MMR Derangement Syndrome

BMJ published the first article in a series documenting how Andrew Wakefield falsified data to publish a purported link between the MMR vaccine and autism. Please read the article and commentary  in full (and future installments as they are published).

A summary from the BMJ article:

How the link was fixed

The Lancet paper was a case series of 12 child patients; it reported a proposed “new syndrome” of enterocolitis and regressive autism and associated this with MMR as an “apparent precipitating event.” But in fact:

Three of nine children reported with regressive autism did not have autism diagnosed at all. Only one child clearly had regressive autism

Despite the paper claiming that all 12 children were “previously normal,” five had documented pre-existing developmental concerns

Some children were reported to have experienced first behavioural symptoms within days of MMR, but the records documented these as starting some months after vaccination

In nine cases, unremarkable colonic histopathology results—noting no or minimal fluctuations in inflammatory cell populations—were changed after a medical school “research review” to “non-specific colitis”

The parents of eight children were reported as blaming MMR, but 11 families made this allegation at the hospital. The exclusion of three allegations—all giving times to onset of problems in months—helped to create the appearance of a 14 day temporal link

Patients were recruited through anti-MMR campaigners, and the study was commissioned and funded for planned litigation

The original paper fueled anti-immunization sentiment, and contributed to decreasing immunization rates and increasing infection rates across the Western world. Although the original paper was retracted last year by the Lancet, and Wakefield was stripped of clinical privileges in Britain, he remains a star of anti-immunization groups.

For his fraud, Wakefield gained fame and filthy lucre (including over $600000 from the legal firm). He remains unindicted, free to peddle his ideas here in the US.

The rest of us have paid a heavy price for these lies, in distrust and alienation between parents and doctors. In millions spent trying to disprove a fantasy. In children with preventable illness and untimely death. 

Doctor Autonomy

Just as a patient has autonomy (self-rule) for health decisions, a doctor has autonomy in practice decisions.

A doctor has autonomy to decide the mode and scope of his/her practice of medicine. Mode, in this context, refers to employment, location, associations, etc. Scope of practice is simply what services the doctor provides. Some conditions of practice are prescibed or regulated by national or local law (such as non-discrimination statutes), and some conditions and practices are prohibited, otherwise current U.S. law allows freedom for doctors to decide these things.

Employee or self-employed? If employed, by whom and under what conditions? Where?
Solo or group practice? Locum tenens? Staff model HMO? Government?
Doing which procedures? Under what conditions? For whom?
(Scope of practice enters into the mode of course, as a doctor needs to perform within the requirements of employment). 

When I chose solo, rural, self-employed practice I accepted certain conditions which came with that decision and are different from other modes of practice. For instance, I have more independence and flexibility to follow my own values, but more responsibility for the business side of practice with less security.  

My scope is based on my training, experience, preferences and belief system. It has changed with time, mostly I have reduced the procedures I perform after my skills atrophied since training (e.g. most joint injections). I no longer do obstetrics for financial reasons. I received no training in procedures I intended to not perform for whatever reason.

My next post will address one threat to this liberty. 

Who is responsible for one's health?

A most important question behind too many health initiatives and medicrat blather is a most basic one.

Who is in charge?
Who is in charge of a person's health?

Is it the patient?
Is it the Doctor?
Is it the Medicrat?

Do you remember the old rhetorical question, "Whose body is it, anyway"?

When I was in training, I was subject to a great deal of instruction to not be "paternalistic" toward patients and to respectfully obey their autonomy. I could advise, warn, and teach, I could give them options and try to help, but ultimately the patient made the decision for him/herself.

Today, however, we are seeing the erosion of patient autonomy and a forced resurgence of paternalism as doctors are blamed when someone makes 'bad choices'. Pay-for-performance (P4P) schemes where the Medicrat decrees the Doctor is responsible for the patient's smoking, weight, exercise, etc. What happened to the patient's autonomy?

It is not the Doctor's prerogative to steal the patient's freedom.
It is not the Medicrat's right to overrule the patient's liberty.
It is a person's right and responsibility to exercise autonomy; self-rule. And to live (or not) with the consequences, whether good or bad.


“Liberty means responsibility. That is why most men dread it.”
George Bernard Shaw