Irony

Fired for being a physician and scientist

Update: Unfired. Thank you all for your overwhelming support and thank you to a true man of integrity for his intervention.

My husband Kirk Milhoan, MD, PhD, FAAP, FACC, and I are at the World Congress of Pediatric Cardiology and Cardiac Surgery in Hong Kong this week, a meeting that occurs once every four years (where he, incidentally, presented information regarding our 25 years of experience with international pediatric cardiac medical missions). While here, we found out he was being dismissed from his current practice of pediatric cardiology solely because of his service as Chair of the Advisory Committee on Immunization Practice (ACIP) of the Centers for Disease Control (CDC). He disclosed to his employer when he accepted the appointment to this committee, and then again when he accepted the role of chairman. He is a respected and valued contributor to his department. He has no patient or family complaints against him, and numerous accolades. Staff enjoy working with him. Those who broke the news to him apologized profusely, commending his integrity. Why did they fire him? Because of the overwhelming number of calls to their organization demanding his firing for his role on ACIP. The court of public opinion is dictating to a medical organization who can be on their staff, and they are bowing to it. It is a staggering turn of events.

I wish I could tell you it surprised me. I’ve spent the week expecting it, while simultaneously shaking my head at the irony of it all as I sit in medical meeting after meeting. The greatest irony is my husband has been a vaccine advocate throughout his career. He never denied risk, and respected principles of autonomy and informed consent, but believed, and recommended, that in most cases the benefit outweighed the risk associated with vaccines. He trusted that the CDC, US Food and Drug Administration (FDA), and National Institutes of Health (NIH) had done their due diligence in examining safety and efficacy of these products. Before the products introduced as prophylaxis against SARS-coV-2 became available, I was investigating their mechanism, discovering their difference from all other vaccines produced to date (they are genetic products which induce bodily cells to produce spike protein, which has toxic effects). When I first proposed to him my thought that this might not be a good idea, he asked me to discuss this only with him, concerned for my contributing to any hesitancy in others to all other vaccines.

My husband, who has a PhD in cardiovascular physiology and pharmacology, obtained before he went to medical school, is a true scientist. You are never going to get to him with a YouTube video, TV program, book, article, or Substack. Pleas of “please read or watch this!” are not going to sway him. He is swayed by data, the scientific method, and clinical experience, founded on principles of anatomy, physiology, biochemistry, pathophysiology, and pharmacology. He has always made me a better clinician because I could never get by with sloppy or incomplete thinking. He loves being a physician. He loves children. He loves being a servant. He has run a free medical clinic in Maui for the almost twelve years we have lived there because he genuinely loves using his skills and abilities to help others. That’s how he came to treat over 700 patients for covid, directly observing what did and didn’t work. His having a public conversation with another pro-vaccine physician about potential treatments for covid and informed consent for the novel genetic products earned him slander in the press and an investigation of his medical license (for which he was cleared). He laments much of what went on in the covid era for decreasing trust in the medical profession he loves, and longs to restore it.

Public debate, evaluation of evidence, and modification of practice are foundational to the practice of medicine. That’s way I sit in wonder at the irony of what he is going through as I participate in this medical meeting. I heard someone comment that sometimes in the absence of data, we are too tempted to establish guidelines. I heard someone posit without controversy that guidelines can be inadequate and we must exercise clinical judgment. I’ve sat through lectures on protecting our most vulnerable patients. Consistently, one of the most vulnerable subsets that we all agree on is newborns. I sat through a lecture yesterday on changes in guidelines in transfusion practice because what we thought was safe wasn’t and exploration of data informed that. We do the best we can, desiring the best for our patients, and modify when we learn we can be doing better. One of our favorite components of this meeting, and other regular pediatric cardiology meetings, that we have been attending for over 20 years is pro-con debates on particular clinical approaches. What I’m trying to convey is debate, evaluation of evidence, and modification of guidelines and practice is a normal and foundational part of our profession. As I’ve listened to topic after topic unemotionally discussed this week, even if controversy and difference of opinion has been involved, I’ve wondered why vaccine discussions seem to have been excluded of late from this normal practice of open discussion in the medical profession.

Kirk was willing to accept an appointment to ACIP because he’s been longing, as a pediatrician, to be a part of the debate and exploration of evidence on the issue of vaccines. After he was appointed to the committee, he was summoned to the office of the Chief Operating Officer of the medical facility where he worked, accompanied by his supportive department chairman, so he could be questioned on his views about vaccines. He was able to defend that he could not be labeled a dreaded “anti-vaxxer” and kept his job, for the time being. When he was asked to be Chair of the committee, we both agreed it was not likely to be a net positive for his career and reputation. My husband served his country in the Air Force, deploying twice to Iraq as a flight surgeon. He likened this call to serve to that one, and was willing to step forward.

Even he has been surprised by where the data has led. He and I have talked a lot about confirmation bias over the past few years. If we believe something, we are often blind to or rejecting of evidence to the contrary. Some people hate to be wrong. Kirk is one of them. If he’s wrong about something, he wants to be corrected as soon as possible. Others so value being right that they will ignore evidence that will force them to admit they’ve been wrong. We’ve been wrong in medicine a lot, and we will continue to be wrong, and we cannot be afraid of admitting that. For the sake of our patients, we should want to be right as soon as possible.

At the last ACIP meeting last week, the results of which led to my husband’s firing, the committee evaluated the recommendation to vaccinate all newborns against Hepatitis B. I’ve already submitted that most physicians agree that newborns are one of our most vulnerable populations. In order for a patient to undertake any risk of a therapeutic, there must be a demonstrated benefit. The question the committee evaluated was: what is the benefit to a newborn for taking a vaccine against an infection for which their mother has tested negative and there is no risk of their participating in activities which will result in their infection? The committee found the data for excluding harm from this therapeutic lacking (while there is actually evidence of harm), and any data demonstrating harm associated with delay also lacking, so only recommended a newborn dose to infants of mothers who are Hepatitis B positive (or whose status is unknown). Their two-day discussion is a matter of public record. In the interest of reducing risk from unnecessary multiple doses, the committee also recommended that serologic testing for immune response can be used to guide whether subsequent doses are necessary. All physicians are accustomed to demonstrating immunity to infectious diseases, as required for our privileges to practice at medical institutions. Serologic demonstration of immunity allows us to forgo additional vaccines. The committee recommended that parents be allowed to exercise this option for their children if they wish to potentially reduce the total number of doses of the Hepatitis B vaccine they are given.

The four basic principles of medical ethics are: nonmaleficence, beneficence, autonomy, and justice. Nonmaleficence can be summed up in our obligation to, “first, do no harm.” If a patient is at zero risk of something, any therapeutic then invites harm and is contrary to this ethical principle. Beneficence is the obligation of a physician to act in the best interest of a patient. I cannot recommend something that risks harm if I cannot demonstrate any benefit. Autonomy, the idea that patients (or their parents on their behalf) have the power to make their own rational decisions and moral choices, undergirds the obligation to give informed consent. As a physician, I must be able to explain the risks, benefits, and alternatives to any therapeutic or procedure, and respect the patient’s refusal, even if I disagree. Justice can apply to the fair distribution of resources. In these vaccine recommendations, insurance coverage is available should a parent choose a vaccine, even for their newborn, or should they choose serologic evaluation. The option to choose the vaccines have not been taken away nor has any financial coverage for vaccine administration.

My husband has been fired because of public outrage that he would choose to participate in scientific medical debate (in service to his country, I’d add) and make recommendations based on the best available evidence, even if that required a modification of previous practice, in support of principles of medical ethics. This is what we do as physicians every day of our lives. But for some powerful segment of the population, there appears to be consensus that some topics or conclusions are off-limits and they can pressure to harm careers and livelihoods of those with the courage and integrity to investigate whether the science is truly settled. The irony is they are trying to destroy the career of someone who was on their side, but willing to re-examine the evidence. I’m so very sorry and disappointed that his employer was not willing to come to his defense but folded to public pressure. Such outcomes are a loss for all of us.