Saturday, October 8, 2022

TikTok, NyQuil, vaccines, the frontal cortex, and making wise decisions: something we all need to do better

FDA warns against cooking chicken in NyQuil”, the title of an article from Family Practice News, and reprinted by MDEdge, may seem a little “Hey, what? Why would the FDA have to issue a warning about this?” It certainly caught my attention. I don’t claim to be a gourmet, or conversant with all the ways recipe books have to cook chicken, but I certainly never heard of using NyQuil. But, then again, I don’t spend a lot of time on TikTok. I read a bit more and caught the key phrases that largely explain why this is an issue, “adolescent” and “TikTok challenges”. Aha. It is not a celebrity chef who has been suggesting that we cook our poultry in a liquid designed to treat the symptoms of colds, and that includes a variety of drugs to treat pain (acetaminophen), suppress cough (dextromethorphan) and decrease sniffles (doxylamine, an antihistamine), which all are concentrated and made more toxic by cooking them down. It is, rather, morons on social media. Or how about the “One chip challenge”, which has led to hospitalizations of children eating a chip made with peppers with 400 times the capsacin (thus hotness) of jalapenos?

Or maybe they’re not morons; maybe they’re smart folks with an agenda, although the agenda is likely to simply be getting more views and becoming more of an “influencer” than intentionally trying to poison our young people. Although the impact can be the same. One question is “why do people (especially young people) get so ‘influenced’ that they do crazy, stupid things?” Actually, it’s easier to answer for young people. They have a biological, developmental excuse. Contrary to what we learned decades ago (or in the last millennium!) about brain development, that no new neurons grew after birth, the development of the brain is not complete until the mid 20s. And the last part of the brain to completely develop is the frontal cortex, which is associated with both executive function and judgement. Judgement is very different from intelligence or knowledge; it is the ability to integrate knowledge and come up with a wise plan of action. It is why a young adult or late teen, otherwise both very smart and even very knowledgeable, can often do something that seems, well, stupid. “Why did you drive into that crowded intersection? What were you thinking?” “Thinking?”…

Addressing this issue (helping learners to know how to integrate knowledge into a wise plan of action) is one of the key goals of education; and in my experience, in medical education. It is important, in making a diagnosis or deciding upon a treatment, to think critically, and this is not necessarily a skill that comes naturally. Before electronic medical records (EMRs) came into being, I would encourage learners to write the important laboratory and x-ray results in their chart notes, on the theory that in going from their eyes to their hands it would go through their brains and significant results that needed further investigation or action would trigger those brains to follow up. Now with EMRs, it is possible to block and paste all those results and insert them into the physician’s note, which does not have the same effect. It does make the notes a lot longer, but that in itself serves no purpose since the results could be seen elsewhere in the chart.  The goal was not to have them in the note (easy with cut-and-paste) but to have awareness of them in the physician’s brain. The traditional “SOAP” note includes “Subjective” (what the patient relates), “Objective” (what is found by physical, lab, imaging examination), “Assessment” (how the physician integrates that information into a decision on what is the most likely diagnosis or diagnoses, and what are the alternatives), and “Plan” (what are we going to do now to clarify the diagnosis and/or treat?). Assessment is by far the most important part; it is the part that requires that the data, relatively easily available, interact with the physician’s knowledge and experience. It is also, unsurprisingly, the one most often lacking in quality and thoroughness. It is, indeed, the one that require the most out of the frontal cortex.

The bigger question is not about adolescents and young adults, whether training in medicine or not, and why they cannot distinguish between a “challenge” that is a gimmicky fundraiser for a good cause (e.g., pouring ice water on your head so people will contribute money for ALS research) and one that is idiocy (e.g., cooking chicken in cold medicine). After all, we train children to irrationally believe things (Santa Claus, the Easter Bunny, parents are omniscient, good guys always win) so it is understandable that aspects of this may persist for a while. The bigger question is about adults. Why do they find it so easy to believe what should be obvious nonsense, and act on it, and have it determine not only what they do in a mildly risky manner (chicken and NyQuil, incredibly hot chips) but in their work, their relationships with others, their beliefs in the world around them, how they vote, and how that affects our world.  

Vaccines, for example, work to prevent disease both in the individuals who receive them and the communities of which they are a part. They are good. They are one of the few things (along with surgery) that healthcare workers can actually do to/for people that enhances their health, as opposed to making recommendations, whether for diet/exercise or giving small pieces of paper, which have to be taken somewhere and, with money, redeemed for medicines that have to actually be taken. But there  is still a lot of vaccine skepticism. Some of it is political; being skeptical of COVID vaccines has become de rigeur for many Republicans and conservatives and this has bled into distrust of other vaccines. But it also a belief of many who think of themselves as liberal, and are economically well off. It is just as wrong and dangerous. We read now that vaccine reluctance is now moving into people’s views about vaccinating their pets; we may soon face not only outbreaks of measles in children but rabies in dogs!

I understand and have written about the fact that all doctors are not always correct, that they sometimes are motivated by interests other than those of their patients’ health (their own financial interest or that of the corporation they work for), and that asking questions is good. But the dangerous irony is the same people who are suspicious of “mainstream medicine” are often far too willing to accept unproven and unlikely alternatives. Because something is recommended by those who are not mainstream physicians does not make it correct; in fact it is often quackery.

People often adopt behaviors, or either eat or eschew certain foods, or take supplements, that they believe will make them healthier. Maybe they do help. No one thing is going to make you healthy; there are too many factors affecting health. People usually choose those consistent with what they already believe and are things that they feel that they can do (thus the popularity of supplements; you don’t have to do anything hard like change your lifestyle). Unfortunately, people often think that doing the things they like or believe in or find easy cancels out other things – “if I take supplement X (or eat a lot of Y but no Z), I don’t have to do A or stop doing B!”

Near the end of Herman Hesse’s novel “Siddhartha”, the protagonist meets his childhood friend Govinda when they are both old men. Siddhartha shocks Govinda, a devotee of the Buddha, by saying that wisdom cannot be taught. Knowledge can be taught, he says, but wisdom must be acquired by the person themselves. I do not think we need less knowledge, but we do need more wisdom.

I’ll share some knowledge: Don’t cook your chicken in NyQuil. And get vaccinated, get your children vaccinated, get your pets vaccinated.

I’ll also try to share some wisdom: Because you want something to be true does not make it true. And if something seems too good to be true, it probably is.


Anonymous said...

Age old aphorism “knowledge comes while wisdom lingers” Thank you

Unknown said...

As a professor of comparative health policy, I think your blog post is excellent and very helpful to readers. What I wanted to add, based on a few months of looking into the debate among PNHP Metro leaders about whether it is on the brink of majorities in both houses in Albany ready to pass a single-payer design for New York, or whether this seeming bi-partisan support is largely mythic, I concluded it’s probably more mythic than real, because the powerhouse lobbies of hospital and physician organizations will fiercely oppose any bill that would cut back on the high revenues and incomes they enjoy under the current, inequitable, racist insurance arrangements. And commercial insurers, another huge, powerful lobby, would also block, sideline, or distort any “single-payer” bill.

What, then, could PNHP, as an organization to which 99% of all physicians do not belong (why not?) do to be more effective in advocating for universal access to quality health care? One thought is to focus on employers as a major power block that advocate for selective, commercial health insurance but who have really suffered from supporting it. Muster the facts about their self-harming actions and convert them. They pay for most of the medical bills, and they hire the insurance companies, a second power block that vigorously supports the current, inequitable, racist insurance arrangements. Employers in every other capitalist country support universe health insurance. Although they have long thought they benefit from health insurance premiums being tax-deductible, business leaders have come to realize that the current, inequitable, racist insurance arrangements raises their labor costs year after year so that their employee costs are not competitive with companies who operate in countries with universal health insurance plans. Further, high premium costs have eroded employees' take-home pay. An effective campaign could be crafted by PNHP and others, like Medicare For All NOW to educate, meet with, and campaign with employers as a strategic ally (although few know it) who have the wealth and power and economic reasons to advocate for some form of universal health insurance.

Yet PNHP and its impressive intellectual leaders are not focusing on employers as a strategic ally. Mobilize employers and they will address the health insurance lobby, the hospital lobby, and the physician/provider lobbies. PNHP physician-leaders should craft and carry out a strategic plan to speak at Rotary meetings near every chapter. Nationally, it's easy to make the case that the current, inequitable, racist insurance arrangements drive up inflation. Here they are: go after them–based_employers_globally
Little (even tiny) PNHP needs a better strategic plan than the one they have focused on for the last 30 years. Donald Light

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