Physicians And The H1N1 Flu

Yesterday I visited the Centers for Disease Control in Atlanta and was taken inside the command center, where almost 100 staffers have been working around the clock to monitor and stem the current outbreak of flu.

I first spoke to Toby Crafton, the manager of the command center, who oversees the day-to-day operations. He and his team have been preparing for a possible pandemic of flu or another infectious illness for years. I also spoke to Michael Shaw, Ph.D., who heads up the virology labs that are studying the H1N1 virus causing the current outbreak. He's spent a career learning the laboratory techniques that are so urgently needed right now. The third person I spoke to was Dr. Richard Besser, Acting Director of the CDC, who has been working at the agency for 13 years and is an extensively published expert in infectious diseases.

I mentioned that last week I had received an email notification from the New York City Department of Health (NYCDOH) about how I should be managing my patients with flu-like symptoms. The advice was actually not intuitively obvious to me. For example, the Department of Health said that for patients with mild illness, treatment with anti-viral meds like Tamiflu and Relenza was only recommended for patients who also had underlying conditions that increased their risk for complications due to influenza. Dr. Besser pointed out that it was especially important right now for physicians to stay up to date with the recommendations being made by public health officials. Doctors can contact their local department of health and sign up for the same type of email notification that I received.

This brings us to the main point of today's blog. Many of us -- patients and physicians alike -- have been thinking about the influenza virus for about a week. Public health officials like the teams at the CDC and the NYCDOH have been thinking about it for years. Physicians, me included, are used to practicing medicine based on "clinical judgment." We understand that medicine is an art and not a science, that there are many different ways to approach a problem, that there's often no clear "right" or "wrong." We are also used to doing things "our way," whatever that way is. But this is not a time for doing things "our way" if it's at significant odds with strong recommendations being made by public health officials. There are recommendations that may seem logical -- like prescribing medication for somebody with mild flu symptoms "just in case" -- that nevertheless go against the judgment of people who have trained for years to think about how to deal with an epidemic.

What if you're a physician who strongly disagrees with a suggestion of public officials? Then challenge that recommendation publicly. Bring the discussion to light; maybe you're right. While this is no time to go rogue, doctors have an obligation to think carefully and independently and to challenge recommendations that seem illogical. But don't silently do things your own way.

"Only On The Web:" CBS News medical correspondent Dr. Jon LaPook speaks with Dr. Richard Besser, acting director of the Centers for Disease Control, about the H1N1 flu outbreak:

Watch CBS Videos Online

Comments

[shimari]

"Clinical judgment' = making the same mistake repeatedly with increasing levels of confidence.

[Squalish]

The reason treatment recommendations are slightly different is that you're a doctor faced with fighting individual ill health. You're treating the patient. They're the epidemiological agency treating not just the patient, but all the potential patients that they could get sick. You're fighting symptoms and causes, but they're fighting the pandemic as a whole. Exercising "caution" means different things in these two different modes.

To use an illustrative extreme - for a catastrophically dangerous fictional plague (something we see often in horror movies), the doctors may want to enter a region and save the patients individually, but the epidemiologists may instead consider the risk of contagion so extreme that the towns have to be sterilized with napalm. Both are considering safety and trying to exercise sound judgement, they are just used to treating entirely different things. It's the press/publ­ic/governm­ent's job to find a balance between the two that suits the level of danger.

[grn1]

"This brings us to the main point of today's blog. Many of us -- patients and physicians alike -- have been thinking about the influenza virus for about a week. Public health officials like the teams at the CDC and the NYCDOH have been thinking about it for years." AND SOME OF OUR MOST CONCERNED AND INTELLIGENT PHYSICIANS AND SCIENTIST HAVE BEEN THINKING ABOUT IT FOR DECADES. www.psrast.org

[grn1]

Why did this article disappear from the main page right after I posted www.psrast.org

[MOMMASHANKS]

In defense of Vice-President Biden: Every one pounced on Vice President Biden - rather unfairly. Mr. Biden did not say anything very different from what all other officials and official agencies have been saying: avoid crowded places, and closed in places. What is more closed in and crowded than airplanes? Especially today's fully packed flights? It is just pure common sense to avoid unnecessary exposure to the H1N1 Flu virus.
I feel Mr. Biden was unnecessarily and undeservedly criticized. Don't embarrass him and scold him simply because we have to make sure the airline industry does not get offended!

[elsellel]

funny... i'm not thinking about it at all. just can't feature any more - fear pushing - from any angle that the mass media wants to pursue in light of more important topics.

[lizzyLoo]

Sadly that photo says it all. No one mentions these poor creatures forced into horribly inhumane conditions. They suffer terribly and society doesn't seem to care as long as we get our cheap meat how and when we want it. Karma is a bitch.

[euthman]

Dr. LaPook: Physicians are heavily conditioned by custom and law to put the interest of the individual patient above that of the population. The only way to balance those interests is by way of a robust and powerful public health system. Relying on individual physicians to short their patients for the good of the population is doomed to failure, I think. --Ed Uthman, MD

[KillTheMessenger]

The moment physicians put the interest of anything before that of the patient, you will be better off going to the veterinary for advice with your ailments.

Grabbing head... rolling eyes... disbelieving the level of discourse on Huffpo.

[schatsie]

That is a thought about going to the Veterinarians.

You know the immunizations they give animals do not contain mercury since 1991 and we are still ingesting it in the immunizations for humans....specially the flu shots and it is not even a good preservati­ve,,(,just like asbestos and nicotine.... big lies...forever in this country while the rest of the world gets serious).

[Aaror]

The point of the regulation mentioned (not giving theriflu "just in case") is twofold:
1. The more we use these medications on mild problems, the higher the chance swine flu will develop an immunity to one or both of the two weapons we have to treat serious cases. The "just in case," dose to keep a healthy individual from a .01% chance of problems could very well lead to multiple deaths.
2. There is a good chance that if this swine flu becomes a pandemic, there will be a shortage of these medications, so every dose wasted would mean that a person dies because the doctor was "putting something else above the interest of the individual patient."
Grabbing head... rolling eyes... disbelieveing the level of intelligence of the trolls on Huffpo

[grn1]

"This brings us to the main point of today's blog. Many of us -- patients and physicians alike -- have been thinking about the influenza virus for about a week. Public health officials like the teams at the CDC and the NYCDOH have been thinking about it for years." AND SOME OF OUR MOST CONCERNED AND INTELLIGENT PHYSICIANS AND SCIENTIST HAVE BEEN THINKING ABOUT IT FOR DECADES. www.psrast.org

[BrianBrawdy]

THIS JUST IN. According to an article in the Wall Street Journal, there is a growing body of evidence of a possible start of the Swine Flu in California, not Mexico.

To that end, I am calling on Congress to order the immediate closing of the border with California. Additionally I demand that the states of Arizona, Nevada, and Oregon mobilize their respective National Guard Units to secure not only their borders with the Ground Zero Swine Flu state but the stockpiles of TamiFlu as well while their respective health departments of each state should use all means necessary to distribute face masks to its 12,890,407 citizens.

I have a few more ideas posted at www.BuriedLogic.com

[KillTheMessenger]

WSJ is a rather poor source on pretty much everything. But I would completely disregard it in terms or epidemiological information.

And I am glad that I don't have to look at any more of your ideas...

[drricklippin]

I respectfully submit that this is yet another botch of risk communication- especially by the WHO. The CDC did better on this scare but not by much.

Until these public health agencies move away from an obsession with specific organisms to a systems approach which looks at organism-h­ost-enviro­nment interactions we will continue to fail.

See my blog on the CDC at http://medicalcrises.blogspot.com

Dr. Rick Lippin
Southampton,Pa

[euthman]

I have reviewed Dr. Lippin's site. It's 100% speculation and 0% clinical/laboratory research.

[KillTheMessenger]

But...but...but... if it's on the internet... it must be true!

:-)

[spaceknife]

Again, You just criticise and bring nothing to this debate doc

Dr. Rick Lippin seems to me much more adept in the art of medicine because he seems to have an open mind which is essential when you deal with such a complex domain as people"s health.

People with high blood pressure and cholesterol have been told by your kind for years not to eat magarine and avoid fat fish which is the opposite of what they should have done and that's just one among others.

[kwinter]

I have no medical training, but, reading this on his website would give any skeptical mind pause:

Ten Prerequisites for 21st Century Health
• freedom
• self esteem
• lifelong growth and learning
• lifelong meaningful work
• pleasure
• to love and beloved
• open communication with others
• a sense of community
• connectedness to a universal life force
• some level of socioeconomic well being
Dr. Rick Lippin
July, 1996
revised November, 1999.

This is not someone I would be seeking medical advice from.

[drbillybob]

We'll all see how nasty this bugger is very soon ... the southern hemisphere will be entering it's flu season very shortly. In this respect, this thing couldn't have hit at a better time for the North America, Europe and most of Asia.

[KillTheMessenger]

There is no sign that this is anything else than a rather weak flu virus. Having said that... the system to control pandemics is obviously not working outside of fully industrialized countries. We need to address that issue and we better start throwing a lot of money at the health care systems of poor countries soon. If we don't, the next one could be nasty and come to us, too.

[shimari]

There's no sign this is anything other than a deadly flu virus, either. The information is lacking. Having said that... wait, now I'm sounding like you.

[Aaror]

I agree with everything you say after "having said that..."
A flu that kills 2% instead of a fraction of a percent is not rather weak, it is rather strong...

[alice09]

Physicians are worried about a second wave in the fall, perhaps more than this current manifestation.

[KillTheMessenger]

I kind of doubt that physicians are "worried". Professionals usually do not worry about their work. They simply do it.

[shimari]

As a physician, I can assure you that doctors worry far far more than normal people.

Disappointing post.

[alice09]

I come from a family of physicians and have also heard this from my own physician. My comment is not a subjective opinion.

[rwext]

Hey Doc,,,, you guys came out the same hysterical way with Avarian flu , and Mad cow disease and ......

[drricklippin]

You are right- the list of scares that never materialized is long.

Many in the public have lost trust in our US health agencies and the docs who blindly follow their lead,

Pathetic and dangerous situation

Dr. Rick Lippin
Southampton,Pa

[shimari]

Save your energy, rwext. You'll need it when you're in the mood to blame physicians for not warning you about the next pandemic.

[csavage]

First off, as a practicing internist, my week has been "pig flu" 24/7. I have had the Tamiflu talk with everyone. My personal opinion is, in this day of evidenced based practice, the dispensing of a limited resource (Tamiflu and Relenza) should not be up to an individual "practice style". When I tell people that 1. I cannot test them in a timely fashion for pig flu, the results come from the health department and there's an inherent lag time in the testing, 2. Tamiflu and Relenza makes the disease run a milder course and shortens the time of illness by about 1 day, but does not produce a miracle cure and 3. mild disease should be treated symptomatically only, I haven't had anyone ask for Tamiflu. The truly sad thing about this is reflected by a question I got from an 8 y/o girl this week who asked why the pig flu was so much worse than the "regular" flu. I told her the regular flu kills about 40,000 Americans every year. She was surprised and said "Why isn't that on the news?" Good question. Our press has effectively panicked the population on this one. Being careful is okay but that should be limited to stressing preventative measures. People shouldn't be presenting to EDs demanding Tamiflu for what they think may be the flu

[spaceknife]

Great post Doc

That sets an example for other practicians

[KillTheMessenger]

That's exactly what I want to hear from my physician.

[JHancock]

What got everyone's attention was that quite a few people died in Mexico in a relatively short period of time. These deaths were not typical flu deaths. They were a lot of young, reportedly healthy adults. Generally the flu kills either the very young or the very old, people who are immuno-compromised and unable to fight off the virus. That is why these are the people generally targeted for flu vaccine. Which is another issue in that this strain was not incorporated into this years flu vaccine. They are already beginning to manufacture next years vaccine, so it isn't in that one either.

The real issue is that no one really knows how this new strain will pan out. It is all guesses. Whether it is as virulent as they first suspected based on the early Mexican cases is still to be determined.

That said all we can do is take reasonable precautions and not panic.

[sheilaofmiami]

Listen to your doctor, just wash your hands more often and keep them off your face, and be vigilant this winter!!!! We could have a major flu problem that will have business and industry and schools closed like a bad snow month. Many will be sick and miserable, and that WILL be the worst of it, but the more people who get it, the more people will get it.

Consider the economic impact of the flu, then wash your hands.

[drricklippin]

Hey Doc- Most of the 40,000 who die from seasonal flu are the frail and elderly

Are they really "flu deaths"? I doubt it. But it sells vaccine.

Dr. Rick Lippin
Southampton,Pa

[springsm]

Dr. Lippin, do you make your patients pass a litmus test before they darken your clinic doors?

[shimari]

What are they then? You just can't say "I doubt it" and expect anyone with a brain to take you seriously. If you want to be skeptical, fine, but back it up. Criticize the methodology, definitions, whatever. Do a case review of 100 consecutive deaths in your county which were labeled "flu death" and see what you come up with.

You can "doubt" facts you don't like or postulate unprovable theories, and that will provide you with an immense sense of satisfaction. Medicine is a science however, and requires the strictest intellectual honesty including the refusal to become complacent. History has suggested that conventional -- and unconventional -- wisdom has a half-life of about 5 years until better research overturns it... When you are satisfied with your version of the facts, then almost certainly that version of the facts is wrong.

[Pamela Beep]

I was late for New Year's dinner with my family, Jan 1, 1996...and so missed saying good-bye to my stepfather. He woke up that day with "a cold", got sicker throughout the day, was taken to the hospital in the evening,died the next day. Of the flu.

I'm one of "the frail" I guess. I got sick with something April 18 of this year. I'm still fighting it. I am exhausted. I have lupus and am on immunosuppressants. I could not get Tamiflu in time.

When I first got the horrific headache and body aches on Day 1 I thought it was migraine and a lupus flare so I had no idea I was contagious. Who knows who I infected, since as a lupus patient I don't have the luxury of staying at home in my bed every sick day (I would never leave my bed in that case!)

I do not understand why people are so angry that they were warned about the virus and it turned out to be relatively mild. Would you all rather it was very deadly? Would you rather NOT be warned and have the choice of deciding what you want to do until more is known? Why do people expect that when something new appears, everything about it will be known INSTANTLY. What were the restrictions? Wash your hands? Avoid crowds? Don't travel to where people are dying of it? We are a pretty spoiled population.

Btw May is Lupus Awareness Month.

[shimari]

Good post. I'm sure you know, but also there is the issue with overuse of Tamiflu and the virus developing resistance.

[Anpan]

Canadians (drs and citizens) can find information on H1N1 at the RSS feed for H1N1 news out of the Public Health Agency of Canada is here: feed://www.phac-aspc.gc.ca/rss/swine-porcine-eng.xml

There's extensive information available for physicians and citizens there and at http://www.fightflu.ca/

Canada's federal, provincial, and local health authorities have been preparing for something like this since SARS. SARS was a huge deal here and its impact has changed how we do things. We're still learning but I think we are doing a decent job. The public news campaign starts today.

[Idytme]

Tamilfu needs to be taken within 48 hours and as someone pointed out, a lot of us don't go to the doctor with the first symptoms of the flu. Sounds hypochondriac, and many doctors just tell you to get rest, take lots of fluids etc,sometimes even if you have been sick a week already and need better attention. If you do want to see a doctor, you may not get an appointment within 48 hours anyway. So, ER rooms get inundated with people worried about their symptoms and real sick people wait longer in the ER.
Tamiflu has been handed out by officials as a preventative - been around sick chickens? Have some Tamiflu. If a person in the household has this flu, the family is given it as a precaution.
Then there was an article in the NYT's about shortages and in France they are limiting it to the hospitals, which to me sounds like a huge mistake, why make anyone who suspects they have the flu crowd ER rooms? Then there are articles almost making fun of people being paranoid about their symptoms going to the ER.
By the time you know you have the flu, or your doctor has determined that it is the flu and not something else the 48 hours have most likely gone by. The only other option is to take it when you just start to feel bad.

[KillTheMessenger]

A friend of mine was told by the receptionist that the doctor was not available and that she shouldn't call them with what looked like a case of flu. Then she dispensed the usual advice on what to do (monitoring, fluids etc.). The ER is the only option for anyone who is presenting worse than usual symptoms. I wouldn't even bother trying anything else. In any case, my insurance will pick up the $1000-2000 bill for an ER visit to rule out pneumonia or worse.

[schatsie]

the last time I was in an ER, we waited 7 hours to see the doc AND we all picked up the nastiest intestinal virus,,, messy really messy...