Sunday, July 5, 2020

Independence Day 2020


This Independence Day is different from all others that I have experienced.
We are so bitterly divided.
We face the fury of a resurgent pandemic.
We cannot even agree if wearing a face mask is the right thing to do.
Tens of millions of Americans have been thrown out of work.
Our politics is increasingly poisonous. 
Anger and frustration over racial injustice has erupted.
How do we move forward?

Will we be able to celebrate the day with the 'bonfires and illuminations' that John Adams forecast?

The Whistleblower




”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

John Adams

Sunday, June 28, 2020

'Face Masks Violate my Rights!


Several decades ago, Thomas ‘Tip’ O’Neill, who was Speaker of the House is associated with the adage, all politics is local.  In other words, caring for the needs of one’s constituents is the best strategy to preserve one’s political viability.  Of course, those were also the days when Democrats and Republicans – despite their philosophical differences – could argue and thrash out a deal.  Indeed, it has become political lore how Speaker O’Neill and President Ronald Reagan could capitalize on their personal chemistry to make progress for the nation.

Those were the days.

There is a different type of chemistry today that exists between Speaker Pelosi and President Donald Trump.  When they are mixed together, they form an unstable compound that is highly volatile and may explode.

Instead of all politics is local, we now have all things are politics, a sad bastardization of O’Neill’s principle.  Now, as we are all so painfully aware, anything can be politicized, which serves only to frustrate and divide us. 

We all know that many issues are highly political, as expected.  For example, if 2 congressmen argue if income taxes for certain Americans should be raised, this falls well within the realm of politics.  If the president proposes a change in our immigration policy, then we expect that various constituents will do their best to exploit the issue to serve their political interests.  In a perfect world, of course, there would be no political tainting of the issues as all good people would strive to serve the greater good and not their parochial interests.  Have you noticed that our world is slightly less than perfect?

Yet, one might have thought that certain issues transcend politics.  But, that naive notion is pure fantasy.  There is no issue today that can escape the predatory tentacles of the political machine.


Is this guy making a political statement?


Readers might be aware that we are in the midst of a pandemic and that our nation’s progress has been halting.  As I write this, nearly 30 states report that their COVID-19 cases are on the rise.  Every public health expert has advised us to wear masks, among other sensible recommendations.   Wearing a mask, as I do, is not a political statement; it is a public health measure.  I do it to protect those around me in case I am unknowingly infected.  And, it is possible that it might also afford me some protection.

Yet, there is a vocal movement of anti-maskers out there who vociferously argue that a mask infringes on their rights.  I reject this.  Their right to mingle near others barefaced is outweighed by the community’s right to avoid infection.  How such a simple act could become a political issue may seem baffling, but it is standard operating procedure today.  Earlier this week I watched citizens in Palm Beach County Florida decrying the mask and those who advocate its use.   One watching this venomous display might have thought that the government was poised to seize their homes.  Alas, it was only about a cloth mask to protect their neighbors, not quite a 'grab your pitchfork' moment.  

I challenge you to identify any issue that is immune to politics.  Apple pie, baseball, Mother’s Day, Sesame Street, stuffed animals,  petting zoos, Halloween, Thanksgiving…  

Stumped yet?







Sunday, June 21, 2020

Ohio City to Remove Christopher Columbus Statue


Progress is a messy business.  The pathways that have led, and are leading, and will lead to societal change have not been straight shots.  The nation is now tightly focused on pursuing racial justice, which has entered the 401st year of a journey that has yet to meet its destination.  You can site your own examples of necessary reforms that were the result of years or decades of struggles that have been wrenching, frustrating and even violent.  None of these successes and ongoing works in progress are easily accomplished.  It’s hard for folks to feel they must give up something, particularly if they do not feel personally responsible for the injustice that is being legitimately targeted. 

The reform process is not clean and many friendly fire casualties often result.  We saw this when the nation become revolted after learning about the horrible and pervasive culture of sexual harassment that permeated many businesses and industries.  I felt that in this instance, and elsewhere, that the net being wielded to snatch up the perpetrators became too wide in another example of zero tolerance.  Whenever zero tolerance is invoked, brace yourself for unfair and absurd outcomes. Do we really think, for example, that Al Franken had to be thrown out of the U.S. Senate for irreverent actions and speech he committed prior to public service when he was a comedian?  And, in our zeal to come to the assistance of harassed women, we were counseled to ‘believe the women’, as if any allegation should be assumed to be true. These examples of overshoot make me uncomfortable.    I endorse our current system when the accused is presumed innocent and the burden of proof is on the accuser.

This past week, I came across an example of overshoot that merited Whistleblower attention.  A city in my own state of Ohio plans to remove a statue of Christopher Columbus, a figure who many  believe to be a dishonorable person who should be removed from the public square.  The city has taken this act to promote diversity and tolerance.   The statue has stood watch over the City Hall since 1955.


The Flag of the City of Columbus Still Waves


There are many Americans who oppose efforts to scrub out Columbus Day and to dismantle statues honoring him.  However, I can understand why a city, particularly in the current political and social climate we are now in, might feel that a Columbus statue is improper.  Here’s what I don’t understand.  Explain to me how a city named Columbus takes down a statue of Columbus but still keeps its name?

If the leadership and citizenry of Columbus aim to remove a statue of the explorer because it is deemed too offensive for public display, then shouldn’t they enthusiastically jettison the city’s name for the same reason?  And if they opt to keep the city’s name, what is their explanation?

Sunday, June 14, 2020

Breaking News! Black Lives Matter vs COVID19 vs Election 2020!


Protests for racial justice continued throughout the country.

Businesses are racing to announce their corporate policies for justice and equality.

New polling reports that a majority of American support the protests and the Black Lives Matter movement.

Even military brass support renaming military installations named after Confederate generals. 

New York City opened up showing bold determination to aim toward normalcy

Over a dozen states are reporting increased cases of COVID-19.

President Trump expressed that policy brutality is committed by a few bad apples.

Attorney General William Barr and others denied that systemic racism exists in law enforcement. 

Over 40 million Americans have lost their jobs. 

Over 150 COVID-19 vaccine efforts are underway.

Major League Baseball still has no agreement between owners and players because of the usual obstacle.

HBO Max pulled Gone with the Wind because of its sanitized portrayal of slavery in the antebellum south.

Polling shows that presumed Democratic presidential candidate Joe Biden continues to gain strength.


Gone!

All of these items occurred just within the past week.  The news cycle is exploding.  Every item is a Page 1 ‘above the fold’ story, but only 1 or 2 can be accommodated. There is simply an avalanche of real breaking news these days.  This is in contrast to CNN, where Breaking News, with it’s bold red font, is used to introduce every newscast, and is often sprinkled throughout their programs.  Of course, if every report is Breaking News or is a Crisis or is Unprecedented then these terms have no meaning.  Fox News has it’s own Fox News Alert designation, but in their defense it is utilized much more sparingly.

But, in the past week and months, we are all struggling to follow so many truly monumental and evolving stories simultaneously.  And we and the media may not have the bandwidth or the attention span to absorb them all.  Since the George Floyd murder and the subsequent protests, the coronavirus pandemic was pushed aside, even though it is still a page 1 story here and abroad. And soon I expect that the protests, even if still present, will be edged out by an event or a controversy that hasn’t yet occurred. 

There’s a whirlwind of information bombarding us in real time   How do we prioritize the news?  How closely should we follow the stories?  How do we know that our news sources are trustworthy?  Do we have the skill and the desire to separate out the static and the noise?  (One man’s static is another man's...)  

When every story is ‘breaking news’ does it mean that the news business itself might be broken?



Sunday, June 7, 2020

A Nation Reels from Police Brutality


In medical terms, the nation has been in status epilepticus – an unrelenting seizure - since the cruel and cowardly killing of George Floyd, an act of evil that we have all witnessed on tape repeatedly.
First, there was the brazen killing of an unarmed man who was already lying face down in handcuffs while a police officer pressed his neck into the pavement.  All the while the officer’s hand was comfortably planted in his pocket, a casual pose that one might expect from an officer ambling down the street greeting folks passing by.  Three of the officer’s confederates hovered over the scene.  Was Mr. Floyd a flight risk?  While I am not a law enforcement professional, Mr. Floyd did not appear to be combative or resisting?

This violence was perpetrated by one who was sworn to protect and serve all of us, including Mr. Floyd.

Protests erupted throughout the nation and beyond our borders.  While Mr. Floyd's passing may have been the spark, the story started hundreds of years ago.

And, there was also violence and looting.

And, there was a reaction to the violence and looting.

And, yes, there was a reaction to the reaction to the violence and looting.

And, so it goes.


How will we find a way out?

Through it all, the nation is headed by one who gives voice and space to the darker angels of our nature.

Astonishingly, for a week or so, COVID-19 was pushed to the back pages of our attention.

Much of the nation who are not black are accepting the existence of structural racism whose roots sprouted here over 400 years ago.  The issue is longer, wider and deeper than we can fathom. And, we have made real progress over the past several decades.  Let’s acknowledge this as we also accept the challenge to pursue fairness and justice.  Making progress will take strength, pain, perseverance, frustration, understanding, protests, compromise, reform, disappointment, fairness, tolerance and, perhaps most importantly,  the ability and willingness to consider an issue from another’s point of view. 

The task is beyond the abilities of any one person to accomplish.  And, we may not personally witness its completion.  

As written in the Jewish Talmud, it is not incumbent upon you to complete the work, but neither are you at liberty to desist from it.




 

Sunday, May 31, 2020

Telemedicine Surges during the Coronavirus Pandemic


Not long ago, Telemedicine was something that I read about.  Now, it’s something I do.  Over the past weeks I have been evaluating patients over the phone from home.  It has been an adjustment, but it has been smoother than expected.  First, I have always thought that the physical examination is overrated.  Yes, I recognize that such a declaration constitutes medical blasphemy, but I stand by it.  Don’t extrapolate beyond my actual meaning.  I am not suggesting that the physical exam is superfluous.  Indeed, there are many circumstances when the exam is absolutely critical.  However, for a good bulk of the routine gastroenterology patients I see, particularly for those who are returning to my office for a follow up visit, the exam contributes little value.

Here is a sampling of patient visits where the history alone is largely sufficient.
  • A patient with years of chronic constipation returns to see me for a 6 month follow up visit.
  • A new patient sees me to evaluate frequent heartburn.
  • A college student returning from a spring break camping trip in Central America sees me for diarrhea.
  • A 35-year-old new patient is referred to me for abdominal cramps that occur after eating dairy products.
  • A 65-year-old asymptomatic patient is sent to me with occult blood in the stool.
For cases similar to those I listed above, it is highly likely that I could obtain sufficient information simply from the patient interview – a hands free encounter.   This is why telemedicine can be a highly functional modality for treating patients.  And, while it is beyond the scope of this post, technology exists and will be further developed that will allow for many aspects of the physical examination to be performed remotely.  Even without futuristic technology, we can evaluate a patient’s appearance skin, pharynx, speech, joint mobility, respiratory effort and ambulation through the miracle of video transmission.  And, a patient can palpate their own abdomen and report if it is tender.


Do you think you could canoe up a waterfall?

My telemedicine encounters have been nearly all conducted by phone, and they have gone well.  At times,  patients have needed to have their expectations revised.  For example, if I have a phone visit with a patient whom I have never seen, who has years of unexplained abdominal distress and has seen digestive specialists and had emergency room visits, it would seem unlikely that a new physician will crack the case on the phone.  

As I have written throughout this blog, I lament how technology has exacted a cost on the doctor-patient relationship, much as it has eroded humanity and intimacy writ large.  To reclaim what has been lost would require canoeing up a steep waterfall.  It can’t be done.

After the pandemic has passed, I hope that I can return to my conventional office practice, which for me is the ideal setting to practice medicine.  But who knows what the new normal will be. 

Sunday, May 24, 2020

Memorial Day 2020 - A Plea to Remember.


Tomorrow will be a Memorial Day worth remembering.  Of course, its core meaning – to remember and honor those we have lost in the service of this nation – remains paramount.  I have thought over the years that the day’s essence has become blurred as the day has become one of family picnics and barbecues.  I confess that I have not sufficiently paused and meditated on the day's meaning in year's past as I think I should have.  I placed a small American flag on our front lawn today, the smallest of gestures to honor a very solemn remembrance.   



But this Memorial Day is different.  To those of us like me who have never served, this may feel as close to a war atmosphere that we will hopefully ever know.  Lockdown.  Shelter in place.  Commerce shuttered.  Empty streets and concert halls.  Fear.  Desperation. Hope.  Propaganda.  Supply chain disruption. Heroes.  Victims.  Agony and death.  

We are battling an invisible and cunning enemy who knows no borders.  Thusfar, he is bulletproof.  Yes, we are winning, but it has a been a tortured grind leaving a staggering wake of destruction.  We are not even sure what winning will look like.  We will get to the other side, holding a collective fantasy that life as we knew it will await us. But that destination is yet unseen and unknown.

Let’s remember those we have lost in the current war, and the loved ones who still grieve, and the ordinary folks who became extraordinary heroes as they ran straight into the fire.


Sunday, May 17, 2020

A Primer on the N95 Mask


A few months ago, most of us had never heard of an N95 respirator or mask.  I had never heard of it. It is an essential element of Personal Protective Equipment, or PPE, which we have all heard so much about.

The N refers to ‘non-oil’, meaning that the mask should not be used in the presence of oil-based substances.  The 95 means that 95% of airborne particles are screened out if the mask is worn properly.  Keep in mind that 95% is less than perfect.  It means that the mask will fail 5% of the time.  And, if the mask is not worn with a tight seal, the efficiency percentage will drop further.  And, the mask wearer is instructed not to adjust the mask during use which will break the seal.  So, the 95% standard is likely under idealized circumstances. 

As of this writing, I have only worn the N95 mask on two occasions.  My initial experience donning the mask was for a fit testing by an occupational health specialist to verify my proper mask size.  The objective, I learned later, was not comfort, but to obtain a tight seal.  The fitting took less than 5 minutes.

After weeks of performing telemedicine from home, I was called into the workplace for the first time this past week to perform a day long marathon of procedures.  I hadn’t touched a scope in over a month, the longest I had been separated from my flexible friends since they first let me loose 3 decades ago.  Hopefully, performing colonoscopy is like riding a bicycle.  Along with my amazing team of medical professionals, I performed 17 procedures without incident.


PPE in place


Scope doctors like me are prone to various aches and pains.  We can be standing for hours which can be tiring.  Our necks can become stiff.  And, we do all sorts of repetitive twisting maneuvers with  both hands which can give rise to various ailments.  There is an actual condition called colonoscopist’s thumb.

But, during this scope jamboree, I became very sorely acquainted with a new malady.  My nose was crying out for relief.  A great contest of Man vs Mask commenced, and it was not a fair fight.  I now know that the N, which I had thought mean ‘non-oil’ really stood for Nasal torture. The N95 mask was burrowing into the bridge of my nose hour after hour.  For those who have not donned the N95, here is some guided imagery to assist you.  

Imagine you are seated cross legged in a pastoral meadow. The sounds and aromas of spring abound.  A sunbeam pierces the clouds as a gentle breeze laps against you. Now imagine that your head is encircled tightly with sharp barbed wire that crosses your nasal bridge.  Now, imagine that every few minutes that the circle tightens...

By the end of the day, my proboscis looked like I either needed plastic surgery or I had just had it performed.  I queried my colleagues and learned that my experience was not unique.  We’ve all seen the photographs of medical personnel whose faces at the end of their shifts are marked with deep grooves and crevices.  

I realize, of course, that my nasal assault is but an inconvenience compared to the suffering of front-line medical professionals and afflicted patients.  But, I was not prepared for the slow grind of a nasal buzz saw.  I have 2 other endoscopy session this month.   I think I know who will prevail in the N95 vs Nose competition.  

Sunday, May 10, 2020

Do Masks Protect Us?

Prior to the pandemic, patients who entered my office building were greeted by 2 staff professionals who would assist patients in checking in and performing the usual logistical tasks that occur prior to a medical appointment.  Shortly after the pandemic commenced, I would arrive to work to witness these 2 ladies in rather different garb. They were now fully gowned, masked, gloved and goggled.  Each carried a bottle of hand sanitizer.  If not for their voices, I would not have recognized either of them.  Patients and medical personnel passing by would extend one an open palm to receive a squirt of the precious cleansing elixir. 

While I acknowledge the necessity for staff interfacing with the public to don protection, it was an eerie site for me to witness, even as a medical professional. It is simply a scene that is foreign to most Americans.

I recall when I traveled to Israel for the first time, I was struck at the site of uniformed and armed soldiers ambling everywhere.  Of course, Israelis paid them no mind, similar to how we might react to police or security guards on patrol in our cities.  But, as a first time tourist, it felt as if I were on a movie set.  

I also recall when I was traveling in Asia years ago, that it was very common to see ordinary folks wearing surgical masks everywhere.  Was I in the midst of an epidemic?   Was the mask to protect the mask wearer or the community from disease?  Or, might it be an effort to filter out impurities in the air?  Might there be a different cultural basis for shielding the mouth and nose?


Folks wear masks for many reasons.

In the coming days and weeks, we will see more masks in public.  In Ohio, our governor announced that he will set an example by wearing a cloth mask when in public, and has urged Ohioans to do the same.  

Experts have advised us that these masks are not to protect us, but are to protect others from us in the event that we are silently infected.   Nevertheless, I suspect that many will be masking up with the belief that the cloth will prevent coronavirus from reaching them.

Masks will soon take on a normal appearance if they are widely used over the coming months.  Most of what we now take for granted appeared odd and novel when we first encountered it.  What was our reaction the first time we saw a cigarette smoker, sushi or a tattoo?

Sunday, May 3, 2020

COVID-19 and Chloroquine and Hydroxychloroquine: First, Do No Harm


In a recent post, I presented why I believe that the fragmentary and anecdotal medical evidence supporting the use of chloroquine and hydroxychloroquine for COVID-19 does not justify its use. Certainly, if I become infected with the coronavirus, I would be reluctant to accept a recommendation to take either of these 2 medications, based on what is currently known.

Ordinary people, especially when they or loved ones are afflicted with a disease, will readily accept unproven remedies, especially when conventional medicine has no effective treatment.  We all understand this.  But the lack of a treatment, in my view, does not justify abandoning our usual standards that physicians rely upon when we make treatment recommendations.  
Shouldn't Physicians Weigh the Risks and Benefits?

Here are some reasons why I object to coronavirus patients taking chloroquine and hydroxychloroquine for COVID-19.   The principles outlined below certainly extend beyond the coronavirus issue.
  • The medical profession should not be prescribing treatments that have no reasonable evidence of efficacy.  Patients should have confidence that our therapeutic recommendations are based on sound science, professional experience and sound judgment.
  • Chloroquine and hydroxychloroquine efficacy against COVID-19, like any treatment, should be tested in well-designed clinical trials.
  • Clinical trials may have difficulty recruiting a sufficient number of patients if coronavirus patients are opting instead to take the medicines being tested on their own outside of a trial.  A clinical trial’s conclusions are more reliable when it contains more patients.
  • It may be true that chloroquine and hydroxychloroquine worsen the condition of COVID-19 patients.  Medicines do not always behave predictably.   Should we be condoning the use of medicines when we have no proof of either benefit or harm?   The safety record of the 2 medicines being discussed here with regard to their established medical indications may not be true for coronavirus patients, particularly when higher dosing is being advised. This is why scientific study of medicines is absolutely necessary. 
  • Prescribing medicines irresponsibly consumes resources that should have been devoted to more worthy endeavors. 
Consider who is publicly promoting chloroquine and hydroxychloroquine use for COVID-19.  Are they our public health experts or politicians and administrative officials?   Whom would you trust more for medical advice? 



Sunday, April 26, 2020

Coronvirus - Test Your Knowledge!


Folks love quizzes and puzzles, especially now when most of us are spending most of our time hunkered down at home.  I had attempted to send one my kids a jigsaw puzzle that I ordered on line, only to discover a few weeks later that the item was out of stock.  Apparently, like hand sanitizer and foster dogs, jigsaw puzzles are in very high demand.

Scarcer than toilet paper.


In an earlier phase of my life, I prepared ‘quizzes’ that were passed around on holidays and family dinners when guests competed for valuable prizes such as stickers, packs of gum and other treasures that are sold at dollar stores.   Not only were these experiences ‘fun for the whole family’, but they were effective educational tools.   Ask a Kirsch kid even today whose portrait is on the $50 bill or how many neck bones are inside a giraffe’s neck, and he or she (I hope) will nail it.

So today, I will offer readers a lighter fare.  Here’s a coronavirus quiz based on recent news reports.  Rely upon your knowledge and judgment.  To relieve your performance anxiety, I have made this a True-False examination.   I could have constructed a multiple choice and even included an essay question, but my generous nature prevailed.  Good luck!
  • Coronavirus takes its name from Corona beer as the virus was first isolated in brewer’s yeast.
  • Coronavirus is named after Rosie, the Queen of Corona, who refused to practice social distancing and contracted the virus.  Julio, who wore a mask, escaped infection.
  • Gargling with Lysol. and followed by a Mr. Clean chaser. kills the coronavirus and also rids the body of various harmful germs and toxins.
  • Anthony Fauci takes a dose of valium before and after the daily Coronavirus Task Force press conferences.
  • Vice-president Mike Pence has shown America that he has a spine of steel.  He is his own man.   
  • Deborah Birx’s scarves are impregnated with a potent antiviral agent, which is the main ingredient in Ty-D- Bol toilet bowl cleaner.
  • President Trump’s scientific knowledge has been credited for the sudden spike in applications to college engineering programs.
  • Masks are for sissies.
  • 4 out of five dermatologists surveyed no longer recommend any sunscreen.  UV light wipes out coronavirus even better than Chlorox.
  • It has been inspiring to witness the seamless and harmonious cooperation between the state and federal governments.  

So, how did you do?  Scores of 80% or higher are prize worthy.  Of course, since we are in the midst of pandemic, you will have to settle for virtual trophy. 





Sunday, April 19, 2020

When Should We Open the Economy after Coronavirus?


In the weeks ahead, there will be growing tension between forces wanting to open up the economy and those who demand that we hold the line.  And no one can tell us now when it will be okay to pull the trigger.  It is so much easier to endure a challenge if there is a firm end date to focus on.   In this case, not only is there no clear trigger-date, but there will never be agreement on when it will be acceptable to pull back.  I’m no expert, but here’s a brief list outlining the complexities of this conundrum.
  • Public health experts will disagree on the economic relaxation date.
  • Corporate leaders will likely favor a sooner and broader opening of the economy.
  • Governors will have diverging views from national leaders about what actions their state should take.
  • Businesses who are not permitted to open may howl and protest as competitors are given a pass.
  • Can schools, for example, be reopened while we are still urged to maintain social distancing?
  • Will the nation accept being told that we are opening up the country when in reality only scattered pockets are being permitted a gradual loosening of restrictions?
  • What happens when COVID-19 rates rise as the economy is revived?   Will we have the tools and the will to do what is necessary?
  • As difficult as it has been to shut down the economy, it will be a much harder and longer process to bring it back to life. 
  • Will we be told, and will we accept, that we will not be able to return to the status quo ante?
The decision of when and how to open the economy will always involve risk.  Doctors and medical professionals understand this reality.   We may advise a patient that there is a choice of surgery or continued medical treatment, and both options have risks.  If we open up the country too soon, we risk a resurgence of the virus and a squandering of what we have accomplished.  If we wait too long until the last remnant of the virus has been vanquished, then we may have no economy left to resurrect.

A Cure for Termites?


If a house has termites, we can cure the infestation by burning the house to the ground, but would the homeowner celebrate this victory?

We will have to balance serious risks in an evolving situation with endless moving parts with no playbook to refer to and disagreements on how to proceed among experts.  Would you like to be making the decision? 




Sunday, April 12, 2020

Chloroquine and Hydroxychloroquine for COVID-19?

Kindly refer to the article linked below explaining my great concern over the massive hype over these 2 medicines that many are perpetuating.    MK

https://www.cleveland.com/opinion/2020/04/chloroquine-for-covid-19-not-for-this-doctor-michael-kirsch.html

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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