Sunday, January 23, 2022

Vaccination is Tyranny!

Thus far, to the best of my knowledge, I have dodged infection with the coronavirus.  I am up-to-date on the recommended vaccinations and have comported myself with caution.  However, I am not in a state of personal lockdown and I still enter area retail establishments to make personal purchases, although I am always masked.  Currently, I am sipping a sugar-free peppermint mocha in a very sparsely populated coffee shop.  I accept that public health experts might challenge my definition of cautious.  Indeed, I’m sure many of them wouldn’t step foot, let alone a toe, into a supermarket these days.

But the risks of catching the corona on my personal forays in the community pale next to the risks I face each week at work when I am in direct contact with several dozens of patients and staff.  The omicron variant spiked into the stratosphere here in Northeast Ohio, but thankfully it appears to be in a steady descent now. It does not seem that the vaccines and boosters protect us against omicron infections as much as they do against serious illnesses.

The percentage of Americans who have been vaccinated has plateaued.  Clearly, those who have not yet been vaccinated have no intention to do so.  Perhaps, some might decide that the vaccine is preferable to job loss. But many will walk away rather than succumb to what they perceive to be an assault on their personal freedom.

There is always a patient or two I see in the office each day who are unvaccinated. Being a seasoned professional, I inquire of them in a measured and neutral manner as to what their concerns are.  'The reasons span a wide spectrum ranging from ‘I don’t believe in it’, ‘they rushed it through’,  I’m already immune' or 'it’s not safe'.


Recently, I heard a more strident exhortation of vaccine antagonism.

‘I won’t let a tyrannical government tell me what to do!’

I reflected on this angry remark afterwards and thought it was possible to connect it back to the January 6th insurrection.  Many of those who stormed the Capitol that day likely felt that they were attacking tyranny in the same way that the colonists rose up against the British a few centuries ago. But, of course, the January 6th insurrectionists can never be fairly analogized with Paul Revere, Benjamin Franklin  or Thomas Paine.  The January 6th rioters were not seeking freedom but tried instead to dismantle our freedom as they joined together on their evil joyride over the cliff.

If only there were a vaccine for every illness.  However, we can see plainly that there are maladies out there that we are not able to prevent or treat.

Sunday, January 16, 2022

Gray Areas in Medical Ethics

While I may consider myself to be an ethical practitioner, I am in imperfect member of the genus, Homo, practicing medicine in an imperfect world.  I don’t commit Medicare fraud or lie to my patients.  When I commit an error, I admit it.  I often counsel patients against proceeding with endoscopic studies, because I don’t feel they are medically necessary.  I do my best to keep my patients’ interests as my paramount concern.

But the world of medicine doesn’t always have bright lines and borders to keep us confined to an ethical zone.  Physicians and ethicists argue over where to draw these boundaries.  What was regarded to be unethical 10 years ago has become standard medical operating procedure in many instances.  Consider how the field of reproductive medicine has evolved.  The definition of death has been relaxed in order to increase the human organ donor pool. We will surely see human cloning in our lifetime.  Medical ethics is not easy to define.

Community physicians like me must tread into the ethical gray area at times.  Do these indiscretions contaminate our personal integrity? 


Could Noah Webster Precisely Define Medical Ethics?


Imagine you are the physician in the following common scenarios. How would you respond? 

A 30-year-old comes to the office with nausea.  He insists that an upper endoscopy be performed so that he can be reassured that no serious issue is present.  I advise that the test result will likely be normal.  I offer a less invasive and safer x-ray examination, but he wants the Cadillac scope exam.  Do you acquiesce and arrange the requested scope test?

A 60-year-old comes to see me because she seeks antibiotics.  She has a cold and antibiotics are not medically indicated.  She rejects my explanation and is unconcerned about the risks of antibiotics.  She points out that her previous doctor, who recently retired, always gave her antibiotics a few times each year for the exact same symptoms, which she believed was responsible for her rapid recoveries.  Do you cave?

You are a gastroenterologist who is asked to place a feeding tube in a failing and demented nursing home patient. The primary physician has already recommended the tube to the family who have been told that we cannot ‘just let her starve’.  The family accepts this physician’s advice.  The gastroenterologist is highly skeptical that the individual will derive any medical benefit or comfort from the procedure, but he has been called in simply for his technical expertise, not to offer an opinion.  Do you keep mum and place the tube as ordered?

While the principles of medical ethics are firm, the landscape can be murky and it can be challenging to find the light among the shadows.  


Sunday, January 9, 2022

Tennis Star Djokovic Held Captive in Australia?

Should the Serbian government send in elite commandos for a stealth rescue?

If you are a political leader or a celebrity, and you’re looking for some media attention, here’s a method that works every time.  Simply flaunt the pesky  rules that the rest of us obey. And then get caught. Remember when Governor Gavin Newsom was photographed dining out at a posh restaurant in violation of the COVID-19 safety protocol that he imposed on Californians?  Such behaviors only reinforce the recognition that many entitled folks believe that rules apply to the hoi polloi, but not to them.

Presently, tennis superstar Novak Djokovic is being detained in Melbourne, Australia after his visa was cancelled upon his arrival. There will be a court hearing tomorrow that will rule if the government can proceed with deportation. Djokovic, whose ranking is number one on the planet, arrived to compete in the Australian Open, one of tennis’s four major tournaments.  Djokovic is keen to compete since a win there would grant him the record of the most wins in singles in major tennis tournaments. 


Djokovic May Soon Be Hoppin' Back to the Airport!

Djokovic, who apparently has not been vaccinated against COVID-19, arrived having received a medical exemption for declining vaccination.  The Australian government has very specific criteria for what constitutes a medical exemption.  While it is true that he was granted an exemption, the waiver was granted by groups who have ties to the tennis tournament.  In other words, the exemption personnel may have had more fidelity to the tournament than they did to adhering to public health rules and restrictions.  Djokovic apparently was granted a medical waiver on the basis of a positive COVID-19 PCR test result last month.  However, the government does not recognize this as an exception and communicated this to the Australian tennis authorities in November 2021.  

Presumably, the Australian federal government has primacy with regard to COVID-19 and border entry policies.

Now, of course, the issue has been internationalized with Djokovic supporters in Serbia and elsewhere claiming he is being held captive.  He is free to leave at any time.

The Australian citizenry is inflamed at the prospect that an elite athlete is angling for special treatment.

Based on my knowledge of the issue, I anticipate that deportation will be deemed  lawful.   Djokovic may expect special treatment, but he deserves the same treatment and outcome that the rest of us would receive.  After all, an athlete of his stature and accomplishment should understand why rules and fairness are so important.


Sunday, January 2, 2022

Looking Back on 2021. Time to Look Ahead.

2022 is here!  2021 has been an annus horribilis for America and the world.   We have simply not been able to vaccinate and boost ourselves free of the suffocating tentacles of an evolving coronavirus. Here in Ohio and elsewhere COVID-19 tests are endangered species.  Folks spend hours trolling around town hoping that a local pharmacy or a public library will receive a supply at the very moment he or she walks in.  My own inquiries have all yielded the same result – no tests available and no idea if and when they may arrive.


Did you watch the ball drop on New Year's Eve?


The pandemic, which in any earlier time in our history would likely have drawn us together, is cleaving the nation.  The day before writing this, I saw 2 patients who had elected to shun the vaccine.  I’ll spare readers their explanations which originated in the huge ‘science-free zone’ that tens of millions of Americans inhabit.  And earlier in the week, a medical professional who had been vaccinated expressed opposition to a vaccine mandate.  Her objection is that the government should not be able to force us to take such an action.  (Keep in mind that this individual and myself and millions of health care professionals are required to accept yearly influenza vaccines, TB testing and to be up to date with various routine vaccinations.)  I understand the personal freedom argument.  And I agree that we must be very cautious about granting the government excessive control over our individual decisions. Clearly, many private businesses and organizations favor a vaccine mandate as is their right. Others are concerned that a mandate would leave them short of workers after a mandate walk out.  I responded to my medical colleague that her argument that a mandate encroaches on her freedom is vulnerable.  I have no objection, I remarked, if she wishes to refuse a mammogram.  Such a decision only affects her health.  But an individual who declines to be vaccinated can affect the health of others.  These folks have rights also.  But I admit that there is nuance and a slippery slope potential here.

And the FDA and the CDC haven’t inspired much confidence with fumbling decisions and mixed messaging.  Who can blame folks for being confused and skeptical?  The CDC’s most recent iteration of quarantine and isolation policies has been roundly criticized - not by anti-vaxxers but by public health experts.  In fairness, the CDC's new and improved version is an acknowledgement that the prior policy of prioritizing public health over the economy and education was misguided and needed to be recalibrated. 

This past year has also laid bare our politics at its worst.  Comity and collaboration are out and hatred and revenge are in.  The mantra for many of our leaders and their constituents seems to be, I win if you lose, not an uplifting strategy.  And, a year ago the nation was treated to an actual insurrection!

Beyond the pandemic, inflation is surging, our southern border is in chaos and lawlessness and violence abound.  We are all horrified at the smash and grab episodes that are captured on video.

And internationally, our relations with China, Russia, Iran are all going swimmingly. 

Here’s to 2022!  Hoping and praying for a new mantra.  How ‘bout, If we both win, we all win?

Sunday, December 26, 2021

COVID Divides a Divided Country

For millions of Americans, the pandemic has been disastrous.  We have lost an uncountable number of Americans. We cannot even grasp the magnitude of the loss.  Have you ever stood at the Vietnam Veterans Memorial on the mall in Washington, DC and scanned through the uncountable number of names etched into the Wall?   We have lost well over ten times this number of Americans in the pandemic.  And it’s not over yet.  Beyond those who have died, we have to contemplate family members and friends who have been left behind.  And those who have become seriously ill or even hospitalized or even spent time in an ICU have been changed forever.   And many who escaped the virus were scared that they might become the next victim, particularly before the release of the vaccines.  And now Omicron has swept onto our shores reminding us that the pandemic still lives.  Will we go through the entire Greek alphabet?

Similarly, we cannot even calculate the economic devastation and disruption that the pandemic has wrought. And, we have all witnessed the Great Resignation, a phenomenon that we still do not entirely understand.  It appears that many Americans simply do not want to return to the grinding jobs that they had become accustomed to.  Many have resisted the lure of substantial wage increases and astronomical signing bonuses.  At first, many speculated that folks were staying home as they were enjoying government subsidies.  These payments have largely ended but there has been no migration back to the work force. Clearly, something deeper is occurring here. 



COVID-19 - Uniter or Divider?

I shudder when I contemplate the consequences of having kept our kids home for a year.  Some are still ‘learning’ virtually.  The damage has extended far beyond the educational realm and reaches into mental health, economic, nutritional and social spheres.  Did we really have sufficient scientific evidence to justify such a draconian measure?  I wonder.

And sadly, a plague that in an earlier time would have bound us together has only further divided a separating nation.  Everything seems to be a fight.  Test yourself on my thesis.  Consider half a dozen or so issues of the day and if they are uniting or fracturing the nation.  Now, test yourself again.  Can you identify a issue that is bringing us together?

Any reader who is inclined to leave an uplifting comment is strongly urged to do so.

Sunday, December 19, 2021

Whistleblower Holiday Cheer 2021!

     

Twas the night before Christmas

And all through the House,

Progressives were screaming,

‘Are you a man or a mouse?’

 

They wanted it all.

No matter the cost.

They wanted it now.

So much would be lost.

 

The voted for Biden,

Who now is their tool,

And dream of ‘reforming’

The filibuster rule.

 

Pelosi’s been smacked,

And Schumer’s been bruised.

Does Biden realize

That he’s being used?

 

And while Biden is napping

In the White House mansion,

The man of the moment,

Is Senator Joe Manchin.

 

And while mainstream Dems

Fight with the ‘Squad’,

The real threat they face?

A circular firing squad!


GOP are no better.

They have no spines.

Trump is their leader.

He is divine!

 

Liz Cheney is out

For telling the truth.

While others are praised

For being uncouth.

 

How do Republicans

The few decent legislators,

Run in a primary

When they’ll be called ‘Traitors!’?

 

Kevin McCarthy

Unhinged and unraveled,

Dreams every night

Of the Speaker’s gavel. 

 

On January 6th,

As criminals crashed,

Now called Patriots

By the GOP unabashed.

 

Health is now politics.

What a crazy scene!

When folks can oppose

An amazing vaccine.

 

Who would have thought

That folks would believe,

That Anthony Fauci

Should be relieved.

 

So who will emerge

Who’s got the roar

To whack away Trump

In 2024?

 

Tom Cotton? DeSantis?

Who else might lose?

Marjorie or Nikki?

How ‘bout Ted Cruz?

 

One thing I know,

One thing for sure

We all know what ails us,

But what is the cure?

 

 

 

 

 

 

 

 

 

 

 

 

Sunday, December 12, 2021

Is the Physical Examination Still Useful?


Medical students, please read no further.

I am going to challenge one of the bedrock beliefs in medical training – the value of the physical examination.  Indeed, I was taught of the primacy of the physical exam as a young pup during my 4 years of medical education in New York City.  I believed it and did my best to acquire these skills from master diagnosticians.  Indeed, this was one of the thrills of being a medical student – learning what those clicks and clacks meant when we listened to hearts with our stethoscopes, seeing changes of diabetes and other diseases when we peered into your eyes with an ophthalmoscope or palpating a pulsating aneurysm that was lurking in your abdomen.

An Ophthalmoscope and Otoscope
The Eyes and Ears of Medicine


I was in awe of these seasoned physicians who could make a diagnosis just by watching a patient walk across the room.

While I still think the physical examination is useful, I have found over the years that it is less valuable than I was originally taught.  Years ago, such a statement would be considered heresy and might risk excommunication from the profession.  But yesterday’s heresy has become today’s dogma.
In general, physicians consider data from 3 separate tranches when evaluating patients:

  • The Medical History – the patient’s narrative
  • The Physical Examination
  • Objective Date including Laboratory and Radiology Reports

Medical students have been taught for generations to rely upon this triad and to regard them as coequal branches of medicine.  But they are not.  If physicians were asked which of the 3 is least helpful, I surmise that most would choose to forego the physical examination.  I would be among them.  Indeed, it is my view that the patient’s history is paramount.  In most cases, I can assemble accurate diagnostic considerations after hearing only the patient’s story.  Of course, the history must be detailed, and the patient given sufficient time to relate it.  Interrupting a patient in mid-sentence or not following the narrative path that a patient creates will not yield a full and useful history.   While less important, I do find that the Objective Data can be useful in narrowing the list of diagnostic possibilities or suggesting other considerations.   For example, abnormal blood test results might point to pancreatitis, a condition I might not have suspected as a cause of a patient’s abdominal pain. 

The reason the physical examination is the shortest leg of the 3-legged stool is because it is either normal or has abnormalities that are not relevant to the current issue.  For example, the vast majority of patients I see in my office with abdominal pain have normal abdominal physical examinations.
I am not counseling that we abandon the physical examination. And there are certainly cases when the exam is a game changer.  But these instances are less common than you might think.




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