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?