By HANS DUVEFELT, MD (7)

The other day I saw a new patient who used to be on Lamictal, a mood stabilizer. The young man explained that he had gone through a difficult time in his life a few years ago and his primary care doctor put him on Prozac, which, as he put it “hijacked” his brain and made him “ugly, hyper and careless”. The man immediately stopped the Prozac and his doctor prescribed Lamictal, which he stayed with for about a year.

He decided to stop the new medication, because he reasoned that he didn’t have any psychiatric issues. It was just a side effect of the Prozac, which he in retrospect probable hadn’t needed at all.

Since then, he admitted, he had felt sad or unsettled in the spring and fall, but it always passed and he didn’t think his wife or anybody else noticed his seasonal mood changes.

“So, did anybody actually use the word “bipolar” in talking about what you went through?” I asked.

He winced and almost seemed teary eyed. “Yeah, but I don’t think that’s right. How can you put a label on somebody that will follow them for the rest of their life because of what their brain did when, basically and literally, they were on drugs?”

I nodded.

“Who knows how many people might react the same way if you give them Prozac”, he continued.

“I think labels can hurt sometimes, but they can also be a way of understanding how our minds and bodies work”, I began. “I don’t believe diagnoses are as cut in stone as some people like to think.”

He looked quizzical as I continued:

“Take diabetes – this country and Canada have slightly different cutoffs for what a normal blood sugar is. Or blood pressure – every few years the experts pick a different number for what’s good enough and what’s  ideal. I believe most things we call diseases are points at the extremes of a spectrum that we all fall somewhere on.”

Now he was the one nodding.

“Take mood”, I continued. “At one end of the mood spectrum there is depression and at the other there is what we call mania. Sometimes that looks like exaggerated happiness and confidence, but sometimes it is more like irritability and agitation. We can all experience any one of those moods, but usually we are somewhere in the middle. So, people are making up disease definitions depending on how far and  for how long we deviate from the middle. But if we never move an inch from neutral, that’s not necessarily being healthy – I think of that as definitely abnormal.”

“I see what you mean”, he nodded again.

“As a clinician, I think of labels as a type of shorthand or mental image that I keep in mind when I approach a problem. They help me choose treatments and they help me explain things. But I tend to be slow in sticking labels on patients or in their medical records. I read a book once called ‘Shadow Syndromes’ that makes the point that looking at the extremes of whatever spectrum we are on helps us understand ourselves and can be very empowering.”

“So, Doc, do you think I’m bipolar?” He leaned forward.

“You have the tendencies, yes, but a condition isn’t a problem until someone sees it as a problem. If neither you nor the people around you see your mood variability, not to use the stronger word ‘mood swings’ as a problem, then fine. But I, knowing what you’ve told me about how your brain works, would be a fool to prescribe Zoloft or Lexapro if you ever came to me feeling terribly depressed. I would then think of you as somewhere on the bipolar spectrum, needing a slightly different treatment approach if we wanted to lift your mood.”

“A mood stabilizer, like Lamictal”, I finsished, “can be like an insurance policy against ever having a manic episode in the future, and we usually recommend long term treatment if a person has had an episode out of the blue. But I’m not so sure it’s necessary if the episode was triggered by Prozac or any other antidepressant. I’m sure there are lots of opinions about that, but that’s what I think, especially since your episode was not severe from what you’ve told me.”

On my drive home that afternoon, I thought of the spectra I may have moved along during my lifetime. I remember my mother commenting on how I had turned into such a slob; “When you were little you were so neat, you used to line everybody’s shoes up in the entryway.”

That’s the OCD spectrum, and I guess I narrowly escaped that diagnosis…

Hans Duvefelt, MD is a primary care physician based in Maine. He blogs at a Country Doctor Writes. This post is exclusive to the Deductible. His first book “” is available from Amazon.com

By DANIEL STONE, MD (3)

President Trump’s wobbly walk down a ramp at his recent West Point visit along with his awkward  two-handed drink from a water glass have stirred recent speculation about a possible undisclosed neurologic issue such as early Parkinson’s Disease.  Although no specific conclusions can be drawn from these observations, they raise important questions regarding the President’s health.    

Trump would not be the first president to conceal health problems.  Toward the end of Franklin Roosevelt’s presidency, his blood pressure rose alarmingly.  As no drug treatments existed his doctors could recommend only that he stop smoking, lose weight and avoid dietary salt.  Less than six months after an un-knowing public re-elected him to a record fourth term, FDR predictably suffered a fatal stroke.  The public was similarly unaware of John Kennedy’s Addison’s Disease, a condition that required daily injections to replace the adrenal hormones his body could not make. 

The known facts about Trump’s health are concerning enough.   Despite taking a statin drug to reduce his cholesterol, Mr. Trump’s age and risk factors at his 2018 physical predicted a 16.7%  risk of a heart attack over ten years, as estimated by a standard American College of Cardiology risk calculator.  Trump was taking a statin at the time of that exam to lower his cholesterol.  As cholesterol levels on a statin may not reflect risk as accurately as un-treated levels, the calculator may under-estimate his true risk.     Although Trump’s doctors tout his health they seemed to be concerned about cardiovascular risk as they subsequently quadrupled his statin dosage, placing him highest dose of the most potent statin available.    In addition, the President’s annual exam revealed that his weight recently drifted up into the obese range, which means additional coronary disease risk along with an increased chance of stroke, chronic kidney disease, diabetes and several types of cancers.  

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By JEFF GOLDSMITH  

The halting and uncertain response to COVID in the US is a tragic civic embarrassment.    While other countries have snuffed out the Covid-19 virus, the US seems to be grinding on toward 200 thousand deaths despite flinging trillions of dollars at the problem.  As summer approaches, the US shows every sign of declaring victory long before the foe has left the field.  Americans may be losing interest in COVID but COVID has not lost interest in us.  

What happened?   Several trillion in lost economic output, massive dislocation of American families and disgraceful disparities in health risks based on race and socioeconomic level all point to a breakdown in a key civic function. No readily deployable testing capability, critical shortages of protective gear, unappreciated and unresolved conflicts between federal and state health authorities, and critical failures in our core federal public health agency, the Centers for Disease Control and Prevention all played a role.  In retrospect, it is clear that US public health effort- $93 billion in spending in 2018, or 2.4% of total health spending, for a population of 327 million people- was grossly inadequate for the magnitude of societal risk. We spend nearly eight times as much on the military.   

Successful public health requires social solidarity and trust both in science and in government.  All are in short supply.  Early statements from political leaders about how this is no worse than the common cold or the flu and was going to “just go away”,  and the fact that the initial wave was concentrated in greater New York (New Jersey, Connecticut, Long Island, etc.) helped lower the national sense of urgency.   

Aggressive early testing would have been confirmed that the disease was, basically, already everywhere in the country by late March, and was not, in fact, just a “Blue State problem”. The failure to deploy testing early led to a far more destructive and costly national economic shutdown than was necessary; the economic cost of a “flash depression” could have been avoided with better planning and more decisive leadership. 

But in those parts of the country initially grazed by the pandemic, an uglier reality surfaced. It was not merely a failure of leadership that hurt us but a failure of followership as well.  As protests against lockdowns proliferated, the signs told the story.  ““My Rights Don’t End Where Your Fear Starts” read one.  “Liberty for Safety- No Deal” read another.  But a sign at a “Re-open Tennessee” rally in Nashville in late April said it all in just three words:  “Sacrifice the Weak”, a jarringly un-American sentiment if ever there was one.     

In addition to underestimating their own risks, and failing to embrace measures that reduced risks for others, many of those initially spared the virus rationalized that the immediate and tangible costs to them of COVID countermeasures far exceeded the costs to others of an unchecked pandemic.  Those “others” were probably going to die anyway (e.g. older folks, people with chronic disease risks like diabetes, workers in meat processing plants, etc.) in some other part of the country that they didn’t care about. It is easy at a distance to dismiss the reality that the typical COVID fatality lost an average of eleven years of life expectancy!

Thanks to all of this, we are likely not in a second wave but rather a continuation of the pandemic in parts of the country spared the first wave.   Eighteen  states, including Texas, Florida, Georgia, the Carolinas and California,  saw increased COVID caseload over the past week.  Leaders in many states will be extremely reluctant to backtrack, and recommit their states to aggressive social distancing, which, again, would not have been necessary if they were well enough organized to test, trace and isolate- the three keys to an effective response to a viral threat.  

And it simply isn’t as if a coherent public response to this threat was impossible. Other countries (New Zealand-22 deaths, Taiwan-seven deaths, Hong Kong- four deaths) succeeded in surmounting this threat while we failed.   It’s not that the sacrifices demanded in their citizens were somehow less onerous than those that were demanded of us Americans.  What these countries did in common:  rapid diagnosis of a major threat, decisive action to sever all (not just ideologically indicated) international arrivals, universal and uncompromising lockdowns, aggressive scaling up of testing, mobility tracking and follow up.    Most of these countries were also smaller in population, had decisive executive leadership willing to take political risks and showed broad-based respect for authority in the face of the crisis.

Even though this crisis is far from over, the next pandemic is a “when”, not an “if”.  Obvious ingredients of a successful response to the next pandemic include:  multi-level planning for rapidly scalable viral testing, a secure medical supply chain,  generous stockpiles of protective gear, an agreed-upon protocol for care system deployment (to protect ongoing health care functions and workers), recruitment and training protocols for emergency workers and contact tracers and assignment of responsibility for covering high risk “hot spots” such as nursing homes, distribution facilities and food processing plants.  A thorough going and bipartisan review of the Centers for Disease Control  and a commitment to increase federal as well as state and local public health funding is also essential

In a functioning country, these would be achievable steps.   However, logical planning and decisive action may be too great a lift for a fractured, angry and distracted nation.  Two key functions- public health and law enforcement- appear to have lost legitimacy with broad swatches of the public.  Our largest political party seems to be the “Are You Kidding Me?” Party.     A failed state cannot protect its citizens against much of anything.  

A society riven increasingly by tribal resentments, fear and suspicion of any leadership is a society at risk.  The failure of the US to respond effectively to the COVID emergency is ominous, because it has shown societal divisions deep enough to paralyze the country from responding to other threats, be the other emerging diseases, a deep economic downturn, aggressive and unprincipled foreign adventurers, or terrorism foreign or domestic.   

 In the Congo, a comprehensively “failed state” if ever there was one, the unofficial national motto is:  “Débrouillez Vous”, loosely translated as “Figure it out yourself”.  This cannot be where we end up.   It seems so obvious that if we are to be an actual country,  we need to take better care of one another, and that we are stronger as a country if we trust one another and work together to address our common challenges.  

Jeff Goldsmith, Ph.D. is a health policy analyst based in Charlottesville Virginia and President, Health Futures Inc.  

By RICHARD GUNDERMAN, MD (3)

Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.

Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me — in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets — feel out of place.

Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.

That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”

No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a health care consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said:

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By NORTIN HADLER, MD (2)

We are all reeling from the language of the COVID-19 pandemic: fatality rates, spread, PPE, distancing, pneumonia, anti-viral drugs, ventilators, second wave, vaccines, serological testing, etc. All of this focuses on the infection with the SARS-CoV-2 coronavirus, and for good reason. People are sick and dying from this infection. However, there is murmuring that will grow in volume as COVID-19 subsides: Will this happen again? Is the annual flu season to become more alarming in the future?  Will we forever be waiting for vaccines and anti-viral drugs with bated breath? 

If we step back and view this nightmare from the perspective of infectivity rather than infection, there may be a way out of this conundrum. Coronaviruses are one of several categories of virus with a proclivity for human respiratory infection. Coronaviruses join Influenza, Ebola, SARS and MERS as respiratory riboviruses. These viruses are tiny bundles, virions, containing a little RNA and not much else. Left alone, little happens. But if they manage to get into a target cell, they commandeer the cell’s metabolic machinery to do their malevolence. They get to their target cell because we inhale them as virions that are aerosolized or carried in the droplets that are produced when infected people exhale. Droplets that are not inhaled settle on surfaces, including surgical and N95 masks, where water evaporates freeing virions to aerosolize unless they are somehow bound to the surface. They are so tiny that even the N95 mesh is an inefficient barrier. One would need filters with such tiny pores that they would impede inhaling.

Infectivity of these riboviruses and probably severity of disease are dose dependent. The more virions one inhales the more likely one is infected. That’s the reason physical distancing is advised. However, these riboviruses retain infectivity for many hours on surfaces during which air currents can launch them and keep them afloat. That’s of little concern out of doors where they are diluted, but not indoors. Modern architectures and civil engineers are well aware of issues that relate to stagnation in built environments. HVAC systems are designed as a compromise between the need to recirculate air for the sake of efficient heating/cooling while turning to filters and air exchanges for the sake of air purity, particularly with regard to inert particulate materials. Concerns about airborne illnesses are seldom primary. In most hospitals, certain rooms are designed as “reverse flow” rooms for patients with contagious diseases with exhaust mechanisms so that the room’s air is released to outside the building, not back into general circulation in the building. Some operating rooms, particularly orthopedic surgical suites, have lamellar flow ventilation to decrease the likelihood of introducing an airborne pathogen along with orthopedic hardware. But otherwise hospitals and other workplaces are not designed with regard to infectivity.

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By DAVID SHAYWITZ, MD (2)

As attractive as it is to think that science exists on a distinctive, untarnished, untrammeled plane, this idealization is dangerously misleading. Science is carried out by real people, within complex social organizations. Debates about science—often civil, occasionally acrimonious—on methods and meaning are the rule.

Which is as it should be: That’s how knowledge advances.

Ignoring what scientists have to teach us about COVID-19 would be a mistake. The virus is not a “hoax.”

But it’s also a mistake to default to the idea that we must “listen to Science,” as if there’s an unambiguous perspective that all researchers share and that all scientific data are established with an equal degree of certainty. This isn’t how science views itself. So we shouldn’t view it that way, either.

Within the universe of the present pandemic, some information seems very well established—the identification of the virus responsible for the condition, for example. Other data, including some very important essential facts, aren’t as clear.

We need to recognize and acknowledge these limitations.

Some people see these limitations are reason not to trust any of the information that comes out of the scientific establishment. For them, the failure of models to perfectly predict the trajectory of the pandemic was enough. What we’ve learned, said New York Post columnist Miranda Devine, is that “computer models are unreliable when it comes to predicting the future.” Instead of relying on supposed experts and their supposed models, she says, we should instead “trust the innate common sense of the American people.”

But there are more responsible ways to understand the problems with modeling.

Respected biostatistician Ruth Etzioni, at the Fred Hutch Cancer Research Center in Seattle, recently wrote that the latest version of the Institute for Health Metrics and Evaluation (IHME) model from the University of Washington “makes me cringe.” The changes revised the death projections significantly higher, and Etzioni argues that the modelers got there by making a number of obscure changes to the model, then presented these updates as reflecting simply the consequences of reduced social distancing.

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By FRANCINE HARDAWAY (6)

I will be 79 next month. What do I think? I think the country should open back up, albeit cautiously. I’m embarrassed to think that people have to up-end their lives for older people like me. For one thing I’ve lived a hell of a life.I’ve been around the world, I’ve been a mom, a foster mom, and a grandmother, and an entrepreneur besides. I have written a few crummy books.

As one of the vulnerable, I’ve been stuck in the house now for six weeks, learning every detail about the Coronavirus. I have seen only about half a dozen people who are part of my quarantine barrier: people with whom I walk my dogs outside in the morning, my roommate, my barista and the woman who sanitizes my home once a week. And that group is considered too risky for most, but I’ve always been a risk taker and I’ve known my housekeeper for 25 years. I know she will do her best not to cause my death.

What do I do all day? Mostly I exercise, walking or taking Zoom yoga. What do I wish I could do? Hang at the bar at Hillstone. When will I be able to do it? Safely, probably not for two years.

Right now Arizona is on lockdown but we are preparing to re open soon. Our case numbers are not declining although the increase has slowed. We are part of the wild west, and our social distancing is not as strict as California’s, or my daughter’s in London. For example, I took a walk along the canal near the Arizona Biltmore hotel on Sunday and there were couples laying in the grass near the putting green of the golf course. They were drinking mai tais and beers and reinterpreting social distancing in their own ways.

They were young and I’m sure they didn’t perceive themselves as vulnerable. There were also more than 10 of them and they were oblivious to the numbers. I was jealous. I don’t want to be one of the vulnerable. I wanted to join them and have fun.

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By ROB LAMBERTS, MD (3)

So this is what we are hearing:

• COVID-19 is a serious crisis and you need to keep away from people and stay at home.
• Things are better and we are re-opening restaurants, stores, churches, and hair salons.
• The death tolls are an underestimate.
• The death tolls are exaggerated.
• No need to wear masks, as they don’t help.
• You should wear a mask.
• 100,000 Americans will die.
• Make that 50,000.
• The virus doesn’t spread through the air easily.
• Simply being near someone who is talking can give you the virus.
• Young people are basically immune from serious infection.
• Anyone can die from it.
• Hydroxychloroquine and Zithromax will cure it.
• No, those don’t work.
• A vaccine is in development.
• A vaccine might not be available until late 2021, and it might not work great.

You get my point. It’s confusing and it’s frustrating. It’s like the old joke about the weather: if you don’t like the weather here, just wait 5 minutes. So if you hear something that bothers you, just wait 5 minutes and you’ll hear the opposite opinion about COVID-19. Why is this? Why can’t we agree? Why are facts being replaced by opinions?

The Nature of Science

The first thing I want to sayis that the nature of science is to get things wrong a lot in the path to getting things right. Contrary to popular perception, science is not about finding one answer and sticking with it because it is “true.” No, science is about gathering data through observation and experimentation and coming up with the best explanation for that data. More data often means that old explanations don’t float any more, but that’s OK because eventually, over time, we get things more and more right and come to a (hopefully) more truthful and useful answer.

6 months ago we knew almost nothing about this virus. 3 months ago, most of us were more concerned about fires in Australia, about all the rain we were getting, and about the Astros cheating. Yes, people were sounding the alarm about the seriousness of the virus, but few foresaw what ended up happening. Nobody was pushing for a vaccine 6 months ago, nobody was looking for medications to treat this disease. Nobody was storing away masks or making emergency plans for ventilators.

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By MARTIN A. SAMUELS, MD (8)

Burnout has become an obsession in the medical profession.  I am almost 75 years old and am not feeling any of the symptoms of physician burnout.  I do not state this out of any sense of pride, but I have tried to be introspective about this to offer some advice as to how to avoid this problem.

My approach is fourfold.  I shall begin by reviewing the definition of burnout, emphasizing physician burnout.   To address the individual issues, I think it is important that we are all on the same wavelength and are using the same definitions.  Secondly, I will review some facts about the reality of American medicine as we now experience it.  Third, I shall articulate a paradox between what seems to be an epidemic of physician burnout in the context of the reality of American medicine.  Finally, I will offer a nine-point set of suggestions, which are meant to help to avoid the symptoms and signs of this syndrome.  

 Burnout is not a new idea, and it is not specific to medicine.  It has been in the psychiatry literature for quite a long time, but it was brought to our attention in medicine in a series of papers by Zeev Neuwirth, who, at the time, was an internist at the Lennox Hill Hospital in New York.  He wrote several papers on related subjects and published an article in the lay press in 1999 that was entitled “The Silent Anguish of the Healers.”  Since that time, it has become evident that “burnout” is an important issue in medicine that needs to be addressed.  Neuwirth and others have defined ”burnout” as a feeling of complete emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.

An Epidemic of Dissatisfaction

In recent years, many have argued that “burnout” is extremely prevalent; not only in society in general but especially in medicine.  It has been said that 50% of physicians have at least one of the three cardinal features:  exhaustion, depersonalization and inefficacy.  The problem with these kinds of data is that are no adequate controls; especially controls from others in the learned professions.  It is probably quite common for many people, at some point or another, to experience one or more of these cardinal features.  The real question is whether this is more prevalent than in a control population and whether they are persistent, rather than transient, symptoms.  That information is not available.  For these reasons, it is likely that the problem of “burnout” is being exaggerated.  Nonetheless the problem undoubtedly does exist in an unknown proportion of physicians.

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BY CLAY FORSBERG

When my daughter Alex was in third grade she had the reigning Marin County (California) Teacher of Year. Her name escapes me (I’ll blame it on the chemo brain). The parents of all the kids in this Tiburon classroom were beside themselves with praise for her. Me … not so much. A big one thing I had a problem with was she encouraged the students to use calculators in her class. Her reason was that it would be good practice for real life – where no one did math long hand anymore. Well, I do.

Now I still use a calculator, but daily I make every effort to do math problems in my head. Percentages, grocery bill estimates, gas mileage … anything and everything. it’s something I’ve always done and probably always will. It’s cerebral exercise, and it’s something I’ve encouraged my daughter to do also. On road trips as a grade-schooler, she’d have to look at the mileage, take in account our speed, and determine when we’d get to the next stop. I don’t know if she liked it … but she did it anyway.

Now I don’t mean to sound like a Luddite. On the contrary, I self-taught myself how to program in college on FORTRAN 77 on my college’s IBM 360/370 (how many of you remember FORTRAN or a 360/370). I’d sneak in to the computer center at night and drop off my boxes of punch cards. I wasn’t so bright that I used a terminal like the other nocturnal geeks in training though. I used punch cards … and for a many months carried around my three boxes of 1400 cards.

I bought my first Mac in 1985 and I was transferring data online before there was an online. My first email address was at the Well in the San Francisco. In fact I gave Well email addresses for Christmas presents. Alexandria was raised on a Mac, and instead of going to college when she graduated high school … she went to Apple.

That said, I didn’t like the idea of supplanting the exercise of the brain for the exercise the fingers hitting the calculator buttons. And the excuse: “they’ll need to learn how to use a calculator in real life when they’re older” is lame. What they’ll need to learn is how to use their brain. And considering who this country elected as president – we’re in short supply of those that either can or will.

Now I’m not blaming calculators and their use in grade school for the clown in the White House and utter disintegration of the democracy before our very eyes … but then maybe I should. Maybe we should look it as a symptom … a touchstone of sorts, emblematic of how we view intellectual development in this country. I get the whole “recognizing the value of tools” thing. But unless the foundation is built for which the tools are to be used (and hopefully complement) – we’re building a skyscraper or citizens’ equivalent of it – on a landfill.

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By NIRAN AL-AGBA, MD

Over Memorial Day weekend 13 years ago, my younger brother, Laith, died in an accident. He was 26 years old. Losing young people in their mid-20’s is particularly devastating because they are embarking on adulthood and their futures hold limitless hopes, dreams, and possibilities. For the survivors, no holiday brings the same joy as it did before. Someone is not there, and never will be.  

Wanda Cooper-Jones, the mother of Ahmaud Arbery, has endured unbearable pain. Gregory and Trevor McMichaels shot and killed her son while he was running down the road. They were not arrested and charged with a crime until 74 days later. A third man, William Bryan, stood by and recorded the murder of Ahmaud Arbery on his cellphone for more than 4 minutes. 74 days passed before he was charged with committing a crime. The gruesome facts of this story have enraged me because I know a little something about the unrelenting grief associated with unexpected death. 

My brother’s death was accidental, which made me incredibly sad. Wanda Cooper-Jones’ son was ruthlessly lynched and then this week George Floyd was killed in broad daylight by a police officer in Minneapolis, both of which make me unspeakably angry. 

Enough is enough. This nation must stop tolerating lynching of black men and women.  While racism is difficult to discuss, it is also necessary, valuable, and essential in order to bring about change. My previous column addressed white privilege and ever since, readers have been asking, “What now?” 

Now, we need to become allies to people and communities of color.   

But what does it mean exactly to be an ally?   

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By DAVID SHAYWITZ, MD

I was recently speaking with a friend of mine, a pulmonologist at a large academic medical center in the Midwest, about his COVID-19 experience. I was especially interested, in the context of iterative experimentation, to learn how his hospital was working on improving the care of COVID-19 patients, especially those in the ICU, which he oversees.

It’s a real problem, he said. On the one hand, there are specific initiatives he’s trying to evaluate, in a classic, controlled fashion, so he can figure out if the intervention is effective and should become part of the standard of care.

That’s the goal.

In reality, however, here’s what he says is actually happening: most of the front-line doctors are hearing about the very latest approaches, generally from social media (such as Twitter or medical podcasts), and are trying to immediately apply these methods to their patients. As a result, the care patients receive depends (to some degree) on the specific physician involved, as well as the extent to which that physician has been influenced by other opinionated doctors.

At a recent Boston innovation conference (discussed here), Dr. Paul Biddinger, an emergency medicine physician who leads emergency preparedness at the Massachusetts General Hospital, made a remarkably similar observation. He praised the “unprecedented information sharing” associated with the COVID crisis. But he also expressed concern about the “practicing by anecdote,” and more generally the “temptation to fall off what have been the time-proven methodologies of science.”

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By KIP SULLIVAN

Over the last three decades, health care policymakers in Minnesota, where I live, have gotten into a bad habit: They recommend policies without asking whether there is sufficient evidence to implement the policy, and without spelling out how the policy is supposed to work. Measurement and “pay for performance” (P4P) schemes illustrate the problem. Multiple Minnesota commissions, legislators, agencies, and groups have endorsed the notion that it’s possible to measure the cost and quality of doctors, clinics, and hospitals accurately enough to produce results useful to regulators, patients, providers, and insurers.

But these policymakers did so with no explanation of how system-wide measurement was supposed to be done accurately, and without any reference to research demonstrating that accurate system-wide measurement is financially or technically feasible. The Minnesota Health Care Access Commission (in 1991) and the Minnesota Health Care Commission (in 1993) were the first of several commissions to exhibit this “shoot-first, aim-later” mentality. Both commissions recommended the establishment of massive data collection and reporting systems, and both articulated breathtaking expectations of the “report cards” these systems would produce. According to the latter commission, for example, the data collection and number crunching would facilitate “feedback of data that reflects the entire scope of the health care process, from the inputs or structural characteristics of health care to the processes and outcomes of care.” (p. 134) Yet neither commission offered even the crudest details on how such a scheme would be executed nor what it would cost, and, not surprisingly, neither commission offered evidence supporting their high hopes.

In 2008, two other commissions and the Minnesota Legislature exhibited the same casual attitude toward evidence and details. That year, the Legislature, egged on by the commissions, passed a law requiring the Minnesota Department of Health (MDH) to create a “standardized set” of quality measures for Minnesota that would be used to punish and reward “health care providers” (Minnesota Statutes, Section 62U.02). The law offered a few guidelines (such as MDH should “seek to avoid increasing the administrative burden on health care providers”), but it offered no details on how MDH was supposed to create useful measures.

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BY JIM PURCELL (3)

Covered California released the first national projection of how the COVID-19 pandemic will affect employer health insurance. The report predicts that employer premiums will rise in 2021 by 40 percent or more, absent federal action, which is certain to alarm many employers. 

As the former CEO of Blue Cross & Blue Shield of Rhode Island, I disagree with these ominous projections, and believe that in the wake of COVID-19, any rise in health premiums will be minimal, one-time events (which I explain below). 

Moreover, I believe it’s time for employers to consider a more important question: whether they should pass any future rate increases to employees, which for years has become a common practice with profound ramifications for both employee well-being and employers’ bottom lines. 

As a former healthcare CEO, I’ve taken part in the complexities of health insurance ratings for years. To better understand how the COVID-19 crisis might impact insurance premiums, I consulted with insurance actuaries about changes that may arise in the coming year.

Overall, I believe that COVID-19 will significantly increase claims expenses in line with Covered California’s projections, which will include higher ER intake and ICU overflows, and increased hospital staffing.  

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By ROB LAMBERTS, MD

Things have changed.

The governor has eased restrictions and now we can go to restaurants, go bowling, get tattoos, and visit many of the stores that were previously closed. Churches are now planning to meet again.

This leaves many of my patients wondering what to do. Is it OK to go to these stores, to get your hair done, to join the neighborhood pool, to go out to eat, to go to church? Is it safe to do now?

No. It’s not safe yet. You are at the same risk of catching coronavirus now that you were 2 weeks, or 1 month ago. The change in the policies in both Georgia and South Carolina were not due to a lessening of the risk of the infection; it is an economic decision. It was very reasonable to shut everything down when we didn’t know how full our hospitals, ICU’s, and ER’s would get with a surge in cases. It was important to “flatten the curve,” and that seems to have worked. We do have enough capacity right now to handle the number of critically ill people in our hospitals. But that could change.

So what will happen now that “stay at home” restrictions are going away? It’s very likely that the number of infected people will go up, as will the number of deaths. So why open things back up? Because we cannot keep everything shut down while we wait for 1-2 years for a vaccine to come out. The economy simply can’t sustain that, and people would suffer because of it (economically, emotionally, and physically). We need people working again, and we need to avoid a total collapse of our economy.

But again, do not think it’s now safer than it was before the governor’s decision. Do not think it’s not still important for high-risk people to remain isolated, for people to stop wearing masks, or to stop washing their hands. This virus has killed nearly 75,000 people in the U.S., and the rise in deaths is not seeming to slow at all. A vaccine is unlikely to come out in 2020, so we will have to adjust to the new normal of living in the shadow of this pandemic. It will take a very long time for things to resemble the way things were before this all started.

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By ANISH KOKA, MD (7)

Our strategy with nursing homes in the midst of the current pandemic is bad.  No, make that terrible. Nursing homes and other long term care facilities house some of our sickest patients in and it is apparent we have no cogent strategy to protect them. 

I attempted to reassure an anxious nursing home resident a few weeks ago. I told him that it appeared for now that the community level transmission in Philadelphia was low, and that I was optimistic we could keep residents safe with simple maneuvers like better hand hygiene, restricting visitors, as well as stricter policies with regards to keeping caregivers with symptoms home.  I was worried too, but optimistic.

I figured the larger medical community would be on the same page if someone did get COVID.  It made sense to me to be aggressive about testing staff and residents and quickly getting COVID-positive patients out of the nursing home.  So when I heard of the first patient that was positive in the nursing home, my heart sank, but it fell even further when I found out the COVID-positive patient was sent back from the hospital because they weren’t “sick enough” to be admitted.

This is exactly what we do with the general public when they arrive in the ER.  If you’re not sick enough, the best place for you to recover from COVID is at home, not the hospital.  But treating nursing home patients like everyone else is really not smart.  Long term care facilities are not designed with pandemics in mind.  They are basically converted dormitories with care staff ratios of 1:10.  Isolating patients in these facilities is close to impossible.  There are usually no flexible spaces in which to isolate residents, and the staff at these facilities are relatively lower-paid, poorly trained and ill-equipped to suddenly handle a patient with COVID that requires a significantly higher level of care than usual.

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Submissions should be between 400-800 words, although we sometimes publish longer pieces. The editors are open to opinion pieces reacting to stories and trends in healthcare, medicine, technology and wellness.

There is no hard and fast format for the posts we publish. Some look like TED Talks. Others look like they belong in the New England Journal of Medicine.  Others are traditional opinion pieces that would not look out of place in The New York Times or the Wall Street Journal.

We’re interested in thoughtful analysis of stories in the news, contrarian takes on trending stories and the established order, first person accounts from healthcare workers and people experiencing the joys of the health care system first hand.

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By ADRIAN GROPPER, MD (9)

Until scientists discover a vaccine or treatment for COVID-19, our economy and our privacy will be at the mercy of imperfect technology used to manage the pandemic response.

Contact tracing, symptom capture and immunity assessment are essential tools for pandemic response, which can benefit from appropriate technology. However, the effectiveness of these tools is constrained by the privacy concerns inherent in mass surveillance. Lack of trust diminishes voluntary participation. Coerced surveillance can lead to hiding and to the injection of false information.

But it’s not a zero-sum game. The introduction of local community organizations as trusted intermediaries can improve participation, promote trust, and reduce the privacy impact of health and social surveillance.

Building Trust with Transparency

Privacy technology can complement surveillance technology when it drives adoption through trust borne of transparency and meaningful choice.

We can try to understand privacy technology from the perspective of decentralization. Decentralization keeps all personally identifiable information under the user’s control, therefore offering total transparency over its use and total choice over how it is used.

Ideally, managing contact tracing, testing, test interpretation, symptom reporting, health records, relationships, and location history should be decentralized. This information should be entirely under the control of the individual, and contribute only aggregated learning to the collective — using differential privacy, homomorphic encryption, and split learning.

While these technologies are still too immature and expensive to be useful for the present pandemic, current technology does not force a binary choice between absolute decentralization and coerced government surveillance. Partial decentralization of technology and technology policy at the level of a cooperative, community, or town can leverage the trust many have in their local relationships and the peace of mind that comes from the ability to choose what information to share with whom.

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By NIRAN AL-AGBA, MD (3)

Two weeks ago, Gov. Jay Inslee announced that Washington will likely reopen in stages. Halfway across the globe, Denmark has already begun a gradual process lifting its nation’s coronavirus lockdown by reopening schools for children in kindergarten up through the age of 11, in an effort to prioritize the education of its youngest students. 

Kåre Mølbak, from Denmark’s infectious diseases agency SSI, commented that the decision to gradually reopen was based on the confidence that citizens would continue upholding social distancing and hygiene recommendations.  Denmark also plans to reopen in phases, though it will focus next on the return of middle- and high-school students to school by May 10. Restaurants, bars and other businesses will remain closed until “the next phase.” The ban on large festivals and other events, thought to contribute significantly to the spread of disease, will remain in place until much later, reportedly through the summer. 

Washington will likely resume activity in the reverse order in which it shut down, however, Denmark might be on to something. Children not only get milder disease, but they also seem far less likely to contract COVID-19.  A study published in the journal Nature Medicine screened 745 children who had close contact with patients or family members with confirmed COVID-19 disease and found only 10 children in the entire group tested positive. Of the 10,000 confirmed cases in Washington state, just 3% have occurred in children under the age of 19. Children’s Hospital in Seattle reported in March that out of 660 children tested, only 4 children tested positive. In my office, though I have only sent about a dozen nasal swab tests, not a single child has tested positive either. 

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By JEFF GOLDSMITH  (6)

By the end of April, the scope of COVID-19 damage to the US hospital system is becoming clearer, measured in tens of billions in lost revenues per month.    While governments can issue an “all clear” order in areas minimally impacted by COVID, restoration of normal clinical operations depends crucially on patient acceptance of the safety of the health system.  Hospitals’ path to operational recovery is fraught with complexity, and will require a disciplined, systematic approach.   

While new COVID cases and deaths seem to be levelling off nationwide,  the disappearance of hospital activity is unprecedented- 40-50% reductions in hospital admissions, surgical cases and, most unexpected of all, emergency department volumes, even for cardiac cases.  Even before state and federal officials recommended cancelling “elective” procedures, hospital executives acted in an abundance of caution, and urged patients to delay care if possible, in order to prepare for a flood of COVID cases that has thusfar failed to materialize in many places.

Given that re-opening the economy has, sadly,  become politicized, and that the public remains skeptical about the adequacy of COVID testing, it is not safe to assume that patients will come thundering back once a governmental “all clear” has been sounded.  Patients and their families still have the deciding vote and caution is likely to be the watchword.  Given these uncertainties. how should hospital and health system leaders approach restoration of their business?

Widen the Circle of Trust

The essential task is to assure the community, both directly and through clinicians, that the hospital is a safe and infection- free place for medical care.  To do this, front line clinical staff, not only in emergency departments and ICUs, but also imaging, laboratory, and regular inpatient units, as well as their supporting cast in housekeeping and food service, must feel safe and protected coming to work.  This feeling of safety presupposes the hospital’s supply of PPE meets or exceeds demand, and  that it maintains a robust and aggressive testing regime that finds both symptomatic and asymptomatic COVID cases among the workforce for isolation and treatment.  

Hospitals and health systems are frequently the largest employers in their communities.   If caregivers and support staff feel safe coming to work, and believe threat of infection has been contained, they will communicate that feeling of safety to their friends and neighbors, both by word of mouth and social media posts.     This widening circle of trust is a far more powerful force for restoration of normal operations than press releases, public service announcements, news broadcasts or paid commercial messages.  

Actively Engage Physicians

Practicing physicians, whether employed by the health system or in independent practice,  still control the decision about when to resume normal clinical activity. Physicians are anxious to return to work, but will need to communicate with patients that may have delayed receiving care, and confirm that they want to move ahead.

To make sure that the resources they need to practice are available to them when they need them, re-opening operating suites, catheterization laboratories, imaging and other services must be tightly coordinated with physicians to assure that the health system can staff and manage the renewed volume.  This complex task will be complicated by the ease with which furloughed or laid off workers can be reclaimed from unemployment and return to their supporting roles.  Particularly for lower paid healthcare workers, it may be financially stressful to return to work before unemployment coverage expires.  Availability of child care will also be a constraint, as will the work schedules of spouses or domestic partners.  

For these reasons, practicing clinicians must be closely consulted and actively participate in the phased resumption of clinical operations.   To simply fling open the doors fully staffed for normal operations and assume patients will show up is not prudent planning.  

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By DAN STONE, MD (8)

Woody Allen once commented that life is composed of the horrible and the miserable, with the latter offering merely lesser calamity.  The COVID epidemic seems to be following “Allen’s Law” as its course diverges in different localities.   Current evidence suggests that measures taken by California and Los Angeles civic authorities as well as by residents and health care providers succeeded in “flattening the curve” and are leading LA toward a merely “miserable” epidemic like Korea’s rather than an explosion like New York’s or Italy’s.  Local epidemiologists have been slow to draw conclusions from the emerging data, perhaps out of concern that even a hint optimism on the last few weeks’ battle might lead the public to believe the war is over when it still just beginning.       

With extensive testing limited by a shortage of test kits, tracking the epidemic requires extrapolation from the number of hospitalizations and deaths.    This week LA’s largest medical center continued to see a stable census of COVID-19 patients at a time that they “should” have been skyrocketing were LA headed for a New York style surge.  We now understand that the typical incubation period for COVID-19– the time from exposure to onset of illness — is about five days and the typical time from exposure to hospitalization, when it occurs, is about twelve.  So, hospitalizations provide insights into COVID transmission about two weeks prior.   The stability over that period confirms the success of the lockdown.  In the three weeks since the state’s lockdown order there have been no athletic events, no movies and no crowds at restaurants nor malls.  So, there were markedly fewer opportunities for person to person spread. 

Additionally, the stability of the epidemic in LA should persist while social distancing remains in place.  As those less compliant with social distancing become progressively infected, the remaining pool of the uninfected is increasing composed of people more attentive to risk and less prone to future infection.  In addition, with the new requirement to use face masks in public, increasing civic policing of public venues and with health systems’ improved ability to protect healthcare workers and non-COVID patients from infection, the future risk should trend downward.  Perhaps the main risk of a break-out would be new infections occurring in populations that have been relatively isolated but  lack the ability to practice individual social isolation.  This would include nursing home patients, prison inmates and the homeless.  However, in a metropolitan area of thirteen million, these populations are probably not large enough to impact the overall course of the epidemic in LA. 

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By KIP SULLIVAN

Measuring and reporting in health care has gone through three phases corresponding roughly to the 1990s, 2000s, and 2010s. During the 1990s, policymakers claimed “report cards” on the quality of clinics, hospitals, and insurance companies should be published so that “consumers” could avoid the bad actors and patronize the good ones. The doomed hospital mortality report card (dubbed the “hospital death list”), published for a few years in the early 1990s by the former Health Care Financing Administration (now CMS), and the useless report card on Minnesota insurance companies published by the Minnesota Health Data Institute in 1995, are examples.

In the early 2000s, by which time it was obvious report cards had accomplished little because “consumers” didn’t use them, Minnesota and federal policymakers decided that if report cards were not going to shift market share from the bad actors to the good, then payers (insurance companies, government programs, and self-insured employers) should punish and reward doctors and hospitals directly with bonuses and financial penalties based on report card scores. This new use of report cards was dubbed “pay for performance” (P4P) circa 2003. By the late 2000s, quality scores on report cards were being arbitrarily smooshed together with cost scores to create scores that allegedly measured “value.” With a few exceptions (Consumer Reports, CMS’s website), insurance companies were now off the hook; in the new millennium, P4P would apply only to “providers” (doctors, hospitals, nursing homes, etc.).

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By JEFF GOLDSMITH (2)

Health systems all across the United States are reeling from a once-in-a-working-lifetime crisis brought about by the COVID-19 epidemic.  Hospitals, care systems and physician practices are hemorrhaging cash in the face of an expected oncoming flood of COVID patients.  Like the prelude to a tsunami, where the tide goes out a half mile, health system revenues have fallen 25-40% month over month, as normal patient care operations have receded. 

Patients have been reluctant to use hospitals over concern about their infection risk, and fresh worries about their ability to pay their share of the cost.   It is likely that the earnings impact will be much worse, since cases being cancelled are relatively high margin elective cases from patients with private insurance coverage that pays more than it costs to take care of them. 

Even with recent increases in Medicare payment rates for care for the COVID cohort, and an increase in federal Medicaid match to support state payments for the indigent and “differently abled”,  hospitals and the health systems will come tens of billions short.

Balancing hospitals’  safety net function of hospitals with their routine care mission is always tricky, particularly in communities with no public hospitals.   The United States commits less than 3% of total health spending on public health, and has chronically underinvested in mental health, infectious disease surveillance and disaster preparedness. 

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By CHRIS DWAN

What are the most important pieces of professional advice you’ve ever received?

I remember one of mine clearly: It was in late 2004, and my colleague Bill told me that it was “time to have an idea.”

I had hired in as the first employee at a small consulting company in early summer. The founders had been handing me pre-specified projects for a few months. These early projects appeared on my desk ready-made, with the Statement Of Work (SOW) already written, the scope negotiated, and the customer interested mostly in when the resource (me) could be scheduled.

Now it was fall, and it was time for me step up my game and spec my own work. I realize now that they were tired of carrying me.

In the spirit of “learn by doing,” they dumped me on the phone with a prospective customer, the IT department for Stanford.

That, in itself, was an incredible opportunity.

Rookies look down on “sales.” I know now about the grinding work that leads to calls like that. The series of interactions with gatekeepers whose only options are to say “no” or else to continue the conversation. The people on the other end of this call could say “yes.”

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By DAVID SHAYWITZ, MD (1)

Technology has been hailed for its ability to connect us; we’ve tended to view this is a positive development, but as rare, high-impact events like the coronavirus epidemic reminds us, a densely-networked world may also be more fragile.

The mixed blessing of interconnectivity was acknowledged back in 2005 by New York Times columnist Thomas Friedman, who observed:

“…we are now in the process of connecting all the knowledge pools in the world together. We’ve tasted some of the downsides of that in the way that Osama bin Laden has connected terrorist knowledge pools together through his Qaeda network, not to mention the work of teenage hackers spinning off more and more lethal computer viruses that affect us all. But the upside is that by connecting all these knowledge pools we are on the cusp of an incredible new era of innovation, an era that will be driven from left field and right field, from West and East and from North and South.”

For techno-optimists like Erik Brynjolfsson and Andrew McAfee, authors of The Second Machine Age, improved interconnectivity catalyzes what they call “recombinant innovation.” This is the idea that “the global digital network” enables us to “mix and remix ideas, both old and recent, in ways we never could before.”

They continue: “Digitization makes available massive bodies of data relevant to almost any situation, and this information can be infinitely reproduced and reused because it is non-rival. As a result of these two forces, the number of potentially valuable building blocks is exploding around the world, and the possibilities are multiplying as never before.”

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By ANISH KOKA, MD (5)

As the globe faces a novel, highly transmissible, lethal virus, I am most struck by a medicine cabinet that is embarrassingly empty for doctors in this battle.  This means much of the debate centers on mitigation of spread of the virus.  Tempers flare over discussions on travel bans, social distancing, and self quarantines, yet the inescapable fact remains that the medical community can do little more than support the varying fractions of patients who progress from mild to severe and life threatening disease.  This isn’t meant to minimize the massive efforts brought to bear to keep patients alive by health care workers but those massive efforts to support failing organs in the severely ill are in large part because we lack any effective therapy to combat the virus.  It is akin to taking care of patients with bacterial infections in an era before antibiotics, or HIV/AIDS in an era before anti-retroviral therapy.  

It should be a familiar feeling for at least one of the leading physicians charged with managing the current crisis – Dr. Anthony Fauci.  Dr. Fauci started as an immunologist at the NIH in the 1960s and quickly made breakthroughs in previously fatal diseases marked by an overactive immune response.  Strange reports of a new disease that was sweeping through the gay community in the early 1980’s caused him to shift focus to join the great battle against the AIDS epidemic. 

The first reported cases of AIDS were reported in the United States in the 1981 Morbidity and Mortality Weekly Report.  5 young men, all previously healthy and all active homosexuals were found to have Pneumocystis carinii pneumonia, a disease that prior had been restricted to the severely immunocompromised.  An avalanche of clinical reports subsequently woke the nation to a disease that appeared to have a predilection for the gay community.  The remarkable subsequent successes of medical therapies that followed to make AIDS a manageable disease to grow old with are now a matter of history, but in the early years this success seemed anything but inevitable.

The charge leveled against the establishment of the day by a public becoming aware of the tragedy of young, previously healthy individuals dying by the thousands was that there was an attempted cover up of a ‘dirty’ disease in a community America would rather not talk about.  But from the first description of the disease by the medical community, the activity in the research industry (both public and private) was intense.  It took 2 years for two labs to simultaneously identify the HIV virus that appeared responsible for the development of AIDS.  Elaborating the mechanism by which the virus destroyed the body’s immune system lead to the discovery of potential therapies. 

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Frequent updates. Email us a .

The Trojan Virus – COVID19

# International

Coronavirus may have infected half of UK population — Oxford study

— Financial Times (@FT)

# Trending on Twitter

It’s working! | scuba gear based ventilators cc ht ⁦⁩

— Azeem Azhar ()

# John

Two weeks later this from is looking prophetic.

Go read it. And remember, there were people who saw this coming and tried to warn us.

There will be more warnings to come.

We need to listen to them.

— John Irvine ()

By NIRAN AL-AGBA, MD

The Trojan Horse is a tale about subterfuge.  After a decade of war, the Greeks had made little progress against the Trojans so they constructed a huge wooden horse and hid a select force of men inside.  Believing the Greeks sailed away, the Trojans pulled the horse into their city as a victory trophy. That night the Greeks crept out of the horse and unlocked the gates for their fellow soldiers, who had sailed back secretly.  The Greeks ended the war by destroying the City of Troy.

COVID-19 is our Trojan Horse.  It has snuck inside the gates and attacked.  How do we fight against an enemy we don’t entirely understand?

When the first presumptive positive case was reported in Kitsap County this week, my clinic began screening patients and their parents for fevers.  As a result, not a single febrile person has stepped through my front door since last Monday, March 9.  There is a temperature triage station set up under a Seattle Seahawks tent in front of my clinic.  For the record, I am no fan of professional football, and I never imagined it would serve as a triage station.

If a patient has a fever, they are asked to return to their car for what is now called a “car visit.” During the measles outbreak, I did “car screenings” to make clear patients to come in to the clinic if they had a rash.  Examining young children out in freezing temperatures while standing outside a car is a whole different thing entirely.

There is no precedent here.   

For a “car visit,” I leave my office and walk into an empty building next door.  In there, I  put on a different jacket (in lieu of a gown, which I don’t have), safety glasses and an N-95 mask, pick up my leather doctor bag—which contains its own set of medical equipment, pen, prescription pad, and other essentials—and walk to the patient’s car, which is waiting in a makeshift “drive through” spot next to my clinic.  

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By ROB LAMBERTS, MD

Updated – 3/11/2020

Things are developing regarding the spreading epidemic/pandemic and so here is an update to let you know the state of things, what we are doing, and what you should do.

There have now been more than 120,000 cases worldwide, with over 1000 in the US. Italy (as an example of what could happen here) is in crisis, with more than 10,000 documented cases and ER’s and hospitals flooded with very sick patients. Schools across the US (including Atlanta) have closed to decrease the spread of the virus. The pattern of illness remains the same:

• People present with a flu-like illness (fever, body aches, cough) with focus of infection more on the lungs.
• Children are largely spared from the severe disease, with the majority of deaths being in the elderly or otherwise high-risk individuals.

The problem we face here is twofold:

1. We don’t have a good test available to diagnose COVID-19 in a clinically useful way (rapid and simple)
2. Even if we did, there is no clear treatment for COVID-19, other than supportive care.

How We Are handling patients with Flu-like Symptoms

• We are trying to identify patients who may have coronavirus and treat them outside of our clinic. While we want to help people who are sick, we don’t want to expose high-risk people to the virus. So…
  
• We ask that if you have a fever or flu-like symptoms, that you do not come into the office. Instead we ask you to contact us via phone, email, or via Spruce. Be patient, as we are likely very busy with other sick people!
  
• Please tell us about your symptoms and we’ll guide you in what to do next.  This may include triage and evaluation in our parking lot.  Remember that we cannot diagnose you, and we cannot give you any treatment if you do have the virus. Yes, that makes things very difficult for all of us, but it is the situation we face.
  
• Also understand that we may have high-risk people at the office with other problems. Infected individuals in our office may spread the infection to others, so please understand, and don’t demand special treatment.
  
• If possible, do not come to the office if you are a high-risk person:
• – Over age 70
• – Diabetic (poorly controlled)
• – Significant lung problems (COPD, moderate/severe asthma)
• – Other immune-compromising problems or medications.

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By FRANCINE HARDAWAY

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I’m writing this for the ER doc who I have a feeling I’m going to be meeting one day soon.

I thought I’d introduce myself.

I’m the one who is going to be triaged: 78 years old, comorbidity of hypertension, not enough useful life left to bother with.

How do I feel as one of the people in the at-risk category? Awful. Mentally awful. There’s no way to escape this virus. Not the virus, but the knowledge that the country is in a state of chaos, doesn’t have enough hospital beds or ventilators, and will be resorting to triage, even though nobody is admitting it yet. I hear the dire predictions about people dying in hallways in my sleep.

Which is not, of course, how I viewed my life two weeks ago. 

That person I saw in the mirror? Still self-supporting, a yogi and a denizen of the gym.  Flexible and fit. Walking 4 miles a day. Still pretty mentally sharp. 3 dogs and a huge network of social connections. Three or four invitations to lunch and dinner every week.

But now my life has been turned upside down. Outside of walking the dogs, I’m a shut-in. If I have to go to the grocery store, I go just as it opens, and I wipe my cart down carefully. I run into the house, put the bags down on the table, and wash my hands. I feel like I have taken an unnecessary risk for navel oranges, vegan cheese and salt free snacks.

I’ve done all the reading. Virologists are the worst for making people fearful. They deal in worst case scenarios. Then come the engineers, who are good at predictive analytics. Many of my younger friends are in Silicon Valley, and they’re hunkering down. They took their kids out of school weeks ago.

In sunny Arizona, day after day they tell us we have nine cases. They’ve canceled all our tourist season, so other than community spread, we won’t have outside infection. Or will we? Or do we already?

I know too much.  I’ve been in health care one way or another for most of my working life, either married to a physician or helping health-related companies get started, or marketing them. So I know that although I’m taking all the precautions I can, I’m never totally sanitized. I feel like climbing into the shower and staying there. I put vaseline at the end of my nose every morning.  I pray to my nasal passages: cilia, keep me free. I order immune-boosting herbs.

 I’d like to call a local emergency room and find out if they are overrun. I’m starting to look for ER docs in my network, just to see what’s really happening, because they have the best chance of knowing.

The women I walk dogs with in the morning have differing political beliefs. We argue a lot, partly because we disagree, and partly because it’s the only fun we have. I’m the yogi, the one who keeps pointing out that we’re stuck with each other for the next six months at least, and we have to get along.

You can imagine what my political beliefs are. I have become some sort of fanatical conspiracy theorist. But this is wrong. Why should it be President Trump’s responsibility to come up with a plan?  Where is the healthcare industry? They’re the ones who decide the number of beds we will have, and how to spend money they could have spent on ventilators and respirators. If they’ve spent it on their own salaries and profits, that’s not his fault. I’ve fallen down a rabbit hole trying to get back to first causes. If we had universal coverage, if we had pandemic planning, if we had more money given to health and less to the military, if,if,if…

But we are where we are. I’m going to put on some disco music and do some floor exercises at home, all while wondering how clean my floor actually is.

By RICHARD GUNDERMAN, MD and MOHSIN MUKTAR (3)

Ironically, the same electronic health records (EHRs) initially designed as a tool to help physicians diagnose diseases have largely evaded diagnostic scrutiny. Talk to physicians who utilize them on a daily basis, however, and it becomes abundantly clear that today’s EHRs are ailing. They are adding hours to the physicians’ workday, siphoning attention from patient care, and sowing the seeds of demoralization across the profession of medicine. To address this problem effectively, physicians need to shift their focus from the symptoms associated with EHRs to the underlying diagnosis.

A key to arriving at the most accurate diagnosis is to cease treating EHRs as information technology problems and instead regard them as organic problems, not so different from the categories we would use in diagnosing a patient. Specifically, we need to seek out a known disease or diseases onto which many of the problems with EHRs can be mapped. In so doing, it is not our intention to stigmatize any disease or the patients who suffer from it, but instead to help physicians peer more deeply into the nature of the electronic malady with which they are wrestling.

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By JEFF GOLDSMITH (13)

After a decade dominated by ObamaCare- its enactment in 2010, the fraught implementation, its near repeal in 2017, and the welter of inconclusive experiments with Medicare payment reform – healthcare in the 2020s is likely to be reshaped by technological and scientific advances, as well as continued political struggles over societal and family cost.  We can expect major change in seven areas:

1. Rising Patient Safety Risks. 

Two emerging patient safety risks will spike in seriousness during the 20s.  One risk, that of drug resistant bacterial infections, boiled under the surface for more than two decades, with the rise of MRSA,  Candida aureas, Clostridiodes difficele and more than a dozen other agents.  

Nearly three million people were infected with these agents in 2017, and more than 48 thousand died.  While hospital infection control has improved, and deaths from hospital infections fell during the 2010’s, antibiotic drug development has lagged, and the potential for one or more breakout infection risks is highly likely in the 2020s.   The Economist published a chilling and entirely possible scenario in July, 2019.

The second major risk has resulted from the confluence of two information technology (IT) trends-  the migration of health system clinical and financial operations to the Cloud and the 5G-enabled connectedness of medical devices and hospital infrastructure to the Internet, the so-called Internet of Things (IOT).  These two linked migrations opened a gaping digital “back door” in hospitals and systems to “black hat” hackers.

The fall of  2019 saw two major health systems-Tuscaloosa-based DCH Health System (AL) and Hackensack Meridian (NJ) – succumb to ransomware attacks that paralyzed clinical operations for days before the system paid cyber-extortionists to stand down.  However, there is a more threatening risk of mass patient casualty episodes in hospitals if hackers gain control over critical life support functions like respirators, infusion pumps, oxygen systems, HVAC and electrical systems.

The virtually unmanaged spread of connected devices and systems in hospitals is a significant threat to patient safety.  Health systems and regulators will be playing catch up in both these patient safety domains during the 20s as the degree of patient risk becomes more clearly understood.  

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By RICHARD GUNDERMAN, MD (9)

The news was bad. Mimi, a woman in her early 80s, had been undergoing treatment for lymphoma. Her husband was being treated for bladder cancer. Recently, she developed chest pain, and a biopsy showed that she had developed a secondary tumor of the pleura, the space around one of her lungs. Her oncology team’s mission was to share this bad news.

Mimi’s case was far from unique. Each year in the U.S., over 1.6 million patients receive hospice care, a number that has been increasing rapidly over the past few years. What made Mimi’s case remarkable was not the grimness of her prognosis but her reaction to it.

When the members of the team walked into Mimi’s hospital room, she was lying in bed holding hands with her husband, who was perched beside her on his motorized wheelchair. The attending oncologist gulped, took a deep breath, and began to break the news as gently as he could. Expecting to meet a flood of tears, he finished by expressing how sorry he was.

To the team’s surprise, however, no tears flowed. Instead Mimi looked over at her husband with a broad smile and said, “Do you know what day this is?” Somewhat perplexed, the oncologist had to admit that he did not. “Today is very is special,” said Mimi, “because it was 60 years ago this very day that my Jim and I were married.”

The team members reacted to Mimi with astonishment. How could an elderly woman with an ailing husband who had just been told that she had a second, lethal cancer respond with a smile? Compounding the team’s amazement, she then went on to share how grateful she felt for the life she and her husband had shared.

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By NORTIN HADLER, MD

To live a year without a backache is abnormal.

Backache is an intermittent predicament of life. No one is spared for long. Furthermore, no approach to avoiding the next episode has proven effective when submitted to scientific testing. To be well is not to avoid backache; it’s to have the wherewithal to cope effectively and repeatedly. 

Almost all of the people we will be talking about in this book were afflicted with regional backache, and that is the only type of backache we will consider here. I coined that term for an editorial in The New England Journal of Medicine over twenty years ago.¹ Regional backache is the back pain experienced by people who are otherwise well. It comes on inexplicably, usually suddenly, in the course of activities that are familiar, and customarily comfortable. This is the common, everyday backache. We will spend some time considering some of the more frequent complications of a regional backache, particularly the “pinched nerve,” which can cause pain to radiate down the leg. We are not going to consider the unusual causes of backache such as metastatic cancer, infections, or inflammatory diseases of the spine. Nor will we consider the back pain that can result from accidents and other traumatic events.

While I am talking about what this book is not, let me say that it is not a self-help manual. Nor is it a medical textbook. Backbone is an exposé of a contrived “disease” and the enormous enterprises it has spawned that conspire to its “cure” and provide fall back when a “cure” is elusive. That industry has developed a life of its own despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American’s wherewithal to cope and persevere, and the American pocketbook are paying a heavy price. 

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By RICHARD GUNDERMAN, MD

Medical historian Stanley Reiser wasn’t kidding when he entitled his best-known book, “Medicine and the Reign of Technology.”  To a large degree, technology has taken over medicine.  I am not talking primarily about our increased reliance on such technologies as advanced imaging equipment or assistive procedural devices.  In such cases, the technology remains largely a tool, and the wielder remains basically in charge.  I am talking about a far more pervasive and insidious form of technology whose very name tells a good part of the tale – health information technology.

Many physicians and other health professionals find health information systems clunky, perverse, and intrusive, but their problems go far deeper.  Underneath unwieldiness lies the temptation that we begin relying on such indicators to such an extent that we stop attending to our internal resources.  Consider the case of the patient said in his admission note to be “status post BKA” – below the knee amputation – but who turns out on rounds to have ten toes.  What happened?  DKA – diabetic ketoacidosis was mis-transcribed into the medical record as BKA, and the error simply propagated like a virus.

At stake is what we mean by knowledge.  Is what we know defined by our own experience – what we have seen, heard, felt, and perhaps even intuited in the presence of the patient?  Or do we instead rely on what is represented on a computer screen?  Which is a more likely occasion for us to exclaim, “That can’t be right!” – when what the computer screen indicates does not comport with what we have observed of the patient, or when what we have observed in the presence of the patient does not jibe with what the computer is telling us? 

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By MARGALIT GUR-ARIE ( 4 )

For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.

It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before.  The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.

At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.

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By KIP SULLIVAN, JD (10)

Three weeks ago I posted a comment here about a decision by the Minnesota Supreme Court in the case of Warren v. Dinter. In that case, the court held, by a 5-2 margin, that hospitalists (and, therefore, the hospitals they work for) can be sued for malpractice even if they were not in a treatment relationship with the patient. I took the position that that decision was the right one. (If you haven’t read my first article, I urge you to do so to understand the facts of the case.)

The ensuing discussion about my article focused primarily on which, if any, of the three health care professionals involved in the decision not to hospitalize Susan Warren were culpable. The question of whether other parties – the hospital, the chain that owned the hospital, Accountable Care Organizations (ACOs) established by the chain, and insurance companies – should be subject to liability received relatively little attention. Two who did comment explicitly on that issue made it clear they thought even asking about third-party culpability was verboten.

In this sequel to “Why did Susan Warren die?” I want to focus on the question, Shouldn’t third parties who make, veto or influence medical decisions be exposed to malpractice lawsuits? My answer is yes. If the answer is yes, then we must support the Warren v. Dinter decision. Imagine if the Minnesota Supreme Court had taken the opposite position. Imagine that the court decided that injured patients cannot sue third parties unless the employee of the third party (the doctor or nurse) who made the decision in question was in a treatment relationship with the patient. Is it not obvious that such a decision would slam the courthouse doors on all patients injured by employees working for insurance companies, hospitals, hospital-clinic chains, and ACOs who were not treating the patients? 

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