Is My New Doctor Qualified?

When one applies for a job or a position, it is expected that the interviewer will assess if the applicant has the necessary skill set and experience. Doesn’t this make sense?  Consider these examples.

A clarinetist applies for a position in a symphony orchestra.  While many criteria will be assessed, he will surely need to audition to demonstrate his musicianship.  Would he ever be hired without playing a note?

A college student wants to join the swim team.  The applicant can expect to show off her speed and technique as she cuts across the pool.  Would any coach accept a new swim team member without watching her swim?

A journalist for a town paper applies for a job at a large metropolitan newspaper.  The interviewing editor will surely review the applicant’s prior work product to gauge his competence and suitability for the new position.  Would an editor bring on a new reporter without ever reviewing his writings?

A college graduates applies to the State Department as a translator.  Would such a hire ever occur without determining if the applicant has the requisite language skills?

Want the job?  

You'll have to show you know how to use this.

So how does the medical profession hire on new medical professionals?  I should certainly know this since I’ve been in the trade for 3 decades and have had enough job interviews to know how the process works.  I’ll ask readers to peruse the following 5 sample gastroenterologist applicant questions. Can you spot the ones I was asked during my prior job interviews?   

Which antibiotics do you typically prescribe for diverticulitis?

What is your age cutoff for offering screening colonoscopies?

What is your complication rate for colonoscopy and other medical procedures?

When is the right time to prescribe steroids in Crohn’s disease?

Does a patient who is having a gallstone attack and a fever need to be hospitalized?

Which ones were I asked?  None of the above.  For reasons I cannot easily explain, I have never been asked any medical question during any prior job interview.  Similarly, when I have interviewed job applicants myself, I have never queried them on any medical issue.  The profession, at least in my experience, assumes that physician applicants have all of the necessary medical skills and knowledge, even though this does not seem to make much sense.  Shouldn’t the applicant at the very least be asked to review case histories of assorted patients and to comment?  It seems it’s a lot tougher to get a job as a clarinetist than as a gastroenterologist.  Does this put your mind at ease?

 

 

 

 

Overutilization of Colonoscopy - An Unusual Suspect

A week or so before writing this post, a patient came to my office requesting a colonoscopy.  Nothing newsworthy so far.  An individual wanted a service that our practice routinely provides.  Yet, I was reluctant to accede to her seemingly reasonable request.   She wanted a screening examination of her colon in search of a benefit that humans have pursued for as long as humans have existed – peace of mind. 

I have found that ordinary folks are often confused by the meaning of the term screening.  Screening exams can be performed on various organs of the body.  When a physician uses the term screening, it means that the patient is not having any symptoms whatsoever.  For example, if I advise a colonoscopy on a patient who is having rectal bleeding or diarrhea, this is considered a diagnostic exam, not a screening test.   

"You're paying the bill?  I'll have the steak!"

Why does this matter?  Insurance companies often reimburse screening and diagnostic exams differently.  Often, but not always, a patient’s financial obligation is higher for a diagnostic exam, when symptoms are present.   There have been occasions when a patient had contacted us after receiving the insurance company bill for a diagnostic colonoscopy, asking if we will ‘revise’ our documentation stating that the test was a screening exam.   Even an infrequent Whistleblower reader would know our response to such a request.

The patient who wanted a screening colonoscopy felt entirely well.  Her bowel pattern was unchanged.  She had no special risk factors for developing colon cancer.  My review of her record indicated that she was due for a screening colonoscopy in 3 years, not now.  I advised her of this, but she wanted to proceed anyway.

We have freedom of commerce in this country.  I can purchase goods and services according to need, desire or even whim.   If a person wishes to buy a meal, a vehicle, an appliance or a vacation, the seller’s role is not to discourage the transaction or point out that the buyer is making a foolish or unnecessary purchase.   Isn’t an individual who wants a colonoscopy, and is properly informed of the risks and benefits of the test, and is made aware that she is not yet due, entitled to the exam?

I thought that she was.  But, I didn’t think that her insurance company should pay her bill.  I explained to her that I would schedule her for the requested exam, but that she should expect that her insurance company would hold her financially responsible for the entire bill.  

Once the patient understood that the cost would be hers, she elected to wait an additional 3 years, as I originally advised.   The lesson?  When folks have skin in the game, they make different decisions.  In my view, this concept needs to be systemically incorporated into our health care system.  

If you are out to dinner at an upscale restaurant, and an insurance company would be paying the bill, would you order differently?

Are We Ready for the Next Pandemic?

 While most of us prefer order and routine, life can turn course unexpectedly and randomly.  Of course, we all know this.  For many of us, our occupation, our choice of mates or where we live are the result of some chance occurrence, not the product of diligent planning.   Indeed, this reality adds some excitement and wonder into our existences.  Would we really want to live according to a prescribed routine like a train schedule?   For me, I am most satisfied when my days include my daily routine pleasures seasoned with some spontaneity.  I suspect that this is true for most of us.  However, we differ in the ratio of random/routine that we prefer.   Some of us plan a trip, for example, with each day carefully planned while others prefer to simply land in their destination and explore untethered to a guidebook or a rigid schedule.

And no force can set order aside more forcefully than nature.  Here is the scene from our window earlier this week.  Does this look like a typical spring day?  Apparently, Mother Nature has her own order of things.

Is Mother Nature Out of Order?

There are certain tasks for which a specified order is the optimal option.  When an airline pilot is preparing for take off or when a surgeon is preparing for surgery, each of these professionals proceeds through a check list of requirements to verify that all safety protocols have been followed so that the risk of a misadventure is minimized.  These safety checks have been devised over time with revisions performed as necessary.  They are born from experience.  Each item on the list is to prevent a specific adverse reaction which was at higher risk of occurrence prior the check list era.  For example, prior to a medical procedure, it is now mandatory for the medical team to verify the identity of the patient.  Any idea why this ID verification came about?

We don’t want airline pilots simply to bring spontaneity to their flights letting them ‘wing it’.  “Maybe today will fly this bird right over the coast so the folks can get a great view.” 

We are still trying wrest ourselves free from the gripping tentacles of the pandemic.  And one of the lessons, which we still haven’t learned is that there is a specific order of measures and mitigation that must be followed to prevail.  As we look around the world, we see that some nations are much closer to the end zone than are others.  Europe is behind the U.S. and we should be much farther ahead than we are.   If we had followed public health directives early and consistently, opening up the economy and schools according to science, rejected distracting political interference, where might we be today?   Has this experience persuaded to use the pandemic check list next time?

 

Should Doctors Pay Patients When We Are Late?

Some time ago, I flew with my youngest kid, then a high school senior, on a college visit.  He’s the last of 5 youngsters, so I’ve had my share of these visits to various centers of knowledge where young minds are molded to face uncertain and unknown futures.   While I’ve never found these visits to be substantively valuable, they were of great value to me as it was fun to be with them on these exciting excursions.

The Hallowed Halls of Higher Learning

Photo Credit

The formats of the school presentations are superimposable.  There’s an information session, which serves as an infomercial that tries to draw students to apply.  Schools favor receiving large volumes of applicants so that their acceptance rate will be lower and they will appear to more selective than they actually are.   How cynical of me to suggest that there are forces in academia that might be pursuing a self-serving agenda!

These sessions are led by effervescent young cheerleaders who present a power point of smiling students who are having fun, doing world class research and shaking hands with world leaders.  Parents are reassured that the only criminal activity within the past 5 years in this urban campus was pick-pocketing. 

Afterwards, prospective students proceed on a tour where they are given critical data they will need when making their ultimate education decision.

“Here’s the cafeteria.”

“Here’s the chem building.”

“Here’s where we play Frisbee.”

In case any of my kids read this post, which is as likely as any of them admitting to being a Republican, I want them to know that I loved every minute of these visits with them. 

When my last kid and I flew on a college visit, we enjoyed the joy and relaxation of air travel, a subject that has crept onto this blog previously.   Was there a flight delay?  Ok, stop laughing now.   I asked my son if he felt that airlines should provide some form of compensation for delays of certain specified time intervals.  For example, if a flight is delayed 30 minutes, possible remedies might include:

• 2 bags of honey roasted peanuts
• Handshake with the pilot
• Special 1-800 customer service phone number which states on the record that ‘your call is important to us…”
• Guaranteed middle seat so you can enjoy a lively conversation with 2 happy travelers.
• Travel voucher for $30 (one dollar per minute of delay) that may be used for any First Class non-refundable ticket that is booked within 36 hours of your plane landing at your destination.

My son did not think that the airlines would endorse the concept that travel delays were compensable.

For a generation or two, patients have lamented that their doctors keep them waiting habitually.  How many times can our staff explain to them that we were saving 7 folks’ lives simultaneously?  What is our patients’ time worth?  Aren’t they often missing work or making special arrangements to see us?  Even if they are retired and have open schedules, doesn’t their time have value?

Should physicians compensate patients when their appointments are delayed?  If so, what remedy would you suggest from a gastroenterologist?

• Extra lube on the next colonoscopy?
• Buy One-Get-One-Free hemorrhoid cream?
• Waiting room magazines that were published sometime in the past decade?

Seriously, do we doctors owe you something when we keep you waiting?

Don’t be too harsh here.  We should also address how you should compensate us when you are late or don’t even show up.  I beseech you to be ‘fair and balanced’, a cable news network’s motto that all of you should know well. 

Why I Don't Advise Patients to Quit Smoking

I don’t advise patients to quit smoking.

I don’t exhort alcoholics to stop drinking.

I don’t preach to my obese clientele to slim down.

And I don’t lecture patients to get the COVID-19 vaccine.

This may be the point were some readers are wondering, “What kind of doctor are you?”

For the record, I do not endorse or advise cigarette smoking, alcohol addiction, obesity or careless behavior during the pandemic.  I favor temperance in my own life.  I exercise.  I am attentive to my BMI. And I wear a mask and have received my COVID-19 injections with enthusiasm.

But it has never been my style, either professionally or beyond the office, to tell people what to do.  Once folks reach a certain age, which for many are the teenage years, you just can’t make them do stuff.  Every parent understands this. This does not mean that I don’t have influence over people who trust me.  I do and I use it.  However, it’s a process issue.  How best can we help individuals make sound decisions?  Are issuing edicts and threats our best weapons?  Are lecturing and hectoring our most effective tools?  Should we devise a reward incentive to motivate folks?  Cash for pounds lost? 

         

Who is stronger, the sun or the wind?

I am more comfortable laying out the facts – the cold hard truth without judgement – and allowing folks to make their own decisions.  Sometimes, multiple conversations are necessary.  When any of us ultimately makes our own decisions freely, they are more likely to be durable.  It just works better if folks are vested with their own choices.  Achieving ‘buy-in’ is critical to maximize the chance of success.  Don’t you feel better when you have made a decision yourself rather than have been directed to act?   I certainly do.

Do you really think that my smoking patients are not aware that this habit poses serious health risks? Do they not know that quitting would likely deliver major medical benefits?  Will a finger-wagging doctor accomplish anything?  Can you imagine a smoker who is advised to quit responding, "Really, doctor?  I had no idea that cigarettes are bad for you!"

Recall Aesop’s fable when the sun and the wind competed as to which of them could separate a man from his cloak.  The wind unleashed all of its strength and fury, but the traveler managed to hold on to his covering.  Then the sun poured down heat to the point that the man removed his cloak and sought shade to get some relief. 

Gentleness and persuasion win against force and coercion. 

 

Tolerating Uncertainty in Medicine

Uncertainty makes everyone anxious, although each of us has a unique threshold for uncertainty tolerance.  In other words, different folks may react quite differently if they are confronted with the same set of facts. 

Consider this hypothetical.  Two patients who are of similar age and enjoy excellent health undergo a CAT scan for a stomach ache.  By the time they follow-up with their physicians to review the results, their symptoms have resolved and they feel perfectly well.  A small spot is seen in the liver which the radiologist suspects is an innocent cyst, but he cannot state this definitively.  Each of the patient’s physicians explain that minor accidental findings like this are common and are very unlikely to pose any health threat.

Patient #1: “Ok, doc. I feel great and if you’re not worried, neither am I.”

Patient #2:  “Are you sure it couldn’t be serious, like a cancer?  Should I have it cut out just to be safe?”

First of all, let me give readers an inside tip on how to pose inquiries to your doctors.  If you begin your question with,  “Doctor, are you sure that…”, the physician’s response will be, “No, I can’t be 100% sure…”  If you begin your inquiry with, “Doctor, is is possible that…”, your doctor will answer, “Yes, anything is possible…”

Life is a casino.  We play the odds every day.

There are no guarantees in medicine or in life.  Uncertainty is everywhere and we all have our own uncertainty tolerance levels.  While there is no correct uncertainty threshold, your own level will determine if you spend most of your time at peace or on edge.  If you demand certainty, for example, then you will be forever seeking more testing and evaluation to eliminate doubt, and you may never reach your destination.  This principle may also apply when making investment choices , considering legal advice, buying a used car, eating street food abroad, considering an extended warrantee on an appliance as well as choosing among medical treatment options.   If I reassure a patient that his colonoscopy is normal and published data suggest that the chance that a lesion was missed is about 5%, will the patient accept the test’s inborn imperfections?  Will I?  Should everyone undergo 2 colonoscopies in order to decrease the miss rate?  How much effort and resources are worth achieving small incremental benefits?  I’m only posing the question here.

And individuals who have excessive risk tolerance may risk unfortunate outcomes.  Cashing in retirement funds for chips to place on the roulette wheel would make most folks uncomfortable. 

A patient I saw recently is eligible to receive the COVID-19 vaccine but does not wish to proceed.  He is aware of the safety and efficacy data but is concerned over potentially unknown adverse reactions that may emerge over time. This is not a right or wrong issue; it’s a matter of judgement.  He isn’t certain that he his making the right choice, but he is certain which option feels more comfortable at present.  Many others would decry his decision as a risky roll of the dice.  Remember, however, we’re all gamblers as we journey through life placing our daily bets and hoping at least most of them pay off.  

 

Lockdowns and COVID-19 - Is the Cure Worse than the Disease?

 There’s been lots of talk about lockdowns lately.  This issue, like masks, has become politically contaminated.  It’s been one of the fascinating lessons of the Pandemic of 2020 – the recognition that issues that would seem to be ‘immune’ to political interference became instead potent partisan weapons.

Consider two rather distinct reactions to the recommendation to don a mask when frolicking about in public.

Citizen #1:  Of course, I will mask up.  This will keep me and others safer.  In a small way, I feel I’m doing my part on the journey to the other side.

Citizen #2:  Mask?  Hell no!  Just more encroachment by the government to rule our lives.  

Similarly, locking down the economy, both here and abroad, has provoked bitter reactions from all sides.

'No mask for this patriot!'

As I have written, I feel awful about the hundreds of thousands of businesses who have closed or are barely hanging on.  I also feel that their plight has not been given the attention it merits from the national press.  We have been regularly informed – as we should be – about the health risks of the virus and the need for all of us to behave responsibly.  But I do not think we have been as fully informed about the economic pain and irrevocable consequences that the nation is enduring.   Additionally, the press tends to villainize political leaders who argue for loosening up on their lockdowns and laud those who call for tight control.  Many businesses who have faced stringent restrictions have been infuriated as other businesses in their communities have been permitted greater latitude for reasons that defy common sense. 

There is a balance between maximizing public health and mitigating economic catastrophe and good people can disagree on where to draw the line.  While I don’t pretend to know how to thread this needle in motion, I do think that both sides deserve consideration and respect.  For example, if hypothetically we were to adopt a total national lockdown, we might stifle the virus much faster but have little to return to afterwards with a nation facing collective bankruptcy.  And the converse is also true.

I also feel that if all of us had uniformly adopted the public health measures advocated by medical experts a year ago, that many lockdowns could have been avoided or have been less onerous  That’s on us.  If folks are packing into bars and clubs at night, what do we expect local and state authorities to do?

Texas and Mississippi have recently opened up their economies in a big way with bravado.  They have been vilified and I share the concern of the critics.  If the COVID-19 cases rise, as many expect, then these political leaders will deserve all the vicious incoming they will receive.  But if no viral surge develops and an economic surge results, will the critics and the press admit they were wrong and celebrate the success?

Imagining the Post-Pandemic Workplace

Millions of Americans are working remotely during the pandemic.  Many of them would have never believed that they could perform their jobs away from the office.  I’m one of them.  But we all now acknowledge that the basic structure and function of the workplace has been forever altered. This transformation was inevitable, but the pandemic was a potent catalyst to bring it about at, shall I say, ‘warp speed’? Did we really believe that in a world with remote robotic surgery, driverless cars, personalized genetic medicine, exploration of Mars, Alexa and the explosion of artificial intelligence, that we would continue to commute to brick-and-mortar offices each day?   It was only a matter of time before the physical workplace would be recalibrated.  

The disruption has been monumental and to a great extent irrevocable.  While I do believe that there will be some backward adjustment after the pandemic has largely resolved, I do not expect a return to the status quo ante.  Do you think that DoorDash will be out of business then?

And as occurs after every disruption and innovation, there will be winners and losers.  The printing press came about in the 15^th century.  Good idea?  Probably yes, but it may have been a job killer for many.

Johannes Gutenberg - Job Killer

Many industries are very nervous now.  If you have earned your fortune up to now in commercial real estate, you may not welcome the prospect that your high-priced office space will no longer be in high demand.  Indeed, huge companies are leaving NYC in search of more economical alternatives.  Will stage theaters and cinemas ever return to full capacity now that most of us have enjoyed these experiences from home?  The hospitality industry has taken a body blow and will do its best to stagger up in the coming year or two.  Would you want to be an investor in a sports stadium now?  Investors may need to factor in that future pandemics may be lurking.

But it’s a good time to be in the vaccine business.  If your manufacturing company could adapt to produce personal protective equipment (PPE), you probably could have run 3 shifts of workers.  Remember when we couldn’t find sanitizer left on the shelf?  Those companies really 'cleaned up'.  Grocery and restaurant delivery services can barely keep up with the demand.  And with all of us hunkered down in our homes, it has been a good season for Netflix and other streaming services.  On-line retail was already doing well pre-pandemic, but they have reached the stratosphere.  How do you think Zoom fared this year?

We are all aching to return to ‘normal’, but the normal of tomorrow will be quite different from the normal of yesterday.  And just when we start to get used to the new normal, guess what will happen?

The Importance of the Medical Receptionist

I am writing this now, prior to the pandemic, from my new favorite coffee shop not far from where I live and work. It’s called Couchland and is located in Wickliffe, Ohio.  As the name suggests, every seat is comfortable.  The large space has several couches and plush armchairs that beckon customers to sink in and stay a while.  This is quite different from many of the other coffee shops I patronize, where upon entering, I scan the room like a seasoned detective to see if any of the few comfortable chairs that are present are still available. Otherwise, I must enjoy the discomfort of a hard wooden chair, a larger version of what I sat on in 3^rd grade. 

It’s a cat and mouse game as customers compete for premium seating in an adult version of musical chairs.  And, there are rules of etiquette that at times require adjudication.  For example, is it permissible to plop your backpack on a favorable available seat before standing in line to order?

When I stroll into Couchland and gaze upon the surfeit of comfortable options, my mood leavens. In other words, I like the vibe.

The initial impression upon entering an establishment is so critical.   This is just as true for physicians’ offices as for a coffee emporium.   In many ways, the medical receptionist is the keystone of the operation.   (Recall from your grade school days would happens to an arch if the keystone is removed.) The receptionist sets the tone and will largely define the patient’s experience.   The job is easy when patients arrive in a friendly and carefree manner.  But his or her professionalism is tested when patients, who may be ill and anxious, are challenging to handle. 

I have been so fortunate in my career to be surrounded by such a capable and caring staff.  I credit them to a great measure with whatever success I have enjoyed.  And, if there is a day when I have missed the mark, my staff’s attentive manner can help to minimize its effect. 

Indeed, I have heard many times in my career that a patient has left a physician whom the patient really likes because of what is described as rude or dismissive treatment from the doctor’s staff.

So, if you are one of those folks who ‘sets the tone’, I salute you.  And, if you are one likes me who depends upon them, I say thank you.

I've really missed Couchland during these days when I have been hunkered down sipping java on my own couch.  But soon I hope to once again sink into one of their comfy couches, reading my newspaper and sipping a cafe mocha. 

Should We Pay People to Get Vaccinated for COVID-19?

I read recently that Kroger, who runs a grocery store chain, has joined with other retailers in paying employees who receive a COVID-19 vaccination.  The $100 payment should serve as an incentive for employees to roll up their sleeves.

There is an ongoing debate whether employers can or should mandate COVID-19 vaccinations for their employees.  The state of play now is that employers are encouraging, but not requiring vaccines, as mandating vaccines creates legal exposure for employers.  For example, if you require that an employee is vaccinated against the worker’s wishes, and a complication occurs, is the employer responsible?  Can an employee be disciplined or terminated for failure to vaccinate if there are no vaccines available within a reasonable distance?  And mandating vaccinations may be complicated when workers are unionized.

The right to refuse treatment is a bedrock medical ethical principle that I support.  For example, if I advise an individual with acute appendicitis to proceed with surgery, this patient has a right to decline, assuming that the patient is competent, and I have properly informed the patient of the risks and benefits of the reasonable options.

This right, along with all of our rights, is not absolute.  If refusing medical treatment has a public health dimension, then the issue becomes more complex.  And the terrain can be murky.  If a parent refuses to have his school age child vaccinated against communicable diseases, this right collides against the rights of other children and personnel in the school.   Indeed, it is for this very reason that school districts can require students to be vaccinated.   If a parent objects, then they are free to home school their youngster.

How much will you pay me to mask up?

This is why the failure to wear masks when advised to do so is not just a personal decision.  It puts other as risk.   I don’t object if someone chooses to become inebriated at home.  But it’s quite different if this individual decides to operate a motor vehicle on city streets. 

While no vaccine or medical treatment is 100% safe, and there may be unknown vaccine risks that will emerge later, I recently received the 2-shot Moderna series enthusiastically.  The only incentive I needed was my belief that I would be much less likely to become infected and to infect others.

If a hundred bucks is a necessary incentive, and a business has the will and resources to expend on this effort, then good for them.  We’re familiar with similar strategies, such as paying kids to do homework.

Should we also pay people to be honest or to be polite or to stop at red lights or to be on time for appointments or to observe speed limits?  What should the per diem reimbursement be for wearing a mask?

In other words, should we pay folks to do stuff that they should be doing for free?

 

 

 

Where is Biden's Bipartisanship?

 There are many concepts and activities that we understand, but yet we have difficulty defining. 

In 1964, Supreme Court Associate Justice Potter Stewart in an attempt to define pornography and obscenity stated that ‘…I know it when I see it.’   Indeed, this phrase has been embedded in pop culture and is used in circumstances far removed from it’s initial prurient reference.

How would one define bipartisanship?  If a bill passes with the votes of 100% of one political party and captures only 1 or 2 votes of the opposition, can the outcome fairly be regarded as bipartisan?  How much support from the other side must exist before the ‘B-word’ can be invoked?  While I don’t have a precise threshold in my mind on this issue,  I don’t think that just a couple of votes is sufficient.

Joe Biden was elected in part because of his promise to pursue unity and bipartisanship.  How many times have we all heard about his decades of reaching across the aisle?  He pledged to us during his campaign, and reiterated forcefully in his inaugural address that he will work as hard for those who didn’t vote for me as those who did.

'I give you my word as a Biden.'  Hmm...

I suggest that there is a widening gap between President Biden’s performance and his prior pledges.  He has issued dozens of executive actions with more to come despite telling us in the campaign that he opposed the overuse of this technique.  It's always edifying to monitor how folks’ views ‘evolve’ when they are governing and no longer campaigning.  (Think of all those candidates who campaigned for term limits until they were elected.)

I am disappointed that President Biden has basically shut out the Republicans in the crafting of his $1.9 billion stimulus bill.  First, there are real policy disagreements on his proposed bill even among Democrats.  Larry Summers, a top economist in the Obama administration, has publicly stated his concerns on the economic risks of the plan.  Ten serious Republicans – not partisan bomb throwers – came to the White House to share their views on the issue with president.  Clearly, this was for show as the Democrats have been racing alone and in lockstep to ram the bill through using the reconciliation process, a mechanism to pass the bill without the need for a single GOP vote.  Couldn't they have pursued a bipartisan compromise first?  The Democrats didn't even to through the motions of consultations here making clear that a partisan victory was their modus operandi.

Is this what we can expect henceforth?

What happened to the unity thing?  The stimulus bill was such a ripe opportunity for the Biden team to make good on their campaign promises to us.  There was a deal to be made here, or at least attempted in good faith.

What is unity?  I’ll know it when I see it, and this isn’t it.

 

 

 

 

Variant COVID-19 Strains Coming to America

 This past week, I received my 2^nd Moderna vaccine uneventfully.  Leaving science aside for a moment, I marveled that a small amount of clear liquid thrust into my upper arm could shield me from a contagious and invisible invader.  Indeed, with the many public health failures we have suffered this past year, the development of safe and effective vaccines in record time has been a monumental scientific triumph.  Obviously, these successes were the result of decades of medical research and development that created a ladder that today’s scientists could ascend.  This is how medical science works.  While it is true that medical breakthroughs can occur ex nihilo – out of nothing – more typically new scientific achievement builds on prior successes and failures. 

We've added a few more rungs this past year.

Even with the advent of vaccines, this remains an uneasy time.  Yes, there will be additional vaccines added to the armamentarium.  Johnson & Johnson’s single-dose vaccine is expected to be granted emergency use authorization by the Food and Drug Administration in the near term.  But, new potential disease threats have appeared and others are surely lurking in the shadows.   We are aware of variant strains of the novel coronavirus in the United Kingdom, South Africa and Brazil.  Do we not think that these and yet undetected mutant strains are already present in other corners of the world?  While many of these variants may contain innocuous mutations, others may confer advantages to the virus with respect to transmissibility and virulence.  At some point, we may need to call for Operation Warp Speed 2.0 to create new vaccines and therapeutics to combat new viral threats.

I feel that we are engaged in global cat and mouse conflict.  It seems unfair that the goal posts are shifting.  But disease and illness are unfair.  They strike and afflict the innocent.  But, we are not defenseless.   We have robust protective techniques available as public health experts have admonished us for months.

The scientific community and the public have learned so much this past year.  And without doubt, these lessons will save many lives when the next pandemic strikes.  We’ve created a few more rungs in the ladder that scientists and researchers will climb in the future.

Donald Trump and the Butterfly Effect

We are all familiar with the ‘butterfly effect’, describing a phenomenon when a seemingly trivial action – a whisper, a smile, a compliment or the fluttering of a butterfly’s wing – causes a soft ripple that can reach a distant continent.  You simply cannot calculate the power and reach of a simple act of kindness. Here’s how it works. 

You are in line waiting to buy your first coffee of the day and you discover that the stranger ahead of you has paid for your order.  You are moved by this this simple act of generosity.  Your mood elevates.  You wonder why such an idea never occurred to you.  You ruminate over this on your drive to work.  You greet your secretary who has been under stress and very distracted over her spouse who is recovering at home after surgery.  You think about what that must be like for her and her family.  It’s Thursday morning and you send her home for the rest of the work week so she can help her spouse get well.  The secretary is overcome with gratitude.  After her return to work, she feels that she wants to emulate the kindness that you showed her.  See receives yet another e-mail from her local food bank, only this time she feels the urge to participate and she does so.  Three families she will never meet will now receive food.  A child from one of these families ends up becoming very wealthy and makes it her mission to give back.  And, with a hope and a prayer, the chain keeps extending one link at a time.

The flutter of a wing can change the world.

Of course, the butterfly effect can also create a chain that leads to darkness.  The impact of an unkind remark a scowl, idle gossip  or a vengeful act can reach far beyond the original action.  Since the ultimate negative effects appear unconnected to the first action, the creator of the first link in this dark chain is unaware that he bears some responsibility for the damage that he seeded.

What might the cumulative effects be of leaders who failed to step up for truth, dismissed and excused dishonesty, supported those who trafficked in baseless conspiracy fantasies, rejected mask wearing and other public health measures during a pandemic, challenged the results of a repeatedly verified presidential election, told an alt-rite group with a history of violence to 'stand back and stand by', fired government officials whose transgression was to tell the truth, whipped up tens of millions of supporters to ‘take back our county’ and voted to reject a state’s electoral vote count?

You don’t think that all of this could lead to a violent insurrection, do you?

As of a few days ago, there's a new butterfly in town. 

What Medicine Can Learn from the Airline Industry - Nothing

I have at times detoured from my typical medical commentaries to rail about the airline industry.  If I may borrow some phrasing from a legendary British Prime Minister, the flying experience is a hassle wrapped in a frustration inside a delay.  We arrive at the airport 2 hours early, drag ourselves through the TSA process, ambulate to the gate, pray the flight is on time, hope that they will not deem my luggage as unfit to carry on, march like snails onto the aircraft, test my lumbar disc strength as I hoist my bag into the overhead bin and then finally relax as I sink into a commodious and plush chair that could comfortably seat a gerbil. 

Do I have to sit in the middle seat?

And, if the flight is delayed, the inconvenienced passengers can expect no compensation.

If my medical practice had adopted airline culture, we would have had no patients. Think of all the reading I could have accomplished!  If we made every office visit with us an unpleasant hassle, we would not have been able to pay the electric bill.  And, I don’t think our patients would have been placated if we tossed them a tiny bag of pretzels when we ran late.

I think the airline industry has been more solicitous of the comfort animals being permitted on board than they are of the human passengers.  Such guests have included

If I am dissatisfied with a restaurant, a tradesman, an attorney or a retail store, then I am free to find an alternative.  This is how most of the world works and is an incentive for all of us to perform well.  If, however, you feel that the air travel experience is wanting and less than you deserve, what recourse is available to you?

It’s one of the few industries that can thrive despite providing mediocre and erratic customer service.  And, for the truly brave travel warriors, just try calling the customer service phone numbers.  If customer service were truly an industry priority, would we be kept on hold longer than the duration of some flights?  Is our call ‘really important to them’?  Let me answer my own question.  No, it isn’t. 

What the COVID-19 Vaccine Meant to Me

 Although I am not a front-line worker, I do interface with several dozen patients each week.  The COVID-19 metrics in Ohio are all coursing in the wrong direction.  Over the past few months, several staff at work and personal friends have contracted the disease.  I’ve had a few close calls with patients whom I learned after an office visit with me were infected.  Thus far, I’ve managed to dodge the virus.   What weapon have I used to repel the invader?  See photo below. 

Two weeks ago, I received my initial injection of the Moderna COVID-19 vaccine at my workplace.  I arrived at the appointed hour expecting to bare my upper arm for a quick puncture.  Not quite.  After entering the building, I was directed to the end of a long line which was trailing outside in the parking lot.  So, I took my place during the pleasant winter climate that all of us in Cleveland adore.

Once I advanced into the building proper, I discovered that the experience reminded me of Disneyworld.   I am not referring to costumed interpreters interacting with the crowd, or hearing ‘It’s a Small World’ piped in or a gift shop where I could purchase a Mickey Mouse doll with a facemask who blurts out ‘keep your distance’ if you cross the 6 feet barrier.  I am referring to the hidden winding lines that awaited all of us who were waiting.  As soon as we would turn a corner, another queue bank came into view.  Very clever.

Ultimately, I was face to face with a retired registered nurse who had come back into service to help the nation resist the virus.  After the inoculation of messenger RNA, I waited the required 15 minutes and then headed back to my car.

I’ve had dozens of vaccines throughout my life, but I will never forget this one.  It was an emotional experience as much as it was an immunological event.  There was a dreaminess about all of it.  There we were, there I was, participating in something so much bigger than ourselves.  The nation had been praying for a successful vaccine and scientists throughout the world broke all records and expectations and delivered.  And we represented the first steps back to normal life for everyone   

While vaccine distribution has been woefully inadequate, I hope that every arm who wants a vaccine, will receive one ahead of schedule.  The incoming Biden administration properly regards this as Priority 1.

So far, in the contest of COVID-19 vs Humanity, we are losing badly.  We will prevail.  Ultimately, the vaccine will vanquish the virus.  Until then, we must do everything to minimize our casualties.

As I reflect on 2020, our annus horribilis, the COVID-19 vaccines were the green shoots of renewal. We need to turn them into forests.

 

 

 

 

 

 

Telemedicine is Here to Stay

Most of us recognize that Operation Warp Speed was the name given to COVID-19 vaccine development, which succeeded brilliantly and in record time.   Early on, no one predicted that by the end of 2020, two safe and highly effective vaccines would gain emergency use FDA approval. 

There were other developments that also rolled out at warp speed.  Telemedicine is now omnipresent.  Prior to the pandemic, telemedicine existed in pockets throughout the country, but most physicians and patients had never participated in it.  The plan was for it to gain a much larger footprint in the medical landscape in the years to come.  Instead, the transformation occurred in weeks.  Physicians and patients who previously would have rejected the notion of a distant and impersonal virtual visit were now enthusiastic participants.  Patients and caregivers of all ages became quite conversant with Zoom and other similar platforms.   

'The Doctor Will See You Now'

The urgency for warp speed adoption of telemedicine was to mitigate the pandemic.  By seeing patients virtually, we could protect medical personnel and the public by limiting close exposure with potentially infected individuals.  The more we limit close contact with others beyond our household, the more likely we will remain uninfected.

It soon became evident that telemedicine offered many advantages beyond viral mitigation. 

Indeed, telemedicine is not only here to stay, but its continued growth is assured.  Patients will have routine access to medical care from physicians who practice in other states or even in other countries.  Technology will continue to be developed to make the virtual visit more similar to a full office visit exam including a physical examination.   While this sounds heretical and fantastical, patients may undergo actual physical exams without a physician laying a hand or a stethoscope on the patient. Stay tuned.

Like with other technological advances, there will be a cost.  Intimacy and humanity will be sacrificed on the techno-altar of progress.  To those who want to hang onto the personal visit, with real eye contact. body language, palpation of your abdomen and interacting with medical staff you know and trust, I hope there will be a place for you.   But there is a transformation underway in how medical care will be delivered.  And telemedicine right now is the profession’s north star.   The old fashioned office visit will likely end up like the old fashioned hardware store – not exactly extinct but harder and harder to find.

Today, we buy (or download) books from our couches.  Yes, it is very efficient and those who do so routinely would never contemplate hauling out to a brick & mortar store.  But, what of the joy and pleasure of wandering through a bookstore’s aisles, checking out various titles and then leaving with a book or two that was not on your intended list?  Are you all about the destination or the journey?

 

 

Happy New Year! -A Look Back & A Look Ahead

                                                                             Division                                                                                                                                                                                                                                                                                                                                                Heartache

                                                                                                            Death

                                           Pain

                                                                         2020  

                                                                                                                       Lies                                                                                                                                                                                                                                    Racism                                                                                                                                                                                                        Revenge

                                                                                             Tearing down

                                                            Vaccine

                                                                                            Unity

                                                                                                                                                                                Bipartisanship

                                                                                                        Honor

                                                                             2021

                                                                                                                                                                                          Statesmanship

                                                                                                                 Alliances                                                                                                                                                                               Forgiveness

                                                                    Repairing the world