Walk-in Health Care: Growing Popularity (and Concerns)

From The Washington Post, April 6, 2014

Not a lot of time for a long blog post today, but I came across this article in this morning's Post and have been thinking about its implications for health care ever since.

The basic arguments in the article are as follows:

1. Between the growth of eligible patients (something that will continue to grow with expanded coverage facilitated by the Affordable Care Act) and the continued decline of doctors graduating from medical schools with specialities in primary care or family practice, gaining access to primary care has become increasingly difficult.

2. Consequently, retail chains, such as CVS's Minute Clinic, have expanded pharmacy offerings in their stores to include basic care for things like infections, vaccinations, and sports physicals. Some offer testing for basic preventative measures, like blood sugar testing, according to the article.

3. The services provided by these retail chains are more convenient, faster, and cheaper than other available options.

In a sense, the clinics solve a few problems. In an environment where people lack easy, quick access to medical services that physicians offices are too pressed to provide, the clinics can dispense antibiotics before infections (and discomfort) become severe, offer timely vaccinations (a critical need during flu season at the very least), and alleviate some of the burdens placed on the existing primary care system.

But, there are problems with this, too, some of which the article addresses but doesn't really offer a clear solution for:

1. The impact this might have on the care of children, in particular, is unknown and troubling. As the article quotes from an American Academy of Pediatrics (AAP) representative: "There is no such thing as a ‘minor illness’ when it comes to children. Pediatricians use these ‘minor illness’ visits to identify other, potentially more serious issues." What seems like a series of acute illnesses may be masking a chronic condition that goes unnoticed because there isn't a consistent physician caring for a child. Pediatricians and primary care doctors also watch for other issues children may be experiencing, such as nutrition issues, developmental problems, or even signs of abuse. All of these may be missed under such a disjointed system of care.

2. A lot hinges on preventative care, from our own long-term health to many health policies (not least of which, the Affordable Care Act). Increasingly, disease is not conceptualized as a single, isolated incident, but as a stress point that occurs at the end of a steady progression of illness, which has been exacerbated by individual circumstances and lifestyle choices. Properly caring for the little things that happen to us over time may be more essential to our long-term health than we realize, and reliance on acute or emergency care may exacerbate the negative affects of short-term thinking.

The problem of the dwindling primary care provider is a really serious issue. It strikes me that, on one end of the spectrum, the issue is addressed by concierge medicine--a specialized, expensive system where access to a physician is restricted by how much one is willing to pay. In this case, a select few can get same-day appointments, a doctor's email address, and, if needed, a quick diagnosis and prescription to treat an ear infection or an in-hospital consultation and coordination of care after a heart attack.

On the other, we have the CVS Minute Clinic. Here, you may not have a doctor's email address (or even see an actual doctor), but the service performs the same functions, providing quick, convenient access to medical information within the time constraints of otherwise busy people. Here, access is almost universal, but it's not as complete or complex and lacks the relationship-building and health maintenance objectives of the concierge option. While this system may solve acute problems, again, we're addressing acute measures to the possible detriment of chronic conditions that go unnoticed.

All of this might not be a problem. But we at least need to acknowledge how it is at complete odds with our larger objectives of preventative medicine that shape expectations for medical care and outcomes today and ask what the impact will be if this is the system that is takes up residence where the doctor's office once stood.

The Rhetoric of Feline Oncology: Or, What Happens When Your Cat Never Had Cancer (But the Doctor Said He Did)

Milton during his follow-up oncology
appointment, 6 months after his
initial cancer diagnosis. 

The title kind of tells it all.

In 2008, after a long bout of excruciating gastrointestinal troubles, my cat Milton—then 8—was diagnosed with intestinal cancer. Specifically, carcinoma of the jejunum and colon.

The pathology report described “multiple intestinal masses that are mucinous in appearance.” The cells retrieved through a fine needle aspirate of the masses revealed a “severe degree of nuclear variation and variation in cell size.” All possible treatment options were either too invasive for him to endure (sick as he was at the time) or unlikely to impact the particular kind of cancer he had. They didn’t even try to book us a follow-up appointment—the letter simply concludes, “I do expect him to decline over the next 2-8 weeks.”

At the time, these words were terrifying, final, the source of hours of tears and lots of Googling for alternative interventions and treatments. In the years since, they have meant afternoons spent at various veterinarian offices investigating mysterious symptoms that may have indicated that the cancer had spread (always turning out to be absolutely nothing), countless ultra-sounds and further small biopsies of his intestines to see how the tumors were doing (fine, by all of our best estimates), so many elaborate diets and supplements that Milton oftentimes ate better than I did, and a lot of fear and anxiety and worry for all of us that any mis-step in his care might bring dire consequences.

But, this week, at an appointment with the very same oncology unit that gave Milton a 2-8 week death sentence 5 ½ years ago, I learned what those words really meant:

There’s actually very little accuracy associated with these tests, surgical biopsy being the gold standard for this type of diagnosis, so although the conclusion at the time was that he likely did have cancer, the fact that it hasn’t killed him yet indicates that he actually never had cancer at all.

What?

Wait, what?

This was my response. Very eloquent.

So, what is wrong with him, then? I asked, still knowing that my dear cat experiences, well, for the sake of protecting his privacy, I’ll say “frequent gastrointestinal distress.”

Hmm. Not sure, the doctor says. IBS? Combined with old age?

So, 5 ½ years of doctors, medicines, alternative treatments, expensive tests, and constant worry all because he has, basically, been an aging cat with an upset stomach?

This experience has been interesting for a wide range of reasons (and infuriating as well), and I’ve had a wide range of reactions to it. But, for right now, I’ll put on my rhetorician hat, and analyze the situation through that lens. Because, looking at this case through its discourse is incredibly revealing.

Looking back through the original pathology reports, you can actually see the spaces where the discourse makes itself available to both offer a devastating diagnosis and explain away a mistake at the same time. As terrifying as the words on the report were, they were still couched in contingencies that I was too saddened to see when I originally read them: “the radiologist suggests carcinoma,” “a carcinoma is suspected but cannot be proven with this cytology,” “surgical biopsy would be required to make a definitive diagnosis.” None of those contingencies ever mattered at the time, and I never revisited them. Once the word “carcinoma” entered my world, my focus was on identifying, addressing, and defeating that, not on questioning its presence.

Yet, the contingent words were the words the oncologist relied upon this week as she delivered the news.

When I said, “But, I thought you took cells out of tumors. I thought those cells were cancerous, and that meant he had cancer.” She said, “Well, all we can see are irregular cell patterns, and irregularity can exist along a spectrum of pathology, from healthy, to sickened, to fully diseased cells. So, we may have seen cells that were cancerous and were later resolved by the immune system or cells that just looked abnormal because of inflammation.”

 

Milton, sitting on papers (of course).
Also, if you look carefully, you can see his belly is
pink after being shaved for an ultrasound.

And, naturally, “this is why surgery is the gold standard for diagnosis,” because without a chunk of diseased tissue, there’s no way to know for certain that what’s really in his body is really cancer and what kind of cancer it is. So, the combination of the ultrasound showing a mass and the extracted cells are the least-invasive best guess. That’s all they really have—a best guess that you can hope isn’t as bad as it seems.

The problem is, of course, that a lot of decisions are made based on that best guess. Most gravely, I could have chosen to have him put to sleep. This wouldn’t have been an inhumane option, given a cat that was pretty sick and going to die at the time. It wasn’t an option that I considered, but it is something that some people absolutely would.

On the other side of things, I could have chosen one of the more invasive options they provided, and that subsequent doctors have recommended since, like chemotherapy and radiation. This is the only point at which the oncologist did express some acknowledgement of the consequences of this error: “Well, in retrospect, it’s really good that you didn’t move forward with any more aggressive treatments, like radiation or chemotherapy treatment for a cancer that wasn’t there.”

“Humph, you think?” was my knee-jerk retort.

Overall, the experience reified everything I’ve read and suspected and analyzed about communication and medicine over the past few years. That, in that examination room, objective truths are hard to find (try as we might to find and rely upon them), conversations are rarely the same for doctor and patient, and the documents produced and the words those pages simply are different for the person who types the words versus the person about whom they are typed.

A similar sentiment is reflected in one of my favorite quotations from Kathryn Montgomery:

“The lump is there. It is a sign, caught in medias res, a clue to a natural history that is unfolding. Science describes and explains it and determines what can be done about it. But the importance of that lump, the acts its discovery entails, and what those acts will mean are social and cultural matters.” How Doctors Think, page 15

There may be cancer—except when there’s not—but cancer isn’t the same thing for the doctor as it is for the patient. Cancer, for this veterinarian, was a series of pieces of paper, test results, and a subsequent medical history that seemed to disprove original observations made by another veterinarian years ago. Cancer, for Milton, had meant that he had lived an entirely different life for the past 5 years than he would have without that diagnosis.

To put it in Montgomery’s terms, the veterinarian offered a scientific ending to the story of the lump, in the form of a conclusion: the lump was never there, and that was a good thing. But, it’s not as simple as that. The lump was never just the lump for Milton and for me. It was a series of treatments that were doing very little or nothing to treat the (still to be determined) disease he actually had; side effects of those treatments that were endured in vain; and a lot of time, energy, and fear funneled into a disease that wasn’t there. The narrative of that experience works very differently with such a scientific twist—gotcha! He didn’t have cancer at all!—at the end.

I share all of this with a rhetorician’s lens and a certain level of seriousness because, well, I can. As much as we love our pets, feline cancer isn’t as important as human cancer—pathology can get a cat’s cancer wrong; oncology can afford the educated guess that turns out to be a mistake. Owners can set the boundaries and refuse treatment without being called—at least openly—negligent. All of it happens without consequence; the consequences for the owner or the vet if one makes the wrong interpretation or the wrong choice aren’t as dire as they are if this were to happen to a human. So, in many ways, the rhetoric of the science here is a bit more raw, closer to the surface, open about its reliance on its own discursiveness. Well, we never knew, for sure, that he had cancer, and we never really said so either.

Regardless, as I say, this is good news. The best news I have ever received in an oncologist’s office, that’s for sure. But that’s only part of the point. Every part of the end of this part of the story is fraught, shaped by discursive contingencies, marred by rhetorical mis-steps, and shaped by the fact that the facts were never as certain as I thought they were. A lesson I still don’t know what to do with but that I should probably figure out before I arrive at the next vet appointment.

Back-to-School means Back-to-Vaccine (Mandates)

http://www.philly.com/philly/blogs/phillylists/States-with-best
-worst-vaccination-coverage-for-kindergarten-students.html

This came across my Twitter feed today, originally posted at Philly.com, about vaccination rates for Kindergarteners. Rates are not uniform across States, which is not surprising, but which States have the highest and lowest rates are.

For example, Mississippi consistently ranks among the highest levels of vaccine preparedness, largely because they have few available exemptions; only medical exemptions, written by a licensed physician, are accepted. No philosophical exemptions, no personal belief exemptions, no religious exemptions. Consequently, Mississippi is at the top of each "Best" list for the rate of vaccine compliance--99.9% in all major categories (MMR, DTaP, Varicella).

This is, of course, of particular interest in the context of Mississippi's health as a State overall. It has high rates of obesity (according to this report, the highest obesity rate in the country, though just reading through some articles on obesity, I'm noticing that there isn't a lot of uniformity in where different outlets are getting their reports on this, which is interesting in and of itself) and hypertension, and its counties have some of the lowest life expectancies in the nation. And child health metrics are not great in Mississippi, especially when it comes to obesity. The Child Policy Research Center reports that 44% of children are obese in Mississippi, and 30% of low-income children ages 2-5 are obese. Although it's not everything, obesity during childhood can have drastic consequences on life-long health outcomes, meaning that many of these children who are obese are at significantly increased risk for issues down the line, such as diabetes, high blood pressure, and all of their related secondary conditions and general pitfalls. (I'd provide more sources and links there, but we already know this, right?) Mississippi is also tied with Louisiana for being the least healthy State in the country according to America's Health Ratings.

At the same time, relatively "healthy" States are ranking among the "Worst" list in the article. Colorado is a particularly curious example, ranking worst in MMR uptake (85.7%), second-worst in DTaP (82.9%), and worst again for Varicella (84.6%). Also consistently on the "Worst" list is Pennsylvania, which, although not quite as bad as Colorado, is a surprising addition to the list. The easiest reason for this is likely Pennsylvania's relatively lax vaccine exemption requirements--according to Pennsylvania code, "

Children need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization on religious grounds or on the basis of a strong moral or ethical conviction similar to a religious belief." 

So, vaccines are relatively easy to get out of--just write a note saying you really, really don't think you should be vaccinated, and you don't have to be.

Yet at the same time, Pennsylvania is a healthier State. Its rates of childhood obesity, while not great, are much better than Mississippi's: roughly 30% of children are obese, and about 25% of low-income 2-5 year-olds are obese.

I was struggling with more comparative ways of measuring how Pennsylvania is healthier than Mississippi (something I felt I knew based on news but have been unsure about) and came across a comparison tool at America's Health Rankings. You can play with this too; just go to their website (http://www.americashealthrankings.org/), go to 2012 Overview, and use the menu on the right-hand side to compare one State to another.

Just a few snippets of data that demonstrate relative healthiness:

Mississippi has

• More cancer deaths
• More cardiovascular deaths
• More incidents of diabetes
• More incidents of infectious disease (AIDS, Tuberculosis, Hepatitis A and B [which are vaccine-preventable])
• Substantially more incidents of preventable hospitalizations

I could go on, but you get the point. 

We have an obvious conclusion here: fewer vaccine exemptions=more vaccinated kids, but not necessarily healthier kids. Nice work for a Monday morning, Heidi.

But, an more interesting question to ask based on that (rather obvious) observation is this: what are the differences between a State like Mississippi and a State like Pennsylvania that could produce such radically different preventative health environments--one relatively good and the other the worst in the nation? And how does the least healthy State in the country manage to have one of the most aggressive preventative healthcare policies when it comes to vaccination?

Pennsylvania is, by all accounts that I can reach through some pretty quick searching, a richer, healthier, more populous state. If, as vaccine advocates often argue, increased scientific literacy is all that is needed to convince people that vaccines are safe and effective at producing healthy children and adults, then why would a more educated, richer State allow more permissive vaccine regulations?

So: what's the deal? What is the history of Mississippi's vaccine requirements? It is one of only two States (West Virginia being the other) in the nation that doesn't allow for religious exemptions (in line with what Paul Offit has frequently recommended as the only solution to waning vaccine rates in certain areas). Why? Who fought for that? When? How? Did anyone object?

I'm working in broad strokes here, but what this facet of the issue says to me is that a deeper understanding of the vaccine mandates (or lack thereof) that manifest in different places and historical moments might be an important link to understanding how different controversies are sparked in different places, who the major players are in dictating the debate (if there even is one at all), and who, ultimately, wins. Because, clearly, Mississippi's vaccine policy is not a product of a fastidious attention to preventative health detail as a product of collective social and cultural concern. Otherwise, it would be healthier by other standards as well (one would hope).

Again, another round of questions to be investigated through a deep understanding of the local manifestations of controversy, rather than those that exist more globally.

Local Vaccination and Rhetoric: An Interview with Bernice Hausman

My dissertation director and director of the Vaccination Research Group (VRG) at Virginia Tech was interviewed recently on our study of H1N1 vaccination practices in Southwest Virginia. The interview also mentions our upcoming article in the Journal of the Medical Humanities, which discusses the implications for this study and our understanding of local publics and medical rhetoric. Brief shout-out to yours truly at 1:57!


http://virginiapublicradio.files.wordpress.com/2013/04/prerollvaccine.mp3

Vaccines in 2013

Happy almost-2013! In honor of the New Year, I thought I would share a couple of the news items I will be watching for in 2013.

First, as always, is flu. This year's flu season has supposedly been off to a very early start, but by my accounting of the total number of infections on the CDC's national influenza summary, through week 51, there have only been 15,106 infections this year. I know--there have also been 16 pediatric deaths, which is absolutely terrible, and if you are one of those 15,000-some who is infected, you're probably in significant discomfort at best and some pretty serious trouble at the worst. And I also know that the number of reported cases represents only a fraction of the number of actual infections. But, still, 15,000 infections doesn't sound like a lot, in a nation of 300 million--to me, anyway. Everyone is going to have a different reaction to that information.

Vaccination rates are about the same as they were last year. I'm sitting in a room of five adults right now, and none of us got our flu vaccine; two say they intend to, but it hasn't been convenient so far. So, I guess we're contributing to the problem. Next year, there will be two quadrivalent flu vaccines: MedImmune's Flumist Quadrivalent and the newly approved Fluarix, an intramuscular vaccine produced by GlaxoSmithKline. Both of these vaccines will protect against the two most common Influenza A-type and Influenza B-type viruses. The addition of a second Influenza B virus may result in fewer infections.

But, as the CDC's website reminded me today:

The seasonal flu vaccine does not protect against influenza C viruses. In addition, flu vaccines will NOT protect against infection and illness caused by other viruses that can also cause influenza-like symptoms. There are many other non flu viruses that can result in influenza-like illness (ILI) that spread during the flu season.

I mean, I knew that, but it doesn't exactly get me excited for a flu vaccine, since it just reminds me of all of the things that can still make me sick no matter what I do. Yippee.

Anyway, next year, I will be looking out to see how these quadrivalent vaccines are marketed, if the uptake rates are higher, if more adults in particular (like those sitting with me in the room right now...) are motivated to be vaccinated, and so on.

Second, I'm also going to continue to watch news of the pertussis outbreaks. I'll be watching to see how/if the epidemic continues, how rates of infection pan out (adults? children? infants? college students?), and how serious is this going to get. Mostly, I'm curious to see how the story gets told: is this going to continue to be evidence of the "evil" of vaccine skeptics, who demanded the (now less-effective) acellular vaccine despite relatively unsubstantiated evidence that the whole-cell DTP vaccine caused neurological side effects? And damaged herd immunity by refusing the TDaP vaccine? Or, will those who remain skeptical use this as evidence of long-term ineffectiveness of vaccinations as a practical public health solution? Both arguments are out there. I'll be interested who uses what argument and when.

Back to dissertating. Happy New Year. Get a flu shot. Or wash your hands a lot. Or both. Or just accept sickness as an inevitability of life. Welcome, 2013!

On the Vaccine-preventable Disease Outbreak Narrative

Articles like this one that appeared in Parade a few weeks ago, "Why so Many Parents Are Delaying or Skipping Vaccines,"not only hit my radar because I follow its author, Seth Mnookin, on Twitter and he tweets like 7 times an hour. Not that I'm complaining--I feel certain at most times that I know everything going on in vaccination just by following him.

I continue to be surprised and intrigued by the number of articles that appear--in the popular media as well as scientific journals--that claim to have answers to vaccine controversy. Yet, not only do these articles rarely provide any actionable answers (other than encouraging people to vaccinate), but they also tend to report mostly by re-hashing a standard narrative about vaccine refusal, complete with cast of good guys and bad guys and what happens when even a few parents refuse to vaccinate:

Bad guys:

• Andrew Wakefield (whose 1998 argument that MMR vaccination caused rising rates of autism is characterized as the impetus for today's vaccine controversy) 
• Vaccine success (diseases now seem so rare that parents aren't afraid of them and skip vaccinations)
• Parents in affluent, well-educated areas who are overly concerned with environmental issues and child development (so, focused on the wrong things, they refuse vaccines to avoid environmental contaminants and instead put their kids--and others--at risk for disease; they also worry about autism and think it is related to vaccines, thanks to Andrew Wakefield [above])

Good guys: 

• Vaccines (of course. They have greatly reduced measles and polio worldwide and have eradicated small pox)
• Herd immunity (which protects everyone--vaccinated and unvaccinated--from contagious disease)
• Health officials, researchers, and doctors (who, try and try as they might, cannot out-persuade Jenny McCarthy)

Narrative:

Parents stop fearing diseases because they have become rare. A segment of parents fears vaccines instead because their resources afford them the time and education to over-research vaccine safety and indulge their personal political whims. Parents delay vaccines. Disease comes to a community, circulates to unvaccinated children, but then vaccinated and immune-compromised children become sick as well. Doctors don't recognize the diseases the children present with because they are so uncommon now. Children die or become very ill. Non-vaccinating parents learn that diseases are serious and that they should vaccinate. Vaccinating parents learn that parents who don't vaccinate their children don't realize that their decisions put others at risk.

I don't disagree with this narrative so much as I am perplexed by its over use. Paul Offit's Deadly Choices begins with a similar story, and Mnookin's book is peppered with similar stories throughout. And even when the full narrative isn't present, the good guys and bad guys are almost always the same. 

What is it about this set-up that is so compelling as a story for why vaccines are necessary? 

After all, the case of the pertussis outbreak in Floyd County, Virginia, which Mnookin mentions off-hand but doesn't delve into here (but does here), offers an excellent example of a vaccine-preventable disease outbreak that didn't happen that way. 

Floyd County is not an incredibly affluent area, and the people in that community clustered at a local, private "alternative" school largely shared values that made them avoid vaccination, so this was not an isolated segment of this community that avoided vaccination--the community was essentially made up of non-vaccinators. The disease ended up spreading to about 30 people and engaged a nearly immediate response from the health department, so there was no widespread confusion about what disease people had, causing surprised doctors and delayed diagnosis. Finally, all of those who contracted pertussis were unvaccinated, so the vaccinated child with a rare disorder that made her susceptible to disease was not present. And there were no fatalities. 

Other than perhaps the ideologies behind not vaccinating (it is unclear if environmental or backlash against the government or something else is why those parents did not vaccinate), this story differs at every turn from the story Mnookin relates here, which has a predictable, convenient narrative arc that has to end with an unvaccinated child getting sick. Not to say that that isn't a serious ramification of vaccine refusal or that it is necessarily incorrect much of the time.

But just as the case of Floyd County demonstrates, it isn't the case all of the time, making it possible that the telling and re-telling of this narrative is serving some other purpose, to reify the dangers of non-vaccination among vaccinating and non-vaccinating parents alike, creating a possible counter-narrative to vaccine safety arguments. After all, the vaccine choice that vaccine skeptics advocate isn't really possible in an environment where everyone is truly at risk, demonstrating the larger rhetorical purpose for the telling and re-telling of this narrative.

 

The Hazy World of Vaccine Messaging

After almost 3 years now of complete absorption into issues related to vaccination, it's no surprise that I continue to be fascinated and dumbfounded by the complexity of the rhetorical situation that occurs when a doctor must convince a new parent (or even an old one) that vaccines are the right course of action for protecting a child. The issue has been researched and studied and battled for hundreds of years, and as much as vaccines may be an "answer" to the scourge of small pox, polio, and measles, no "answer" has yet emerged that guarantees that vaccines will be accepted by the people they are intended to protect. I'm fascinated and in some ways encouraged that, in this case, a scientific discovery comes along quicker than a rhetorical one.

On Twitter (my new, sole connection to the outside world since I started writing my dissertation) today another piece of yet more confusing information about vaccine messaging rolled across my feed. This article in Scientific American reports on a study published in Health Psychology about the role that pro-vaccine messages play in convincing parents of vaccine efficacy and safety. 

The article states, in what seems like a completely counter-intuitive conclusion, that after participants were told to "imagine parenting an 8-month-old" (maybe a problematic scenario; I'd have to read the study to understand this, but couldn't they just have gotten participants who actually were parents of 8-month-olds?) and were told about a serious disease that the doctor wanted the parent to vaccinate against: "Those who were told there was no evidence for risk [from the vaccine] reported greater concern about vaccination and less intention to vaccinate their child than those who read the moderate messaging. The effect intensified when the messaging came from a perceived untrustworthy source, like a pharma company."

The conclusion the article draws is that a harder sell for the vaccine might produce the opposite effect, and so therefore a softer sell may be more effective. 

I have two thoughts: first, I have a lot of questions about the population/participants here, and I really wish I had time to find this study and give it a closer look. To imagine you're the parent of a baby, and then to imagine being told about a disease, and then to imagine how you might react to different ways of "selling" the vaccine constitutes a lot of imaginative leaps. I don't want to extrapolate too much on that without reading the full study, but I am really curious why they didn't ask actual parents of 8-month-olds. I also wonder whether they had a doctor, pediatrician, or a researcher present this scenario. Here, I'm thinking ethos: did the person seem concerned, did the person seem like an advocate for children, or did he/she seem disinterested? That could have played a role in how the "parent" interacted with the person delivering the information relative to disease perception and need for vaccination. 

Second, I don't think this is about hard/soft sells. I think the believability, in this case, has to be tied to trust in some way. Does anyone really think that any medical treatment comes with absolutely no risk? We are so engrossed in a culture and scientific reality now that knows about and accepts side effects as an expected part of any treatment, that it would strike me as suspect if someone told me that there were no risks rather than just some risks. 

In my Literature, Medicine, and Culture class a few weeks ago, we looked at commercials for Ambien, one from 2000 or 2001 and another from 2012. The list of side effects in the 2012 commercial takes up more airtime than the actual description of what the drug is supposed to help, and the list ranges from mild side-effects to ridiculous things (that have by now been well-publicized) like hallucinations and sleep walking. 

This expectation of risk may not stop us from being surprised or annoyed when we take a medication and it makes us sick in ways we weren't anticipating, but at the outset, I think I would feel lied to if a doctor told me there was absolutely no risk as a result from treatment, and that is particularly true with parents and vaccines. Even people who are pro-vaccine know that there are risks associated with the vaccination, even though they are rare when severe. 

So, again, I don't think this has to do with the "hardness" or "softness" of the information as presented. My sense is that it has more to do with believability, trust, and the logos at work here. If the participant feels liked to or deceived by being told that the vaccine carries no risks, then that person may be less likely to trust the related recommendation. But, if the speaker acknowledges the side effects and risks, then the appeal matches the expectation of risk, and the person feels leveled with, spoken to honestly. 

The inherent persuasiveness trust, even if risks are involved, may be more convincing than the imaginary notion of a risk-free world, or even a risk-free treatment.

Placebo/Nocebo/Bad(?) Science

Just a quick post today. Article to finish. Classes to plan. Dissertation to write.

Somehow through the snarl of articles and news and live-tweeting of random events that is Twitter, I've encountered two intersecting items of interest lately that I think warrant further discussion.

The first is this, a Ted Talk that I had somehow never heard of, by Ben Goldacre. Not only is Goldacre great to listen to (as are all Ted Talks, right? You're laughing, you're learning, it's all great fun), but he makes an excellent point about the fuzziness of science, particularly pharmaceuticals. I don't know that I actually realized before that pharmaceutical companies conduct trials not against existing treatments but against placebo. I agree with him--that doesn't seem right. If you're proposing an alternative drug, shouldn't you measure its effectiveness against the current recommendation? Even more problematic and ethically fuzzy is the idea that companies can skew the effectiveness and preferences for the drug by administering existing medications at the higher end of the recommended dosages, artificially increasing the incidents of side effects and adverse outcomes.

Goldacre ends on an interesting point, which reminded me of an article my friend Virginia sent me about a month ago on the "nocebo effect." We all know about the placebo effect--I take a sugar pill in a clinical trial, I feel better because my brain tells my body that it might be getting medicine that makes it feel better. It's an amazing phenomenon that, I agree with Goldacre, we almost take for granted. It is amazing how much the simple availability of medication skews our interpretations of our bodies so much. But lesser known is the nocebo effect, where people experience false side effects from sugar pills. So, the operation is the same but the outcome is different--I take a sugar pill in a clinical trial, and I feel worse because I think I'm experiencing the side effects of the medication.

I can't say much more than summary and awe for right now, but I do think the placebo/nocebo effects are worth some more study, and by rhetoricians in particular. The NYT article about the nocebo effect shows--as have many studies in rhetoric on the discourses of patients and doctors--that the ways that side effects are described situate the expectations of the patient in certain ways. If pain is downplayed, patients feel less pain; if it's emphasized, patients feel more. Certainly the rhetorics we're given, in clinical trials and in popular media, about the benefits and drawbacks of medications are affecting our own perceptions of health and pain as well as how medicine figures into maintaining or avoiding symptoms.