A Tamiflu Rx question for my prescribing colleagues

[fls]

You are really reading into this things that are not there.Have you never bounced ideas and feelings about your practice off your colleagues? Does it always have to be a cross examination to re ask a question emphasizing a particular part of it?

Why did you choose to see this as a cross examination? That is the hostility I am talking about.

Um...I didn't actually realize that "cross examination" was a bad word.

You've made false assumptions. The thread title tells you what I wanted to discuss. There is a legit dilemma here. If I just wanted to rant about stupid providers who missed another chance to save a life with Tamiflu, that's what I would have made the thread about.

I'm trying to reconcile the CDC guideline with my practice. I've pointed out the shortcoming of not being very clear about what constitutes a serious case. I want to discuss it with other people and explore what they think about the situation.

I got that part.

That's out of context.

Does everyone assess 'severe enough to prescribe Tamiflu' the same? Is assessing what constitutes severe disease within the first 48 hours the same as recognizing what more clearly might be severe disease in general?

That's what I was asking whether you were asking.

I can't believe you are seriously asking for documentation that health care workers, like much of the rest of the population, believe in myths about influenza infection and vaccine.

My question was referring to the statement that immediately preceded my question (sorry that was confusing)..."the number of health care providers, physicians and nurses alike, who tell their patients flu vaccine is not safer than flu..."

Here are some very specific findings from a number of studies supporting the opinions I have expressed here.

Immunization policies in Canadian medical schools.

That seems to be a different issue. This was actually my undergrad research project (whether colleges should implement mandatory requirements), and the issue isn't whether anyone thinks vaccination is useful, but rather to what extent public health can/should mandate recommendations.

Influenza vaccination in paediatric nurses: cross-sectional study of coverage, refusal, and factors in acceptance.

Influenza vaccination among primary healthcare workers.

Factors affecting influenza vaccine uptake among health care workers.

Yes, I realize that uptake is variable and generally much lower than the ideal. I was interested in the specific bit of misinformation that you know to be in common use - doctors and nurses who tell people that the flu is safer than the flu vaccine.

In addition to what I addressed about this already, it is rather idealistic to think one's experiences with certain significant cases do not affect one's practice. Pediatric deaths have a huge impact on most providers.

I agree. I'm just pointing out that it will be a tiny minority of providers who have that particular experience, so it would be odd to expect most providers to act as though they had had that experience (if we are going with the idea that it is reasonable to look to one's own experience to guide one's behaviour).

I'm sorry if you are having a bad week.

I was telling you that I was having a good week. I thought you would recognize that getting a response from a teacher, especially if one had not been previously forthcoming, is a good thing.

I think you are one of the nicest posters on the forum and I love your sense of humor. But you do seem annoyed in this thread.

Oh I am. I am way pissed off.

Linda

 

[Skeptic Ginger]

Um...I didn't actually realize that "cross examination" was a bad word.

It was a discussion, not a cross examination.

My question was referring to the statement that immediately preceded my question (sorry that was confusing)..."the number of health care providers, physicians and nurses alike, who tell their patients flu vaccine is not safer than flu..."

Are you suggesting the health care providers who refuse vaccine for themselves because of their beliefs about flu vaccine are going to tell their patients the opposite?

The literature suggests most health care providers advise their elderly and high risk patients to get flu shots. But that is not the case for providers recommending vaccine to children and pregnant women.

My experience:
I give 1,000-1,500 flu shots every year mostly to health care workers and have for about 18 years. Every year I hear over and over about doctors who've told their patients they don't need flu vaccinations, and in fact, the doctor would not risk getting one themselves. The studies I looked at did show a higher rate of physician vaccinations than other categories of health care workers. And I realize patients rationalize their decisions with fake reasons like claiming a doctor told them something when in fact that was not true. However, studies of why patients in whom vaccine is recommended don't get vaccinated suggest there is some truth to it.

We know how low the rates are among health care workers getting their own flu vaccinations: 2009-10 Influenza Prevention & Control Recommendations
Influenza Vaccination Coverage Levels

national survey data demonstrated a vaccination coverage level of only 42% among HCP during the 2005--06 season, and 44% during the 2006--07 season (Table 3).

It is higher for physicians as a group

And while self report physician surveys show flu vaccine recommendations are consistently high, when you look at patient outcomes, the rate of vaccine coverage for younger patients is very low. It is even lower for pregnant women.

Self-reported influenza vaccination coverage trends 1989 - 2008 among adults by age group, risk group, race/ethnicity, health-care worker status, and pregnancy status, United States, National Health Interview Survey (NHIS)


From the first link above:

Studies conducted among children and adults indicate that opportunities to vaccinate persons at risk for influenza complications (e.g., during hospitalizations for other causes) often are missed. In one study, 23% of children hospitalized with influenza and a comorbidity had a previous hospitalization during the preceding influenza vaccination season. In a study of hospitalized Medicare patients, only 31.6% were vaccinated before admission, 1.9% during admission, and 10.6% after admission. A study in New York City conducted during 2001--2005 among 7,063 children aged 6--23 months indicated that 2-dose vaccine coverage increased from 1.6% to 23.7% over time; however, although the average number of medical visits during which an opportunity to be vaccinated decreased during the course of the study from 2.9 to 2.0 per child, 55% of all visits during the final year of the study still represented a missed vaccination opportunity. Using standing orders in hospitals increases vaccination rates among hospitalized persons, and vaccination of hospitalized patients is safe and stimulates an appropriate immune response. In one survey, the strongest predictor of receiving vaccination was the survey respondent's belief that he or she was in a high-risk group, based on data from one survey; however, many persons in high-risk groups did not know that they were in a group recommended for vaccination.

Now why would that be if providers were advising their patients to get flu vaccinations?

Well let's see:

As has been reported for older adults, a physician recommendation for vaccination and the perception that having a child be vaccinated "is a smart idea" were associated positively with likelihood of vaccination of children aged 6--23 months. Similarly, children with asthma were more likely to be vaccinated if their parents recalled a physician recommendation to be vaccinated or believed that the vaccine worked well.

Seems to suggest not enough recommendations are forthcoming. Perhaps physicians who answer surveys about their advice to patients may not represent the actual percentage of recommendations occurring.

And in OBGYN clinics:

In a study of influenza vaccine acceptance by pregnant women, 71% of those who were offered the vaccine chose to be vaccinated. However, a 1999 survey of obstetricians and gynecologists determined that only 39% administered influenza vaccine to obstetric patients in their practices, although 86% agreed that pregnant women's risk for influenza-related morbidity and mortality increases during the last two trimesters.

So obstitricians know the flu risk is there yet don't offer vaccine in their own clinics? Perhaps this needs to be explored. I would hypothesize the tradition of fearing vaccines could do fetal harm despite the research flu vaccine is safe in pregnancy is playing a role here. Perhaps you have another hypothesis?

That seems to be a different issue. This was actually my undergrad research project (whether colleges should implement mandatory requirements), and the issue isn't whether anyone thinks vaccination is useful, but rather to what extent public health can/should mandate recommendations.

At those same institutions, other vaccines were recommended or required in greater numbers. Only flu vaccinations had such a low priority.

Yes, I realize that uptake is variable and generally much lower than the ideal. I was interested in the specific bit of misinformation that you know to be in common use - doctors and nurses who tell people that the flu is safer than the flu vaccine.

Clearly you doubt health care providers are part of the problem. You seem to prefer the default position that my experience listening to health care workers' anti-flu-vaxer beliefs for 18 years has led me to make false assumptions about health care workers' beliefs about influenza vaccinations.

I agree. I'm just pointing out that it will be a tiny minority of providers who have that particular experience, so it would be odd to expect most providers to act as though they had had that experience (if we are going with the idea that it is reasonable to look to one's own experience to guide one's behaviour).

That amazes me. I would think almost any health care provider, especially one with decision making responsibilities, who has had a decade or more of experience would have had a number of practice altering events occur. I've had many in my 33 years of practice.

Oh I am. I am way pissed off.

Linda

And a tad defensive.

 

[fls]

It was a discussion, not a cross examination.

Okay.

Are you suggesting the health care providers who refuse vaccine for themselves because of their beliefs about flu vaccine are going to tell their patients the opposite?

I'm just wondering how you get from "don't need flu vaccine" to "flu vaccine is not safer than the flu".

The literature suggests most health care providers advise their elderly and high risk patients to get flu shots. But that is not the case for providers recommending vaccine to children and pregnant women.

My experience:
I give 1,000-1,500 flu shots every year mostly to health care workers and have for about 18 years. Every year I hear over and over about doctors who've told their patients they don't need flu vaccinations, and in fact, the doctor would not risk getting one themselves. The studies I looked at did show a higher rate of physician vaccinations than other categories of health care workers. And I realize patients rationalize their decisions with fake reasons like claiming a doctor told them something when in fact that was not true. However, studies of why patients in whom vaccine is recommended don't get vaccinated suggest there is some truth to it.

So you don't actually know whether or not doctors and nurses tell patients that the flu vaccine is not safer than the flu, let alone the numbers.

From the first link above:Now why would that be if providers were advising their patients to get flu vaccinations?

To answer that, you would also need information on the amount and kind of opportunities for this information to be conveyed, and on the proportion of messages which are recalled. I imagine that some of the people in that survey saw a provider under circumstances where that message could have been conveyed. And I imagine that some proportion of those people would recall that message. Of course, there's no way to guess at that number from the link you provided.

Well let's see:Seems to suggest not enough recommendations are forthcoming. Perhaps physicians who answer surveys about their advice to patients may not represent the actual percentage of recommendations occurring.

It shouldn't be a surprise that the numbers are different. One will be based on what the physician said, and one will be based on patient recall of what the physician said. We already know that there's a large disparity between the two. If you use two entirely different ways of measuring, you should expect that they won't necessarily be comparable.

And in OBGYN clinics:So obstitricians know the flu risk is there yet don't offer vaccine in their own clinics? Perhaps this needs to be explored. I would hypothesize the tradition of fearing vaccines could do fetal harm despite the research flu vaccine is safe in pregnancy is playing a role here. Perhaps you have another hypothesis?

I usually leave 'making stuff up to fill in the gaps' to others.

At those same institutions, other vaccines were recommended or required in greater numbers. Only flu vaccinations had such a low priority.

Which makes sense if you think about it. Most of those recommendations will reflect institutional requirements, rather than the efforts of individual departments. And it is relatively easy for institutions to implement a mandatory requirement for something like MMR, as each student can be captured at registration. That wouldn't work for influenza. So in addition to the possible lack of a precedent (i.e. individual departments charged with developing and implementing their own policies as opposed to the institution), an inability to implement the policy would also discourage it.

Clearly you doubt health care providers are part of the problem. You seem to prefer the default position that my experience listening to health care workers' anti-flu-vaxer beliefs for 18 years has led me to make false assumptions about health care workers' beliefs about influenza vaccinations.

I don't know why you decided that I doubt health care providers are part of the problem. It doesn't help your claim that you don't make false assumptions if you start off your paragraph with a false assumption.

That amazes me. I would think almost any health care provider, especially one with decision making responsibilities, who has had a decade or more of experience would have had a number of practice altering events occur. I've had many in my 33 years of practice.

Odd. I refer to the particular kind of experience that we have been talking about all along - the death of a healthy teenager. Yet you answer as though we have been talking about any practice altering event. Unless you meant that you have had this particular experience a number of times, in which case I change my characterization to "scary".

And a tad defensive.

Oh yes. That too.

Linda

 

[Skeptic Ginger]

...I'm just wondering how you get from "don't need flu vaccine" to "flu vaccine is not safer than the flu".

Both lines of thought are a recurring theme in health care worker reports of why they choose not to get flu vaccine. With the recommendation health care workers receive the new 2009H1N1 I've had increased reports of health care workers believing the vaccine is unsafe.

...So you don't actually know whether or not doctors and nurses tell patients that the flu vaccine is not safer than the flu, let alone the numbers.

It's your prerogative to say my experience counts for nothing.

I teach health care workers infection control and infectious disease hazards. Students tell you their beliefs. It led to my joining this community. I was dealing with bad medicine beliefs on a daily basis as a barrier to improving worker safety when I heard Phil Plait on the radio talking about bad astronomy. I contacted him, joined his forum community and eventually found this community.

In my position I talk with health care workers specifically about their health care beliefs. So we aren't talking about a couple anecdotes here, we are talking about 20 years of experience which includes dealing specifically with health care worker beliefs about influenza and influenza vaccine both in teaching them about infectious disease safety and in giving the vaccine and developing influenza vaccine programs geared to increasing worker acceptance of the vaccine.

I know for a fact the research backs up my observations. I have read lots of it. It's my job to try to turn superstitious health care workers into science evidence based health care workers. To do that you look at lots of studies about why people believe bad medicine.

I posted some of the studies on influenza vaccine beliefs for you. You haven't seen enough research, fine, go look for more. But don't play this game with me like I'm some little twit who has drawn conclusions from a couple anecdotes. I'm drawing conclusions from 20 years in a medical specialty. That means observing, but also reading related literature on a regular basis.

...To answer that, you would also need information on the amount and kind of opportunities for this information to be conveyed, and on the proportion of messages which are recalled. I imagine that some of the people in that survey saw a provider under circumstances where that message could have been conveyed. And I imagine that some proportion of those people would recall that message. Of course, there's no way to guess at that number from the link you provided.

I won't be writing a thesis here. I posted enough for this discussion. If you aren't convinced, that's fine.

...It shouldn't be a surprise that the numbers are different. One will be based on what the physician said, and one will be based on patient recall of what the physician said. We already know that there's a large disparity between the two. If you use two entirely different ways of measuring, you should expect that they won't necessarily be comparable.

Gee, I never knew that.

You are cherry picking the data and not looking at the whole picture. It's one thing if a few patients cannot recall what was said to them by their doctor. It's quite another when the data ties lack of physician communication to a patient outcome.

Even if lots of doctors were telling their patients they needed flu shots and the patients were hearing something else, you would think the medical community would notice the communication was ineffective. If doctors thought flu vaccine was important, they should be working on better means of communicating that to their patients and looking for an increase in vaccine uptake as an indicator they were improving patient outcomes. Progress is very slow in this area.

..I usually leave 'making stuff up to fill in the gaps' to others.

Well I usually look at patient outcomes to measure the effectiveness of care. You don't' seem to be suggesting any alternative hypothesis for the poor vaccine uptake in this group. Do you think OBGYNs are taking action to correct the problem? Or do you think perhaps they don't see it as a problem at all? Low priority?

...Which makes sense if you think about it. Most of those recommendations will reflect institutional requirements, rather than the efforts of individual departments. And it is relatively easy for institutions to implement a mandatory requirement for something like MMR, as each student can be captured at registration. That wouldn't work for influenza. So in addition to the possible lack of a precedent (i.e. individual departments charged with developing and implementing their own policies as opposed to the institution), an inability to implement the policy would also discourage it.

What that says is the medical school administration puts a low priority on the benefit of influenza vaccination. And that attitude is reflected in the staff as well as rubbing off on the students.

Are you aware of the hospital battles here in the US trying to make mandatory flu vaccinations in patient care areas? Our hospital accreditation organization has taken the stand that protecting patients from infection requires staff to get flu shots. If you can require employees to wash their hands and get TB skin tests, you can require employees to get flu shots. The health care workers are in a tizzy over it.

One need merely compare hepatitis B vaccine and MMR vaccine compliance in health care workers to the reaction you get when you discuss flu vaccinations to see there is a problem here with underlying health care worker beliefs both with influenza and the vaccine.

..I don't know why you decided that I doubt health care providers are part of the problem. It doesn't help your claim that you don't make false assumptions if you start off your paragraph with a false assumption.

..Odd. I refer to the particular kind of experience that we have been talking about all along - the death of a healthy teenager. Yet you answer as though we have been talking about any practice altering event. Unless you meant that you have had this particular experience a number of times, in which case I change my characterization to "scary".

Not just the death of a healthy teen, Linda. An avoidable death. A death which would not have occurred if different decisions were made about the care.

Such events happen. If you work long enough, they probably happen to a good many of us. You make the best decisions you can. But when your decisions if different would have prevented a healthy teen from dying, you cannot help but re-examine your practice decisions. You may decide to continue the same practices. But I believe most providers would be very likely to lower their threshold for what constituted, sick enough to get Tamiflu, in the next pediatric patient.

 

[Puppycow]

Re the OP, I think you did the right thing. Better safe than sorry.

 

[fls]

Both lines of thought are a recurring theme in health care worker reports of why they choose not to get flu vaccine. With the recommendation health care workers receive the new 2009H1N1 I've had increased reports of health care workers believing the vaccine is unsafe.

If both lines of thought are present, then wouldn't it be reasonable to present the evidence for the thought that I specifically asked you about instead of the other line of thought?

It's your prerogative to say my experience counts for nothing.

I'm not saying that your experience counts for nothing. It's that you didn't describe the kinds of experiences that I would be looking for when attempting to consider your claim. Rather than describing the beliefs of those doctors and nurses who are primarily responsible for ensuring that targeted groups get vaccinated, you described second and third-hand reports from patients. Then you described the beliefs of some health care workers without any indication of what proportion, if any, represented the group we are talking about. You also did not describe what steps you have taken to avoid the biases that will creep in when our conclusions are based on recollection of personal experiences, including attempts to estimate prevalence on the basis of whether one can readily think of an example.

I teach health care workers infection control and infectious disease hazards. Students tell you their beliefs. It led to my joining this community. I was dealing with bad medicine beliefs on a daily basis as a barrier to improving worker safety when I heard Phil Plait on the radio talking about bad astronomy. I contacted him, joined his forum community and eventually found this community.

In my position I talk with health care workers specifically about their health care beliefs. So we aren't talking about a couple anecdotes here, we are talking about 20 years of experience which includes dealing specifically with health care worker beliefs about influenza and influenza vaccine both in teaching them about infectious disease safety and in giving the vaccine and developing influenza vaccine programs geared to increasing worker acceptance of the vaccine.

'Health Care Worker' describes a pretty diverse group of people with a diverse set of requirements as to knowledge. When you talk about a group of those workers who are naive when it comes to influenza and vaccines, it strikes me that this group will mostly not consist of primary health care providers, who should already have some knowledge and experience with vaccines.

I know for a fact the research backs up my observations. I have read lots of it. It's my job to try to turn superstitious health care workers into science evidence based health care workers. To do that you look at lots of studies about why people believe bad medicine.

I posted some of the studies on influenza vaccine beliefs for you. You haven't seen enough research, fine, go look for more. But don't play this game with me like I'm some little twit who has drawn conclusions from a couple anecdotes. I'm drawing conclusions from 20 years in a medical specialty. That means observing, but also reading related literature on a regular basis.

Which is why I thought asking you for the relevant information would be the easiest way to get to it.

I won't be writing a thesis here. I posted enough for this discussion. If you aren't convinced, that's fine.

Is that really an appropriate response? If you are complaining about writing too much, wouldn't it make sense to provide the most relevant information, rather than information which doesn't really answer the question that was asked?

Gee, I never knew that.

You are cherry picking the data and not looking at the whole picture. It's one thing if a few patients cannot recall what was said to them by their doctor. It's quite another when the data ties lack of physician communication to a patient outcome.

Even if lots of doctors were telling their patients they needed flu shots and the patients were hearing something else, you would think the medical community would notice the communication was ineffective. If doctors thought flu vaccine was important, they should be working on better means of communicating that to their patients and looking for an increase in vaccine uptake as an indicator they were improving patient outcomes. Progress is very slow in this area.

But this would be important to know. If one simply assumed, based on poor patient recall, that the patients were not being told, and if one assumed that the patients were not told because the doctors didn't believe in the efficacy of the vaccine, efforts to redress that problem would be directed at changing physician beliefs. But those efforts would be useless, if it was discovered that all those assumptions were wrong, and what was really needed was improved communication. This is why I am reluctant to make assumptions without some sort of evidence to indicate that I am on the right path.

Well I usually look at patient outcomes to measure the effectiveness of care. You don't' seem to be suggesting any alternative hypothesis for the poor vaccine uptake in this group. Do you think OBGYNs are taking action to correct the problem? Or do you think perhaps they don't see it as a problem at all? Low priority?

I don't know.

What that says is the medical school administration puts a low priority on the benefit of influenza vaccination. And that attitude is reflected in the staff as well as rubbing off on the students.

This is the sort of thing I'm talking about. You have elected to make a series of assumptions from something that simply seems to reflect a normal administrative hierarchy - implicating all sorts of beliefs and motivations for which there is no evidence. I don't want to do that.

Are you aware of the hospital battles here in the US trying to make mandatory flu vaccinations in patient care areas? Our hospital accreditation organization has taken the stand that protecting patients from infection requires staff to get flu shots. If you can require employees to wash their hands and get TB skin tests, you can require employees to get flu shots. The health care workers are in a tizzy over it.

One need merely compare hepatitis B vaccine and MMR vaccine compliance in health care workers to the reaction you get when you discuss flu vaccinations to see there is a problem here with underlying health care worker beliefs both with influenza and the vaccine.

Like I said, I am aware that uptake is generally much lower than ideal. It seems to me that this reinforces the idea that it is better to fully understand why, than to act upon assumptions and waste resources on efforts that are ineffective.

Not just the death of a healthy teen, Linda. An avoidable death. A death which would not have occurred if different decisions were made about the care.

Such events happen.

Again, what is the point of shifting the goalposts here? Are you suggesting that any avoidable death, even those completely unrelated to influenza in a teen, will have the effect of altering a health care providers estimate of the severity of influenza? Really?

If you work long enough, they probably happen to a good many of us. You make the best decisions you can. But when your decisions if different would have prevented a healthy teen from dying, you cannot help but re-examine your practice decisions. You may decide to continue the same practices. But I believe most providers would be very likely to lower their threshold for what constituted, sick enough to get Tamiflu, in the next pediatric patient.

I agree. Like I said, this particular experience (a teen dying from influenza who did not receive Tamiflu) is so rare that the effect evaporates when you try to generalize it to the overwhelming majority of providers whose experience has been that of teens not dying from influenza when they haven't received Tamiflu.

Linda

 

[Skeptic Ginger]

Linda, I will get back to you later. I'm too busy with H1N1 and seasonal flu vaccine campaigns right now to address your issues. I know what the literature says. I know what health care worker attitudes are regarding flu disease and vaccine. I know many physicians are out there giving bad advice or no advice to patients and friends. I know many physicians who are probably good at caring for infected patients know less about infectious disease transmission and prevention than they should. I know this from years of experience with this very thing.

I also posted a number of supporting papers. They weren't good enough. You are looking for something else, yadda yadda yadda. It appears to me you have a fixed conclusion here you are not wavering from. If you think you are arguing what it takes to think critically about this issue, that may be. But it is not possible to provide you with everything I have that has gone in to my expertise in this area. So you are not capable of assessing whether I have thought critically about this issue or not.

You are not obligated to take my expertise as valid, I really don't care. And I am not arguing by authority I am including my years of experience as supporting data.

I'll address your specifics later with this exception: I didn't shift any goalposts. You insist on dragging the discussion off on sidetracks. The original issue if you recall, was my asking Paxi if that 14 yr old was his patient, would it have altered his future practice. It is often very hard to follow your obtuse discussions, and this was one of them.

Rarity is relative. There are now over 80 fatal, likely preventable, pediatric cases in the US from this new variant of influenza. That experience is more than sufficient for providers to take a second look at how we are, as a collective, interpreting the guidelines about who to prescribe Tamiflu to and how we are assessing and defining what constitutes a severe case. Just as important, we as a collective should be reassessing how seriously we take pediatric and young adult cases of influenza. Maybe that 14 year old with a temp of 104F should be seen, not brushed off over the phone because our tunnel vision sees influenza in healthy children as benign.

You seem to be arguing the principle no one should modify their practice based on an individual patient experience. I am saying the more experience we get the more we modify our practices. That experience comes in many forms. A preventable death is almost certain to affect a health care provider if it occurred on their watch. I would imagine that most of the time, such an experience leads providers to alter their practices, even if just a small amount.

Both situations, having one of these fatalities in one's practice and the accumulating numbers of them, should make providers re-think their beliefs and practices on how serious influenza can be even in otherwise healthy people.

 

[fls]

Linda, I will get back to you later. I'm too busy with H1N1 and seasonal flu vaccine campaigns right now to address your issues.

Don't worry about addressing my posts. I'm responding so that if you have the opportunity to come back to it, it's here. But you don't need to take time away from your work for me.

I know what the literature says. I know what health care worker attitudes are regarding flu disease and vaccine. I know many physicians are out there giving bad advice or no advice to patients and friends. I know many physicians who are probably good at caring for infected patients know less about infectious disease transmission and prevention than they should. I know this from years of experience with this very thing.

If that's the case, then why haven't you chosen to describe that experience or refer to that literature? Also, how is one supposed to reconcile a substantial, but different experience?

I also posted a number of supporting papers. They weren't good enough. You are looking for something else, yadda yadda yadda.

It is disturbing that when I describe what kind of information we need in order to answer specific questions that you act so dismissively about it. What is so wrong with looking at information that can answer these questions instead of using guesses based on related but different information?

It appears to me you have a fixed conclusion here you are not wavering from. If you think you are arguing what it takes to think critically about this issue, that may be. But it is not possible to provide you with everything I have that has gone in to my expertise in this area. So you are not capable of assessing whether I have thought critically about this issue or not.

I wasn't wondering whether you had thought critically about this issue, so much as I was looking for the kind of information that I would expect from someone who had thought critically about the issue. When a medical resident asks me why I recommend the use of a particular antibiotic for a specific condition, I don't tell them that it's because I used it in a patient last week and they got better. I tell them about the result of a clinical trial in patients with that specific condition. Even though both reasons are true, the first isn't a reason which should carry much weight and I shouldn't be surprised if they look askance at it.

You are not obligated to take my expertise as valid, I really don't care. And I am not arguing by authority I am including my years of experience as supporting data.

I'm sorry. I would like to take your expertise as valid, and I'm trying to do so. But you are making it hard for me, for the reasons I outlined in my previous post.

I'll address your specifics later with this exception: I didn't shift any goalposts. You insist on dragging the discussion off on sidetracks. The original issue if you recall, was my asking Paxi if that 14 yr old was his patient, would it have altered his future practice. It is often very hard to follow your obtuse discussions, and this was one of them.

I wasn't trying to be obtuse. I agreed that there is a tendency to alter behaviour in light of experiences, including the death of a 14-year-old. I also pointed out that if we expect experiences to guide our behaviour, surely it makes sense to take into consideration what will be the overwhelming majority of experiences? Why is this idea obtuse, a side-track, and cherry-picking?

Rarity is relative. There are now over 80 fatal, likely preventable, pediatric cases in the US from this new variant of influenza.

Compared with hundreds of thousands of office visits for ILI in kids and teenagers where recovery was uneventful.

That experience is more than sufficient for providers to take a second look at how we are, as a collective, interpreting the guidelines about who to prescribe Tamiflu to and how we are assessing and defining what constitutes a severe case. Just as important, we as a collective should be reassessing how seriously we take pediatric and young adult cases of influenza. Maybe that 14 year old with a temp of 104F should be seen, not brushed off over the phone because our tunnel vision sees influenza in healthy children as benign.

You seem to be arguing the principle no one should modify their practice based on an individual patient experience. I am saying the more experience we get the more we modify our practices. That experience comes in many forms. A preventable death is almost certain to affect a health care provider if it occurred on their watch. I would imagine that most of the time, such an experience leads providers to alter their practices, even if just a small amount.

I am simply pointing out that if you want people to modify their practice as their experience accumulates, what will be accumulating the vast majority of the time will be the experience of dozen of kids and teenagers recovering uneventfully from the flu.

Both situations, having one of these fatalities in one's practice and the accumulating numbers of them, should make providers re-think their beliefs and practices on how serious influenza can be even in otherwise healthy people.

Very few practitioners will enjoy the luxury of that experience, though.

How many fatalities have you had this season?

Linda