Sunday, April 5, 2020

CDC Advises Cloth Masks for Everyone. Why Now?

I haven’t seen so many masks since I was a Trick or Treater.  Even as a physician, I have worn surgical masks very rarely as it was uncommon for me to be in an operating room, where masks and gowns are part of the dress code.  Until I embarked upon a transition to telemedicine recently, many of the patients coming to see me in the office were masked.

The official dogma on wearing masks during the pandemic is evolving. Experts at the Center for Disease Control and Prevention (CDC) the World Health Organization (WHO), the Surgeon General as well as many prominent public health officials had advised just recently that masks were not an effective barrier against coronavirus.  This is why asymptomatic individuals were not advised to mask up.  In contrast, we were told that these masks should be worn by symptomatic individuals who were coughing or sneezing as masks may reduce the risk that others will become infected.

Just days ago, there was a sudden change in policy.  Now the CDC and many of the president's advisors and others are recommending widespread cloth mask use to keep those who are silently infected from transmitting the germ to others. The WHO has not signed on to these revised recommendations. While it is still true that cloth face coverings are not likely to protect a healthy individual from infection, the hope is that such a barrier may prevent a asymptomatic infected individual from spreading the virus.  It's not clear to me why the revision was issued now as we have known for months that asymptomatic individuals can spread the infection.  The explanation for the policy change has been murky  

Could there be a downside?

It is confusing when an important safety recommendation undergoes dramatic and abrupt revision, particularly when there is already endemic anxiety.  The public needs consistent messaging.  It is unsettling when organizations, experts and government officials have different opinions on what precautions we should take.

Here are some of my concerns about widespread use of cloth face coverings:
  • Frequent adjusting of the cloth covering by new users will increase hand to face contact, which is a sure method of coronavirus infection
  • Individuals, despite CDC advice, may use medical grade masks which should be reserved for medical professionals
  • False sense of security of masked folks who may relax their social distancing practices, which every expert maintains is our paramount strategy to flatten the curve and save lives
  • Symptomatic individuals who should be at home might feel that a mask will allow them to enter out into the community risking transmission as they may believe that they are less infectious
  • Will mask wears know how to carefully remove the mask when they return home, clean it after every use and wash hands well when placing and removing the mask?
Don't misunderstand me.  I'm not qualified to opine on the wisdom of the policy.  I do think that the abrupt policy change and mixed messaging is confusing.   And, I don't think it's quite as simple as slap on a mask and all will be well.  I offered above a listing of some of my concerns that I do not think have been sufficiently considered or publicized.  .  
I worry that the expanded attention and use of masks may distract us from two measures that every expert unwavering insists upon.   Keep your distance consistently  And wash your hands often and thoroughly as if you have just touched the virus. 

Sunday, March 29, 2020

Do Doctors Wash Their Hands Properly?

There is no person unaffected by the coronavirus pandemic.  It does seem that the public and the government are responding belatedly in a manner commensurate with the threat.  I write this knowing that less than a week ago from the time I am composing this, Florida beaches were teeming with vacationers.  A memorable quote from one of these selfless and enlightened partiers was:

“If I get corona, I get corona. At the end of the day, I’m not gonna let it stop me from partying.”

This individual, from my own state of Ohio, did apologize for his remarks.  I would suggest that his mouth be mandated to take a 14 day quarantine from all speech. 

Look, we’ve all said dumb stuff.  I know I have.  My advice?  If you sense some dumb words about to erupt, and there are cameras rolling, sprint in the opposite direction as if the coronavirus is on your tail and gaining ground.

Right now, Ohio and many other states are in a ‘shelter-in-place’ status, in an effort to enforce social distancing.   I’m trying to do my part.  I’ve learned about curbside grocery pick up.  I haven’t shaken hands in weeks.  I try to keep my distance from others as best as I can. And, I am practicing telemedecine.  I watched a video that demonstrated ideal hand washing technique.  I’m in a profession that should be model hand scrubbers.  I’ve washed my hands probably hundreds of thousands of times and I’ve seen many colleagues lather up.  But I’ve never seen hand washing as depicted in the training video. This was no mere soap & water exercise.  It was a performance, a veritable choreography of cleanliness.   In other words, I think my own profession could use a hand hygiene refresher course, as could the rest of us.

Scrub Vigorously
(You Don't Have to Get This Deep.)

Interestingly, when the president and his medical minions are giving their frequent news conferences, they all seem huddled together, much closer than 6 feet apart. 

But, at most I’ve been inconvenienced during the pandemic.  For so many, this pandemic has been devastating medically and economically.  The job losses and company closures are horrifying.  I am more sanguine about prevailing over the virus than I am over recovering our economy.   And, there is tension between public health experts and many in the business world about when to permit economic activity to resume.  

As I write this, the U.S. Senate has still not agreed on the zillion dollar recovery package, which I anticipate will occur shortly.   If there was a legislative bill that was against cancer, would it be able to pass the House and Senate easily? I wonder.

We will get to the other side.  And, we will recover eventually.  But we will not be the same. We and the world will have learned about the ferocity and tenacity of an invading microbe and the strategy and tactics necessary to defeat a wily and stealth enemy.   And, we will surely need these battle skills again and again. 

Sunday, March 22, 2020

Coronavirus or Coronoverse?

A worker was told of corona.
Who's boss said, "You're on your own-a."
"Leave the arena"
"Begone! Quarantina!"
"You mean I'm gonna be all alone-a?"

Coronavirus - An Invisible Foe

We will get to the other side.   Clearly, the path to a safe and secure future has not been a straight shot.  Both the government and the public have fallen short. The initial coronavirus testing launched here was a debacle, in contrast to other countries that knew how to aim straight.  We have seen price gouging for hand sanitizer and face masks.  As recently as this past Thursday, Florida beaches were teaming with folks who brazenly and selfishly risked contracting the virus and transmitting it to others.

But, most of us have fallen into line.  And, so have our leaders.

I feel more sanguine that we will prevail in the medical arena than we will on the economic front.

Epidemics and pandemics will join the array of natural disasters that have become commonplace events in our lives.  And, we will learn to combat them more skillfully.

It's scary.  It's surreal.  A microscopic entity with no brain and no motive can bring the world to its knees.  The world will surely stand up again, but we may need to hold on to each other.

Sunday, March 15, 2020

Doctor-Patient Relationship Needs John Adams

In 1770, in Boston, British soldiers fired into a crowd of colonists who were taunting the soldiers.  Several colonists died and several soldiers were arrested and charged with murder.  This event known as the Boston Massacre was a seminal historical episode that contributed to the colonists’ growing desire to separate from the British Crown.

Boston was a cauldron of the independence movement.   Hatred against the British was prevalent.  Who would be willing to defend the accused soldiers at trial risking opprobrium or worse?  John Adams, our future second president, defended the soldiers believing that every accused deserves adequate representation.  To this day, America distinguishes itself with our belief and practice that an accused man is presumed innocent and is entitled to a competent legal defense.  As we all know, lawyers are often assigned or volunteer to defend unsavory individuals to protect their clients’ constitutional rights, ensure that the legal process is being respected and to prevent a rush to judgement from taking hold.  Understandably, many lawyers would not rush to defend accused child molesters, terrorists, white supremacists, kidnappers or abusers of the elderly or other vulnerable people, and yet these accused people fully deserve and are entitled to representation. 

John Adams Sets Example for Doctors

But, John Adams accepted defendants who were reviled and thereby burnished his own reputation as a principled statesman performing the noble mission of the legal profession.  Six of the soldiers were acquitted and two were convicted of manslaughter.

Both lawyers and physicians don’t choose their customers.  They come to us.  While many who come to physicians for assistance are pleasant and cooperative, others have less sanguine traits.  I have seen patients who are argumentative, demanding, rude, dishonest, hostile and overtly racist.  A few days before writing this, one of our secretaries became rattled when a patient cursed her. Of course, patients who are worried or sick are entitled to great latitude, which doctors and our staffs extend to them.  But, aside from this, there are disagreeable patients whom I just don’t like.  But, these folks are entitled to the best medical advice I can provide, and I do my best to meet this obligation.  Everyone has a right to competent medical care.  But, as doctors and nurses would testify, it is easier to do our jobs when patients and their families are pleasant and cooperative.

First, let me admit that not every physician is a clone of Marcus Welby, MD, and patients may legitimately complain that some of their doctors are wanting in their bedside manners and attitude.  If readers wish to speak on this issue, leave a comment.

There is no application process to become a doctor’s patient.  Universities and employers can reject applicants, but physicians, for the most part, see everyone.   While I like and enjoy the majority of my patients, there are some whom I serve despite harboring some negative feelings.  And, of course, even those whom I enjoy being with may have a variety of private views and opinions that differ from mine.  Part of my job is to make sure that any personal feelings I have do not interfere with my ability to serve the patient well. 

I’d like to think that I could serve any patient, but I recognize that this idealistic statement is not realistic.  Humans cannot be expected to exhibit superhuman behavior.  If the doctor-patient relationship is strained beyond the point where the doctor can give sound and sober medical advice, then the physician may need to step aside. 

John Adams has set a stratospheric example for lawyers, physicians and, indeed, for all of us.

Sunday, March 8, 2020

Has Coronavirus Infected our Politics?

Have you heard enough about Coronavirus yet?   If not, feel free to tune in to the Coronavirus News Network, also known as CNN.

I have zero medical experience in virology and public health, so read no further if you are looking for a Whistleblower travel advisory or if it’s safe to pet Scruffy if he develops a fever.

I’m also not here to gripe about our nation’s response to this incipient pandemic.   Although we have a first class team in place now, even they admit that they stumbled initially.  I'm more interested in making progress than in racking up debate points.

My observation is that there is no issue or event that is immune to politicization, a reality that depresses me.  We all agree that prior to the virus’s emergence from China, we were already rabidly hyper-polarized and hyper-partisan in the zero sum game that now defines our political landscape.  I won’t add to this sentence so as not to waste readers’ time in reading what we all know and agree on. 

On many issues we should expect differing views from our two main political parties that are philosophically distinct.  For example, changing income tax rates, border issues, health care policy, funding our defense department, trade policy are examples that will give rise to spirited policy debates. This is as it should be.  During normal times, meaning decades ago, these differences would be debated and a solution forged by resorting to the diabolical technique called compromise. 
But, or so I had thought, some issues should hover above this chaos in the rarefied region of the stratosphere where reasonableness prevails.   

Illustration of Coronovirus
Is it Democrat or Republican?

To offer an absurd hypothetical, if a lawmaker offers a bill declaring cancer to be evil, would this pass unanimously?  It seems non-controversial, but who knows?  Perhaps, the opposing party might be suspicious of the motive, or fear that this is the entry point to the slippery slope that will lead to Medicare for All.   Or, the opposition will agree to vote for the bill only in exchange for votes on some unrelated issue.  We all know how this works.

I have hear many pundits and partisans in recent days who can’t resist taking political shots at their adversaries when they are questioned about Coronavirus issues.  These crass responses give this gastroenterologist heartburn.   Let them save their partisan venom for an appropriate issue.  Coronavirus is a potential global health crisis and, as a medical professional, I assure you that it is non-partisan.  It will infect anyone.  So, when a salivating political hack is asked about it, he should be telling us how he intends to help rather than angling for a cheap political dividend.

I wonder how my patients might react if I queried them about their political leanings as they were about to be sedated before undergoing a procedure.  

Sunday, March 1, 2020

Can Sherlock Holmes Teach Today's Doctors?

To Sherlock Holmes, she is always the woman.   Thus begins Conan Doyle’s, A Scandal in Bohemia published in 1891.   In this gripping tale, Holmes is bested by a woman who proves to be the detective’s equal in intelligence and deception.  

For reasons I cannot explain, I restrict my exposure to Holmes and Dr. Watson to podcast listening when I am airborne.  Years ago, I did love watching the classic movies starring Basil Rathbone and Nigel Bruce who defined the roles for me. 

Conan Doyle, a physician, was a superb story teller, who wove his tales with texture, plot and humanity.  I think he wields words with surgical precision.   I admire his skill.

I wonder to what extent Conan Doyle’s medical training influenced his writing?  Certainly, the stories often discuss arcane medical conditions that provide the detective with important clues.  In The Adventure of the Blanched Soldier, Holmes suspects that the protagonist is suffering from leprosy, a diagnosis that is revised after Holmes arranges for a consulting dermatologist to examine the soldier. 

Holmes would have been master diagnostician.

Beyond these medical intricacies that the author includes, I suggest that Conan Doyle has a more direct connection to the world’s most famous sleuth.  Physicians operate as detectives.  We gather facts and evidence in real time.  We have suspicions which may be strengthened or refuted as additional data emerges.  There may be competing theories that torture us.   At times, we are forced to make judgments and recommendations when our knowledge base in incomplete.   And some of our patients’ dilemmas remain unsolved, similar to crime solvers’ cold cases. 

In The Sign of the Four, Holmes remarks to Watson, How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth.  Holmes would have been a superb physician.  

Sunday, February 23, 2020

Can Doctors Help You Lose Weight?

As a gastroenterologist -a trained specialist in digestive issues - I should have expertise in obesity, nutrition and weight loss strategies.  I really don’t.  While I have knowledge on these issues that likely exceeds that of most of my patients, I received inadequate formal training on these subjects during my gastroenterology training.   It is inarguable that digestive doctors – and indeed all physicians – should bring a high level of expertise on these medical issues into their exam rooms.  The impact of obesity reaches nearly every medical specialty.   Obesity is linked to heart disease, stroke, cancer, arthritis, diabetes, sleep apnea, high blood pressure and many other illnesses. 

Most of my overweight patients tend to remain so.  Many of them are simply resigned to a shape and size that they feel they cannot alter.   Some are not motivated to engage in the hard work and long journey that can lead to a leaner dimension.  Some do not recognize that successful weight loss requires a steely and sustained mental commitment to the task.  Others have food addiction issues and need an appropriate strategy to break through.   Some are convinced that they are plagued with a lethargic metabolism that retains pounds despite minimal food intake.  Many eat, not because they are hungry, but because of anxiety and stresses in their lives which have not been adequately addressed. 

Of course, medical professionals need more knowledge and skill in addressing nutritional issues.  How relevant are these skills to medical practice?   According to the CDC, over a third of American adults are obese.   And, more of us will be classified as obese if the definition of obesity is broadened.  This is analogous to what has happened with diagnosing folks with elevated cholesterol levels.  The medical profession, with a huge assist from the pharmaceutical industry, has lowered the ‘normal’ level of blood cholesterol over the years.  The result is that previously healthy people now have a cholesterol condition.   We saw a similar result last year when ‘normal’ blood pressure levels were made lower which instantly created millions of new hypertensive individuals.  Now, many of them may be subjected to the risks, expense and psychological effects of being told that they are diseased.   The argument, of course, is that this more aggressive approach saves lives.   Let’s see over the next decade or two if this hypothesis will be supported or refuted by medical evidence.   Keep in mind that many medical ‘breakthroughs’ announced with fanfare and optimism have been proven wrong. 

So, if you are among the millions who are struggling to shed some pounds, there are pathways available.   It can be a challenging road.  After all, if it were easy, then we'd all be think.  But, it can be done.  The first step on the journey takes place in your mind.  Are you all in?  

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