Antibiotic Resistance: A Disney Musical in Three Parts

There has been a lot in the news recently about antibiotic stewardship and resistant bacteria. Someone even died recently due to a bacteria that was resistant to all our currently available antibiotics! But rather than lecture you on antibiotic resistance, I thought it might be fun to tackle the topic with a few little musical numbers.

Part 1

[The curtain opens on a single E coli bacterium.]

E coli: It sure is lonely here. [Splits in two] Oh! That was unexp- [Splits in two again] Wow! Hi you guys, I was just- [Splits in two again, and again, and again. Before we know it there are millions of bacteria on stage.]

E coli: Hey guys, I’m bored here in the colon. Let’s see if we can go stir up some trouble in the bladder.

The crowd: Yeah! Sounds great! Sure, let’s go!

[All the bacteria take the path of least resistance from the colon to the bladder.]

You Need Some Relief (sung to the tune of Beauty and the Beast)


Standing in the line
For the Porta-John
Then you take your turn
And it starts to burn

Just a little bug
Small to say the least
But it brought some friends
Now the burning will not end

You need some relief!

Take the little pill
Take it twice a day
Until the pills are gone, don’t leave even just one, or you’ll have to pay

One bacterium
Allowed to survive
I can guarantee
Continues to breed
Right before your eyes

This time it has learned
How to evade the meds
It’s quite a bitter pill
When you find you still
Dread your bathroom break

There will be a time
You’ll think of these words
The infection will not clear
You’ll shed a little tear
You need some relief!

The infection will not clear
You’ll shed a little tear
You need some relief!

Part 2:

Strep pneumonia: [talking to himself] Don’t mind me, just hanging around in my natural habitat, the lungs—ohh, look at that cute little virus, so tiny…[gazes adoringly at the virus] What’s your name, little guy?

Virus: Name’s RSV, and I’m here to get this party started!

Strep pneumonia: Are you sure that’s a good idea? I mean, things have been going pretty well…

[RSV ignores strep pneumo, starts infecting cells]

[Host starts to sneeze and cough]

It’s a Cold (to the tune of Let it Go)

Mucus is thick in the lungs tonight
Not an alveolus to be seen
A kingdom of inflammation
And I think I hear a wheeze
The host is coughing like they’re going to drop a lung
The power here has shifted
Pendulum has swung

Chills, body aches
Sore throat, fatigue
Fever to one-oh-one point three
His kids, his wife
All blow their nose
Well now he knows

It’s a cold, it’s a cold
It’s gonna have to run its course
It’s a cold, it’s a cold
A Z-pac could make things worse
I don’t care
If it helped last time
It was likely a fluke
A cold never killed anyone, anyway

It’s funny how a man-cold
Makes everything seem worse
And dealing with the sniffles
Can feel like it’s a curse

It’s true, it sucks, a cold just blows
But normal flora that’s exposed
To antibiotics, right or wrong
Gets strong!

It’s a cold, it’s a cold
Don’t you let them see you cry
It’s a cold, it’s a cold
You don’t wanna be that guy
The doctor says
Penicillin won’t help
It’ll just take time…

The virus flurries through the air each time you sneeze
Cover your mouth and wash your hands, keep friends free from disease
You’ll give your immune system the extra boost it needs
And next time you’re exposed, you’ll fight it off with ease

It’s a cold, it’s a cold
It’s gonna have to run its course
It’s a cold, it’s a cold
A Z-pac could make things worse
I don’t care
If it helped last time
It was likely a fluke
A cold never killed anyone, anyway

Part 3:

[Enterococcus is in the boxing room with his trainer]

Trainer: Okay, now we’re going to practice everything you’ve learned. Ready?

Enterococcus: Ready.

Trainer: Cipro.

Enterococcus: Jab, jab, uppercut.

Trainer: Augmentin!

Enterococcus: Head-body, head-body.

Trainer: Good. Now, Zosyn!

Enterococcus: Right-left, right-left, kick, kick, uppercut.

Trainer: Excellent. Now we’re going to try the one that tripped you up before. If you can get this, you’ll be unstoppable. Meropenem!

Enterococcus: Jump kick, jump kick, jab, jab, jab, cross, cross, head-body.

Trainer: [looks pleased] We’re going to go out there and crush your opponents.

Love, Your M.D. (sung to the tune of Part of Your World)

Look at these meds, aren’t they neat?
Wouldn’t you think my job is complete?
I’ve got so many treatment plans,
How could none of them work?
Look at this plate where bacteria grow
At your first glance, you’d never know
This bacteria has become
Resistant to everything

We’ve got antibiotics aplenty
Some are oral and some are I.V.
You want it rectally?
Go ask Jenny
So what’s wrong?
It’s not enough.
We need more!

It can take decades to make a new med
And if it doesn’t work
Then it’s right back to square one
Right back to work in the
Whadd’ya call it? oh- lab
Penicillin doesn’t get too far
When you’re treating resistant pneumonia
A quinolone may work
Or – what’s that name again? Vanc

Kidney infection
Acute bacterial endocarditis
Harder to treat
We’re getting beat
At our own game

Oh, how I wish
That petri dish
Showed no resistance
How would I feel
If I could heal
Without I.V.s?
Gotta be smart
‘Cause there’s an art
To diagnosing each patient’s infection
It might be viral
Worth a trial
Of the tincture of time

Be ready to hear what your doctor thinks
Ask ‘em your questions
And get some answers
Why don’t they write scripts for everything
Every time?

Why not this once?
Just on the chance
That I’m the one in ten that might improve?

Not trying to be a jerk,
But that’s not how it works.
Your M.D.


If you’ve made it this far, thank you for indulging my sillier side. And please share! I want ZDoggMD to see this because – let’s be honest – who doesn’t want to see ZDogg as a Disney princess?

The Condition


I feel a familiar flutter of uncertainty as I stand on the porch of the old farmhouse. What awaits me on the other side of this door? Will it be a condition I haven’t seen before, for which I can’t even offer the comfort of a name? Or worse, a death sentence, for which all I can offer is my condolences? I grip my black bag, take a deep breath, and lift my hand to the door. My fist hovers for a second before my knuckles come down on the heavy wood door. One, two, three sharp raps. The noise is so loud against the background of crickets in the early morning quiet it makes me jump a little. I look around, embarrassed, but my horse only snorts and looks away. No one else is here to witness my apprehension.

I have not been here before, have only heard second- and third-hand of the well-to-do couple that moved here from the city. Moved for the fresh sea air, a tonic I’ve prescribed on more than one occasion, myself.

Her eyes are heavy in their sockets, pitch black against her papery, pale skin. She stares at me for a few seconds through a two-inch opening between the door and its frame, lids drooping over those dark eyes, before recognition startles her fully awake.

“Doctor.” She takes a step backwards, the door creaking open now of its own accord.

I run my index finger down the arm of my glasses, a nervous habit, then squint into the darkness ahead of me. “The patient?”

“Oh. Yes. Come with me.” She turns on her heel and strides quickly down the hall, as if time is of the essence.

There is so much furniture in the house and so little light that I am shocked when I make it to the back room unscathed. She perches herself on a small chair—a child’s chair—beside a figure in the bed. A candle flickers on the table beside her. The patient’s profile is outlined by the soft light, delicate curls framing the small forehead. I realize this is not an invalid parent, as I had secretly hoped. Not the woman’s husband, either.

I look down at the tiny frame for a moment while I acknowledge my emotions and then shove them down to that inaccessible place. I am not the victim here, although I can’t help but feel that way sometimes. Who else must face the bitter chill of death every day and then get up to do it again the next?

The woman doesn’t take her eyes off me, but I feel confident I have revealed nothing to her. I have perfected my presentation in the first few moments of the patient encounter. It is of no use to anyone for me to reveal uncertainty. Sadness. Horror. I stand with one hand on my chin and one gripping my bag. I put a look on my face that says, “I am calm and experienced. You did the right thing by calling me.” I give a subtle nod, then slide down to kneel beside the little girl’s bed.

“We received word of her illness eight days ago. It was a cold, nothing more. Fevers, cough, runny nose. But when other children developed the rash, the head mistress required any child with a fever be evacuated. We sent Charles to fetch her.”

“And that was…?”

“Six days ago. By the time she reached us, another day had passed and her little face was red, like a sunburn.” The woman’s voice quivers slightly, and she reaches out a hand to caress her daughter’s cheek. “By the next day it had spread down to her legs.”

The girl sleeps soundly, completely oblivious to the conversation going on around her. She takes small, almost imperceptible breaths, several in a row followed by a pause and a gasp. Then the pattern repeats.

“How long has she been sleeping like this?”

“She didn’t sleep all night last night. She was writhing and moaning…then the convulsions began. That’s when we sent for you.” She holds her daughter’s hand, stroking it with urgency, purpose. “I couldn’t watch it anymore. Peter went into town and the druggist sent a tonic, something to calm her.”

“And she’s been sleeping ever since?”

The woman’s head shoots up to look at me. “Is something wrong?” Her eyes search mine.

I look back at the child, studying her in silence, considering my next words carefully. “Please, don’t read too much into my questions, ma’am. I just need to get the whole story.”

She nods and looks down again at her daughter. A single tear splashes onto the girl’s hand.

“Tell me about the time between her arriving and the events of last night. Don’t leave anything out.” I open my black bag as she begins to talk.

The girl had not been herself upon arriving home. Weak, no appetite, complaining about various aches and pains. But something had changed two days ago. Just when her fever seemed to be breaking, she began to talk “out of her head.” Then she developed the pain, clutching her head in agony. She had required all the curtains be pulled and the room to be as dark as possible.

I have finished my exam. Suddenly exhausted, I place the tuning fork and the ophthalmoscope back in my bag, hold the stethoscope limp in my hand. The power of knowledge is no power at all.

“I kept thinking it would run its course.”

I nod, meeting her gaze as I do so. She needs to know she has done nothing wrong. This knowledge will steel her in the difficult months ahead. Hopefully prevent us losing a second life to hysteria or…worse.

“Many of her classmates have had this and recovered. They’re saying it’s measles.” Her eyes beg me for hope.

I take the woman’s hands in my own. “Yes. She almost certainly had the measles. For many, the disease consists of fevers and a rash and then they are done with it. For others—”

Her hands shake uncontrollably beneath mine. “For others?”

“Your daughter has developed a toxicity in the brain. Encephalitis.”

“And? What does that mean? What do we do?”

I try to swallow, but my mouth has gone dry, my throat like sandpaper. “You should call your husband.”

She looks at me through watery, sorrowful eyes. Then she collapses onto her daughter’s bed, sobbing, grabbing at the covers, at her daughter’s arms and legs. Grabbing her face between her hands.

“Eleanor, can you hear me? Eleanor, you’re going to be fine. Open your eyes, Eleanor.”

I place a hand on her back. There are no words, but I close my eyes and concentrate on sending peace, courage, and strength to her through my fingertips. God willing, she will not remember this day. But if she must, I hope she will recall a kind touch.

I reach into my bag and pull out a glass bottle. Place it on the bedside table. “Paraldehyde. It will calm the convulsions. Allow her to rest.”

The woman is silent now. Listening, but refusing to meet my gaze.

“A few drops on the tongue should be effective. If not, you can repeat the dose.”

The woman walks me to the door, slowly this time. She is melancholic, sinking already into a dangerous place from which she may never return. I pull another bottle out of my bag. “For you. For sleep.”

She takes the bottle from me and I step onto the porch. The door closes, and I am once more alone with the silence, feeling helpless. Useless.

A disease for which there is no cure, no prevention other than complete isolation from humanity. It is the human condition, to risk death from simply involving our lives in the lives of others, in the pursuit of something greater than ourselves.

I lean against the door and close my eyes tight, but not before a single tear escapes. It is my condition, the doctor’s condition, to care.

The Opioid Epidemic: Where Do We Go From Here?


In my last post, The Opioid Epidemic: How Did We Get Here?, I outlined the many factors that contributed to the current state of affairs in this country in regards to opioid use. But now that we’ve established we’ve got a problem on our hands, what exactly do we do about it?

We need to stop placing blame. This is the least constructive thing I’ve witnessed so far when it comes to addressing the current crisis. It is not one person’s fault. Heck, it’s not even one group’s fault. The second we start acting like it is, we lose all sense of personal responsibility. And it’s hard to right what’s wrong if no one will take ownership. So, for the sake of this exercise, let’s just assume it’s everyone’s fault and get on with it.

We need to remember that we’re on the same team. Lately, it seems like the healthcare setting might as well be a season of Survivor. Doctors vs Patients: Who Will Prevail? Doctors feel rushed, taken for granted, and sometimes taken advantage of. And patients feel like they’re not being heard and their needs aren’t being addressed. But it’s important to remember that we both want the same things when it comes to chronic pain: to reduce pain and to increase function. Patients with pain want to feel better and doctors want to help them feel better. Honestly. But we may have different ideas about how to achieve that, so it’s more important now than ever that we are open about our concerns, our expectations, and the plan going forward. (If X doesn’t work, then we’ll try Y.)

pills-1021444__180If doctors are resistant to prescribing pain medications, it’s not because we want to maintain some sort of control or power over the situation. It’s the easiest thing in the world to write a prescription, and to feel like a hero for it, but that’s not doctoring. Doctoring is talking to your patient, listening to their complaints, and deciding on a treatment plan that has the best chance of helping them without harming them. When we are faced with data that shows no long-term benefit to opioid medications, and then we see the potential harm they can cause, we do not take the decision to prescribe these medications lightly. That is not to say that I will never, ever prescribe opioids ever again. But each and every time I do, I think long and hard about it. And I hope my patients can appreciate that about me, because it’s unlikely to change.

We need to understand the purpose of pain. Pain results when a neurologic signal is sent from a certain body area to the brain to alert us that something is wrong. It lets us know to jerk our hand away from a hot stove or to seek medical attention after an injury. In a perfect world, anything that generated pain would be fixable. Unfortunately, that is often not the case. Patients sometimes have pain from an identifiable problem that can’t be fixed. Patients may also have pain whose origin cannot be detected using our current diagnostic tools. In those cases, it is important to understand that we can rule out the potentially life-threatening causes of pain by taking a good history, doing a good physical exam, and ordering the appropriate blood work and imaging studies based on our patient’s complaints. After that, we are often left with pain and other symptoms that can be managed, but not fixed.

Once we have established we are dealing with a condition that causes pain but does not have other damaging effects on the body, our goal is then to reduce the pain—or, more pain-1015579_960_720accurately, reduce the perception of pain. Pain causes an increase in certain neurotransmitters in the brain. Just like depression, managing it is often an issue of modulating the neurotransmitters to alter the experience of pain. Actually, a few antidepressants have been found to be effective in the management of certain chronic pain conditions for this very reason.

A long time ago, someone asked me a question I didn’t have a great answer for: If a tree falls in the forest and no one is around to hear it, does it make a sound? In that same vein, I ask you: If a pain signal is generated but the brain doesn’t perceive it, does the pain really exist? I would argue that there is one answer to satisfy both of these brain teasers: It doesn’t really matter! It shouldn’t matter if I’m taking an antidepressant instead of a narcotic. If I don’t feel pain (or even if I feel less pain) and there’s nothing life-threatening going on in my body, I’m happy. End of story.

We need to be open to other options. Contrary to popular belief, opioids are not the be-all and end-all for pain unless they’re being used strictly for palliation (i.e. focusing on pain management without concern for regaining function, usually for patients that are nearing the end-of-life). It’s easy on a physician’s part to write the prescription, and it’s easy on the patient’s part to take it, but opioids don’t do anything about the underlying reason for a patient’s pain. They don’t improve patients’ ability to function, and they can actually lead to an increased sensitivity to pain. As I like to tell my patients, opioids are a sledgehammer when what you need is a chisel: they’ll get the job done, but it ain’t gonna be pretty.

massage-1015570_960_720Happily, there are many other options available to us for the treatment of pain. There are non-pharmacologic treatments such as physical therapy, yoga, massage therapy, meditation, and multiple other modalities. On the medication front, we have anti-inflammatory medications, anticonvulsants, antidepressants, muscle relaxers, topical medications, and anti-anxiety medications. There is also the option of regional analgesia, which includes a variety of procedures that can be performed to focus in on a specific painful area. Depending on the type of pain a patient is having, one or more of the above options is likely to be more beneficial than opioids and will almost certainly result in improved function and lifestyle.

A major hurdle we face is that some (not all) of these treatments take time to be effective. The obvious benefit of opioid medications (i.e. I take my pill and I feel better in about thirty minutes) is hard to overlook in favor of a treatment that may take weeks to become effective. However, they have the potential of benefitting our patients long-term, as opposed to opioids, which have not been shown to be beneficial in the treatment of chronic pain. But if we can convince patients to invest in themselves, in their long-term well-being rather than a short-term improvement in symptoms, then we may help them avoid a lifetime of opioid dependence, depression, and chronic misery.

We need to stop viewing ourselves as the outliers. The sooner we accept that we are all subject to the same rules, the better off we’ll be. If we don’t, we stand to lose even more autonomy when it comes to pain management. I’m speaking to physicians and patients, here. Most of us wear a seatbelt when we drive, even though we don’t expect to get in a car accident. We do it because 1) it has the potential to be helpful and 2) there could be consequences if we don’t. It is not advisable to throw caution to the wind, say “it’s not going to be me today,” and leave the seatbelt in its casing. Seatbelts work because the majority of people use them the majority of the time. Once people start feeling like the rules don’t apply to them, the system breaks down. What you really don’t want is for doctors to be deciding who looks like they could be a drug addict, and treating those people differently than their other patients. No, we need a standardized system and we need physicians and patients to agree to play by the rules.


The fact remains, the United States comprises 4.4% of the world’s population, but consumes 80% of the world’s opioids. The problem in this country is not pain. Other populations struggle with chronic pain, they undergo surgeries, and they suffer from terminal illnesses just like we do. The problem is much deeper. It’s cultural, it’s engrained, and it’s not going to be fixed overnight. We are all part of the American culture, even if we’ve never taken a pain pill, and we cannot be isolated from our environment as different from everyone else.

Recent surveys have suggested anywhere from 11-15% of the United States population suffers from chronic pain, defined as pain lasting at least 3 months. That’s about 45 million people. Let’s say for the sake or argument that doctors only prescribe opioids for about 10% of those people, and only 1% of those develop an addiction or experience a fatal overdose. Those numbers seem pretty small, right? That’s 45,000 people whose lives have been ruined by injudicious use of opioid pain medication. It’s easy to say “it won’t be me,” but as physicians we have to remember that it will be someone. We treat enough people that the numbers say we will likely pills-824994__180harm someone by prescribing opioids. That is why we can seem so unnecessarily cautious. That is why we weigh the options so carefully. That is why we have pain contracts and rules. If your doctor is cautious about prescribing opioids, it usually means they care.

We need to accept that the problem won’t be fixed overnight. It took twenty-plus years to get to this point, and there is no quick fix. It will be tedious, painful, and slow. But if we—doctors and our patients—don’t use this opportunity to shift the pendulum, it will be shifted for us in a much less desirable way.

There will be hoops, so many hoops, to jump through in order to prescribe opioids when we think they are necessary. Someone outside of the medical profession may have to approve each prescription—much like the prior authorization that is necessary for certain medications and diagnostic studies now. There may be regulations about how many of these medications drug companies can produce, therefore driving up the cost for patients.

I really don’t want it to get to that. I don’t think anyone does.






The Opioid Epidemic: How Did We Get Here?

Welp, we’ve done it, folks. It’s finally come to this. There have been so many deaths from opioid overdose, so many addicts created, so many pills diverted, that the CDC is getting involved. Opioid pain medications, commonly prescribed to treat acute and chronic sources of pain, are a significant cause of morbidity (harm) and mortality (death) in America. In 2014, the CDC reported a total of 47,055 drug overdose deaths in the United States, 61% of which were attributable to opioids.

So how exactly did we get here? Like most things in medicine, there is not one simple answer. But it’s not that hard to trace things back a few decades and pinpoint some major influences.

pain-1015579_960_720Pain as the fifth vital sign. In an effort to standardize and improve pain treatment for patients, a national initiative called Pain as the 5th Vital Sign (P5VS) was rolled out in the late nineties. The well-meaning folks who began this initiative were trying to improve the health and well-being of the over 34 million patients in this country that suffer from chronic pain. Unfortunately, a study published in the Journal of General Internal Medicine in 2006 ( showed no improvement in pain control after this initiative. However, this practice still persists throughout medicine, despite there being little evidence to support it.

One problem with assessing pain as a vital sign is, unlike blood pressure and oxygen saturation, it’s completely, 100% subjective. I can’t count the number of times I’ve had a patient tell me their pain – on a scale of 1 to 10 – is an “eleven” or even “ a hundred.” How do I, as a physician, interpret that? It’s impossible. Objective signs of pain – elevated heart rate, elevated blood pressure, inability to speak comfortably, and certain exam findings – don’t correlate reliably with patients’ self-reported pain scales. I’ve had patients writhing in obvious, excruciating pain who would rate their pain as a seven, and I’ve had patients casually texting on their smartphone who tell me they have 15/10 pain. Both of these people deserve to have their pain treated, but it often involves a little trial and error to get it just right.

Another issue with the initiative is that the goal is for pain to be a zero out of ten. Often, especially in the case of chronic pain, that shouldn’t be the goal. The goal should be getting a patient to the point that they can be functional, so they can reasonably do the things they need to do to be a productive member of their family, their community, and society as a whole. Unfortunately for those with chronic pain, the concept of being pain-free may be unrealistic. If you must be completely sedated before you experience zero out of ten pain, then we’ve missed the mark. We haven’t improved your life, we’ve erased it. There needs to be a happy medium.

OxyContin. The time-release version of oxycodone, OxyContin, was brought to market in medicine-385947__1801996. It was heavily marketed, both to consumers directly and to doctors. It was supposed to be the best thing to happen to chronic pain in the history of chronic pain (i.e. civilization). We were told the chances of addition were miniscule because of the time-release formulation, and the potential benefits were unimaginable. The pharmaceutical company that made OxyContin (getting a new patent for a drug that had been around for the better part of a century) did a phenomenal job of getting their product out there, and doctors who hesitated to prescribe it were vilified. It was a veritable love fest, reminiscent of an Oprah Winfrey episode. “You get OxyContin! You get OxyContin! Everyone gets OxyContin!”

If you’re reading this, you probably know (or at least have a hunch) that things played out a little differently. Oxycontin became one of the most abused prescription drugs to date and is estimated to cause 100,000 drug-related deaths worldwide per year.

Of course, OxyContin isn’t the only prescription drug out there making its way through our communities. It seems there are too many to count these days. And at $10 to $40 per pill, they are worth more than their weight in gold. It’s not uncommon for people who become dependent on prescription pain pills to end up turning to heroin because it’s cheaper and easier to get than a Percocet.

Patient Satisfaction: Patient satisfaction is not, in and of itself, a problem. It’s not that we don’t want our patients to be happy. It’s quite the opposite. But since we’re dealing with health issues and not an ice-cream sundae, sometimes it’s just not in the cards. For cigarettes-83571__180example, sometimes we must tell a patient that their weight is negatively affecting their health. Or their smoking. Or any other number of bad habits. It’s the right thing to do. If we didn’t do it, we would be doing our patients a disservice. But it’s still not always nice for patients to hear. It doesn’t necessarily give them a warm, fuzzy feeling when leaving our office, nor does it make them want to send their friends and family to us to receive the same kind of tough love.

In a much talked about study published in the Archives of Internal Medicine in March 2012, Dr. Joshua J. Fenton and colleagues reported that the most satisfied patients had an increased hospital readmission rate, had the highest healthcare expenditures, and had a 26% higher mortality rate than their less satisfied counterparts.

It is not always satisfying to be seen by a doctor, told that you don’t need a test or prescription, and be sent on your way. But sometimes that’s the best care. Sometimes it’s a viral infection, and antibiotics are more likely to hurt you than help you, so we don’t prescribe them. Patients often don’t feel as if they’ve gotten their money’s worth when that happens, but it is important to remember that your doctor has had a minimum of seven years of training to be able to provide their expert opinion, and that it is much, much harder to provide reassurance than it is to write a prescription or order a CT scan.

In the case of opioid pain medication, not only is it often not medically indicated to use pills-824994__180these medications, but we also take a significant risk each time we prescribe them. We risk our patient developing a dependence or addiction, we risk the medications being diverted or abused, we risk saddling patients with side effects that can be worse than their primary complaint (such as severe constipation and even narcotic bowel syndrome), and we risk someone dying from an overdose of medications we prescribed. Not only are we then “doing harm,” which we took an oath against, but we could even possibly be implicated in someone’s death. I’m sure no one’s forgotten Conrad Murray, the personal physician of Michael Jackson, who was convicted of involuntary manslaughter after Jackson’s death. That’s an extreme case, sure, but it can happen.

michael jackson

So, what can we do now that we’ve gotten ourselves into this mess? Stay tuned for my next blog post, The Opioid Epidemic: Where Do We Go From Here?

Originally published on Huffington Post May 8, 2016:



Pain as 5th Vital Sign:

CDC Morbidity and Mortality:

Patient Satisfaction associated with higher readmission and death rates: Fenton, Joshua J., MD, MPH, et al. Archives of Internal Medicine. March 2012.

The Dirty Secret about CPR in the Hospital (That Doctors Desperately Want You to Know)


accident-1128236__180A few things have changed in medicine over the last few decades. Okay, a lot has changed, and most of it good. But along with the improvements in patient care there has been an exponential increase in expectations. We’ve somehow gone from “your loved one has a life threatening illness and we will do what we can to treat it and in the meantime ensure they don’t suffer” to “your loved one has a life threatening illness that we have the capacity to cure, and if we don’t we will have done something wrong.”

The problem is, last I checked, everyone dies. Let me say that again for good measure. Everyone. Dies. The problem is not with that truth alone, but with the fact that patients with terminal illnesses – and their caregivers – rarely understand their mortality. And when patients and families have unrealistic expectations about what their doctors can accomplish, many people die in a way they never planned for or wanted: in the hospital, dependent on strangers for the basics such as eating and bathing, and often hooked up to machines.



If that makes you feel hopeless, you’re not alone. Many doctors and other healthcare professionals I work with feel that way, too. In the hospital, your code status – whether you want to be resuscitated or not when your heart stops – has become a sort of surrogate for determining whether you really understand your prognosis. Of course, it’s not quite that simple. We know there are other considerations, such as deeply ingrained core values and past experiences with death – good or bad – that play into a patient’s wishes about their death. But the hospital is often the worst place to begin to have these important conversations. Patients in the hospital are sick, they’re scared, and they usually have no prior relationship with the physician who is trying to paint a realistic picture of their condition.

Everyone in healthcare – assuming they don’t have their head in the sand – knows that the system, especially regarding end of life care, is terribly broken. While I believe we are on the path to improving this (within the last year, Medicare approved payment for voluntary end-of-life counseling), we still have a long way to go. But there are things patients can do to take back control of their health and the health of their loved ones.

1. Understand What Resuscitation Is: It almost uniformly involves chest compressions, intravenous medications, mechanical ventilation, and defibrillation. Currently, resuscitation is performed unless a patient has “opted out” in the form of a DNAR order (Do Not Attempt Resuscitation). Many people in healthcare feel that resuscitation should be approached like any other procedure in medicine, requiring consent from a patient to initiate it in the first place. And in the case of resuscitation – when the patient and family goal is not only survival, but a return to prior level of functioning – the chances of success are alarmingly low. After all, if a doctor offered you a surgery that had a 1.7% chance of improving your condition, was painful and distressing, and had to be done without sedation or pain control of any kind, you may just choose not to proceed.

Patients and their family members are often presented with the ever-important “code conversation” in the following way: “If your heart stops or you stop breathing, do you want us to do everything?” For a doctor, it’s a lazy way of asking “Would you want to be
eyes-305799__180resuscitated?” without explaining exactly what that entails. But what patients often hear is: “Do you want us to do everything or nothing?” or, worse: “I think you might die during this hospitalization.”

Of course, neither of those things is what the physician is really trying to convey with this question. First, there is a lot we can offer in the way of treatment short of resuscitation. Many times, our treatments are able to circumvent the need for resuscitation altogether. And, even if death is unavoidable, there is so much we can offer patients and families to reduce suffering and provide support. We, as a society, often equate doing “everything” will showing our love. (“I will never let mom die.”) Many times, nothing could be farther from the truth. As people age and their chronic illnesses progress, quality of life – rather than quantity of time – should be the central focus. But, as we see too often, it rarely is. Second, we are almost never implying that death is imminent with this question. We try to bring up the issue of code status with every admission. Since we don’t have a crystal ball, we can’t always predict a medical emergency (sometimes, yes, we pretty much know it’s coming). But regardless, we want to be prepared to act, at a moment’s notice if necessary, in a way that respects your wishes.

We, as doctors, as a healthcare system, cannot afford to be poor communicators about this issue. But patients and families, for their parts, cannot afford to be uninformed.

2. Understand What Resuscitation Is Not: It is not a guarantee of survival, and it’s certainly not a guarantee of survival with the same quality of life you enjoyed previously (or even a quality of life you deem acceptable). We’ll talk about this concept a little more below.

Codes are not what Hollywood would have you believe. One study in which the researchers watched 97 episodes of popular medical dramas in the accident-1128236__1801990s reported a 75% survival rate for fictional patients immediately after resuscitation and 67% survival rate to hospital discharge. In stark contrast, an article in the Journal of the American Medical Association published in 2013 studied a prediction tool for survival after in-hospital resuscitation. In it, they used four branch points to stratify patients’ chance of survival with a meaningful quality of life: very low (<1%), low (1-3%), average (>3-15%) and higher than average (>15%). That bears repeating. A higher than average success rate for resuscitation was >15%.

thirty-1173248__180Presented another way, the average chance of successfully resuscitating a young, healthy person (when success means the patient is neurologically intact, i.e. not physically or mentally dependent on others) is only 30%. The average success rate of resuscitation in an elderly nursing home resident with several chronic medical issues (who may have even been going along just fine prior to their illness) is 1-3%. For some patients, the success rate approaches zero.

3. Understand Your Health: A young, previously healthy person with a treatable (i.e. fixable) condition is the poster child for resuscitation. Nearly everyone else is not. That’s not to say we should never try CPR in the hospital, but there are many cases when it is clearly the wrong thing to do. In the end, it is an individual decision that each person should make with the help of their doctors and other healthcare professionals. But patients should be aware that many chronic medical conditions, such as dementia and COPD, negatively affect their chance of surviving an in-hospital cardiac arrest, and patients should know what they are getting into. Complications such as kidney damage, liver damage, low blood pressure, and mental status changes also worsen your chances of surviving. Increasing age, as you might imagine, does, too. This is not the only thing to consider when deciding or updating your code status, but you cannot make an informed decision without this knowledge.

4. Understand the Risks of Resuscitation: The risks? Wait, I thought resuscitation was good, that it was supposed to save lives. Sure, it is and it does…sometimes. But all medical treatments have risks or side effects associated with them. It’s the inherent nature of the practice of medicine.

Long term, patients can end up with poor neurologic function, dependent on ventilators which breathe for them and which they have no hope of coming hospital-699461__180off of because of their previous lung disease or other complicating medical issues. Even if not dependent on a ventilator, they may require feeding through tubes introduced into their gut because they aren’t able to swallow. They can be bedbound and develop ulcers on the dependent areas of their bodies. These ulcers can become infected. They are often tied down to keep them from pulling at their numerous tubes due to their delirium. They get urinary tract infections because they require a foley catheter or are incontinent.

Many families feel trapped after their loved one has “beaten the odds” and survived a cardiac arrest just to be in a situation similar to the one described above. It is important to mention that it’s never too late to withdraw care in these situations. This is not equivalent to causing death, as the underlying illness is doing that. It is simply removing the artificial means of keeping the patient alive.

Death is an inevitability. Modern medicine is amazing in that we can often treat the complications of terminal disease. But we cannot change the terminal nature of those diseases. And when the treatment starts to cause more harm than good, we need to take a step back and re-evaluate our goals. One of the most amazing things about medicine, one of the reasons I love practicing, is the experience we gain over the years. We can counsel a patient who may be experiencing illness for the first time on what to expect – because we’ve seen it. No, we can’t tell them the day and the hour of their death, but we can give them an idea of how things are going to go, so they can decide on their own terms when enough is enough.

And it’s different for every person. We know that. And we respect that.

5. Fill out a Five Wishes or MOST Form and Talk About Your Wishes with Your Loved Ones: Close your eyes and picture how you imagine your death. mai-tai-1220775__180Is it surrounded by family members in your own home? Is it on a tropical island with a Mai Tai in your hand? Is your pastor at your bedside saying a prayer over you? Chances are, it’s not tied to a bed in a cold hospital room, sedated and unaware.

Of course, many people don’t get to control how they die. They die in car accidents or of a heart attack in the middle of the night. They aren’t even aware that life is passing from them during their final moments. But if you are blessed enough to have time to ponder your mortality and the ability to dictate the terms of your death –wouldn’t you want to take advantage of Unknownthat? A Five Wishes ( or MOST form ( tells those who will care for you and who will make Unknowndecisions for you what those decisions should be. Gift your family with your wishes so they know how to take care of you in the way you envision.

Too often, caregivers are placed in the impossible situation of guessing what their loved ones would have wanted. Though they come from a well meaning place, they usually do everything to keep their family member alive, even if it prolongs a quality of life inconsistent with who they were in life (and one they would never want for themselves). Take the time to speak with your family and document your wishes – and you just may end up with that Mai Tai, after all.

The end of life is a part of life. It should be part of our legacy, not a desperate last-ditch effort to escape the inescapable. Talk to your family and your doctor now and on a regular basis as your condition changes. Take control of your legacy.


The information for this article was obtained from review of the articles below and conversations with Alisha Benner, MD, who has conducted research regarding end-of-life care.


The 7 Habits of Highly Effective Patients*: 7 Secrets to Getting the Most out of Your Doctor Visit

A lot has changed in medicine, and in a relatively short amount of time. I mostly blame the internet. The rare, dramatic story gets the headline (and the Facebook shares) causing patients to think that Predators in white coats are lurking around every corner to perform unnecessary procedures or misdiagnose their illnesses simply out of meanness. Unfortunately, “Doctor Practices Good Medicine, Doesn’t Prescribe Antibiotics, and Patient Gets Better Anyway” just doesn’t make for a very sensational headline. But good medicine happens every day, everywhere. It’s so much more common than we are led by the media to believe.

Usually within the first thirty seconds of a patient visit, I know which way things are headed. The best physician-patient interactions I’ve had have always centered around mutual respect and appreciation. I leave these interactions feeling refreshed, invigorated, and at peace with my decision to go into medicine. The patients leave having gotten the best version of me—the smartest, most attentive, most hard-working me that there is. It’s a win-win.

So, what do you need to do to get that version of your doctor, and not the exhausted, underappreciated, unfulfilled version? Not much, it turns out.

cocaine-396751__1801. Don’t Lie. It doesn’t do you any favors to be untruthful to your doctor. Unless you tell your doctor something along the lines of “I want to kill my spouse and I have a loaded gun in my car which I am going to use for said crime,” whatever you say during your visit is completely confidential. And certain things can actually factor into medical decision-making. For example, a thirty-year-old who complains of chest pain is very unlikely to be having a heart attack, unless…(wait for it)…he’s been doing lines of coke. Then, a big ol’ heart attack is back on the differential. And heart attacks are treated a little bit differently than your run of the mill musculoskeletal chest pain.

2. Do treat your doctor with respect. Now, I’m not saying you need to bow and kiss his ring everydoctor-784329_960_720 time he walks in the exam room. I’m just talking about extending the same respect you give to the people who bag your groceries and cut your hair. Respect them when you think they look young (they have been through years of training and probably still remember most of it), respect them when they say they don’t know (which is much better than pretending they know when they don’t), and respect them when they don’t order every test known to man (they probably have a good knowledge base and/or physical exam skills and don’t require the extra reassurance from unnecessary and sometimes harmful tests). You don’t have to trust them blindly, just respect them.

I’m going to drop a truth on you here that might just blow your mind: Doctors are        human. And, being human, most of us tend to want to avoid conflict. If you argue with and yell at and threaten your doctor (or your family member’s doctor), they will naturally want to spend less time around you. Or they may acquiesce and write a prescription for a medication they don’t feel is necessary and could end up harming you. Your relationship with your doctor should be a therapeutic one. It should not be approached with the same angst as a call to Time Warner Cable’s customer service department.

3. Don’t mention Google. Under any circumstances. Ever. Look, we both know you Googled your symptoms before coming in. Let’s just agree to not talk about it, okay?


Don’t get me wrong, you can ask all the questions you like. We love that, because how else would we know what you’re really worried about? Questions like “Do you think this could be cancer?” or “Do I need a CAT scan?” can really open up a great dialogue. But don’t underestimate the years of school and training we went through to get where we are, and the experience and knowledge we gather on a daily basis by caring for patients. If we could treat you using a quick Google search…well then, you’re wasting the heck out of your co-pay.

4. Do leave your demands at the door. Not to be harsh, but it has to be said: Your doctor’s office is not McDonalds, and Augmentin is not a Big Mac. There are reasons why most medications require a doctor’s prescription, reasons like the potential for serious side effects, the possibility of drug interactions, and the need for close monitoring on certain medications.

One of the hot-button topics is medicine right now is antibiotic resistance. Bacteria
multiply at a rate so fast that they can develop resistance to an antibiotic simply by chance through the random mutations that occur in their DNA during replication. Therefore, any time you expose a bacteria to an antibiotic without entirely eradicating it, you introduce superbugsthe possibility of resistance (that’s why you need to take every single pill in the bottle, even when you’re feeling better). This is relevant because bacteria are developing resistance faster than we are able to develop new antibiotics, therefore resulting in the “superbugs” you’ve heard so much about. By and large, these are just “regular bugs who are now too smart for our usual defenses”—but that doesn’t have quite the same ring to it, does it? Anyway, all that to say when your doctor doesn’t want to prescribe antibiotics she’s not trying to punish you or be withholding. She’s trying to practice responsible medicine. Please, let her do her job.

Another subject that consistently creates tension in the doctor-patient relationship is narcotic pain medication. The availability of these meds has become such an issue in this country that the Obama administration has asked for $1.1 billion from Congress to address the issue. And nearly four in ten people know someone addicted to prescription pain meds. Every time a doctor writes a prescription for opioids, he should ask himself, “Is this absolutely necessary, or can we get by with something else? Is this worth even a 1% chance of creating an addict?” Because a 1% rate of narcotic abuse is significant when you treat hundreds of patients a week, which many physicians do. And potential addicts are not always easy to spot. They don’t wear a sign on their chest or come in with track marks up pills-824994__180and down their arms. They often have good jobs, families, and responsibilities. They have a lot to lose. It has much less to do with willpower or a moral compass than you  might think, and more to do with a genetic predisposition (that a patient wouldn’t even know they had). I’ve heard the story before, and I’ll hear it again, of a person who lost everything after a seemingly innocent prescription for Percocet totally derailed their life.

5. Do ask questions. Wait, didn’t I say that already? Yes, but this point is important enough that it needs its own number. Medicine used to be paternalistic. The doctor said, so the patient did. The pendulum has swung very far from that norm (perhaps too much, but that’s a conversation for another day). In today’s healthcare climate, when you have too little face-time with your doctor and way too many tests, drugs, supplements, and diet restrictions for anyone to keep up with, you MUST ASK QUESTIONS. Questions like: “Why does this medication work?” or “What could happen if I don’t have this test?” or “Are there any other things I could try?” We have no way of knowing what your day to day life is like, what worries you, what’s important to you, or what might keep you from following your treatment plan unless you communicate your concerns. We have no idea which part of our conversation you didn’t understand unless you ask.

Honestly, most of us love teaching, love sharing what we know. I would much rather teach a man to fish than give him a fish any day.

6. Do follow your doctor’s advice. Or at least know why the advice is being given and what the potential consequences are of not following said advice (see above point). It is so sad to see a patient diagnosed with stage 4 colon cancer that could have been detected at stage 1 if they’d had their screening colonoscopy. It’s even sadder to realize they never understood the purpose of the colonoscopy.

Same with quitting smoking, losing weight, taking your blood pressure pills, eating right, carrot-1085063__180and controlling your blood sugar. Patients who take ownership of their health often stay out of the hospital and even their doctor’s offices for the most part. Practicing a healthy lifestyle significantly limits the amount of healthcare and medications you have to rkayaking-569282__180eceive over your lifetime. We know that high blood pressure and cholesterol leads to strokes and heart attacks;
uncontrolled diabetes causes chronic kidney disease, amputations, and dialysis; and obesity complicates nearly every other chronic medical problem. And I should take this time to mention that YOU CAN CURE type 2 diabetes by losing weight.

Believe it or not, physicians do prescribe lifestyle changes, but these recommendations often fall on deaf ears. And sometimes the proverbial horse is already out of the barn (or at least we need to bridge the gap until we can coax the horse back into the barn), and we must prescribe medications—medications that cost money and may at times have unpleasant side effects. But we don’t do it to line the pockets of the pharmaceutical industry (no, they have direct-to-consumer advertising for that). We do it because we know what your future holds if we don’t. We’ve seen it over and over and over again.

7. Do be open to suggestions. I once took care of a patient who had respiratory failure. She declined not one, not two, but three different therapies that could have quickly improved her symptoms. Then, as she continued to struggle for air, she said to me, “It seems like there would be a medication that could make me feel better right away.” I wish I was exaggerating.

You don’t have to agree with everything your doctor says (I feel like I’m beating a dead horse, here, but I want it to be very clear that we don’t expect that), but if you are going to shoot down every suggestion she makes, you might as well save your money and your doctor’s time.

pills-dispenser-966334__180You go to a doctor because they are trained to take care of the human body during times of illness. You may not have experience with a certain ailment, but you can rest assured that your doctor almost certainly does (and they should tell you if they don’t). Most of the time, their prescribed course of therapy—while it could seem strange or inconvenient to you—is a tried and true, common, safe, and effective treatment.

Bottom line, if you do choose to seek a medical opinion, please be open to what that might entail, be ready to hear some things you may not like, and don’t expect to dictate your own care. And always remember, you catch far more flies with honey.


Bernstein, Lenny. Four in 10 say they know someone who has been addicted to prescription painkillers. The Washington Post. 24 Nov 2015.

Harris, Gardiner. Obama Seeks More Than $1 Billion to Fight Opioid Abuse. The New York Times. 2 Feb 2016.


*The author of this piece does not assume any affiliation with the author of The 7 Habits of Highly Effective People, Stephen R. Covey.



How We Broke a Generation: 5 Lessons We Taught the Twenty-Somethings I Wish They Would Just Forget, Already

Much has been written lately about today’s young adults and how they apparently suck. At college, at work, and at life in general. Of course, not every twenty-something falls into this unfortunate category. Maybe even the majority doesn’t. But if even a portion of them do indeed suck (who am I to judge?), I would argue that it may not be their fault. I know, I know, that’s enabling. But just hear me out.

These kids were raised in entirely different conditions than we were (“we” being those with an arbitrary cut-off age of, let’s say, 30). There are a few “truths” in the minds of these kids that they didn’t come up with on their own. We taught them. And I’m not just talking about their parents. We all did it, and it’s time to own up. If we do, maybe we can change things for the next generation.

  1. twitter-292994__180Social Media is Your Friend. There is no place on earth that boasts more judgment and less accountability than the internet. Just look at anyone in the spotlight, how little they have to say to get raked over the coals, and how inflammatory and hateful the resulting comments about said person can get. Today’s college kids grew up in this culture. This is their social norm. So why not expect this twisted habit of expecting-the-world-from-others juxtaposed with having-absolutely-no-personal-accountability to inundate every other aspect of life? We wonder why bullying is such a thing now, despite the fact that we use every chance we can to talk about how terrible it is. We have literally been asking these kids to do as we say, not as we do. And we all know how well that goes over. (At this point, you may be thinking this article’s mere existence is irony at it’s finest, as I’m picking on a group of people and they can’t really fight back. Noted.)

This generation knows the only thing you have to do to get noticed is to “go viral.” And, as I am often reminded by my two-year-old, negative attention is still attention. How much valuable learning and personal development time (read: growing up time) has been wasted on these kids trying to be the Next Big Thing, whatever that is?

  1. The Rules Don’t Apply to Me. Right now, there is an alarming trend in society. The rules don’t get followed, they get changed. If a deadline is missed, if a disciplinary action is invoked, it’s easy to get our way if we go to the media. Proclaim ourselves victims of some deeply unfair and persecutory regulation. Is this the norm? No. Does it seem like it sometimes? Absolutely. And how do we expect kids to know the difference when they interact more online than anywhere else?

As parents, we want our kids to have a better life than we had. It’s practically the definition of parenting. So when things don’t work out for our kids—in school, on the playground, wherever—the best way to fix it is to intervene, right? So. Wrong.

And everyone reading this knows it. So why, then, do parents argue with teachers, coaches, and other authority figures about disciplinary actions, playing time, and grades? Could it be we’ve forgotten one of life’s cruelest but most helpful lessons: That life isn’t fair? Entitled children grow up to become entitled young adults. It was only a matter of time before the “I am the most important person here” mentality seeped font-533232__180into the nation’s colleges. But eventually these kids will receive the rude awakening we’ve so helpfully delayed for them. They will be denied jobs (or lose them) because they lack work ethic. They will lose friends and become unpopular because they always put themselves first. If they seek special treatment, they may succeed temporarily, but they will lose in the long run because they will have alienated everyone around them.

Life is a marathon, not a sprint. It matters how you treat people. It’s the Golden Rule. But it got lost somewhere along the way amidst all the tweets and facebook statuses. Let’s bring it back. It doesn’t take much. I’ll go first: I will let someone into the lane in front of me today. #GoldenRule.

  1. Teachers are Part of the Service Industry. In a lot of ways, teachers raise our children, and we should respect and thank them for that. School is about preparing kids for life in all it’s facets, not just establishing an acceptable GPA so that they can go on to college to learn about life. As we’ve seen, that mentality doesn’t serve our school-class-401519__180children very well.

Depending on your talents and your aspirations, it is not necessarily imperative to be at the top of your class in school. But if this is your goal, you should know that you must be smart and work hard. Novel concept, I know.

You are not entitled to a good grade just because you spent hours on homework. Imagine yourself saying: “My financial advisor isn’t very bright, is terrible at math, and has lost me a ton of money, but he sure does try hard. I’d hate to hurt his feelings by firing him.” Wouldn’t happen.

You are also not entitled to a good grade because you have the highest IQ in the room. How about this: “My surgeon graduated at the top of his class in med school, but has only done a few of these procedures because he spends so much time on the golf course. I think I’ll give him the benefit of the doubt and let him operate on me.” Psssh.

In the real world, we make decisions based on what is best for us and our families. Feelings don’t often enter the equation. Why should we expect oschool-79612__180ur kids’ teachers to shield them from that reality? Why would we want them to? I want my kids to strive for excellence, not mediocrity. I want them to work for what they get, not expect a free ride. Lately, high school seems to be considered fluff. A means to an
end (the end being acceptance into college, which in all actuality is more like the beginning in a lot of ways). Are we surprised that kids are floored when they get there and meet challenges?

  1. Nothing is Permanent. Between Target and Amazon Prime, things are more accessible than ever. But buying these things often feels temporary. You know you can return most them (even if you rarely do), and so the click of the button doesn’t feel like a commitment at all. I remember as a child ordering things from a catalog and waiting weeks to receive them. And you better believe it wasn’t going back once it was delivered. I don’t even know how that would have worked.


Everything is temporary. That picture you send through Snapchat. The major you choose in college. Your relationships. Your wireless plan. Everything can be replaced or changed.

war-469503__180Even death feels temporary with video games being so realistic. You can shoot your
buddy with a semi-automatic weapon and he will be playing again in a few seconds. We adults realize this is far from reality, but do kids? These are kids who are figuring out the water-gun-312826__180world through their experiences, who are adding each of these experiences to their repertoire for reference later. They are literally learning through personal experience that you can shoot someone—whether in anger or just out of boredom—and they will come back.

  1. It’s Enough Just to Try. I realize a three-year old shouldn’t have to worry about being the MVP of her soccer team, but kids are more resilient than we give them credit for. And a little healthy competition teaches them so much about life, more than words ever could. In my opinion, being legitimately good at something does wonders for the human psyche. What’s wrong with a kid knowing they suck at soccer and are good at drawing?

football-461340__180If your not-at-all athletic son never realizes he’s not athletic, won’t he waste a lot of time when he could be figuring out what his true talents are? Sure, if he enjoys playing football, by all means, let him. But it’s not really fair to let him put all his eggs in the football basket and not realize until high school that he doesn’t have a chance at starting.

Learning your strengths and weaknesses is part of growing up. It’s part of choosing your way in life. It’s part of finding fulfillment in your job instead of just a paycheck.


Plus, the real world isn’t going to care how many participation trophies you have on your shelf.

How to Prime your Young Child for Academic Success (Spoiler Alert: It Might Not Be What You Think)


I am the mom of a toddler. A toddler who I am fairly certain is going to grow up to do amazing things. If you have ever parented a young child, you can probably relate to this sentiment. The world is his oyster, he can do absolutely anything he wants, it’s just up to me to figure out what things to expose him to: what classes, what sports, what people. And when. It needs to be within a certain time frame—not too late but not too early, either. And it needs to be in a way that fosters his love and appreciation for said activity, instead of inducing dread and distaste.

It is now 8:05 am and I’m ready to crawl back under the covers. Surely delaying these life-altering decisions for one more day won’t have eternal negative consequences on his potential.

He can still be the phenomenally successful future adult that I know is graduation-879941__180hiding inside that little two and a half year old body. President of the United States or CEO of a Fortune 500 company or amazingly talented artist or professional athlete. He’ll still get into a decent college. Have friends. Be happy.


Actually, according to an official statement from the American Academy of Pediatrics, the best thing I can do for my son right now is just let him play. Use his imagination, figure out things on his own, navigate interactions with other kids. Forcing his involvement in activities that are too structured for him at this age will likely just backfire. He will come to dread those activities when he might have really enjoyed them had he discovered them on his own.

And when he’s ready for school and scheduled activities in a couple of years, he still needs to have plenty of unscheduled time to figure the world out on his own terms. Research has shown that, on average, kids who start kindergarten—or even first grade—behind their peers on basic math and reading skills ennotepad-926046_640d up equal to or even ahead of them by the end of the school year.

So why the push for pre-elementary academia? Like most things, it’s probably multifactorial: the marketing that has gone into early childhood preparedness tools, government initiatives and mandates such as “No Child Left Behind,” and the Fear-of-Missing-Out equivalent parents feel when hearing about everyone else’s children’s achievements. But despite our best intentions, are we helping our kids or hurting them?

Kids These Days…

Sadly, this generation of children is showing more difficulty in several areas that are vital to success and happiness. Teachers—who are often expected to “teach to the test”—notice a difference. But with their marching orders coming from above, they are often powerless to change what they recognize to be a serious shortcoming in early education: limited time for play.

Kids who begin formal education at an earlier age often have a paradoxical response to the exposure. Some of the detrimental effects are outlined below.

  1. Difficulty with socialization. This makes sense, right? Kids who sit in desks and complete worksheets alone have difficulty connecting with others. We see this with sharing, taking turns, etc. Kids tend to figure this stuff out on their own if we will just let them. Now, I’m not saying a preschooler who plays more is always awesome at sharing. That’s crazy talk. But he will most certainly understand the concept and know what he means when he says no!


“In contrast to parent-child relationships in which parents are typically in charge, peer interactions have a relatively even distribution of power. Thus, in play among peers, children must jointly establish the rules of the game, and in doing so they practice the skills of planning, negotiation, and cooperation (White).” Who doesn’t recognize the value of this? That it can’t be taught in a classroom? That there’s no worksheet to teach leadership or working together like experience can?

  1. Clumsiness. Believe it or not, when your kid jumps off the back of the couch for the thousandth time or runs from one corner of the house to the other (despite you yelling after her to slow down), she is learning! We take it for granted, but there is a certain way the floor feels underneath your feet when you’re walking, running, or jumping. Our nervous system transmits that sensation to our brain, which interprets how hard the next step should be, and at what angle, if we want to slow down, go faster, or avoid hitting something.

We aren’t born with this knowledge, with this experience. We learn it (sometimes by making painful mistakes). And the more we practice, the better we get. It’s no surprise that children who spend less time playing and more time sitting in desks are less graceful. But teachers today are actually noticing the difference: kids fall and run into things more than kids ten or twenty years ago.


  1. Trouble with problem solving. Kids naturally practice the scientific method when they play. “If I try to put this triangle on its corner, will it stand up? No, it falls down.” “What happens when I throw this ball against the wall? It comes back.” Again, we didn’t always know these things. We learned them. And not because someone told us what would happen.


Kids who play and experiment are more resourceful. When they try, try again, and finally succeed, they feel a sense of accomplishment. Nothing is out of reach. But when a child is told if they are smart or not, based on the fairly arbitrary scales used in schools today, that can feel like a label that’s impossible to shake. The “smart” child will have their world rocked when they finally meet a challenge (and may avoid challenges altogether), while the “dumb” kid will feel like there’s no point in trying.

  1. Difficulty paying attention. I know when I’ve been sitting at the computer for a couple of hours, my mind starts to wander and I will use any excuse to get up. I need a drink. I have to go to the bathroom. Is that a baby crying?

And I’m a grown adult. Why would we expect our hyper little balls of energy to feel any differently? ADHD is a real diagnosis, I’m not saying it’s not. But are we medicating some children because they can’t achieve our unrealistic expectations for them? Is that helping or hurting them in the long run?

sad boy

  1. Increased anxiety and depression. We’ve seen increased rates of psychiatric issues in the younger population. And why not? This is a day in the life of today’s youth: Get up and go to school. Then go to after school activities. Then come home and do homework. Take a break for dinner. More homework. Get ready for bed. Do it all over again.


I don’t know about you, but I need my downtime. For my sanity. And, frankly, for my husband’s sanity. I become a miserable excuse for a human being if I don’t get a reasonable amount of time to “veg out.” Kids need to veg out, too. They need to play. They need to get their energy out so they can use their brains.

  1. Trouble playing alone. This is a little counterintuitive, I suppose. I chalk it up to the amount of creativity it takes to play alone. You have to have an imagination. You have to have experiences to draw upon. You have to have a frame of reference.

playing alone

The Only Prescription? More Free Play!

If I haven’t already convinced you of play’s importance by outlining the negative consequences associated with a decrease in playing, then let’s talk about the benefits.

  1. Cognitive Benefits. Think about the smartest person you know. Unless you know Ken Jennings, the record holder for the longest winning streak on Jeopardy, you’ve probably got someone in mind who has intelligence instead of just knowledge. Someone who has a fresh way motivation-721825__180of thinking about things, who figures things out and is always trying something new. The most successful businessmen, doctors, researchers, and engineers are people who tackle old problems in new ways. This kid of gift is fostered early on by allowing kids to figure things out on their own—or with friends—instead of jamming it down their throats against their will. Play has been shown to benefit kids by increasing conceptual knowledge, problem-solving, creativity, skills required in STEM (Science, Technology, Engineering and Math) fields, language and literacy, and self control.
  1. Physical Benefits. Free play allows kids to test their physical limits, try boy-932422__180new things, and figure out what they’re good at and what they enjoy. It also fosters a love for physical activity in whatever form it may take for that child, resulting in a healthier weight and lifestyle. And who knows, if you just sit back and watch, your kid may just tell you he could be the next Wayne Gretzky.
  2. Social Benefits. In my opinion, there is no substitute for on-the-job training when it comes to social interactions. Left to their own devices with other kids, children will develop an intuitive understanding of interpersonal interactions. As long as they’re not hanging out with a bunch of a-holes (which, don’t get me wrong, is a legitimate concern), they will learn empathy, kindness, generosity, fairness, among many other traits developed from socialization. These are the kind of characteristics shared by people who change the world.

girls holding hands

  1. Emotional Benefits. Similarly, there is no way to learn how to deal with conflict or disappointment other than doing it. Kids learn emotional regulation and coping skills from dealing with their peers regularly in a variety of scenarios.

Amazingly, your kids will do most of the “work” of play naturally and joyfully, if you’ll let them. There is no play syllabus, no set of national play standards, and no play test at the end of the year. But the benefits—some measurable and some not so much—are undeniable.

All this is not to say there is no role for formal education. Certainly, it needs to be a part of your young child’s life (albeit a small part), and a growing part as they get older. If, for no other reason, that is how the world is at this moment in time. Same with organized sports and activities. But, in my opinion, these things should never completely supplant play and free time in our children’s lives.


There will be enough of that when they’re grown-ups.

Ginsburg, Kenneth R. The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-Child Bonds. Pediatrics. Jan 7, Vol 119:1.

Schweitzer, Kate. How Today’s Preschools Are Actually Harming Your Kids. 9/20/15.

White, Rachel E., Ph.D. The Power of Play: A Research Summary on Play and Learning. Minnesota Children’s Museum.




Where’s The Beef? 5 FAQs about the new WHO report on processed meats.


The nation was stunned on Monday when the World Health Organization announced that hot dogs are not healthy…said no one, ever. We all knew—or at least had a sneaking suspicion—that those little tubes of mushy meat product were a questionable dietary choice at best. But if I’m completely honest with myself, sometimes they just hit the spot. And sometimes they’re the only thing those little maniacs that terrorize my husband and me on a daily basis (a.k.a. our offspring) will eat. You know I’m right.

cancer-389921__180So why the uproar? Is it because the WHO report used the “c-word?” Or because they compared processed meats to cigarettes? Or perhaps because they told us eating processed meats increased your risk of cancer by a whopping 18%? Probably all of the above, plus the fact that it got so much press (thanks, Mark Zuckerberg). Imagine if a report came out tomorrow about smoking. It would be loaded with terrifying (and real) statistics like “smoking increases your risk of lung cancer 25-fold” and “smoking causes 90% of all lung cancers.” It would, rightfully so, get a lot of attention.

I have compiled a list of Frequently Asked Questions about the report and shared it below. For educational purposes, the WHO definition of processed meat is “meat that has been transformed through salting, curing, fermentation, smoking, or other processed to enhance flavor or improve preservation.” Okay, now we know. Moving on.


  1. Does the study apply to me? Probably, but maybe not. As a physician, you want a research study to use a population of patients that is similar to the one you treat. Otherwise, it’s less helpful (and, at times, completely useless). The WHO combed through over 800 epidemiological studies, which were done in multiple countries spanning several continents. Many ethnicities and diets were included in the mix. That’s good, right? Well, yes. It means that the information is probably generalizable for a lot of people. It also means they compiled data from many different studies to include lots and lots of people, which typically strengthens research. But it can also potentially water down the data. Let me show you what I mean:

farmer-554470__180-Situation 1: In a Pennsylvania town, which is predominantly Amish, almost everyone consumes only food that can be produced within the community without using modern conveniences. However, a small portion of the population eats 50 grams of processed meat daily. The difference in health between the Amish folk and the processed meat lovers will likely be drastically different for reasons other than the differences in processed meat consumption.

-Situation 2: In a poor Southern town, the population tends to eat more affordable foods which tend to be less healthy overall. In this group, the difference in health between someone who eats 50 grams of processed meat and someone who does not will probably not be very different.

large-895567__180Now, average the two studies. See what I mean? This is an extreme example, but it illustrates what the WHO scientists did in their analysis. Which is fine, because they’re the World Health Organization. But when you try to apply their research to a specific population (i.e. Americans), just be careful that you don’t under- or overestimate the impact of the thing being studied. My point is this: We are in America. Americans tend to have a Western diet which can differ drastically from the diets followed in other countries.

  1. Have I already screwed the pooch and given my child cancer because of that week he ate only hot dogs for every meal? No.
  1. An 18% increased risk of cancer sounds like a lot. What does that really mean? You’re right, it does sound like a lot. But it’s all relative. If your lifetime risk for developing colorectal cancer is 80%, then an 18% increase brings your risk up to a whopping 94.4%! Ain’t nobody got time for that. Likewise, if your risk is 0.5% (hardly worth worrying about), then an 18% increase brings that up to 0.59% (still hardly worth worrying about). Something else will most likely kill you. In reality, the average lifetime risk of developing colorectal cancer is 1 in 20, or 5%. So, a daily diet rich in processed meats would be associated in a nearly 1% increase in colorectal cancer.

Just being human puts you at 5%. Adding processed meats adds another 0.9%.


  1. But seriously, though. Cancer is no joke. That’s not a question, but whatever. I get your point. And I agree with you that cancer is no joke. But here are some things to consider:

-Colorectal cancer is a cancer that can be screened for. This means that more cancers are found at early (i.e. treatable and even potentially curable) stages. This is one of many reasons it’s different from a cancer like lung cancer (see below for others).

-Speaking of colorectal cancer screening, it is estimated that if everyone received screening for colorectal cancer according to the guidelines, it would result in a 40% decrease in cancer. That’s because colonoscopies not only allow us to take a look at the colon to see if there are any cancers there to be treated, it also allows us to remove precancerous lesions before they ever cause problems to begin with.

An ideal screening test is applicable to most of the population, screens for a relatively common disease, and changes outcome by diagnosing disease at an earlier stage or preventing the disease altogether.

But anyway, back to my original point: Colorectal cancer screening can reduce your risk from 5% to 3%. That’s a 2% absolute risk reduction. More than two times the increased risk attributed to processed meats.

  1. smoking-397599__180Is eating processed meats the same as smoking a cigarette? The WHO compared the two because they both result in exposure to carcinogens that have been linked to cancer and they both have shown to be associated with an increased risk of cancer in epidemiologic studies. But I want to give you some perspective. The WHO scientists attributed an 18% increase in colorectal cancers to eating 50 grams of processed meats daily. Cigarette smoking results in a 15-30 fold increased risk of lung cancer (the wide range has to do with amount of exposure, both in years and packs per day). Said another way, that’s a 1,500-3,000% increase. Wow. Even the low end of that range is something I want nothing to do with.

And here’s one more little statistic nugget for you: the IARC says there were 34,000 deaths attributable to processed meats in 2012, and 8.2 million cancer deaths total. Feel free to check my math, but, by my calculations, that works out to 0.4% of all cancer deaths (not all deaths) caused by excessive processed meat consumption. On the other hand, smoking is blamed for about 30% of all cancer deaths. So yeah, that’s 2.5 million.


Bottom line, everything can be bad for you if taken in a high enough quantity. Literally everything. Illicit drugs? Of course. Medications? Certainly. Foods high in fat/carbs/etc? Uh-huh. Water? Yes, even water. Processed foods lie somewhere on that spectrum, closer to the other harmful foods than either illicit drugs or water.

Did I write this piece to make light of cancer or to give blanket permission to eat whatever you want “all day err day?” Of course not. But I give each and every one of the [five] people reading this article permission to not be perfect 100% of the time. And if you are in fact reading this, you probably already think about what you put in your body day in and day out, and you probably don’t eat 50 grams of processed meats a day. If you do…stop it! It’s bad for many reasons, not just for increasing your cancer risk. But if you have the occasional hot dog, don’t kill yourself over it. The most successful dieters are the ones for whom nothing is completely off limits.

Processed meats are just one of many things in this world that contributes to your daily risk of dying. Here are some others: Car crash, plane crash, train crash, bus crash, bike crash, stabbing,… okay, the internet is telling me I’m running out of space, so I’d better wrap it up.

In conclusion, there’s enough badness out there to keep you worrying 24/7. Just try to do your best, make good decisions most of the time, and enjoy living.

That is all.

I referred to the following when writing this:

“Cancer Facts & Figures 2014”

“Carcinogenicity of consumption of red and processed meat.” Véronique Bouvard, Dana Loomis, Kathryn Z Guyton, Yann Grosse, Fatiha El Ghissassi, Lamia Benbrahim-Tallaa, Neela Guha, Heidi Mattock, Kurt Straif on behalf of the International Agency for Research on Cancer Monograph Working Group. Published Online: 26 October 2015

International Agency for Research on Cancer

“Long-term colorectal-cancer incidence and mortality after lower endoscopy.” Reiko Nishihara, Kana Wu, Paul Lochhead, Teppei Morikawa, Xiaoyun Liao, Zhi Rong Qian, Kentaro Inamura, Sun A. Kim, Aya Kuchiba, Mai Yamauchi, Yu Imamura, Walter C. Willett, Bernard A. Rosner, Charles S. Fuchs, Edward Giovannucci, Shuji Ogino, Andrew T. Chan, New England Journal of Medicine, September 19, 2013, 369:1095-1105

My brain

WHO: Processed meat cancer report message ‘misinterpreted.’ The Irish Times. Friday, October 30, 2015.

Vaccines: 5 Reasons to Ignore the Haters


  1. Haters Gonna Hate. And Post. A Lot. You can find anything on the internet. Anything. If you want someone to validate your distaste for cute, cuddly, perfect Cocker Spaniel puppies, just Google it. You’ll probably find an article called “20 Things I Hate About Cute, Cuddly, Perfect Cocker Spaniel Puppies” in about 2.2 seconds. It will be full of compelling reasons to hate puppies and, if you weren’t a puppy hater before, by the end of the article you’ll certainly be considering it. It’s easy to find both sides of any argument on the internet. And it’s even easier to share said argument with 500 of your closest friends. Most of the time, the articles are well written and authoritative. Most of the time, they are nothing more than opinion pieces written by someone who lacks the credentials to have an actual opinion. (Case in point: former Playboy model Jenny McCarthy. Yes, I went there.) Harsh, I know, but true. Admit it.
  1. Haters Wanna Benefit from Everyone Else. Haters be like “I got Herd Immunity.” Aww, nah. Herd immunity is like that lane on the interstate that’s closed 500 feet ahead. There’s always that one guy who drives up the lane and cuts in at the last second, causing all the cars behind him to have to slow down. Dude. It’s 7:50 on Monday morning. Everyone is running late. You are no more important than anyone else on the road right now. Notable exceptions are as follows (in no particular order):
  1. The pregnant woman in active labor, extra points if the baby is crowning. Negative points if the woman is driving herself—that’s just all kinds of dangerous.
  1. Any emergency vehicles (this is an obvious one), especially if they are going to fix the problem that got the lane closed to begin with.
  1. The unfortunate sufferer of food poisoning, viral gastroenteritis, or even an especially bad flare-up of IBS.
  1. The person who will suffer serious consequences if they are late. This category is on the honor system. You usually know deep down if your situation justifies trumping everyone else on the road. Examples include those going to a job interview, an important meeting, his or her own wedding (e.g. the bride or groom – everyone else in the wedding party is going to have to roll in late).

But I digress. Herd immunity, where enough people are immune that an outbreak doesn’t occur in the first place, is to be enjoyed only by those who can’t safely get vaccines. I’m talking about the immune-compromised, the very young, the seriously allergic, the pregnant (in some cases, not all). Otherwise, it just doesn’t work. The goal vaccination rate for the total population is 90-95% for herd immunity to work. We got a first-hand look at this breakdown in herd immunity with the 2015 outbreak of measles beginning in California. It can be quite scary for those of us with children too young to be vaccinated.

  1. Haters Don’t Really Get It. They be like “Vaccines are bad for you.” This is actually a three part argument.


3a. Haters say vaccines give you the infection you’re trying to avoid. We’ve all heard some iteration of the following: “I never got the flu until the one year I actually got the flu vaccine.” Seems like a compelling argument. Either the vaccine gave your friend the flu or, at the very least, it didn’t protect him against it. Here is an example of similar logic: I got in a car accident while wearing my seatbelt and suffered an injury. Oh man, must have been because you had the seatbelt on. Or at the very least, the seatbelt didn’t protect you. Or what if the seatbelt actually caused the accident?

Everyone reading this can appreciate the flawed logic in the above statement. There is no cause and effect. Just coincidence and perhaps some unrealistic expectations. And while the seatbelt may not have kept you from getting injured, it may have just saved your life. The flu vaccine often keeps one from contracting the flu in the first place, but it also lessens the severity of the illness in those who get infected despite receiving the vaccine. In the case of the flu, this protection is often as important as the prevention aspect. Some years, despite their best efforts, the vaccine developers don’t get the match quite right because of mutations that occur after the strains are chosen for the vaccine.

And as for whether the flu shot causes the flu, it doesn’t. It just doesn’t. While the intranasal form of the vaccine has a theoretical risk of causing a flu infection (because it is an altered form of the live virus and therefore has the afore-mentioned propensity for mutation), the injection is a dead virus. And viruses are not zombies. They do not come back alive for one last hurrah terrorizing humans.

There are over 300 million people in this country. Everyone has heard a story from someone about the flu shot “making them sick,” but in the end it’s all about odds. They were going to get sick, anyway. It’s just coincidence. And if it was at least two weeks after the shot, then they can be grateful because it could have been a lot worse.

3b. They say vaccines cause autism: This is the argument that’s gotten the most press recently. Autism rates have increased at alarming rates over the past two decades. Over the same time period, the number of recommended vaccines has increased. Again, correlation does not prove causation. A lot has changed in that time frame. One notable change was in the criteria used to diagnose autism. Another was in provider awareness of the disorder. These two things don’t actually change the prevalence of a disease, they just change the perceived prevalence.

A now infamous study by Andrew Wakefield claimed to show a connection between vaccines (specifically, the MMR vaccine) and autism. Usually, doctors evaluate the quality of a study based on its ability to prove its hypothesis by how well it was designed: were there enough patients? Was it randomized? Was all potential bias removed? You get the point.


However, this study failed on several more serious counts. The study authors began the study in an attempt to provide a basis for a lawsuit to win money. That’s just a bad start. Then, patients were recruited by an anti-vaccine group. This is an example of selection bias. Then, medical records were intentionally falsified. Wait, isn’t that?…Why yes. Yes it is quite illegal. It’s called fraud. And that’s why the article was retracted by the original journal in which it was published.

But people still want to trust lying, cheating Andrew Wakefield over the doctor they have chosen to care for their child in all other aspects. The doctor who has taken a Hippocratic Oath to “first, do no harm.” The doctor who, dollars to donuts, has vaccinated the crap out of his or her own children. Yes, there are bad people in medicine. Just like there are bad people in every profession. But the law of probabilities would argue that we can’t all be bad. If it’s true that the entire medical community can’t be trusted, then society has much bigger problems than anyone realized.

As a side note, the preservative thimerosal has also received a bad rap lately because it contains mercury in very small amounts. Again, there has been no literature to prove a negative effect of this, but as a precautionary measure, the AAP/USPHS recommended removing thimerosal from several vaccines to reduce the cumulative exposure over time. So to recap, the regulatory boards recognized a potential health risk, albeit one that had not been proven, and decided to err on the side of caution and eliminate the possibility of this preventable risk.

3c. Haters say vaccines overwhelm the immune system: Some worry that children are exposed to too many antigens at once, that it weakens the immune system or causes it to be oversensitive and lead to illnesses such as autoimmune conditions or asthma. Again, there is just no evidence to support this.

Anyone who knows me knows I am a huge proponent of letting my children eat dirt, lick the floor, etc. I wholeheartedly believe we shouldn’t follow our children around, sterilizing each surface they come into contact with. There is a benefit to challenging their little immune systems so they aren’t completely taken off guard when they finally come into contact with a more dangerous bacteria or virus.

But a vaccine is a challenge to the immune system in the purest sense. It simulates a “first” infection so that it will then respond much more quickly if exposed a “second” time. Scientists figured out this is the way immunity works and used it to our advantage. Science is awesome that way.


And while I do believe in encouraging natural exposure to infections at an early age, if given the opportunity to test this theory with potentially fatal illnesses in my children, my answer will always be, “Thanks, but no thanks.” I’ve seen enough to know better. In my opinion, that would be akin to letting child jump off a 100 foot bridge to teach him not to jump off 100 foot bridges in the future.

If you’re still not convinced, I’ll share this interesting fact: with ongoing vaccine development, the number of antigens children are exposed to today is about 10% of what it was in 1980.

  1. Haters haven’t learned from the past. They think vaccines are irrelevant. Who’s scared of polio, anyway? Do you even know anyone who has polio? Exactly. But let me assure you, people used to be plenty scared of polio. And the measles, mumps, rubella…I could go on, but in the interest of time I won’t. Everyone has a grandparent or great-grandparent who had a sibling or child die when he or she was a child. The cause of death for most of these children, if it didn’t occur during childbirth, was usually some sort of infection. In fact, the leading causes of child mortality in 1900 were infectious diseases—a whopping 61.6%. In 1998, death attributable to infectious disease was only 2%. During that same time period, the absolute death rate plummeted from >3% to <0.2%, reflecting an even greater absolute (total) reduction in infectious diseases. While this decline reflects many changes during that time period including improved antiseptic techniques, antibiotic development and cleaner living conditions, vaccines played a major role in this shift.

And, lest we forget that not all vaccine-preventable infections end in death, other potential consequences include but are not limited to hearing loss, increased susceptibility to other infections, encephalitis, pneumonia, ear infections, bronchitis, dehydration, vomiting, difficulty breathing…it’s a little reminiscent of the disclaimer at the end of a Viagra commercial, isn’t it?

  1. Haters say doctors just want to give a bunch of medications.


Vaccines are actually a prime example of preventative medicine. Yes, they come in a vial. But when used correctly, they significantly lower the need for hospitalizations, antibiotics, and other therapies. Like a healthy diet and lifestyle, in an ideal world, vaccines should lead to fewer doctor visits and interventions.

In conclusion, medicine is not black and white, as much as we would often like it to be. There are times when we have to choose the best for our patients based on a risk-benefit analysis. And based on the information available, the benefits of getting vaccinated far, far outweigh the risks. And so we will carry on, spending extra time educating our patients, cringing when we hear of the next outbreak that could have been prevented, and praying for the children and the parents of the children who fall ill or even die from a preventable illness.

Disclaimer: The opinions expressed in this blog post are not meant to offend, but to reinforce proven information in an entertaining way. The facts presented in this blog post are facts.

The following resources were referred to during the preparation of this post:

Deer B. How the case against the MMR vaccine was fixed. BMJ 2011; 342:c5347. (An interesting article by the investigative reporter who uncovered Andrew Wakefield, et al., had committed fraud.)

DeStefano F, Price CS, Weintraub ES. Increasing exposure to antibody-stimulating proteins and polysaccharides in vaccines is not associated with risk of autism. J Pediatr 2013; 163:561.

Guyer B, Freedman MA, Strobino DM, Sondik EJ. Annual summary of vital statistics: trends in the health of Americans during the 20th century. Pediatrics. 2000 Dec; 106(6): 1307-17.

Iqbal S, Barile JP, Thompson WW, DeStefano F. Number of antigens in early childhood vaccines and neuropsychological outcomes at age 7-10 years. Pharmacoepidemiol Drug Saf 2013; 22:1263.

Lieberman JM. Myths regarding immunization. In: An Ounce of Prevention: Communicating the Benefits and Risks of Vaccines to Parents. Infectious Diseases in Children. Slack Incorporated, Thorofare, NJ 2003. P.6.

Lyren A, Leonard E. Vaccine refusal: issues for the primary care physician. Clin Pediatr (Phila) 2006; 45:399.

Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics 2002; 109:124.

Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351:637. (The original article “linking” vaccines and autism which was later retracted.)

*There have been many large studies and reviews showing no link between the MMR vaccine and autism, too many to list here. If you are interested, please contact me for a comprehensive list.