HPV Confusion

I am all for parents making informed decisions about their children’s healthcare and not just being passive bystanders. The key to that is that they need to have accurate information on which to base their decisions.

One subject on which there seems to be a lot of confusion is the HPV vaccine. This vaccine was introduced in 2006 to decrease the risk of contracting the Human Papilloma Virus which can lead to cancer of the cervix, penis, and mouth. One of the early concerns was that by giving young people a vaccine against a sexually-transmitted disease, this would give them license to have sex. This reasoning never made sense to me. I doubt that when young people are contemplating having sex they spend much time considering the risk of cervical dysplasia years in the future. A study in the journal Pediatrics in 2012 found no increase in sexual activity in teens who had had the vaccine when compared to those who did not.

More recently, the concern has been about side effects of the vaccine. Parents sometimes cite “horror stories” they have heard but they often cannot remember exactly what they heard. They often just have a vague unease about the vaccine. In other situations, parents have concerns about specific side effects. When these arise, I have tried to trace their concerns to the original incident in question. When I have done this, I have either run into a dead end because there does not appear to be any actual evidence to support the concern or have found that the circumstances of the alleged side effect were very different from the headlines that end up on the internet.

One concern that has been raised was that the vaccine could cause premature ovarian failure in young women. Premature ovarian failure is when the ovaries stop functioning at an early age, essentially menopause happening at the wrong time. A parent gave me something they had printed from the internet about this. I investigated it as far as I could go and didn’t find anything concerning. In case I was missing something, I asked around and no other physicians I talked to were aware of any evidence of this. Because gynecologists would be the ones likely to hear if there was an increase in this problem in young women since the vaccine went into use, I contacted several gynecologists I know and they also were unaware of any evidence to support this link.

Prior to the introduction of the vaccine, the incidence of premature ovarian failure was reported to be around one in ten thousand women by age 20 and one in a thousand women by age 30. In the first nine years after the vaccine was introduced, six cases were reported in girls who had received the vaccine. During that time around 170 million doses of the vaccine had been given which means the rate was lower than the rate reported prior to the introduction of the vaccine.

Prior to licensure of the HPV vaccine, its safety was studied in 30,000 persons over seven years with no significant adverse effects noted.  Since licensing, more than a million more patients have been studied. In the past seven years, our practice has given almost 9000 doses of HPV vaccine with no significant side effects.

As physicians, we have all taken the Hippocratic Oath which states in part, primum non nocere, “First, do harm.” While we are humans who make mistakes, we would never do anything which we thought would harm a patient. If you have concerns about the vaccine, by all means have that discussion with your child’s doctor. You may even reach a different conclusion than the doctor. Just make sure the decisions being made are based on accurate information.

Three Easy Steps to Make Your Child Behave (or not)

Discipline and behavior issues are a frequent topic of conversation in our office. There are many discipline techniques that are available for children of different ages and in different situations – timeouts, loss of privileges, natural consequences, etc. But none of these approaches will magically make a child behave.

I occasionally will hear parents say something along the lines of “He is too big for me to make him listen.” Hopefully our parental authority is not based on superior physical strength because I would have lost that battle starting about seven or eight years ago. I want my children to listen to me because they respect me, not because they are afraid of me. And now that they are older, I don’t want them to just listen to me. I want them to do the right thing because that is who they have become, something they have internalized.

If a child listens only out of fear, what will they do when that fear is no longer operative? We all have situations in which we could probably get away with doing things we should not. Hopefully we have some internal motivation to do the right thing when the external controls are not present.

I think the internal motivation to behave in appropriate ways starts with modeling of appropriate behavior by the adults in a child’s life and by having relationships with those adults which are based on love and mutual respect. A child is much more likely to listen to an adult who he knows cares about him and wants what is best for him.

Imagine two different children contemplating a forbidden activity. One thinks “I shouldn’t do this because if I get caught I will get whipped.” The other thinks “I shouldn’t do this because this is the type of thing my mother has warned me about and she is generally right about these things.” Which thought process is more likely to produce desirable behaviors in the long run?

I am not talking about just letting kids do whatever. Clear, consistent limits are important and those limits need to be consistently enforced. But they need to be enforced in a way that helps the child to learn and does not demean him as a person.

I have not always done a great job of applying these principles myself but I think I did get better at it over time with successive children (sorry Zach). And clearly not all children react the same. Sometimes parents parent well and the behavior outcomes are not what they had hoped for.

I don’t think there is a magic “just do this” approach to parenting that will make everything turn out well. But I think spending time with your children and showing them that you love them is a good start.

 

Some Thoughts on Thanksgiving Day

2017 has been a crazy year so far in many ways. It seems like there is a lot of anger and anxiety out there. But when I step back and look at the big picture, I have many things for which to be thankful.

Fortunately I do not know any losers or haters, bloviators or fools. I do know a lot of folks who have intrinsic worth and are making their way through life the best they know how, some more gracefully and successfully than others. I am thankful for folks who agree with this view of humankind because they believe that we are all made in the image of God. I am thankful for those who agree because they believe we are all exquisite, inter-related products of cosmic randomness. And I am thankful for those who agree because they believe some combination of those two.

I am thankful for the folks who build and repair the things I use every day, from the house I live in to the computer network at the office. I am thankful for teachers, farmers, mechanics, bankers, nurses, and the people who make sure I have clean drinking water and electricity at my house. I am thankful for my medical colleagues and my friends who hash through my questions and anxieties with me. I am thankful for people who run homeless shelters and food banks.

I am thankful for my friends in Zambia who have helped me develop an expanded perspective on life and the world. I am even thankful for politicians. Someone has to make decisions about how we live our shared lives. I have met some politicians who I think are principled, ethical, good people. We need more of them.

I am thankful for the life and teachings of Jesus which provide us guidance on how to live; loving neighbors and enemies, seeing the best in those who are different from us, healing the sick, feeding the hungry, and clothing the naked. I am thankful for scientific discoveries like those of Robert Guthrie that have made life-changing advances for people I love. I am thankful for books, music, and nature, and a beagle who runs through the woods with me.

I am thankful for Cindy and that we had all three of our children and our soon-to-be daughter-in-law under our roof last night. I am thankful for going to ball games with the boys, hugging Rachel until she is annoyed, and that look that Cindy gives me when I think I have said something clever but she thinks it is stupid. I am thankful for all of my other family members and how they love and support me despite my quirks and "nerdish tendencies."

My hope for the remainder of 2017 is that we can all listen to those with whom we disagree, work for those who are less fortunate than we are, seek justice, love mercy, walk humbly, and each do our part to make the planet we share a better place for everyone.

Life is Hard

I recently had a teenager in the office say to me “Life is hard and I don’t know why I feel this way.” I had two initial reactions. The first was to acknowledge that life can certainly be hard. The second, unspoken one, was that I hear a variation of this far too often from too many young people.

A significant number of adolescents have reasons to feel that life is difficult. Family problems, lack of physical and emotional resources, medical problems, and a host of other issues can make life difficult for young folks. Anyone who thinks every child has an equal opportunity to succeed could be easily disabused of that notion by working in a general pediatric practice.

But there are also some things that I think one can do to help offset the gloom associated with living life. I would put these in my file entitled “Things I Believe but Cannot Prove.”

·         Exercise – My patients probably get tired of hearing this but exercise is good for almost everything, including elevating one’s mood. You do not need to run marathons or play high-level sports but some sort of activity that gets your heart pumping on a regular basis can make a big difference.

·         Spend time with people – If you are feeling down, a surefire way to make it worse is to isolate yourself from other people.

·         Get away from the electronics – I have seen in myself and others that too much time watching TV, playing on some electronic device, or scrolling through social media is a great way to get grumpy.

·         Do not compare yourself to other people – No matter how good you are at something or how handsome you are, you will eventually run into someone better and prettier than you. If your view of yourself is based on how you compare to others, you will eventually, inevitably be let down.

·         Get involved with something bigger than yourself – Be involved in a faith group, work for a good cause, meet with people with similar interests to learn from each other, be part of an athletic team, or do something else that gets you working with others towards a common goal.

·         Spend time outside – Spending time in nature can be therapeutic. If you live in town, find a park to walk in. If there is not a park nearby, observe the plants growing up through the sidewalk and see what the bugs are up to. I enjoy watching stink bugs because they are kind of like tiny dinosaurs (although I have been told that this is weird).

·         Eat real food – Anyone who exists on fast food, snacks, and soda is going to feel bad.

·         Don’t self-medicate with alcohol, marijuana, or other drugs – It may make you feel better temporarily but will make things worse in the long run.

·         Help other people – Looking out for the needs of others is a great way to take the focus off your own problems and helps others in the process.

Clearly some folks have more difficulties than can be solved by eating a good dinner and going for a walk through a park. For those folks, we have other things to offer. But I suspect a lot of people could feel better by trying these suggestions.

Maybe I'm crazy but...

As I was running through the woods with my beagle thinking about the fact that it was time to write another blog post, one part of my brain said to the other, “You are going to write about guns? Are you crazy? Why not write about how it is good to read to your children or the fact that apple pie tastes good?” So maybe I am crazy but I have some honest questions so here goes.

I grew up going hunting with my father and brother. My brother and his friends also used to let me tag along which is an awesome thing for a younger brother. I wasn’t a great hunter but I enjoyed being in the woods, the smell of the leaves, hearing the drumming of a grouse, watching squirrels (especially those big fox squirrels in the mountains of western Virginia), turkeys, and pileated woodpeckers. I enjoyed sleeping in a cabin warmed by a fire, hiking up the ridge in the freezing predawn darkness, falling asleep in the leaves when it got warmer later in the day, the smell of burned gunpowder from a used shotgun shell, and warming up by the woodstove after a long day in the woods. I still have the antlers from my first deer. It was just a spike but my brother mounted them on an expertly finished wood base for me. I also still have a gray squirrel he mounted for me (I have a pretty awesome big brother).

I think it is self-evident that shooting guns can be fun, especially if you have ever had the opportunity to dispose of a partially rotten watermelon by shooting it. I have no idea why it is fun to blow up spoiling melons with a shotgun but it is. But I think anyone who has ever disposed of fruit in this way would agree that an instrument that can do that to a melon is obviously potentially dangerous if not handled carefully. After all, the primary purpose of a gun is to kill.

I have a hard time understanding how discussions of gun safety and whether or not assault weapons should be easily available infringes on the rights of hunters. I am certain that my brother could feed a large number of people with only a bow and a few arrows or a flintlock with some powder and mini balls.

I have never even considered having a gun for self-defense for a variety of reasons (a longer essay for another day). I once walked into a store and the other three customers all had handguns on their hips and I wondered about the wisdom of being somewhere where everyone apparently felt the need to be armed. That doesn’t seem like the type of society I want my family to live in. And since the mass murderers are now using what are essentially automatic weapons, does that mean that soon people will be walking through the grocery store with assault rifles slung over their shoulders to protect themselves from the suspicious-looking guy in the cereal aisle?

I am also puzzled by discussions of the second amendment. I am not a lawyer or constitutional scholar but I don’t think I have ever heard anyone bring up the “well-regulated” part of the second amendment in these discussions. What does that mean? If I go down to the store and buy a rifle and take it home, that does not seem to me to fit into the idea of a “well-regulated militia.” Some folks are not good at self-regulation.

I welcome any calm, well-reasoned responses.

Peace.

On Vaccines and Knowledge

I was recently discussing vaccine recommendations with a parent and it went something like this:

Me: “I see she hasn’t had any vaccines. Can we get some started today?”

Parent: “We don’t like the ingredients in the vaccines.”

Me: “Which ingredients?”

Parent: “Mercury.”

Me: “Okay that’s fine because there is no mercury in any of the immunizations we would recommend giving today.”

Parent: “Well we don’t believe in vaccines.”

I found this confusing. Vaccines aren’t something to “believe in.” I am still not sure what that even means. I wouldn’t tell my mechanic that I believe or don’t believe in rotating my tires. I may ask pros and cons, how much it costs, etc. to learn more about it and help me make an informed decision, but it is not a matter of faith.

Maybe I am just turning into a grumpy old man but it seems that as a society we are losing the ability to differentiate between what we know and what we believe. When the evidence showed that the nasal flu vaccine was not effective, we didn’t cling to some kind of belief in it and keep giving it anyway. We stopped using it. It was the same when the initial Rotavirus vaccine showed a small, but real, increase in the incidence of an intestinal blockage known as intussusception. We stopped giving it.

There is nothing wrong with believing things. There are things that I believe but cannot prove but I am up front with folks about what I believe to be true and what I know to be true and the difference between the two.

But when one equates believing something with knowing something, it shuts down all discussion and opportunity to learn something new. I have learned a lot of new things through the years by listening to different perspectives and being open to new evidence. If I had not been willing to consider that what I believed was not true, I would have missed out on a lot of interesting, important, exciting, life-giving knowledge. Of course, I have also learned some things along the way that I wish I didn’t know, although knowing them makes me a better person.

So believe what you believe, but be open to the possibility that you may be wrong and willing to change your mind if that is where the evidence leads.

The Importance of Meeting Different Types of People

I think one of the most important things we can do to help ourselves and our children grow is to meet and talk to people whose lives and experiences are different from our own.

I recently had the opportunity to travel to Zambia with two of our children. I have been to Zambia before in my work with a small non-profit organization of which I am a part. But each trip resets my perspective, at least temporarily.

Seeing folks with basic medical needs which have not been addressed for years, sometimes for reasons as basic as not having access to transportation, is frustrating. Using a toilet which is basically a hole in the ground inside of a small structure made of mud bricks while children playing just outside are visible through the cracks is humbling. Seeing a plate of dead mice awaiting preparation to be eaten while making a house call to see someone who is in too much pain to make it to our makeshift clinic is sobering. Hearing about the woman who died in childbirth and the child who drowned in an open well the week before we got there is depressing.

On the flip side, seeing folks who have made economic progress with the small opportunities they had is exciting. And teenagers who walk several kilometers to school each day or live in a mud house but take every educational opportunity they get are inspiring. And it was comforting that the Muslim owner of the bush camp we visited, knowing that we had already sliced our spare tire on a rock so no longer had a back-up, volunteered to come and rescue our vehicle full of Christians if we had not made it back to the paved road in three hours.

Not everyone has the opportunity to go to Africa. But there are plenty of people all around us who have different life experiences which we can learn from. This happens for me on a daily basis in my office in the heart of the Shenandoah Valley. We can all learn by seeking out folks who are different from us and hearing their stories. Maybe they have a different type of job or are of a different race or religious or ethnic background.

Hearing the stories of others helps take our focus off ourselves and our problems and helps us understand why others do what they do. As one of the kids said after we got back home, “I feel bad complaining about anything now.” Exactly.