small,” or the “variables were not adequately controlled for,” or simply because I thought the study was poorly done.

It turns out that my skepticism has not only been well founded, but should have been broader in scope. In a recent study published in the journal Science, three young psychologists undertook a heroic and courageous effort to reproduce 100 studies from three leading psychology journals (Science 2015 Aug 28. doi:10.1126/science.aac4716). Chosen from a larger group, these studies were thought to reflect the core knowledge from which psychologists develop their understanding of such basics as learning, memory, and relationships.

The investigators found that in more than half the studies, they were unable to reproduce the results reported in the original studies despite the fact that in many cases, they were assisted by the original investigators in their attempts to replicate the conditions of the initial studies.

The authors quickly assert that their findings do not suggest that the original investigators were attempting to deceive. Nor does the failure to reproduce results necessarily mean that other future studies might confirm the original findings. Their primary point is that evaluating reproducibility is difficult.

However, this new study is troubling for two reasons. First, it casts even more doubt on the decision to expand the MCAT (Medical College Admission Test) by adding several hours of questions based on psychosocial topics in hopes of creating physicians who are more in tune with the emotional needs and social challenges of their future patients. If the results of more than half of the studies that might be considered the underpinnings of modern psychology can’t be reproduced, are we just asking aspiring medical students to learn a larger collection of half truths? And thus have medical students spend less time learning basic science and developing better critical thinking skills? There are better ways to sort for more empathetic and sensitive physicians than by building an unevenly weighted exam.

Second, although this study highlights the core of what makes science such a powerful and effective tool for discovering the truth, the anti-science folks will point to it as just another example of how we shouldn’t trust anything science tells us.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

In my struggle to keep abreast of all things pediatric, I sample a variety of sources.

Of course each month I scan almost all of the abstracts in the journal Pediatrics. But to get a sense of what the nonmedical community is reading, I begin each morning with a cruise through the electronic versions of the New York Times and the Portland (Maine) Press Herald.

By lunch time I usually have hopscotched my way through the Wall Street Journal. And during our evening adult beverage quiet time, I amuse myself with our local daily. If a news story includes a link to an original article, I usually bore down deep enough to at least read the abstract. Keep in mind that this whole process of keeping current takes little more than a half an hour, 45 minutes tops.

It seems that psychology-related topics dominate the science and medicine stories that I encounter. This shouldn’t surprise you because most of us want to know more about why humans behave the way we do. We also wonder if animal behavior may provide some clues.

It may be because I was trained by careful and skeptical “hard” scientists that I have always read psychosocial and behavioral studies with several grains of salt. Despite my skepticism, I am not beneath embracing the odd study that seems to support one of my biases. The studies that don’t sync with my world view I quickly cast on the rubbish heap because the “sample group was too small,” or the “variables were not adequately controlled for,” or simply because I thought the study was poorly done.

It turns out that my skepticism has not only been well founded, but should have been broader in scope. In a recent study published in the journal Science, three young psychologists undertook a heroic and courageous effort to reproduce 100 studies from three leading psychology journals (Science 2015 Aug 28. doi:10.1126/science.aac4716). Chosen from a larger group, these studies were thought to reflect the core knowledge from which psychologists develop their understanding of such basics as learning, memory, and relationships.

The investigators found that in more than half the studies, they were unable to reproduce the results reported in the original studies despite the fact that in many cases, they were assisted by the original investigators in their attempts to replicate the conditions of the initial studies.

The authors quickly assert that their findings do not suggest that the original investigators were attempting to deceive. Nor does the failure to reproduce results necessarily mean that other future studies might confirm the original findings. Their primary point is that evaluating reproducibility is difficult.

However, this new study is troubling for two reasons. First, it casts even more doubt on the decision to expand the MCAT (Medical College Admission Test) by adding several hours of questions based on psychosocial topics in hopes of creating physicians who are more in tune with the emotional needs and social challenges of their future patients. If the results of more than half of the studies that might be considered the underpinnings of modern psychology can’t be reproduced, are we just asking aspiring medical students to learn a larger collection of half truths? And thus have medical students spend less time learning basic science and developing better critical thinking skills? There are better ways to sort for more empathetic and sensitive physicians than by building an unevenly weighted exam.

Second, although this study highlights the core of what makes science such a powerful and effective tool for discovering the truth, the anti-science folks will point to it as just another example of how we shouldn’t trust anything science tells us.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

“I have acute appendicitis,” I told my wife. “I need to go to the radiologist.”

A computed tomography (CT) scan of my abdomen confirmed my suspicion. After learning that I also had leukocytosis, we headed to the emergency department. The ED doctor was pleasantly surprised that someone had come to his facility completely evaluated. All he had to do was call the surgeon. But first he introduced me to a 4th-year medical student who was participating in a surgical rotation.

Prioritizing the EMR over the patient

The student wheeled his large computer to the side of my gurney and began to question me about my abdominal pain. Within 5 minutes, this unsupervised student had somehow acquired all the information he needed for my admission. He thanked me for my time and told me that he would see me in the operating room.

Unfortunately for him, I was not about to let him leave my cubicle without a redirect. I told him I have type 1 diabetes and several comorbidities. I wear an insulin pump and continuous glucose sensor that alerts me to impending hypoglycemia. I take 11 medications to successfully manage my metabolic disorders.

The student wheeled his machine back to the side of my gurney.

With his eyes fixed squarely on his computer and his finger on a mouse, he asked me to list all of my medications. He had never heard of a rapid-acting insulin analogue, nor was he familiar with my GLP-1 receptor agonist or SGLT2 inhibitor. And the pump and sensor? There were no check boxes for these devices in his electronic medical record (EMR).

He—like several of the doctors I met during my subsequent stay—suggested that I remove the pump and meter so that they could manage my diabetes.

Still in considerable pain, I suggested to the student and anyone else who would listen that my pump and sensor were off limits. As long as I was conscious, I would self-manage my diabetes.

I also told him that his history and physical exam were deficient. Although he did listen to my bowel sounds (or lack thereof) through a blanket and hospital gown, he overlooked examining my heart, lungs, eyes, mouth, and feet.

It frightens me to think what might have happened during my hospital stay if I hadn’t provided information that wasn’t required by the EMR.

“You failed to ask me about my medical history or my diabetes," I said. The student searched his EMR for the appropriate questions to ask, but to no avail. Stunned, he appeared to be at a loss of words. I suggested that he ask about the type of diabetes I had, the duration of the disease, how well my glucose levels were controlled, my most recent HbA1c, and if I had developed any long-term microvascular or macrovascular complications. He politely thanked me, moved the mouse around on his computer stand, and began to wheel his computer away.

“Wait!” I thought. “Don’t you think you should examine my eyes, mouth, and feet?” I reminded myself that this student hadn’t evaluated me for peritoneal signs. So why should I insist that he look at non-critical parts of my body?

My physical pain was increasing and I was becoming increasingly distressed. The student was more interested in inputting data into the EMR than learning about acute abdomens and type 1 diabetes.

Postop: From bad to worse

My postoperative course was dreadful. I nearly died from complications that included acute renal failure, dehydration, hypokalemia, and a postoperative ileus that persisted for 8 days. My blood glucose levels, however, were perfect. Still, the Attendings and the students blamed my complications on diabetes.

“Yeah, I see this all the time,” said the hospitalist who was caring for me. “Diabetes causes gastroparesis. What we should do is have you take off that pump and sensor device. We’ll have the pharmacist help you manage your diabetes.” The hospitalist who suggested this course of action was immediately relieved of his duties by my wife as I drifted in and out of consciousness in the intensive care unit (ICU).

Despite the state of my health, I began to provide professional guidance for my own care. I demanded that the nurse give me a 250 cc rider of normal saline and increase my IV flow rate from 50 cc to 150 cc. The nasogastric tube was removed and I began using IV erythromycin, which increases gastric motility. I received oral and IV potassium.

I suggested that the medical students needed to unplug their smart phones, computers, and iPads and spend a day or 2 with one of us “old-time docs.”

While in the ICU, I was questioned by physicians and medical students, but never examined. I am convinced that had I not been an experienced family physician, I would have suffered a fatal postoperative event. The medical students assigned to my care would not have known that I died, unless they received a notification via Twitter.

Providing care in a digital age

My experience as a patient was in stark contrast to the way I practice medicine.

I use an EMR only to e-prescribe, and have chosen not to participate in submitting meaningful use data to the government. Rather than spending 2 hours a day making eye contact with an EMR, I prefer to use that time to listen to my patients’ concerns about their health. I know how to conduct a review of systems and I touch my patients at each visit. I look at their feet, skin, and eyes, listen to their heart and lungs, and palpate their abdomen. I perform a rectal exam on every patient who presents with abdominal pain.

I have learned to communicate my suspicions and thoughts (both positive and negative) to all of my patients. I take notes on scratch paper, not on a computer, just as my grandfather and father used to do when they were practicing medicine. I only order tests to confirm a suspected diagnosis, not as a primary means of evaluating patients.

Could my hospital experience lead to change?

Upon my discharge from the hospital, I reached out to the director of clinical studies at the local medical school and explained the deficiencies I’d encountered. I explained that the 4th-year medical students were ill-equipped to perform an adequate history or physical exam. They lacked knowledge of basic pharmacology. And they failed to appropriately follow a patient during the perioperative period.

The director appreciated my concern and provided me with the details of a corrective action plan that she had been working on.

“We need to implement our patient simulation computer program designed to teach our students how to appropriately interact with their distressed patients,” she said.

Really?

I suggested that the medical students needed to unplug their smartphones, computers, and iPads. Let them spend a day or 2 with one of us “old-time docs” who still work with our hands—hands that are skilled at evaluating patients, rather than texting and data entry. We’ll show these students how to become caring, intelligent, and dedicated clinicians.

“I have acute appendicitis,” I told my wife. “I need to go to the radiologist.”

A computed tomography (CT) scan of my abdomen confirmed my suspicion. After learning that I also had leukocytosis, we headed to the emergency department. The ED doctor was pleasantly surprised that someone had come to his facility completely evaluated. All he had to do was call the surgeon. But first he introduced me to a 4th-year medical student who was participating in a surgical rotation.

Prioritizing the EMR over the patient

The student wheeled his large computer to the side of my gurney and began to question me about my abdominal pain. Within 5 minutes, this unsupervised student had somehow acquired all the information he needed for my admission. He thanked me for my time and told me that he would see me in the operating room.

Unfortunately for him, I was not about to let him leave my cubicle without a redirect. I told him I have type 1 diabetes and several comorbidities. I wear an insulin pump and continuous glucose sensor that alerts me to impending hypoglycemia. I take 11 medications to successfully manage my metabolic disorders.

The student wheeled his machine back to the side of my gurney.

With his eyes fixed squarely on his computer and his finger on a mouse, he asked me to list all of my medications. He had never heard of a rapid-acting insulin analogue, nor was he familiar with my GLP-1 receptor agonist or SGLT2 inhibitor. And the pump and sensor? There were no check boxes for these devices in his electronic medical record (EMR).

He—like several of the doctors I met during my subsequent stay—suggested that I remove the pump and meter so that they could manage my diabetes.

Still in considerable pain, I suggested to the student and anyone else who would listen that my pump and sensor were off limits. As long as I was conscious, I would self-manage my diabetes.

I also told him that his history and physical exam were deficient. Although he did listen to my bowel sounds (or lack thereof) through a blanket and hospital gown, he overlooked examining my heart, lungs, eyes, mouth, and feet.

It frightens me to think what might have happened during my hospital stay if I hadn’t provided information that wasn’t required by the EMR.

“You failed to ask me about my medical history or my diabetes," I said. The student searched his EMR for the appropriate questions to ask, but to no avail. Stunned, he appeared to be at a loss of words. I suggested that he ask about the type of diabetes I had, the duration of the disease, how well my glucose levels were controlled, my most recent HbA1c, and if I had developed any long-term microvascular or macrovascular complications. He politely thanked me, moved the mouse around on his computer stand, and began to wheel his computer away.

“Wait!” I thought. “Don’t you think you should examine my eyes, mouth, and feet?” I reminded myself that this student hadn’t evaluated me for peritoneal signs. So why should I insist that he look at non-critical parts of my body?

My physical pain was increasing and I was becoming increasingly distressed. The student was more interested in inputting data into the EMR than learning about acute abdomens and type 1 diabetes.

Postop: From bad to worse

My postoperative course was dreadful. I nearly died from complications that included acute renal failure, dehydration, hypokalemia, and a postoperative ileus that persisted for 8 days. My blood glucose levels, however, were perfect. Still, the Attendings and the students blamed my complications on diabetes.

“Yeah, I see this all the time,” said the hospitalist who was caring for me. “Diabetes causes gastroparesis. What we should do is have you take off that pump and sensor device. We’ll have the pharmacist help you manage your diabetes.” The hospitalist who suggested this course of action was immediately relieved of his duties by my wife as I drifted in and out of consciousness in the intensive care unit (ICU).

Despite the state of my health, I began to provide professional guidance for my own care. I demanded that the nurse give me a 250 cc rider of normal saline and increase my IV flow rate from 50 cc to 150 cc. The nasogastric tube was removed and I began using IV erythromycin, which increases gastric motility. I received oral and IV potassium.

I suggested that the medical students needed to unplug their smart phones, computers, and iPads and spend a day or 2 with one of us “old-time docs.”

While in the ICU, I was questioned by physicians and medical students, but never examined. I am convinced that had I not been an experienced family physician, I would have suffered a fatal postoperative event. The medical students assigned to my care would not have known that I died, unless they received a notification via Twitter.

Providing care in a digital age

My experience as a patient was in stark contrast to the way I practice medicine.

I use an EMR only to e-prescribe, and have chosen not to participate in submitting meaningful use data to the government. Rather than spending 2 hours a day making eye contact with an EMR, I prefer to use that time to listen to my patients’ concerns about their health. I know how to conduct a review of systems and I touch my patients at each visit. I look at their feet, skin, and eyes, listen to their heart and lungs, and palpate their abdomen. I perform a rectal exam on every patient who presents with abdominal pain.

I have learned to communicate my suspicions and thoughts (both positive and negative) to all of my patients. I take notes on scratch paper, not on a computer, just as my grandfather and father used to do when they were practicing medicine. I only order tests to confirm a suspected diagnosis, not as a primary means of evaluating patients.

Could my hospital experience lead to change?

Upon my discharge from the hospital, I reached out to the director of clinical studies at the local medical school and explained the deficiencies I’d encountered. I explained that the 4th-year medical students were ill-equipped to perform an adequate history or physical exam. They lacked knowledge of basic pharmacology. And they failed to appropriately follow a patient during the perioperative period.

The director appreciated my concern and provided me with the details of a corrective action plan that she had been working on.

“We need to implement our patient simulation computer program designed to teach our students how to appropriately interact with their distressed patients,” she said.

Really?

I suggested that the medical students needed to unplug their smartphones, computers, and iPads. Let them spend a day or 2 with one of us “old-time docs” who still work with our hands—hands that are skilled at evaluating patients, rather than texting and data entry. We’ll show these students how to become caring, intelligent, and dedicated clinicians.

“I have acute appendicitis,” I told my wife. “I need to go to the radiologist.”

A computed tomography (CT) scan of my abdomen confirmed my suspicion. After learning that I also had leukocytosis, we headed to the emergency department. The ED doctor was pleasantly surprised that someone had come to his facility completely evaluated. All he had to do was call the surgeon. But first he introduced me to a 4th-year medical student who was participating in a surgical rotation.

Prioritizing the EMR over the patient

The student wheeled his large computer to the side of my gurney and began to question me about my abdominal pain. Within 5 minutes, this unsupervised student had somehow acquired all the information he needed for my admission. He thanked me for my time and told me that he would see me in the operating room.

Unfortunately for him, I was not about to let him leave my cubicle without a redirect. I told him I have type 1 diabetes and several comorbidities. I wear an insulin pump and continuous glucose sensor that alerts me to impending hypoglycemia. I take 11 medications to successfully manage my metabolic disorders.

The student wheeled his machine back to the side of my gurney.

With his eyes fixed squarely on his computer and his finger on a mouse, he asked me to list all of my medications. He had never heard of a rapid-acting insulin analogue, nor was he familiar with my GLP-1 receptor agonist or SGLT2 inhibitor. And the pump and sensor? There were no check boxes for these devices in his electronic medical record (EMR).

He—like several of the doctors I met during my subsequent stay—suggested that I remove the pump and meter so that they could manage my diabetes.

Still in considerable pain, I suggested to the student and anyone else who would listen that my pump and sensor were off limits. As long as I was conscious, I would self-manage my diabetes.

I also told him that his history and physical exam were deficient. Although he did listen to my bowel sounds (or lack thereof) through a blanket and hospital gown, he overlooked examining my heart, lungs, eyes, mouth, and feet.

It frightens me to think what might have happened during my hospital stay if I hadn’t provided information that wasn’t required by the EMR.

“You failed to ask me about my medical history or my diabetes," I said. The student searched his EMR for the appropriate questions to ask, but to no avail. Stunned, he appeared to be at a loss of words. I suggested that he ask about the type of diabetes I had, the duration of the disease, how well my glucose levels were controlled, my most recent HbA1c, and if I had developed any long-term microvascular or macrovascular complications. He politely thanked me, moved the mouse around on his computer stand, and began to wheel his computer away.

“Wait!” I thought. “Don’t you think you should examine my eyes, mouth, and feet?” I reminded myself that this student hadn’t evaluated me for peritoneal signs. So why should I insist that he look at non-critical parts of my body?

My physical pain was increasing and I was becoming increasingly distressed. The student was more interested in inputting data into the EMR than learning about acute abdomens and type 1 diabetes.

Postop: From bad to worse

My postoperative course was dreadful. I nearly died from complications that included acute renal failure, dehydration, hypokalemia, and a postoperative ileus that persisted for 8 days. My blood glucose levels, however, were perfect. Still, the Attendings and the students blamed my complications on diabetes.

“Yeah, I see this all the time,” said the hospitalist who was caring for me. “Diabetes causes gastroparesis. What we should do is have you take off that pump and sensor device. We’ll have the pharmacist help you manage your diabetes.” The hospitalist who suggested this course of action was immediately relieved of his duties by my wife as I drifted in and out of consciousness in the intensive care unit (ICU).

Despite the state of my health, I began to provide professional guidance for my own care. I demanded that the nurse give me a 250 cc rider of normal saline and increase my IV flow rate from 50 cc to 150 cc. The nasogastric tube was removed and I began using IV erythromycin, which increases gastric motility. I received oral and IV potassium.

I suggested that the medical students needed to unplug their smart phones, computers, and iPads and spend a day or 2 with one of us “old-time docs.”

While in the ICU, I was questioned by physicians and medical students, but never examined. I am convinced that had I not been an experienced family physician, I would have suffered a fatal postoperative event. The medical students assigned to my care would not have known that I died, unless they received a notification via Twitter.

Providing care in a digital age

My experience as a patient was in stark contrast to the way I practice medicine.

I use an EMR only to e-prescribe, and have chosen not to participate in submitting meaningful use data to the government. Rather than spending 2 hours a day making eye contact with an EMR, I prefer to use that time to listen to my patients’ concerns about their health. I know how to conduct a review of systems and I touch my patients at each visit. I look at their feet, skin, and eyes, listen to their heart and lungs, and palpate their abdomen. I perform a rectal exam on every patient who presents with abdominal pain.

I have learned to communicate my suspicions and thoughts (both positive and negative) to all of my patients. I take notes on scratch paper, not on a computer, just as my grandfather and father used to do when they were practicing medicine. I only order tests to confirm a suspected diagnosis, not as a primary means of evaluating patients.

Could my hospital experience lead to change?

Upon my discharge from the hospital, I reached out to the director of clinical studies at the local medical school and explained the deficiencies I’d encountered. I explained that the 4th-year medical students were ill-equipped to perform an adequate history or physical exam. They lacked knowledge of basic pharmacology. And they failed to appropriately follow a patient during the perioperative period.

The director appreciated my concern and provided me with the details of a corrective action plan that she had been working on.

“We need to implement our patient simulation computer program designed to teach our students how to appropriately interact with their distressed patients,” she said.

Really?

I suggested that the medical students needed to unplug their smartphones, computers, and iPads. Let them spend a day or 2 with one of us “old-time docs” who still work with our hands—hands that are skilled at evaluating patients, rather than texting and data entry. We’ll show these students how to become caring, intelligent, and dedicated clinicians.

Okay, I admit that from time to time I have embellished the anecdotes that I include in these letters. Sometimes, I feel I need to make sure that you are paying attention. But this time, I am relating this story in its true, unvarnished state.

Two mature women with whom I am acquainted (No, one was not my wife!) had just finished their habitual Saturday morning walk through a wooded upper middle class neighborhood here in town. It was nine o’clock in the morning and the sun was shining. Suddenly, a mangy-looking fox trotted out of the woods and down the road toward them. Aware that from time to time local raccoons, skunks, and foxes have tested positive for rabies, these women began to run and flagged down the first car they saw, and without a word hopped in the back seat.

The surprised occupants of the vehicle were two mature men. You might call them strangers, but here in Maine, we don’t have any strangers. We have tourists. If a fellow Mainer doesn’t know you, he probably knows two people with whom you are acquainted.

As the women began to breathlessly explain their actions, one of the women felt a searing pain in her right thigh and assumed she had torn a muscle as she sprinted away from the fox. Within a few hundred yards, the car began to fill with smoke. Believing that the vehicle was on fire, all four occupants tumbled out into the street like four carnival clowns.

It quickly became clear that the cause of the smoke and the searing pain was that the woman’s pants were on fire. Throwing all caution and modesty to the wind, she quickly shed her pants in the middle of the road and in full view of these men, with whom it turns out she does share several acquaintances.

The source of the fire was the woman’s cell phone. The resulting injury was a palm-size, painful, deep, second-degree burn of her anterior thigh. In a quick Internet search, you will discover several very similar stories – minus the fox and the strangers. Some of the victims were children.

It turns out some cell phones have a tendency to spontaneously explode and/or catch fire. There seems to be no common factor in the events, although some of the ultrathin and flexible cell phones may be more prone to conflagration. However, the victim in our scenario has a storied past with cell phones. She has dropped them in the toilet at least once (history is a little unclear here on the exact number). On another occasion, she placed one in the sink of a public restroom, we can assume to prevent a second or third toilet submersion. As she approached the sink to retrieve it, the clever water-saving faucet – sensing her presence – turned itself on. But in the fox and fire incident, she denies any previous submersions or unusual events with this particular phone. A lawyer is now involved.

So while you and I as pediatricians may be concerned about the relationship between cell phones and health of our patients primarily because cell phones can be a dangerous distraction for young drivers, cyclists, and pedestrians, I share this anecdote to make you aware of another of their health hazards. You also may want to reconsider where you carry your cell phone.

I am not worried myself. I have a little flip phone for which I pay $100 for 500 minutes of usage a year, way more than I need or use. It couldn’t be considered a smartphone as its only noteworthy skill is taking pictures of the inside of my pants pocket. I suspect that its battery must be so small and impotent that even if it decides to self-immolate, I doubt I will notice. However, I do worry about scraggly-looking foxes meandering through my neighborhood.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

Okay, I admit that from time to time I have embellished the anecdotes that I include in these letters. Sometimes, I feel I need to make sure that you are paying attention. But this time, I am relating this story in its true, unvarnished state.

Two mature women with whom I am acquainted (No, one was not my wife!) had just finished their habitual Saturday morning walk through a wooded upper middle class neighborhood here in town. It was nine o’clock in the morning and the sun was shining. Suddenly, a mangy-looking fox trotted out of the woods and down the road toward them. Aware that from time to time local raccoons, skunks, and foxes have tested positive for rabies, these women began to run and flagged down the first car they saw, and without a word hopped in the back seat.

The surprised occupants of the vehicle were two mature men. You might call them strangers, but here in Maine, we don’t have any strangers. We have tourists. If a fellow Mainer doesn’t know you, he probably knows two people with whom you are acquainted.

As the women began to breathlessly explain their actions, one of the women felt a searing pain in her right thigh and assumed she had torn a muscle as she sprinted away from the fox. Within a few hundred yards, the car began to fill with smoke. Believing that the vehicle was on fire, all four occupants tumbled out into the street like four carnival clowns.

It quickly became clear that the cause of the smoke and the searing pain was that the woman’s pants were on fire. Throwing all caution and modesty to the wind, she quickly shed her pants in the middle of the road and in full view of these men, with whom it turns out she does share several acquaintances.

The source of the fire was the woman’s cell phone. The resulting injury was a palm-size, painful, deep, second-degree burn of her anterior thigh. In a quick Internet search, you will discover several very similar stories – minus the fox and the strangers. Some of the victims were children.

It turns out some cell phones have a tendency to spontaneously explode and/or catch fire. There seems to be no common factor in the events, although some of the ultrathin and flexible cell phones may be more prone to conflagration. However, the victim in our scenario has a storied past with cell phones. She has dropped them in the toilet at least once (history is a little unclear here on the exact number). On another occasion, she placed one in the sink of a public restroom, we can assume to prevent a second or third toilet submersion. As she approached the sink to retrieve it, the clever water-saving faucet – sensing her presence – turned itself on. But in the fox and fire incident, she denies any previous submersions or unusual events with this particular phone. A lawyer is now involved.

So while you and I as pediatricians may be concerned about the relationship between cell phones and health of our patients primarily because cell phones can be a dangerous distraction for young drivers, cyclists, and pedestrians, I share this anecdote to make you aware of another of their health hazards. You also may want to reconsider where you carry your cell phone.

I am not worried myself. I have a little flip phone for which I pay $100 for 500 minutes of usage a year, way more than I need or use. It couldn’t be considered a smartphone as its only noteworthy skill is taking pictures of the inside of my pants pocket. I suspect that its battery must be so small and impotent that even if it decides to self-immolate, I doubt I will notice. However, I do worry about scraggly-looking foxes meandering through my neighborhood.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

Okay, I admit that from time to time I have embellished the anecdotes that I include in these letters. Sometimes, I feel I need to make sure that you are paying attention. But this time, I am relating this story in its true, unvarnished state.

Two mature women with whom I am acquainted (No, one was not my wife!) had just finished their habitual Saturday morning walk through a wooded upper middle class neighborhood here in town. It was nine o’clock in the morning and the sun was shining. Suddenly, a mangy-looking fox trotted out of the woods and down the road toward them. Aware that from time to time local raccoons, skunks, and foxes have tested positive for rabies, these women began to run and flagged down the first car they saw, and without a word hopped in the back seat.

The surprised occupants of the vehicle were two mature men. You might call them strangers, but here in Maine, we don’t have any strangers. We have tourists. If a fellow Mainer doesn’t know you, he probably knows two people with whom you are acquainted.

As the women began to breathlessly explain their actions, one of the women felt a searing pain in her right thigh and assumed she had torn a muscle as she sprinted away from the fox. Within a few hundred yards, the car began to fill with smoke. Believing that the vehicle was on fire, all four occupants tumbled out into the street like four carnival clowns.

It quickly became clear that the cause of the smoke and the searing pain was that the woman’s pants were on fire. Throwing all caution and modesty to the wind, she quickly shed her pants in the middle of the road and in full view of these men, with whom it turns out she does share several acquaintances.

The source of the fire was the woman’s cell phone. The resulting injury was a palm-size, painful, deep, second-degree burn of her anterior thigh. In a quick Internet search, you will discover several very similar stories – minus the fox and the strangers. Some of the victims were children.

It turns out some cell phones have a tendency to spontaneously explode and/or catch fire. There seems to be no common factor in the events, although some of the ultrathin and flexible cell phones may be more prone to conflagration. However, the victim in our scenario has a storied past with cell phones. She has dropped them in the toilet at least once (history is a little unclear here on the exact number). On another occasion, she placed one in the sink of a public restroom, we can assume to prevent a second or third toilet submersion. As she approached the sink to retrieve it, the clever water-saving faucet – sensing her presence – turned itself on. But in the fox and fire incident, she denies any previous submersions or unusual events with this particular phone. A lawyer is now involved.

So while you and I as pediatricians may be concerned about the relationship between cell phones and health of our patients primarily because cell phones can be a dangerous distraction for young drivers, cyclists, and pedestrians, I share this anecdote to make you aware of another of their health hazards. You also may want to reconsider where you carry your cell phone.

I am not worried myself. I have a little flip phone for which I pay $100 for 500 minutes of usage a year, way more than I need or use. It couldn’t be considered a smartphone as its only noteworthy skill is taking pictures of the inside of my pants pocket. I suspect that its battery must be so small and impotent that even if it decides to self-immolate, I doubt I will notice. However, I do worry about scraggly-looking foxes meandering through my neighborhood.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” Email him at [email protected].

Infectious disease morbidity and mortality continue to disproportionately impact pregnant women and young infants.

In California, the incidence of pertussis approximates 100 cases per 100,000 in infants less than 5 months of age; a rate threefold greater than any other age group. Seven of nine (77%) deaths in 2013/2014 occurred in infants less than 3 months of age (California Department of Public Health Pertussis Report, Aug. 3, 2015).

Influenza severity and mortality is increased in pregnant women, and there is a greater risk of fetal morbidity and wastage. In the 2009 H₁N₁ pandemic, there was a 20% case fatality rate in women sick enough to be admitted to the ICU. The incidence of low birth weight also was increased among pregnant women delivering while hospitalized for influenza-related illness. These examples highlight the burden of vaccine-preventable disease in two vulnerable populations, pregnant women and infants too young to be protected by vaccines mandated by the U.S.immunization program.

The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and many other national and state organizations endorse immunization of pregnant women to improve women’s and infants’ outcomes. Recent studies demonstrate that infants born to women vaccinated with influenza are 45%-48% less likely to be hospitalized for culture-proven influenza.

Benowitz et al. reported a 91.5% effectiveness for maternal influenza vaccination for prevention of hospitalization of infants caused by influenza in the first 6 months of life. The presumed mechanisms of protection are both the transplacental transfer of protective antibody as well as indirect protection from disease prevention in the mother (Clin Infect Dis. 2010 Dec 15;51(12):1355-61). The recommendation is that inactivated influenza vaccine can be given at any time during pregnancy; however, live attenuated influenza vaccine (LAIV; FluMist) is contraindicated, as are all live-virus vaccines. In contrast, Tdap is recommended for use either during pregnancy or post partum.

However, Healy et al. (Pediatr Infect Dis J. 2015;34(1):22-60) failed to demonstrate a benefit to postpartum immunization and cocooning for reducing pertussis illness in infants 6 months of age or younger. The likely explanation for this failure is revealed in a recent study in infant baboons where immunization with Tdap failed to decrease colonization or transmission of Bordetella pertussis, compared with natural disease or whole-cell pertussis. Thus, even though protective against disease, Tdap failure to prevent transmission within the community still occurs. The current Advisory Committee on Immunization Practices recommendation, immunization between 27 and 36 weeks, is designed to ensure high antibody concentrations in both mother and newborn at the time of birth and bridge the time period until infant immunization can elicit protective antibody.

The benefits achieved with maternal immunization must be weighed against potential for adverse events. There is no evidence of risk to either mother or infant from inactivated vaccines administered during pregnancy. Still, the recommendations for influenza and Tdap vaccine incorporate the high likelihood of exposure, the risk of morbidity or mortality from the infectious agent, and the likelihood of harm. During the H₁N₁ epidemic, a cohort study by Chambers et al. of H₁N₁ vaccine in exposed and unexposed pregnant women concluded that there was no increase in risk for major congenital defects, spontaneous abortion, or small for gestational age (Vaccine. 2013 Oct 17;31(44):5026-32). There was a signal for increase in prematurity, but the difference between H₁N₁-vaccinated and unvaccinated pregnancies was 3 days. In addition, a review of 11 studies, including one of 10,428 pregnant women, concluded there were no harmful maternal or fetal effects.

Additionally, no adverse risks have been identified in women who were inadvertently vaccinated during pregnancy with live-attenuated rubella, influenza, and yellow fever vaccines. Tetanus vaccination has been administered safely to several millions of pregnant women without documented serious adverse outcomes. Ongoing postmarketing surveillance continues as an important tool for identification of potential adverse effects.

One potential limitation is the blunting of infant immune responses to vaccination due to high serum antibody concentrations at the time of primary immunizations. Some studies have found lower antibody concentrations prior to booster vaccinations at 1 year of age. However, as morbidity and mortality is greater in the first months of life for many infectious diseases, this may be an acceptable trade off if high morbidity and mortality can be reduced in the first months of life.

Immunization during pregnancy represents only one aspect of prevention of vaccine preventable diseases. Preconception, prenatal, and postpartum visits with health care professionals represents an opportune time to discuss the benefits of immunization and their contribution to a healthy pregnancy outcome. Inactivated vaccines are safe for administration during pregnancy, live virus vaccines, despite being attenuated, are a theoretical risk if spread to the fetus occurs and therefore are contraindicated and should be administered during preconception counseling if indicated. The table below outlines vaccines that can be administered before, during, and after pregnancy.

Although once considered potentially contraindicated in pregnant women, evidence now supports specific vaccines as both safe for a pregnant woman and her fetus and effective for preventing serious disease in both. Universal immunization with influenza vaccine and Tdap, as recommended by multiple national professional medical organizations, will improve the outcome of pregnancy by prevention of morbidity and mortality from common community pathogens.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. E-mail him at [email protected].

Infectious disease morbidity and mortality continue to disproportionately impact pregnant women and young infants.

In California, the incidence of pertussis approximates 100 cases per 100,000 in infants less than 5 months of age; a rate threefold greater than any other age group. Seven of nine (77%) deaths in 2013/2014 occurred in infants less than 3 months of age (California Department of Public Health Pertussis Report, Aug. 3, 2015).

Influenza severity and mortality is increased in pregnant women, and there is a greater risk of fetal morbidity and wastage. In the 2009 H₁N₁ pandemic, there was a 20% case fatality rate in women sick enough to be admitted to the ICU. The incidence of low birth weight also was increased among pregnant women delivering while hospitalized for influenza-related illness. These examples highlight the burden of vaccine-preventable disease in two vulnerable populations, pregnant women and infants too young to be protected by vaccines mandated by the U.S.immunization program.

The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and many other national and state organizations endorse immunization of pregnant women to improve women’s and infants’ outcomes. Recent studies demonstrate that infants born to women vaccinated with influenza are 45%-48% less likely to be hospitalized for culture-proven influenza.

Benowitz et al. reported a 91.5% effectiveness for maternal influenza vaccination for prevention of hospitalization of infants caused by influenza in the first 6 months of life. The presumed mechanisms of protection are both the transplacental transfer of protective antibody as well as indirect protection from disease prevention in the mother (Clin Infect Dis. 2010 Dec 15;51(12):1355-61). The recommendation is that inactivated influenza vaccine can be given at any time during pregnancy; however, live attenuated influenza vaccine (LAIV; FluMist) is contraindicated, as are all live-virus vaccines. In contrast, Tdap is recommended for use either during pregnancy or post partum.

However, Healy et al. (Pediatr Infect Dis J. 2015;34(1):22-60) failed to demonstrate a benefit to postpartum immunization and cocooning for reducing pertussis illness in infants 6 months of age or younger. The likely explanation for this failure is revealed in a recent study in infant baboons where immunization with Tdap failed to decrease colonization or transmission of Bordetella pertussis, compared with natural disease or whole-cell pertussis. Thus, even though protective against disease, Tdap failure to prevent transmission within the community still occurs. The current Advisory Committee on Immunization Practices recommendation, immunization between 27 and 36 weeks, is designed to ensure high antibody concentrations in both mother and newborn at the time of birth and bridge the time period until infant immunization can elicit protective antibody.

The benefits achieved with maternal immunization must be weighed against potential for adverse events. There is no evidence of risk to either mother or infant from inactivated vaccines administered during pregnancy. Still, the recommendations for influenza and Tdap vaccine incorporate the high likelihood of exposure, the risk of morbidity or mortality from the infectious agent, and the likelihood of harm. During the H₁N₁ epidemic, a cohort study by Chambers et al. of H₁N₁ vaccine in exposed and unexposed pregnant women concluded that there was no increase in risk for major congenital defects, spontaneous abortion, or small for gestational age (Vaccine. 2013 Oct 17;31(44):5026-32). There was a signal for increase in prematurity, but the difference between H₁N₁-vaccinated and unvaccinated pregnancies was 3 days. In addition, a review of 11 studies, including one of 10,428 pregnant women, concluded there were no harmful maternal or fetal effects.

Additionally, no adverse risks have been identified in women who were inadvertently vaccinated during pregnancy with live-attenuated rubella, influenza, and yellow fever vaccines. Tetanus vaccination has been administered safely to several millions of pregnant women without documented serious adverse outcomes. Ongoing postmarketing surveillance continues as an important tool for identification of potential adverse effects.

One potential limitation is the blunting of infant immune responses to vaccination due to high serum antibody concentrations at the time of primary immunizations. Some studies have found lower antibody concentrations prior to booster vaccinations at 1 year of age. However, as morbidity and mortality is greater in the first months of life for many infectious diseases, this may be an acceptable trade off if high morbidity and mortality can be reduced in the first months of life.

Immunization during pregnancy represents only one aspect of prevention of vaccine preventable diseases. Preconception, prenatal, and postpartum visits with health care professionals represents an opportune time to discuss the benefits of immunization and their contribution to a healthy pregnancy outcome. Inactivated vaccines are safe for administration during pregnancy, live virus vaccines, despite being attenuated, are a theoretical risk if spread to the fetus occurs and therefore are contraindicated and should be administered during preconception counseling if indicated. The table below outlines vaccines that can be administered before, during, and after pregnancy.

Although once considered potentially contraindicated in pregnant women, evidence now supports specific vaccines as both safe for a pregnant woman and her fetus and effective for preventing serious disease in both. Universal immunization with influenza vaccine and Tdap, as recommended by multiple national professional medical organizations, will improve the outcome of pregnancy by prevention of morbidity and mortality from common community pathogens.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. E-mail him at [email protected].

Infectious disease morbidity and mortality continue to disproportionately impact pregnant women and young infants.

In California, the incidence of pertussis approximates 100 cases per 100,000 in infants less than 5 months of age; a rate threefold greater than any other age group. Seven of nine (77%) deaths in 2013/2014 occurred in infants less than 3 months of age (California Department of Public Health Pertussis Report, Aug. 3, 2015).

Influenza severity and mortality is increased in pregnant women, and there is a greater risk of fetal morbidity and wastage. In the 2009 H₁N₁ pandemic, there was a 20% case fatality rate in women sick enough to be admitted to the ICU. The incidence of low birth weight also was increased among pregnant women delivering while hospitalized for influenza-related illness. These examples highlight the burden of vaccine-preventable disease in two vulnerable populations, pregnant women and infants too young to be protected by vaccines mandated by the U.S.immunization program.

The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and many other national and state organizations endorse immunization of pregnant women to improve women’s and infants’ outcomes. Recent studies demonstrate that infants born to women vaccinated with influenza are 45%-48% less likely to be hospitalized for culture-proven influenza.

Benowitz et al. reported a 91.5% effectiveness for maternal influenza vaccination for prevention of hospitalization of infants caused by influenza in the first 6 months of life. The presumed mechanisms of protection are both the transplacental transfer of protective antibody as well as indirect protection from disease prevention in the mother (Clin Infect Dis. 2010 Dec 15;51(12):1355-61). The recommendation is that inactivated influenza vaccine can be given at any time during pregnancy; however, live attenuated influenza vaccine (LAIV; FluMist) is contraindicated, as are all live-virus vaccines. In contrast, Tdap is recommended for use either during pregnancy or post partum.

However, Healy et al. (Pediatr Infect Dis J. 2015;34(1):22-60) failed to demonstrate a benefit to postpartum immunization and cocooning for reducing pertussis illness in infants 6 months of age or younger. The likely explanation for this failure is revealed in a recent study in infant baboons where immunization with Tdap failed to decrease colonization or transmission of Bordetella pertussis, compared with natural disease or whole-cell pertussis. Thus, even though protective against disease, Tdap failure to prevent transmission within the community still occurs. The current Advisory Committee on Immunization Practices recommendation, immunization between 27 and 36 weeks, is designed to ensure high antibody concentrations in both mother and newborn at the time of birth and bridge the time period until infant immunization can elicit protective antibody.

The benefits achieved with maternal immunization must be weighed against potential for adverse events. There is no evidence of risk to either mother or infant from inactivated vaccines administered during pregnancy. Still, the recommendations for influenza and Tdap vaccine incorporate the high likelihood of exposure, the risk of morbidity or mortality from the infectious agent, and the likelihood of harm. During the H₁N₁ epidemic, a cohort study by Chambers et al. of H₁N₁ vaccine in exposed and unexposed pregnant women concluded that there was no increase in risk for major congenital defects, spontaneous abortion, or small for gestational age (Vaccine. 2013 Oct 17;31(44):5026-32). There was a signal for increase in prematurity, but the difference between H₁N₁-vaccinated and unvaccinated pregnancies was 3 days. In addition, a review of 11 studies, including one of 10,428 pregnant women, concluded there were no harmful maternal or fetal effects.

Additionally, no adverse risks have been identified in women who were inadvertently vaccinated during pregnancy with live-attenuated rubella, influenza, and yellow fever vaccines. Tetanus vaccination has been administered safely to several millions of pregnant women without documented serious adverse outcomes. Ongoing postmarketing surveillance continues as an important tool for identification of potential adverse effects.

One potential limitation is the blunting of infant immune responses to vaccination due to high serum antibody concentrations at the time of primary immunizations. Some studies have found lower antibody concentrations prior to booster vaccinations at 1 year of age. However, as morbidity and mortality is greater in the first months of life for many infectious diseases, this may be an acceptable trade off if high morbidity and mortality can be reduced in the first months of life.

Immunization during pregnancy represents only one aspect of prevention of vaccine preventable diseases. Preconception, prenatal, and postpartum visits with health care professionals represents an opportune time to discuss the benefits of immunization and their contribution to a healthy pregnancy outcome. Inactivated vaccines are safe for administration during pregnancy, live virus vaccines, despite being attenuated, are a theoretical risk if spread to the fetus occurs and therefore are contraindicated and should be administered during preconception counseling if indicated. The table below outlines vaccines that can be administered before, during, and after pregnancy.

Although once considered potentially contraindicated in pregnant women, evidence now supports specific vaccines as both safe for a pregnant woman and her fetus and effective for preventing serious disease in both. Universal immunization with influenza vaccine and Tdap, as recommended by multiple national professional medical organizations, will improve the outcome of pregnancy by prevention of morbidity and mortality from common community pathogens.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. E-mail him at [email protected].

In late 2013, there were 45 cases of acute liver failure (ALF) in Hawaii, and 29 of those people reported taking OxyELITE Pro (an herbal dietary supplement marketed for weight reduction and “fat-burning”) 60 days before illness onset. Of 8 initial cases, 2 patients needed urgent liver transplants, one died, and 5 eventually recovered.¹ The manufacturer of OxyELITE Pro voluntarily recalled the product after receiving a warning letter from the US Food and Drug Administration (FDA).

One way to prevent situations like this from occurring might be to ban the sale of weight loss or sports enhancement supplements unless they are rigorously tested and approved by the FDA. Voluntary reporting to the FDA is time-consuming and it takes time for the FDA to follow up on these reports.

As primary care physicians, we need to consistently ask patients about their use of supplements, educate them about the potential dangers, and identify those who are experiencing adverse reactions. While we can’t put a stop to the harm that some herbal dietary supplements might inflict on a public eager to embrace quick fixes for weight loss and improved strength, we can be the best first responders.

Linda L. Wong, MD
Honolulu, Hawaii

In late 2013, there were 45 cases of acute liver failure (ALF) in Hawaii, and 29 of those people reported taking OxyELITE Pro (an herbal dietary supplement marketed for weight reduction and “fat-burning”) 60 days before illness onset. Of 8 initial cases, 2 patients needed urgent liver transplants, one died, and 5 eventually recovered.¹ The manufacturer of OxyELITE Pro voluntarily recalled the product after receiving a warning letter from the US Food and Drug Administration (FDA).

One way to prevent situations like this from occurring might be to ban the sale of weight loss or sports enhancement supplements unless they are rigorously tested and approved by the FDA. Voluntary reporting to the FDA is time-consuming and it takes time for the FDA to follow up on these reports.

As primary care physicians, we need to consistently ask patients about their use of supplements, educate them about the potential dangers, and identify those who are experiencing adverse reactions. While we can’t put a stop to the harm that some herbal dietary supplements might inflict on a public eager to embrace quick fixes for weight loss and improved strength, we can be the best first responders.

Linda L. Wong, MD
Honolulu, Hawaii

In late 2013, there were 45 cases of acute liver failure (ALF) in Hawaii, and 29 of those people reported taking OxyELITE Pro (an herbal dietary supplement marketed for weight reduction and “fat-burning”) 60 days before illness onset. Of 8 initial cases, 2 patients needed urgent liver transplants, one died, and 5 eventually recovered.¹ The manufacturer of OxyELITE Pro voluntarily recalled the product after receiving a warning letter from the US Food and Drug Administration (FDA).

One way to prevent situations like this from occurring might be to ban the sale of weight loss or sports enhancement supplements unless they are rigorously tested and approved by the FDA. Voluntary reporting to the FDA is time-consuming and it takes time for the FDA to follow up on these reports.

As primary care physicians, we need to consistently ask patients about their use of supplements, educate them about the potential dangers, and identify those who are experiencing adverse reactions. While we can’t put a stop to the harm that some herbal dietary supplements might inflict on a public eager to embrace quick fixes for weight loss and improved strength, we can be the best first responders.

Linda L. Wong, MD
Honolulu, Hawaii