Weird question!

[leah]

------------

[A-Stark]

Personally opposed? Why? On the basis of what evidence? I have to seriously question your judgement if this is based on some spurious concern with the "toxicity" of trace amounts of ethyl mercury (which does not bioaccumulate) resulting from thimerosal-containing vaccines. Not only is there far, far more (methyl) mercury in your average can of tuna, but I suggest you do some proper research rather than coming with "personal" opposition to something that is standard, safe practice.

[NewfieMike]

Hi everyone,

 

I'm not really sure if this question belongs on these forums at all, but I'm not sure where else to ask. I figured primary care residents might know something about this...

 

I'm considering applying to med school and I would be most interested in going into either family medicine or pediatrics. I have one major concern, though. Obviously as a family doctor or pediatrician, I would be giving a lot of vaccines. Some vaccines (ex. the multidose flu and hep B vaccines) contain the preservative thimerosal (which contains mercury). I personally am very opposed to the use of thimerosal in vaccines, as I don't believe it's necessarily safe, and for ethical reasons I would never be able to administer a thimerosal-containing vaccine. As a resident or physician, would I have the ability to refuse to administer such vaccines? I know there are thimerosal-free versions of most if not all vaccines, but I don't think these are all readily available.

 

Or is it silly of me to consider med school when I am so opposed to the use of something the medical community asserts is safe?

 

Thanks in advance.

 

 

please elaborate.

[Ollie]

I would suggest you learn about the concept of evidence-based medicine and why we base policies and guidelines on evidence and not conjecture you read on the internet.

[leviathan]

If you want to be a physician you have to learn how to use evidence from research and the scientific method to guide your decision-making. This actually means you won't necessarily do certain things the way doctors have always known to be safe when there is evidence to suggest the contrary. However in the case of vaccines, there is no evidence to show any danger to the use of those vaccines containing thimerosal.

[hastin11]

Yes, it would be silly for you to consider medical school. In fact, if you want to guarantee that you are never admitted, try bringing that up in an interview. Maybe try naturopathy instead?

[cardiomegaly]

I'm going to use abortion as an example (in no way do I think the two are comparable)

 

If a doctor is against abortion, he or she is obligated to inform the patient of all the options and pros and cons. If patient wants said abortion you must refer them to a doctor who will treat them, even if you don't believe in it ethically.

 

Apply this to vaccines. If you are opposed to them;

you are still obligated to give full disclosure to your patient (without bias) and if they want the vaccine they have every right to get it. Does this mean you are so opposed you wouldn't write them a

prescription for the shot or even allow your nurses to administer it for you (I mean seriously doctors

rarely gives vaccinations). That's the bottom line

question I think you need to ask yourself. Most

doctors believe in the good value of vaccines so if you have an issue you might have other fundamental ethical disagreements with modern medicine.

[tooty]

Leah, can you pm me the papers that point to the harm of thimerosal? I found a few on pubmed but I'd like to read what you found.

[A-Stark]

I have done my research (looked at studies). Ethyl mercury does accumulate in the organs. I didn't want this to turn into a debate about thimerosal, so I'll leave it that. Thank you for your responses.

 

By all means, provide ONE study from a peer-reviewed journal showing this.

[hastin11]

I do respect how well the OP is taking the critical comments they are getting

[cheech10]

Ethyl mercury (and other alkyl mercury compunds) do accumulate in the brain and other organs, and do have a long half-life. There is no debate about this (see Goldfrank's Toxicologic Emergencies for more info). The issue is that the amount of these substances found in thimerosal-containing vaccines, is lower than the amount you get from eating fish, for example.

 

Thimerosal in vaccines is <15 mcg, of which 40% is ethyl mercury, or 6 mcg. The current safe limit for methyl mercury (found in fish, higher toxicity, and with a much longer half-life, months vs days) is 0.1 mcg/kg/day, or 7 mcg/day for an average person. Given that the compound is less toxic, and you don't get vaccinated daily, the mercury exposure is quite low.

 

Mark Geier's studies on this have been largely discredited, with accusations of scientific misconduct, and some of his papers have been retracted by the journals they were published in (a rare and severe form of censure). Very few toxicologists believe that there is any harm from thimerosal, and certainly the benefits of vaccination outweigh the risks of thimerosal. Many professional organizations have also come out with strong position statements supporting this stance. I would have no concern with giving out vaccines containing thimerosal.

[A-Stark]

I'll just post these here since A-Stark wants to see, too.

 

http://ehp03.niehs.nih.gov/article/fetchArticle.action?articleURI=info:doi/10.1289/ehp.7712

 

"The inorganic form of Hg was readily measurable in the brain of the thimerosal-exposed monkeys. The average concentration of inorganic Hg did not change across the 28 days of washout and was approximately 16 ng/mL. This level of inorganic Hg represented 21–86% of the total Hg in the brain (mean ± SE, 70 ± 4%), depending on the sacrifice time."

 

The others I found on pubmed...

 

http://www.ncbi.nlm.nih.gov/pubmed/804725

http://www.ncbi.nlm.nih.gov/pubmed/14698570

 

And what level of mercury exposure occurs in the absence of thimerosal exposure? Are you familiar with the concept of a dose-response curve?

 

Edited to add: I realize there is little scientific evidence that mercury from thimerosal, at the levels to which we are exposed via vaccines, actually produces harmful effects. However, I don't believe there is sufficient evidence to conclusively prove the contrary. I would not feel comfortable injecting even tiny amounts of an extremely toxic substance into another person. The idea that the benefits of vaccination (with thimerosal-containing vaccines) outweigh any potential risks is not a fact; it's a subjective issue that partly depends on the situation of the person receiving the vaccine. I am guessing that as a medical doctor, I would not be even be "allowed" to suggest to a patient that the thimerosal in a vaccine he or she is about to receive could potentially be harmful in any way.

 

It is not possible to "prove" a negative proposition. The overwhelming evidence shows no association between thimerosal exposure and any adverse effects. This isn't even an issue where the precautionary principle is relevant, since this preservative has been in use for decades without any evidence of toxicity at the levels used in vaccines.

 

Frankly, you don't get it and do not understand that all substances have distinct pharmacokinetics that imply levels of no effect whatsoever, therapeutic efficacy, and toxicity. Will you take the same illogical approach to the administration of narcotics, digoxin, neuroleptics, local anesthetics, inotropes, and any other kind of drugs?

 

It would be unethical to tell a patient that a thimerosal-containing vaccine could be harmful due to thimerosal for the precise reason that this is unsubstantiated, unsupported, and without any evidence to justify such a claim. Your duty is to the patient, not to your personal opinions.

 

For that matter, to suggest that the hypothetical - and repeatedly unsubstantiated - risk of thimerosal outweighs the benefits of protection from the likes of HBV shows an appallingly poor grasp of the most basic epidemiological and population health principles, combined with apparent ignorance of the sequelae of HBV infection, a virus which is transmitted parenterally at 100 times the rate of HIV.

[TheEggman]

1.http://ehp03.niehs.nih.gov/article/fetchArticle.action?articleURI=info:doi/10.1289/ehp.7712

2.http://www.ncbi.nlm.nih.gov/pubmed/804725

3.http://www.ncbi.nlm.nih.gov/pubmed/14698570

 

1. "Reports have indicated that infants can receive ethylmercury (in the form of thimerosal) at or above the U.S. Environmental Protection Agency guidelines for methylmercuryexposure,...

...The initial and terminal half-life of Hg in blood after thimerosal exposure was 2.1 and 8.6 days,...

...Brain concentrations of total Hg were significantly lower by approximately 3-fold for the thimerosal-exposed monkeys when compared with the MeHg infants...

...The results indicate that MeHg is not a suitable reference for risk assessment from exposure to thimerosal-derived Hg. Knowledge of the toxicokinetics and developmental toxicity of thimerosal is needed to afford a meaningful assessment of the developmental effects of thimerosal-containing vaccines."

 

-EtHg and MeHg are VERY different substances, the toxicity of EtHg is far lower than MeHg, they just use the MeHg guidelines for safety.

-Half life of 9 days means all of the Hg is gone in a month and a half. Very unlikely to cause chronic problems with a few vaccinations.

-Third part makes me think that EtHg has significantly reduced bioaccumulation.

-By keeping our current exposure levels based on MeHg we are probably being much safer than we need to be.

 

2. "Squirrel monkeys were dosed intranasally with saline or thiomersal (sodium ethylmercurithiosalicylate, 0.002 percent w/v) daily for six months....

...Mercury concentrations were significantly raised over control values in brain (high dose group only),...

...No evidence of toxicity due to thiomersal was seen in any animal. Nevertheless accumulation of mercury from chronic use of thiomersal-preserved medicines is viewed as a potential health hazard for man."

 

-Thats a lot of vaccinations, I think I would go see a new doctor if I got upwards of 180 vaccinations

-The high dose group got 2.28 mg over the course of the experiment, low dose got 0.418 mg, so you need a ton of it to start seeing any accumulation in the brain.

-Nice general safety statement at the end, but NO toxicity in animals getting daily exposure to high levels? Sounds pretty innocuous.

 

3. "The potency of 10 microM thimerosal to increase the [Ca2+]i was less than that of 10 microM methylmercury...

...Results indicate that thimerosal exerts some cytotoxic actions on cerebellar granule neurons dissociated from 2-week-old rats and its potency is almost similar to that of methylmercury."

 

-I'll keep this in mind the next time I pull out my brain, slice it into sections and bathe it in 10 uM thimerosal. Yes it is probably slightly cytotoxic, but based on the above studies there is basically none of it floating around in the brain at vaccination exposure levels.

 

Based on the fact that thimerosal can't really be seen to do much if any harm whereas there are debilitating diseases caused by viruses that are easily vaccinated against, the benefits for vaccination far outweigh any harm from thimerosal exposure.

 

Pretty much everything in medicine is going to have some pros and cons. Every drug on the market is potentially a toxic substance you are introducing into your patient and any surgery is a dangerous procedure. Every decision is a cost benefit analysis based on scientific evidence. Acting on personal feelings about the potential toxicity of something with little scientific evidence to back up those feelings has the potential to cause suffering to a patient. Patients need to be told the facts about any treatment, but those facts should not include unsupported personal opinions.

[national]

i love how some of the people on this website are willing to instantly proclaim that someone is unfit for medicine, and their signature inevitably contains the grad year 2013 or thereabouts. these people also seem to enjoy telling us, definitively, the "realities" of medicine (surgeons are always like this, family medicine is useless, etc etc). humility counts for something you know.

 

having a rationed, researched opinion doesn't make you unfit. questioning "common" knowledge is a damn fine trait for a physician to have. far too often we just go with the flow and conform to the confines of the profession. i do appreciate the sensible tone of your debate, even though some people here just enjoy talking down to you. med students are like that.

 

that being said, i disagree with your opinion (as does the majority of medical research) and as someone before pointed out with the example of providing aboritons, you would almost certainly have to put aside some of these concerns if you want to practice modern medicine. not providing vaccinations, and actively advising against them would fly in the face with current professional standards and evidence.

 

someone else pointed out that perhaps you'd be interested in an alternative health career. it's worth checking out. though for all we know, you could end up being one of the most competent MDs in the world.

[A-Stark]

Thank you I appreciate that.

 

My opinion of thimerosal is not based on nothing but personal feelings. It's based on the evidence we have that it does accumulate in the organs, that mercury is highly toxic (neurotoxic, etc.), and that a large number of children with autism, whose primary source of exposure to mercury was vaccines, have been essentially cured with mercury chelation. I am not extremely knowledgeable in the sciences (I only became interested in science and health relatively recently), but I know some people who are and who hold the same opinion (ex. Andrew Hall Cutler, PhD).

 

We don't know all there is to know. If every doctor sets out just to prove the generally accepted beliefs, we'll never make any progress.

 

Take care, everyone.

 

In other words, you're ignorant, misinformed, and justify your baseless opinion by an argument of authority. Not only has there never been any kind of association shown between autism and ANY vaccine, you are propagating a very dangerous kind of nonsense that increases morbidity in the population via declining rates of vaccination.

 

And, no, I am not setting out the "talk down" to you or talk about the "realities" of medicine. My signature doesn't have anything to do with this. I invite you to further do some further PubMed searches (ideally with no articles from 1975) or better yet look for Cochrane reviews supporting your views. Or perhaps read about the Lancet's retraction of Wakefield's paper.

 

If mercury chelation "cured" autism patients, don't you think this would be standard practice by now? Or is it just some big conspiracy?

[mavrik13]

Hopefully your view will change in the future. The backbone of the medical field is evidence based medicine. EBM dictates not only that receiving a vaccine is safer in terms of mercury poisoning than eating a tuna sandwich, they save thousands of lives by preventing infectious diseases.

 

You mention the connection between vaccinations and ASD. Here is a systematic review exploring MMR vaccinations and ASD: http://archpedi.ama-assn.org/cgi/content/abstract/157/7/628 - The scientific literature clearly states that the pros outweigh the cons. In fact, studies indicating a potential link between vaccinations and ASD have even been retracted from the literature: http://www.theglobeandmail.com/life/health/study-that-linked-autism-and-vaccinations-retracted/article1454629/.

 

The main reason for public misconception that there is a link between vaccinations and ASD is that ASD develops around the same time that vaccinations are administered. There is no causal evidence to link vaccinations and ASD, but there is a clearly causal evidence between not getting MMR vaccinations and the development of measles, mumps, or rubella and their associated consequences (acute illness, long term disability, and death).

 

How this all relates to ones duty as a physician is to inform the public and/or patient in an unbiased manner. While you are entitled to your feelings and opinions (physicians are not to be robots), ethically you cannot attempt to dissuade the public from receiving vaccinations. The situation of abortions applies here as a (slightly extreme) example.

[Cnussey]

In other words, you're ignorant, misinformed, and justify your baseless opinion by an argument of authority. Not only has there never been any kind of association shown between autism and ANY vaccine, you are propagating a very dangerous kind of nonsense that increases morbidity in the population via declining rates of vaccination.

 

And, no, I am not setting out the "talk down" to you or talk about the "realities" of medicine. My signature doesn't have anything to do with this. I invite you to further do some further PubMed searches (ideally with no articles from 1975) or better yet look for Cochrane reviews supporting your views. Or perhaps read about the Lancet's retraction of Wakefield's paper.

 

If mercury chelation "cured" autism patients, don't you think this would be standard practice by now? Or is it just some big conspiracy?

 

Take two autistic children and have one given vaccines from birth and the other none and they'll STILL be autistic--problem is, you don't notice autism until they start skipping milestones (about the same time as the vaccines) unless you actually know what to look for.

 

In the autism community, a lot of parents actually associate autism (which seems to prevail in males? Someone can correct me if I'm wrong) with a trauma during the mother's pregnancy, such as death of a family member.

[cardiomegaly]

I wouldn't say most, maybe a small minority. Depends on the perspective of the parent. You'd be surprised how many very well educated couples end up having autistic kids.

Autism is a spectrum disorder so you will have kids that are autistic for no apparent reason, families

With 3 autistic kids, autistic kids who improve dramatically after being put of a gluten free diet, kids who improve after mercury chelation therapy (though I feel like that's more rare).

 

Cnussey is right - autism starts showing around the time of vaccinations and because of idiot celebrities like Jenny McCarthy, people will always fear that vaccinations gave their children autism.

 

I think it's absolute bull****. The reason why more kids are being diagnosed with autism is because people are more aware of it, they pick up on the signs sooner and doctors will diagnose it more often. Prevalence is close to 1/100. But remember it's a spectrum - some autistic kids are fully functional and can learn to be independent while others will need help for the rest of their lives.

[Mourning Cloak]

I personally am very opposed to the use of thimerosal in vaccines, as I don't believe it's necessarily safe, and for ethical reasons I would never be able to administer a thimerosal-containing vaccine. As a resident or physician, would I have the ability to refuse to administer such vaccines?

 

This is easy. Medicine is full of these things called "standards of care". A standard of care is the expected level of performance that you are required to meet (by law), given that you are a physician working in a given situation. Our Canadian template for the standard of care for babies is the "Rourke Baby Record". In terms of vaccination, the Rourke refers to our national vaccine guidelines (found on the Health Canada website): http://www.phac-aspc.gc.ca/publicat/cig-gci/. These are also referenced by the Canadian Paediatric Society and the College of Family Physicians of Canada.

 

Germane to the conversation are the recommended immunizations (I post children but they exist for other age groups / circumstances as well).

http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-01-eng.php

This does not, of course, apply in situations where the vaccine is obviously contraindicated (e.g. allergies).

 

Long story short, if you do not meet these standards (either due to ignorance, carelessness or whatever), or so advise your patients, you will be failing to meet the minimum standard of care*. At the minimum, this is a serious breach of your responsibilities as a physician. Worse case scenario (harm results), you can & will be sued for malpractice, and won't have a leg to stand on.

*This, of course, does not apply in situations where you are dealing with parents who refuse to permit vaccination (DOCUMENT DOCUMENT DOCUMENT!) The Canadian Paediatric Society has a nice little collection of papers and pamphlets, including information for parents, skills training to aid MDs in becoming more effective advocates for immunization and so forth: http://www.cps.ca/English/HealthCentres/immunization.htm

 

For the OP, if you are entirely opposed to vaccination, then it would probably be advisable to plan to avoid fields where your professional duties might come into conflict with your life philosophy (e.g. family medicine, pediatrics, internal medicine, OB-GYN, possibly surgical fields & ER - the plastics guy I shadowed ordered a hell of a lot of tetanus vaccine prior to sewing up clumsy farmers in the ER.) You most likely will be required to vaccine children during family medicine rotations (although it's unlikely during other rotations), and to refuse (as a clerk or resident) would certainly not endear you to your preceptors. However, there are provinces where routine childhood vaccinations are done by public health (not by family physicians), and if you happen to be accepted into med school in one of these, a conflict is less likely to arise.

[bloh]

Thank you I appreciate that.

 

My opinion of thimerosal is not based on nothing but personal feelings. It's based on the evidence we have that it does accumulate in the organs, that mercury is highly toxic (neurotoxic, etc.), and that a large number of children with autism, whose primary source of exposure to mercury was vaccines, have been essentially cured with mercury chelation. I am not extremely knowledgeable in the sciences (I only became interested in science and health relatively recently), but I know some people who are and who hold the same opinion (ex. Andrew Hall Cutler, PhD).

 

We don't know all there is to know. If every doctor sets out just to prove the generally accepted beliefs, we'll never make any progress.

 

Take care, everyone.

 

But your evidence is misled. In fact, the NEJM paper that started all this nonsense was officially retracted publicly not so long ago.

 

You are certainly welcome to have your objections in medicine and are allowed to give opinions as long as they aren't based on purely personal grounds. The best example is abortion:

 

1. You may refuse to do abortions

2. But you must educate your patient without personal bias and you must provide the patient another avenue to get said abortion.

 

The attitude that you have portrayed here, even among all the negative feedback from your future colleagues, is very disconcerting. That is something that has no place in medicine.

[cardiomegaly]

Mourning cloak that was a brilliant post

 

To the OP: only you can decide if medical school is for you. I would only suggest that you have a good understanding of your own values ad how that might affect the quality of care you can deliver to your patients. We don't have to all agree with every aspect of medicine. Imagine if you were a vegan doctor. Pretty sure they won't choose to be a cardiac surgeon and implant pig valves into their patients. Or if you're a strict Catholic who doesn't believe in ivF, don't do obs gyn. There are some

Doctors who are opposed to

The use of contraception too.

 

Just figure out if the fundamental values of modern western medicine are ok with you. Honestly there are some decent naturopathic schools in the US. I'm not saying don't be a doctor, just don't be an unhappy doctor who doesn't agree with what the standards of Care and evidence based medicine dictate

[Methodnike]

I'll just post these here since A-Stark wants to see, too.

 

http://ehp03.niehs.nih.gov/article/fetchArticle.action?articleURI=info:doi/10.1289/ehp.7712

 

"The inorganic form of Hg was readily measurable in the brain of the thimerosal-exposed monkeys. The average concentration of inorganic Hg did not change across the 28 days of washout and was approximately 16 ng/mL. This level of inorganic Hg represented 21–86% of the total Hg in the brain (mean ± SE, 70 ± 4%), depending on the sacrifice time."

 

The others I found on pubmed...

 

http://www.ncbi.nlm.nih.gov/pubmed/804725

http://www.ncbi.nlm.nih.gov/pubmed/14698570

 

 

Edited to add: I realize there is little scientific evidence that mercury from thimerosal, at the levels to which we are exposed via vaccines, actually produces harmful effects. However, I don't believe there is sufficient evidence to conclusively prove the contrary. I would not feel comfortable injecting even tiny amounts of an extremely toxic substance into another person. The idea that the benefits of vaccination (with thimerosal-containing vaccines) outweigh any potential risks is not a fact; it's a subjective issue that partly depends on the situation of the person receiving the vaccine. I am guessing that as a medical doctor, I would not be even be "allowed" to suggest to a patient that the thimerosal in a vaccine he or she is about to receive could potentially be harmful in any way.

I appreciate that you posted studies.

However, these are old and outdated. As per my 2009 notes from variable sources, all vaccines are now thimerosal free. (one of them being the Kaplan lectures notes for Step 2 CK)

[Mourning Cloak]

I just saw this message after my last post. Thank you for an actually helpful reply!! This is what I needed to know.

 

You're welcome!

 

It sounds like you're really interested in medicine and particularly primary care. If you don't mind advice off-topic, I would suggest not trying to make this decision right now. You have lots of time to think about how to reconcile your personal beliefs and the expectations of the medical profession - you don't need to rule anything in or out yet.

 

If I were in your position, I think I'd focus on getting my undergrad degree and going through the application process - it's a long process, and lots of things can change over the years. If you really think family medicine is for you, you can revisit this question when you are accepted into medical school, at which point you can get professional advice (e.g. ethical / legal / spiritual) from the MDs who populate the undergrad office. You wouldn't be the first medical student who had a crisis of conscience

 

In summary:

Yes, there are specific standards that the medical profession expects its members to uphold, but on the other hand, you never know what the future has in store. Maybe, in time, this conflict might resolve itself.

[Starling]

Just figure out if the fundamental values of modern western medicine are ok with you. Honestly there are some decent naturopathic schools in the US.

 

I did some shadowing in a family practice clinic that, in addition to family docs and the odd specialist, had an ND. From what I saw, she typically saw patients with minor complaints (things that could be helped by changes in nutrition, vitamins, lifestyle changes etc.) and did preventative-type stuff. It all seemed quite non-flakey, and there was mutual respect between her and the MDs. If you're interested in primary care but leery about aspects of modern medicine, maybe something like that could be the way to go? I totally don't know anything about naturopathy (and it's not something I'd personally be interested in), just sharing my limited observations.

[astrogirl]

Another option for you might be to only offer thimerosal-free versions of vaccines, which would actually be a really good way to get some kids vaccinated whose parents would otherwise object. And by the time you get to that point, it might not even be an issue anymore since there might not be thimerosal in any vaccines by then. Like Mourning Cloak said, I think you should keep your options open and don't close any doors just yet, especially if this is your only big issue.